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A slow growing firm swelling over proximal nail fold with nail dystrophy


1 Department of Dermatology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Department of Pathology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission29-Nov-2019
Date of Decision27-Jan-2020
Date of Acceptance08-Apr-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Suman Patra,
Department of Dermatology, All India Institute of Medical Sciences, Bhopal - 462 020, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/idoj.IDOJ_591_19



How to cite this URL:
Patra S, Agrawal A, Chaurashia J, Rupla R. A slow growing firm swelling over proximal nail fold with nail dystrophy. Indian Dermatol Online J [Epub ahead of print] [cited 2020 Oct 29]. Available from: https://www.idoj.in/preprintarticle.asp?id=295472

A 23-year-old male presented with asymptomatic swelling over the proximal nail fold of the left index finger for the last 6 months [Figure 1] and [Figure 2]. There was gradually associated progressive thinning and triangular-shaped depression at the proximal nail plate. He was a cook by occupation and there was no history of trauma. The swelling was solid and firm on palpation, non-tender, and fixed to the underlying structures. The skin overlying the lesion was movable. The entire lesion was excised with a vertical incision over proximal nail fold. During excision, it was found to be whitish solid mass attached to the extensor tendon. The specimen was sent for histopathology and special stain and findings are demonstrated [Figure 3], [Figure 4], [Figure 5].
Figure 1: Swelling over proximal nail fold with nail dystrophy over the proximal portion of the nail plate

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Figure 2: Lateral view of the swelling associated thinning of the nail plate

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Figure 3: Showing numerous multinucleated osteoclastic giant cells (arrows) with mononuclear cells in the background (H and E, ×125)

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Figure 4: Higher magnification showing numerous multinucleated osteoclastic giant cells (arrows) with mononuclear cells in the background (H and E, ×500)

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Figure 5: Showing hemosiderin-laden (arrows) histiocytes (Pearl's; ×500)

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   Question Top


What is you diagnosis?


   Answer Top


Giant cell tumor of the tendon sheath.


   Microscopy and Further Evaluation Top


Histopathology of the excised specimen revealed a nonencapsulated tumor composed of numerous multinucleated osteoclastic giant cells admixed with mononuclear cells in the background. The mononuclear cells had abundant glassy cytoplasm with round nuclei and prominent nucleoli. The osteoclast-like giant cells had nuclei of variable number ranging from 2 to 12 which were round, folded, or grooved with no discernible nucleoli. Occasional lymphocytes were seen within the lesions, dispersed between the mononuclear cells. Mitotic figures were rarely seen. Pearl's stain revealed hemosiderin-laden histiocytes. The histopathological features were suggestive of giant cell tumor of the tendon sheath. After complete excision, he was kept under follow-up with no recurrence noted till the 8th month of follow-up.


   Discussion Top


Nail fold tumors usually present with swelling over proximal nail fold with or without longitudinal nail dystrophy. It causes significant diagnostic dilemmas and such tumors could arise from the nail matrix, underlying blood vessels or bone.

Giant cell tumor of tendon sheath is the most common benign neoplasm of hand after ganglion cyst. It is usually found in the fourth and fifth decade of life with the female predisposition. The middle finger is the most common site followed by thumb and index finger.[1] Only 20–30% of giant cell tumors of the tendon sheath are clinically diagnosed before surgery. In such a presentation, like ours, the myxoid cyst is the most common differential diagnosis and histopathology is the only way to reach the diagnosis. Other differentials are glomus tumor, exostosis of bone, squamous cell carcinoma, melanoma, etc. Multinucleated giant cells, histiocytes, and hemosiderin deposits are the consistent findings in histopathology.[2] Excision is the treatment of choice with the recurrence rate ranging from 4 to 44%.[3] Here we present this unusual case of nail fold tumor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Di Grazia S, Succi G, Fraggetta F, Perrotta RE. Giant cell tumor of tendon sheath: Study of 64 cases and review of literature. G Chir 2013;34:149-52.  Back to cited text no. 1
    
2.
Lanzinger WD, Bindra R. Giant cell tumor of the tendon sheath. J Hand Surg Am 2013;38:154-7.  Back to cited text no. 2
    
3.
Richert B, Andr J. Laterosubungual giant cell tumor of the tendon sheath: An unusual location. J Am Acad Dermatol 1999;41:347-8.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

 
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