Glomus Tumor in the Groin Mimicking an Inguinal Hernia

Ambikavathy M,a Kumar Sb

a. Department of Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bangalore; b. Department of Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore

Abstract

Glomus tumor is an uncommon lesion constituting 1-2% of soft tissue  tumors.  These tumors are usually seen in the subungual region and nail bed of the upper and lower extremities and are very painful.  Occasionally glomus tumors are found in unusual sites.  We  report  a  case  of  a  65 year  old male patient who  presented to us with a three year history of a painless swelling in the right inguinal region.  On examination the swelling was diagnosed as an inguinal hernia with bladder as content.  On exploration a large loculated cystic swelling was seen.  Histopathology  confirmed it as glomus tumor.

Keywords: , ,

Introduction

Glomus tumors are known to arise from the perivascular smooth muscle  cells of the glomus body  present in the dermis of  the  skin which  is  involved in thermoregulation.1,2  They  are  painful  swellings  occurring  in  the subungual regions and may be solitary or multiple.Occasionally these tumors are seen in unusual sites, cutaneous and extracutaneous,  and may be misinterpreted.3  We report a case of 65 year old  male  patient  who  presented with a painless solitary inguinal swelling which  was initially diagnosed  as an obstructed  inguinal  hernia.  At surgery  a large loculated  cystic swelling was seen, histology  confirmed a  glomus tumor.  We report this case for its unusual site of presentation and rarity.    

Case History

Fig 1. Preoperative  photograph  showing  a  right  inguinal  swelling  mimicking  an inguinal  hernia

Figure 1. Preoperative photograph showing a right inguinal swelling mimicking an inguinal hernia

A 65 year old male patient presented with a three year history of a  painless  swelling in the right inguinal region.  He gave a history of gradual  increase  in  size  of  the swelling.  He complained  of  dragging  sensation  in the right groin after taking food and on micturition.  There was no history of trauma to the groin.  The swelling was irreducible.

Figure 2. Ultrasound picture showing  large cystic swelling in the right groin

Figure 2. Ultrasound picture showing large cystic swelling in the right groin

On clinical examination a swelling of size 11×6 cms was noticed in the right groin, which was non tender and soft in consistency. Cough impulse was absent, transillumination test was positive and differential diagnosis of encysted hydrocele of the cord / obstructed inguinal hernia with bladder as content was made (Figure 1).  The patient was evaluated further.  All routine investigations were within normal limits.  When ultrasound scan of the groin showed a large inguinoscrotal cystic swelling measuring  approximately 6 x 10.7 x 8.5 cms  with 300 cc  of  clear fluid (Figure 2),  a  probable  diagnosis  of an encysted hydrocele  of  the  cord  was  made.

Figure 3.  Operative  photograph   showing  the  glomus  tumor  popping  out  of  the incision

Figure 3. Operative photograph showing the glomus tumor popping out of the incision

The patient underwent surgery under spinal anaesthesia through a conventional right inguinal incision.  Operative  findings  were  a  large  cystic  swelling  popping  out   just below the  skin  incision  enclosed  in  a  very delicate capsule and small blood vessels  over  it,  measuring 13 x 7  cms  with  clear  mucoid  fluid.  The cystic swelling was excised after  meticulous  release  from  neighbouring  structures,  the  plane  of  swelling  was  subfascial and weighed 400 gms (Figure 3, 4).  Our  operative diagnosis was that of lymphatic cyst.

Figure 4. picture of the excised specimen, the thin capsule with blood vessels are seen

Figure 4. picture of the excised specimen, the thin capsule with blood vessels are seen

The histopathology report was as follows:

Sections showed dilated spaces intervened by fibrous delicate septa.  Focal clusters of round cells with punctuate nuclei and scanty cytoplasm was seen.  The stroma showed  edema  and  myxoid  change.  No lymphoid  cells  were seen.  Imp: Glomus Tumor with  extensive  myxoid  change (Figure 5,5a).

Figure 5,5a. Microphotographs  showing  edema  with  loose  stroma  and  foci  of  solid sheet  of  tumor  cells

Figure 5,5a. Microphotographs showing edema with loose stroma and foci of solid sheet of tumor cells

Immunohistochemistry was positive for smooth muscle actin, vimentin and cytokeratin (Figure 6).

