Painful tumors of the skin: "LEND AN EGG"

Douglas N. Naversen, MD,a David M. Trask, MD,a Frank H. Watson, MD,b and
John M. Burket, MDC Medford and Portland, Oregon

Some tumors of the skin are difficult to diagnose because they are clinically nondescript.
However, if they are painful, nine unique tumors should be considered. In addition to the
commonly accepted tender lesions, we describe a painful nodule in a patient who provedto
havea granular cell tumor. We summarizethe clinicaland histologic featuresof the "LEND
AN EGG" tumors: leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angioli-
poma, neurilemmoma, endometrioma, glomus tumor, and granular celltumor. (J AM ACAD
DERMATOL 1993;28:298-300.)

Subcutaneous nodules may be difficult to diag-
nose clinically because they do not have a charac-
teristic surface change that allows recognition with
the naked eye. However, it is possible to make a rea-
sonable differential diagnosis if the nodule is painful.
The acronym "GLENDA" or "ENGLAND" is of-
ten used to recall these painful tumors: eccrine
spiradenoma, neuroma, glomus tumor, leiomyoma,
angiolipoma, neurilemmoma, and dermatofibroma.
We recently treated a patient who had a painful
nodule that was not an "ENGLAND" lesion.
CASE REPORT
A 19-year-old white woman had a painful and tender
lump on her right chest for 1 year; the lump slowly
enlarged. Examination revealed a 12mm, tender, subcu-
taneousnodule.Therewerenoepidermalorcolorchanges.
Resultsof a skinbiopsyspecimenshowed an encapsulated
nodule surrounded by normal fat. Large polyhedral
tumor cells had small, centrally placed oval nuclei and
pale cytoplasm(Fig. I). Distinctivecytoplasmic granules
with coarse eosinophilic color were noted.Thesegranules
were periodic acid-Schiff positive and diastase resistant.
Tumor cellswerelocated in clustersand weresurrounded
by fine strands of collagen. Although there was no
pseudocarcinomatous hyperplasia, the appearance was
typical of granular cell tumor.!
DISCUSSION
This case aroused our interest in painful skin tu-
mors. We reviewed a standard text book of dermato-
From the Departments of Dermatology" and Pathology," Rogue Val-
ley Medical Center, and the Department of Dermatology," Oregon
Health Science University.
Reprint requests: Douglas N. Naversen, MD, 2959 Siskiyou Blvd.,
Medford, OR 97504.
Copyright @ 1993 by the American Academy of Dermatology.
0190-9622/93 $1.00+.1016/4/40350
298
pathology, which listed lesions that were either
painful or tender.' We excluded painful but reactive
and self-resolving lesions (nodular fasciitis) and
small lesions (papules) with degenerative changes
(chrondrodermatitis nodularis helicis). We also ex-
cluded large, bulky tumors that hurt because of me-
chanical pressure and not because of their intrinsic
painful nature. Combined with our clinical experi-
ence, we review the "LEND AN EGG" tumors
(Table 1).3
Leiomyomas develop from smooth muscle." Sol-
itary and multiple piloleiomyomas are derived from
the arrector pili muscle, and angioleiomyomas (an-
giomyomas) are derived from the muscles of veins.
Genitalleiomyomas are usually asymptomatic, but
the other types may be painful. 5 The firm, smooth
nodules may be red, pink, purple, brown, waxy, or
translucent, and individual or grouped. A cold stim-
ulus applied to the lesion can produce contraction
and pain. Leiomyomas have interlacing bundles of
smooth muscle fibers with characteristic eel-shaped
nuclei. On cross section the muscle bundles show
vacuolization. Angiomyomas are encapsulated with
smooth muscle bundles that extend tangentially
from central veins. Masson's trichrome may stain
the muscle red.
Eccrine spiradenomas can be painful and have a
blue color. Clinically they are small and nondescript.
They differentiate toward intradermal eccrine duc-
tal and secretory cells. Results of a biopsy specimen
reveal deeply basophilic-staining, sharply margin-
ated lobules that lie free in the dermis. The nodule
may have a delicate fibrous capsule without connec-
tion to the overlying epidermis. Two epithelial cell
types are present in intertwining bands: those with
small, dark nuclei at the periphery and those with
large, pale nuclei central to the bands. Some lumina
Journal of the American Academy of Dermatology
Volume 28, Number 2, Part 2 "LEND AN EGG" 299

I ~ . , . -.

