SCIENTIFIC ARTICLE
Multifocal Nodular Fasciitis of the Hand and Shoulder: Case Report Guruvardhan Kumar Kotha, MS, Venkatramana BJ, MS, Venkateshwar Reddy Maryada, MS, Harshad Jawalkar We report a case of nodular fasciitis occurring on the dorsum of the right middle finger, the dorsum of the right hand, and the right upper back associated with cortical erosions of the scapula. Ray amputation of the middle finger and marginal excision of the hand and periscapular masses were performed. There was no recurrence of the tumor at either site a year later. (J Hand Surg Am. 2014;39(12):2468e2471. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Bone erosions, dorsum of the middle finger, multiple sites, nodular fasciitis, hand and periscapular region.
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growing benign soft tissue tumor. Often, it is clinically mistaken for a malignancy. It is common on the volar aspect of the forearm;1e4 multiple site occurrences are rare. We report a case of multisite nodular fasciitis occurring on the dorsum of the right middle finger, on the dorsum of the right hand, and on the right periscapular area to highlight the unusual presentation and to review the literature for various treatment options. ODULAR FASCIITIS IS A RAPIDLY
CASE REPORT A 30-year-old laborer presented with painful masses on the dorsum of her right middle finger and hand as well as her right periscapular area of 3 months From the Department of Orthopedics, Kamineni Institute of Medical Sciences, Narketplly, Andhra Pradesh, India. Received for publication December 12, 2013; accepted in revised form July 10, 2014. The authors are grateful to Dr. R.S. Murthy and Dr. Venkat Kishan of the Radiology Department and Dr. Seshagiri Rao of the Pathology Department, Kamineni Institute of Medical Sciences, for good histopathological images. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Dr. Guruvardhan Kumar V Kotha, Flat no 401a, Jaya Durga Towers, Door no. 6-4-11 to19, Bholakpur, Musheerabad, Secunderabad 500 080, India; e-mail: [email protected]. 0363-5023/14/3912-0019$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.07.023
2468
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
duration associated with numbness of the middle finger. She had a history of a thorn prick to the dorsum of the right hand 3 months prior to the appearance of the masses on the dorsum of the right middle finger and hand. She noted another mass on the right periscapular region one month after the appearance of the hand masses. The masses measured 6 3 cm on the middle ring finger, 4 3 cm on the hand (Fig. 1), and 10 8 cm on the shoulder. The masses were tender and firm. The mass on the middle finger had extended to the radial and ulnar borders of the finger. Both passive and active movements of the middle finger at the metacarpophalangeal joint were 0 to 20 of flexion. There was no active or passive movement at the proximal and distal interphalangeal joints of the middle finger. The hand and periscapular masses were in the subcutaneous plane and were not adherent to skin or tendons. There was no epitrochlear or axillary lymphadenopathy. There was loss of protective sensation in the middle finger. Radiographs showed increased soft tissue shadow over the dorsum of the middle finger and the dorsum of the hand, and cortical erosions of proximal phalanges and metacarpals of the middle and ring fingers (Fig. 2). Similar erosions were seen at the inferior angle of the right scapula (Fig. 3). Magnetic resonance imaging (MRI) showed a hypointense lesion arising in the subcutaneous plane on T1-weighted images and hyperintense signal on T2-weighted
MULTICENTRIC NODULAR FASCIITIS
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FIGURE 1: Nodular fasciitis on right middle finger and hand.
FIGURE 3: Radiograph shows erosions at the inferior angle of right scapula.
FIGURE 2: Radiograph shows cortical erosions of middle and ring finger proximal phalanges and metacarpals.
images of the middle finger, the hand, and the right periscapular region (Fig. 4). The tumor on the dorsum of the middle finger was adherent to the neurovascular bundle. An incisional biopsy from both the hand and the periscapular masses indicated nodular J Hand Surg Am.
