Taking Charge of Recurrence of a Glomus Tumor: About a Case and the Review of the Literature

Glomus tumors of the hand are benign vascular tumors, which develop at the expense of the neuro-myo-arterial glomus. They represent about 1% -5% of all hand tumors. Their diagnosis is frequently delayed by the absence of specific signs, its confirmation is based on anatomopathological examination. Their treatment is based on complete surgical excision and restitution of the nail apparatus, the only guarantees of a good evolution without recurrence. We report the case of a recurrence of a glomus tumor of the ring finger in a woman where the pains reappeared 6 months after the first intervention.


INTRODUCTION
The glomus tumor is a very rare benign neuromyo-arterial proliferation, initially described by Masson [1], their favorite site is the hand, particularly the subungual region and the lateral surface of the fingers. The clinical symptomatology is little known, which explains a frequent diagnostic delay. The interest of the radiological assessment is discussed, diagnostic certainty is provided by histology. In all cases, the treatment is surgical and is based on complete excision. Recent work shows that recurrences are not uncommon [2,3].
The goal of this work is to define, recurrences, the contributing factors and how to avoid them.

PATIENT AND OBSERVATION
A 45 year old woman, manual worker, without ATCD, who has had pain for 3 years, from the distal end of the ring finger, spontaneous, exacerbated by the slightest pressure and accentuated by the cold. The patient benefited from a surgical intervention, in another establishment, after an ultrasound exploration, where an exegesis of a tumor mass was carried out, the diagnosis of a glomus tumor was retained after histological examination. In front of the reappearance of the symptomatology 6 months after the surgical operation, the patient consulted our establishment a year later. The clinical examination revealed a scar from the anterior latero-nail intervention, with no palpable mass or nodular or reduction in the articular amplitudes of the finger ( Figure 1). All three tests (de love, cold water immersion and Hildreth's ischemia) were positive. The patient benefited from an ultrasound exploration which objectified a small hypoechogenic, oval, well limited nodule, vascularized with doppler, on the external face of the 3rd phalanx of the ring finger ( Figure 2). An MRI was performed which objectified an infra-centimeter mass, in T1 hyposignal and T2 hypersignal, evoking a glomus tumor ( Figure 3). An exegesis biopsy was performed, using the old incision, with a microscopic technique ( Figure 4). Histological examination of the part ( Figure 5) allowed the diagnosis of certainty of a recurrence of a glomus tumor.
The immediate aftercare was simple. After an 18-month follow-up, the patient reported a safe transformation in their daily lives, with no recurrence.

DISCUSSION
Masson's glomus tumor [1] is a benign tumor formed at the expense of neuromyo-arterial tissue, located at the level of capillary-venous anastomoses of regulation, particularly numerous, at the level of the digital extremities. These tumors are rare, but not exceptional [4], their frequency varies from 1.6 to 5% of all tumors of the soft parts of the hand [5,6]. It mainly affects young adults of the female sex, and sits with predilection at the ends of the fingers and particularly under the nail.
The diagnosis is evoked before a small painful nodule of the extremities associated with a characteristic triad: cold hypersensitivity of the affected area, paroxysmal pain and exquisite pain on touch. The diagnosis of certainty is based on a bundle of arguments because only histology is formal. The clinic, when it is typical, can alone be sufficient for the diagnosis. However, the surgeon requests evidence of the existence of a tumor of the finger, and wishes to know precisely its location which determines the surgical approach, medial trans-nail or lateral.
Complete surgical excision of the glomus tumor remains the treatment of choice, it makes it possible to obtain indolence and avoid recurrence by a total excision of the tumor and its environment [7,8], in cases where the limits of the tumor are unclear due to hemorrhage, complete removal of the tumor is often not possible and the possibility of tumor recurrence is probable [9].
Recent work shows that recurrences are not rare, according to the authors, 4 to 24% of patients require a new intervention [2,3], however recent literature indicates that the rate of recurrence can reach 50% [10]. Early recurrence (less than a year) is considered to be the result of incomplete excision [3] or the presence of a second tumor that was not diagnosed and excised during the first intervention [11]. In our patient, there     is no evidence of incomplete excision, nor of the presence of a second undiagnosed tumor, since the patient did not benefit from a preoperative MRI. Late recurrence (more than a year) is attributed to the development of a new lesion in or near the same excision site [8]. It is not always possible to differentiate between a real recurrence and a new lesion [12]. Thus, most authors believe that recurrences are due to incomplete excision [3,13,14], and that the probability of recurrence is higher in the case of: subungual glomus tumors [15,16] or a tumor with color close to that of the skin [17,18]. For Straham [14], recurrence is the rule when the tumor is found to be unencapsulated during the first intervention. Therefore, in front of symptoms which persist more than 3 months after excision, it is strongly recommended to re-explore [16]. Heim and Hanggi [19] report in their series that the number of patients with early recurrence was almost equal to that of patients with late recurrence, with a slight predominance of early recurrences (54%). In Madhar.M's series [20], no tumor recurrence has been observed. Several measures have been maintained in order to ensure complete excision and reduce the rate of recurrence: some authors [14,21,22,23] recommend excision wider than the apparent limits of the tumor, microscopic surveillance [24] or intraoperative ultrasound [25] can also be useful to ensure adequate resection, finally a procedure of exsanguination of the finger by a double tourniquet (one at mid-height and the other at the root of the finger) has also been proposed to better visualize the tumor intraoperatively [18]. Percutaneous sclerotherapy can be used to treat recurrent glomus tumors [26].

CONCLUSION
Recurrences of glomus tumors are not uncommon, for this, several measures must be taken: a preoperative MRI, an excision wider than the apparent limits of the tumor, by a microscopic technique or under ultrasound control.

ACKNOWLEDGEMENT
We want to acknowledge Madame SABRA BEZZANIN for her helpful revision of the English language.