. "~ .~ !;" . .. ~~>

" .:.~. ~ r '
1?; .: " ~)'
'"~; .:~ ... -'\. .
: f<"
. . '; .

Fig. 1. Granular cell tumor shows large, polyhedral cells with small, centrally placed oval
nuclei and pale cytoplasm. Distinctive cytoplasmic granules show coarse eosinophilic color.
(Hematoxylin-eosin stain; X40.)

may be present,and hyalinemay be prominentwith Table I. Painful tumors of the skin: "LEND AN
cylindromatous foci,6, 7, 8 EGG"
Neuromas include both the painful amputation
Leiomyoma: May be inherited as autosomal
and Morton's varieties, which differ clinically and dominant trait
histologically." The former occur at the site of a sev- Eccrine spiradenoma: "Blue balls in the dermis"
ered nerve (traumatic neuroma) and appear as a Neuroma: Nerve twiglets form at severed nerve
firm nodule. Proliferative bundles of nerve fibers Dermatofibroma: The most common of the painful
may besurrounded by a capsule.Morton's neuroma lesions
Angiolipoma: Increased. familial incidence
is not a true neuroma but a reactive, persistent, and Neurilemmoma: May be associated with von
degenerative nodule on the sale that usually occurs Recklinghausen's syndrome
between the heads of the second and third or third Endometrioma: Rare; especially occurs in scars of
and fourth metatarsals with a fusiformenlargement lower abdomen
of the plantar digital nerve. A denseperineural and Glomus Tumor: Solitary glomus may be painful;
glomangiomas may be inherited as autosomal
perivascular fibrosis may extend in a concentric dominant trait
fashion. Granular Cell Tumor: A newly described painful
Dermatofibromas often occur on the legs of lesion
women. Diagnosis may be suggested by the "dimple
Modified from Thompson RA Jr. J AM ACAD DERMATOL 1985;
sign."lo Although most dermatofibromas are 13:865-7.
asymptomatic, some are tender. Fibrous (dermat-
ofibroma) and cellular (histiocytoma) patterns are
typical. Characteristic epidermal hyperplasia may
overlie the tumor, and lipidand hemosiderin may be cay bodies are characteristic. Edematous stroma,
present in the dermis.I I mucin, and mast cellsmay also be found. Both An-
Angiolipomas can be painful and are one of the toni A and Antoni B tissue may be present.
varieties of lipomas.12 Results of a biopsyspecimen Endometriosis of the skin is rare, but it may be
reveal mature fat cells with varying numbers of associated with pain or bleeding that is worse at the
blood vessels. Fibrin thrombi may be found within time of menstruation. It is often located near the
capillaries, and the degree of vascular proliferation umbilicus or on the lower abdomen and is usually
mayor may not be associated with pain.12, 13 associated with a scar.l? Endometriosis of the skin
Neurilemmomas, or schwannomas, occur along may develop spontaneouslyor occur after implanta-
the courseof a peripheral nerve.14They may be ten- tion of endometrial cells in a surgical scar. Results
der and firm and have a flesh- to pale-pink color. of a biopsy specimen reveal a cellular, vascular
Results of a biopsy specimen reveal encapsulated stroma with irregular lumina similar to the normal
neural tissue with typical "S"-shaped nuclei. Vero- endometrium of the uterus. A range of histologic