The patient was discharged on the 6th  postoperative  day   and  is  on  regular  follow up  with  no  recurrence  till  date.

Discussion

Figure 6. Immunohistochemistry photograph showing smooth muscle actin antibody positivity in tumor cells

Figure 6. Immunohistochemistry photograph showing smooth muscle actin antibody positivity in tumor cells

Glomus  tumor  is  an  uncommon  soft  tissue  tumor  and  is  classically  seen  in  the subungual  region.  It  is  known  to  occur  at  any  age  with  a  female  preponderance.1,2  Glomus  tumors  are  known  to  occur  as  single or  multiple  blue-red  nodules.  These tumors  are  very  painful  and  tender,  a  classical  feature  of  glomus  tumor.  Surprisingly our patient had a painless swelling.  Clinical diagnosis is not very difficult when  the  tumor  is  small  and  situated  in  the  usual  sites  as subungual  region.3,4   They can be confusing with large swellings presenting in unusual sites leading to misdiagnosis; as in our case the tumor looked like a  inguinal  hernia.  Literatures  have reported  unusual  sites  such  as  stomach,  small  bowel, female genitals, bone, oral cavity etc.5  With  a  wide  variety  of  histological  features  they  are  grouped  into three  main  types (a) vascular form  (b)  myxoid form, and  (c) solid form.

Depending on the cell types they are classified as (a) glomus tumor with predominant glomus cells, (b) glomangiomas with blood vessels, and (c) glomangiomyomas with smooth muscle cells. Our case fits into the myxoid type.6

Although glomus cells are histologically diagnostic of glomus tumors, it has to be complimented by immunohistochemistry.  Glomus tumors are positive for actin and vimentin and negative for desmin.6 The various  modalities of treatment are laser, sclerotherapy and  intralesional  injection  of hypertonic  saline.  Malignant transformation can occur, hence follow up is mandatory.7  Surgical excision is curative in solitary tumors.  Total excision with the capsule reduces recurrence rate.8

Conclusion

Glomus tumor can occur in unusual sites in the cutaneous and subcutaneous plane.  The differential diagnosis of cystic lesions should include glomus tumor.  Glomus tumor can present as a large swelling when compared to the conventional 1-2 cms nodular or plaque like lesions. Surgical excision is the treatment of choice and is curative in solitary glomus tumors.  Malignant transformations are known to occur, hence regular follow up is mandatory.

References

  1. Gombus, Z; Zhang, PJ. Glomus Tumor. Archives of Pathology & Laboratory  Medicine  2008; 132:1448 – 52 ,Int J Surg Pathol 2011;19:499.
  2. Van Geertruyden J, Lorea P, Goldschmidt D, et al. Glomus Tumor of the hand. A retrospective study of 51 cases. J hand [Br] 1996;21:257-60.
  3. Apfelberg DB, Teasley JL. Unusual locations and manifestations of glomus tumours(glomangiomas). Am J Surg 1968; 116:62-64.
  4. Moor EV, Goldberg I, Westreich M. Multiple glomus  tumours: a case report and review of literature. Ann Plast Surg 1999;43:436-8.
  5. Holck S,  Bresenden JL.  Solid  glomus  tumor  presenting  as  an  axillary  mass: report of a case with morphologic study, including cytologic characteristics. Acta Cytol 1996;40:555-62.
  6. Gu M,  Nguyen PT,  Cao S,  Lin F. Diagnosis  of  gastric  glomus  tumour  by endoscopic  ultrasound  with  cytologic,  histologic  and immunohistochemical studies.  Acta  Cytol.  2002;46:560-6.
  7. Folpe AL, Fanburg-Smith JC, Miettnen, Weiss SW. Atypical and malignant glomus tumours: analysis of 52 cases, with aproposal for the reclassification of glomus tumors. Am J Surg Pathol Jan;25(1):1-12.
  8. Dailiana ZH,  Drape JL,  Le Viet D.  A  glomus  tumour  with  four  recurrences.  J Hand    Surg  [Br] 1999;24:131-2

Author Information

  1. Associate Professor, Department of Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bangalore-66;
  2. Department of Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore-66

Conflict of Interest: None declared

 

 

 

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