ARTICLE
Auteur(s) : Akie
Matsunaga1, Toyoko Ochiai1, Ikuko
Abe1, Ai Kawamura1, Ritsuko Muto1,
Yasuyuki Tomita2, Masahiro Ogawa3
1Department of Dermatology, Surugadai Nihon
University Hospital, 1-8-13 kanda-Surugadai, Chiyoda-ku, Tokyo
101-8309, Japan
2Tomita Clinic, Kashiwa-shi, Chiba, Japan
3Department of Internal Medicine, Surugadai Nihon
University Hospital, 1-8-13 kanda-Surugadai, Chiyoda-ku, Tokyo
101-8309, Japan
accepté le 3 Août 2006
Subungual glomus tumour is a benign neoplasm that arises from the
neuromyoarterial apparatus. The existence of tumours is suspected
in the presence of characteristic clinical signs such as localized
pain, tenderness, and sensitivity to temperature change. These
symptoms usually signal the need for the complete removal of the
tumours [1]. However, the tumours are usually only a few
millimetres in diameter and are rarely palpable clinically.
Moreover, incomplete surgical treatments easily cause recurrence
and residual nail deformity [2, 3]. We describe two cases of
subungual glomus tumours which we examined by ultrasound scanning
methods including B-mode, C-mode, Color Doppler imaging (CDI), and
B-flow imaging (BFI). Our findings indicate that they were
non-invasive and nonionizing evaluation methods. The purpose of
this paper is to clarify the significance of these methods for the
preoperative assessment of subungual glomus tumours.
Patients and methods
Patients
Case 1: A 40-year-old man was referred to our hospital with a
7-year history of nail deformity on his left thumb. Physical
examination revealed that the proximal part of the nail had a
purplish red flush with a partial nail split on his left thumb (
(figure 1A) ).
Pain was provoked by direct pressure to the nail. Laboratory
investigations were within the normal range. Clinical diagnosis was
subungual glomus tumour.
Case 2: A 47-year-old woman with one-year history of the
change of color in her right thumb. Physical examination showed
that her nail had white longitudinal discoloration and onycholysis
with Beau’s line ( (figure 2A) ). She was
suspected of having a subungual glomus tumour, but neither the red
flush nor the tumour was observed under her nail plate. Plain X-ray
films revealed no apparent bony erosions in either case.
Methods
Ultrasound scanning examinations were performed with a LOGIQ 7
system (GE Yokogawa Medical Systems, Tokyo, JAPAN) equipped with a
5- to 14-MHz broadband linear array transducer and a thin standoff
pad. In the B-mode scanning, the transducer was arranged in
longitudinal and transverse projections of the dorsal aspect of the
distal phalanx of the thumb. For the subungual lesion, the size,
localization, echogenicity and the relationship with the
surrounding tissues were evaluated. Secondly, the transducer was
swept over the whole subungual lesion manually at a constant speed,
and volume data were stored. Three-dimensional images were
reconstructed by a built-in 3D ultrasound system, and slice images
with other orientations including C-mode (parallel to the surface
of the transducer) were produced. The vascularity and vascular
architecture of the lesion were assessed with CDI in both cases.
The CDI gain was set at the maximal value to obtain blood flow
signals without any background noise. In case 2, vascularity was
evaluated by BFI, in which the gain was set at the maximal value to
obtain blood flow signals without any background noise, and the
blood flow was displayed in red. The B-flow method visualized
groups of moving red blood cells within the blood, using grayscale
sonography by extending the coded excitation schemes developed by
GE Medical Systems [4, 5]. Based on the sonographic findings, a
surgical excision was made. The specimens were histologically
examined.
Results
In Case 1, the B-mode scanning demonstrated an isoechogenic
6 × 5 × 4 mm lesion between the nail plate and the dorsal
cortex of the distal phalanx, which was situated in the proximal
nail bed ( (figure 1B
and C) ) . The CDI examination showed prominent blood flow
signals within the lesion ( (figure 1D) ). The patient
was treated with surgical excision. Two incisions were made in the
lateral paronychial folds. Eponychial flap and the whole
nail were elevated proximally. A window was open in the nail bed
and the tumour was excised. Pathological examination revealed a
glomangioma-type glomus tumour in which numerous small blood
vessels and a proliferation of uniform cells with eosinophilic
cytoplasm and round nuclei were observed ( (figure 1E) )[6]. After the
operation, the symptoms disappeared; the nail deformity improved;
and there has not been a recurrence. In Case 2, the B-mode imaging
showed a 6 × 5 × 3 mm isoechogenic nodule between the
eponychium and the dorsal aspect of the distal phalanx ( (figure 2B) ). The
lesion was situated in the nail matrix in the B-mode and C-mode
imagings ( (figure
2C) ). CDI and BFI showed prominent blood flow signals
within the lesion. In BFI, a detailed hemodynamic imaging was
shown. ( (figure
2D) ). For surgical treatment, the lateral paronychial fold
was lifted, and a partial window was open on the nail. The matrix
was opened with an H incision, and the tumour was excised.
Histopathology showed the glomus tumour. Since the completion of
the operation, neither pain nor tumour recurrence has occurred.
Discussion
We examined two cases of the subungual glomus tumours, and found
that the accurate preoperative diagnosis using ultrasound scanning
methods resulted in more effective surgical excisions and relief.
In case 2, the ultrasound findings allowed us to gain the patient’s
acceptance for the surgical operation.
In subungual glomus tumour cases, successful excision leads to
complete surgical cure. However, it is difficult to diagnose
preoperatively. The tumours are usually small and rarely palpable.
Biopsy is difficult to perform, and incomplete removal often causes
postoperative recurrence of pain. For the preoperative diagnosis,
plain X-rays, arteriograms, magnetic resonance imaging and
ultrasound imaging have been made available [7-12]. In this study,
we applied the B-mode and C-mode methods to confirm the subungual
tumour localization and to measure the size and depth. Our results
revealed that ultrasound imaging with a 5~14 MHz broadband
transducer had great advantages in defining the three-dimensional
imaging of the tumours. Recent studies have demonstrated the
utilities of CDI and/or Power Doppler imaging combined with the
B-mode scanning to differentiate glomus tumours from other small
hypoechoic tumours in the subungual region. Chen et al. examined
digital glomus tumours with 5~9 MHz ultrasonography and CDI,
and showed the presence of a hypoechoic nodule with prominent
vascularity in all subungual tumours [12]. They declared that the
high-resolution ultrasonography demonstrated small tumours and had
great advantages for the diagnosis and preoperative localization of
the glomus tumours. In our cases, tumour vascularity was assessed
by CDI and BFI, and a prominent blood flow was visualized. Compared
to CDI with which it is not easy to clarify the exact blood vessels
within a small tumour, BFI provides high frame rates and high
spatial and temporal resolution, and reveals the exact fine blood
vessels with no blooming. We are unable to find other reports that
applied BFI to detect the fine blood vessels within a glomus
tumour.
In conclusion, the results of the present study suggest that the
5~14 MHz B-mode and C-mode scanning combined with CDI and BFI
are non-invasive and nonionizing evaluation methods, and that a
complete resection of subungual glomus tumours would be possible
with assistance of accurate preoperative ultrasound methods.
Acknowledgements
Financial support: None. Conflict of interest: None.
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