300 Naversen et al.
features are found that are similar to the main
phases of the menstrual cycle."
Glomus tumors may be spontaneously painful.
They develop from the Sucquet-Hoyer canal.!?
Glomus tumors may be purple or blue-red and oc-
cur commonly in the nail bed. 18 Solitary glomus tu-
mors are well circumscribed and surrounded by a
fibrous capsule. Several narrow vascular lumina
lined by a single layer of flattened, elongated, endo-
thelial cells are present, and peripheral to them are
multiple rows of glomus cells. These characteristic
cells have eosinophilic cytoplasm and large, pale,
round-to-oval nuclei of uniform appearance. Multi-
ple glomus tumors (glomangiomas) have greatly di-
lated vascular spaces and a thin layer of glomus cells
peripheral to the endothelial cells that are only one
to three layers thick, 19 Glomangiomas are much less
likely to be painful than a solitary glomus. 20
Granular cell tumors may be painful and occur
most commonly in the tongue but also in the skin and
internal organs.' The granular cytoplasm is charac-
teristic, as described in the case report above.
Although not a diagnostic problem in our patient,
pseudocarcinomatous hyperplasia overlyingthe nod-
ules should not be confused with squamous cell car-
cinoma.
The histogenesis of granular cell tumor has been
controversial. In a thorough review, Apisarntha-
naraxfavored a multipotential undifferentiated mes-
enchymal cell origin. I More recently, others pro-
posed a probable Schwann cell origin based on
electron microscopic findings and immunohisto-
chemistry. 21,22 With a neural differentiation, it
would not be unreasonable to expect some tumors to
be painful, as are neuromas and neurilemmomas.
There is a close relationship between peripheral
nerves and granular cells. Results of a biopsy spec-
imen may show nerve sheath cells and dermal nerve
fibers encased by typical granular cellsadmixed with
a lymphoid infiltrate.P Although one studyindi-
cated that 19% of granular cell tumors were "pru-
ritic" or tender, I other literature has underempha-
sized the painful nature of the granular cell tumor.
Journal of the American Academy of Dermatology
February 1993
REFERENCES
1. Apisarnthanarax P. Granular cell tumor [Review]. J AM
ACAD DERMATOL 1981;5:171-82.
2. Lever WF, Schaumburg-Lever G. Histopathology of the
skin. 7th ed. Philadelphia: J B Lippincott, 1990:1-940.
3. Thompson JA Jr. Therapy for painful cutaneous leiomyo-
mas. J AM ACAD DERMATOL 1985;13:865-7.
4. Fisher WC, Helwig EB. Leiomyomas of the skin. Arch
Dermatol1963;88:51O-20.
5. EnzingerFM, WeissSW. Soft tissuetumors.St. Louis: The
C V Mosby Co, 1983:282-5.
6. Kersting DW, Helwig EB. Eccrine spiradenoma. Arch
Dermatol1956;73:199-227.
7. Mambo N C. Eccrinespiradenoma:clinicaland pathologic
study of 49 tumors. J Cutan Pathol1983;10:312-20.
8. Lever WF, Schaumburg-Lever G. Histopathology of the
skin. 7th ed. Philadelphia: J B Lippincott, 1990:614-6.
9. EnzingerFM, WeissSW. Soft tissuetumors. 81. Louis: The
CV Mosby Co, 1983:583-5.
10. Fitzpatrick TB, GilchrestBA. Dimple signto differentiate
benign from malignant pigmented cutaneous lesions. N
Engl J Med 1977;296:1518.
11. Sanchez RL. The elusive dermatofibromas. Arch Derma-
tol 1990;126:522-3.
12. Howard WR, Helwig EB. Angiolipoma. Arch Dermatol
1960;82:924-31.
13. DixonAY, McGregor DH, Lee SH. Angiolipomas: an ul-
trastructural and clinicopathological study. Hum Pathol
1981;12:739-47.
14. Das Gupta TK, Brasfield RD, Strong EW, et al. Benign
solitary schwannomas (neurilemomas). Cancer 1969;
24:355-66.
15. Steck WD, Helwig EB. Cutaneous endometriosis. JAMA
1965;191: 101-4.
16. Tidman MJ, MacDonald DM. Cutaneous endometriosis: a
histopathologic study. J AM ACAD DERMATOL 1988;
18:373-7.
17. EnzingerFm, WeissSW. Soft tissue tumors. St Louis: The
C V Mosby Co, 1983:450-60.
18. Holzberg M. Glomus tumor of the naiL Arch Dermatol
1992;128:160-2.
19. Naversen DN, Worland RG, Burket JM. Giant glomangi-
oma. J AM ACAD DERMATOL 1986;14:1083-4.
20. JelinekJE. Aspectsof heredity,syndromicassociations, and
course of conditionsin which cutaneous lesionsoccur soli-
tarilyorin multiplicity. JAM ACAD DERMATOL 1982;7:526-
40.
21. Lever WF, Schaumburg-Lever G. Histopathology of the
skin. 7th ed. Philadelphia: J B Lippincott, 1990:748.
22. EnzingerFM, WeissSW. Soft tissuetumors.St. Louis: The
C V Mosby Co, 1983:745-53.
23. Murphy GF, Elder DE. Atlas of tumor pathology,melano-
cytic tumors of the skin.Washington, D.C.: Armed Forces
Institute of Pathology, 1991 :245-8.