r
fasciitis. Biopsy specimens were not sent for culture because the clinical examination, the normal blood investigations (complete blood picture, erythrocyte sedimentation rate, and C-reactive protein), the MRI, and the intra-operative findings were not suggestive of infection. All 3 lesions showed similar histological features of spindle cell growth, vascular hyperplasia, and lymphocyte infiltration. The spindle cells formed Sor C-shaped fascicles in the highly cellular area (Fig. 5). In the hypocellular area, plump and spindle cells were present between the hyalinization of fibrous stroma. There was little variation in the size and shape of the nuclei. There were 2 to 3 mitotic figures per 10 high-power fields without any atypical mitoses. In view of the adhesions to the digital neurovascular bundle and the digital tendons, ray amputation of the middle finger was performed. Marginal excision was performed for the hand and periscapular masses. Margins of all the excised masses were free of tumor. At 1-year follow-up there was no recurrence of the tumor either on the hand or shoulder on clinical examination. Vol. 39, December 2014
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MULTICENTRIC NODULAR FASCIITIS
FIGURE 4: On MRI, the mass has low intensity on T1-weighted images and is heterogeneously hyperintense on T2 weighted images. A Middle finger. B Hand. C Scapula.
DISCUSSION Nodular fasciitis is a benign reactive soft tissue tumor reported by Konwaler et al as a subcutaneous pseudosarcomatous fibromatosis.3,4 It is benign but has rapid proliferation of fibroblasts and myoblasts, which mimics a malignant tumor. Etiology is unknown but is attributed to injury or infection.3,4 It is a self-limiting reactive growth and is not neoplastic.1 It commonly occurs in patients between the ages of 20 and 40 years. The common sites of occurrence are the upper extremity (48%), trunk (20%), head and neck (17%), and lower extremity (15%). Nodular fasciitis is rare in the hands and feet.4,5 It most commonly occurs on the volar aspects of the upper limb and rarely is seen dorsally.3,4 Park et al reported a case of nodular fasciitis on dorsoradial aspect of the thumb.4 J Hand Surg Am.
r
Clinically, the lesions are oval to round, rapidly grow over 1 to 3 months, and cause pain and tenderness. The differential diagnoses for nodular fasciitis in the hand includes deep fungal infection, giant cell tumor of tendon sheath, desmoid tumors, fibromatosis, high grade pleomorphic sarcoma, dermatofibrosarcoma protuberans, and fibrosarcoma. Incisional biopsy is usually recommended for a definitive diagnosis.4 Plain radiographs show the soft tissue mass with or without cortical erosions of the underlying bones. MRI features of nodular fasciitis depend on its histological composition. An immature nodular fasciitis lesion has a myxoid matrix rich in acid mucopolysaccharide. Mature lesions have a more fibrous appearance microscopically. The 3 types of nodular fasciitis are myxoid, cellular, and fibrous. Myxoid Vol. 39, December 2014
MULTICENTRIC NODULAR FASCIITIS
FIGURE 5: Histopathological examination shows spindle cells forming S- or C-shaped fascicles.
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Graham et al reported complete regression of a 5-cm lesion on the volar aspect of the forearm following intralesional corticosteroid injection.10 Marginal excision is the treatment of choice for a rapidly growing tumor.5 Yoshihiro et al reported 4 cases of nodular fasciitis; 2 cases (4 3 cm on the hypothenar aspect of the hand and 1.5 1.5 cm on the index finger) were excised for their rapid growth, and the other 2 (2 1 cm on the volar aspect of the interphalangeal joint of the thumb and 2 2 cm on the volar aspect of the metacarpophalangeal joint of the thumb) showed partial regression over one year.11 Recurrence is low (1% to 2%) and is due to incomplete excision.4 REFERENCES
and cellular lesions are iso- to hyperintense to skeletal muscle on T1-weighted images and iso- to hyperintense to fat on T2-weighted images. Fibrous lesions are markedly hypointense on T1 and T2 images.6,7 As these tumors usually show nonspecific MRI features, soft tissue sarcoma cannot be excluded. Microscopically, these lesions are characterized by a cellular spindle cell growth in a loosely textured mucoid matrix with lymphocytic infiltration and extravasations of red blood cells. An important diagnostic finding is the presence of undulating wide bands of collagen lined on the side of spindle cells. The high cellularity of the lesion and the presence of mitotic figures are responsible for the frequent confusion of this lesion with sarcoma. Atypical hyperchromatic nuclei have never been seen in nodular fasciitis.8,9 Ultrastructurally and immunohistochemically, the proliferating spindle cells have features of myofibroblasts. The DNA pattern is always diploid.9 Observation, intralesional steroids, and marginal excision are treatment options for nodular fasciitis.
J Hand Surg Am.
r
1. Bernstein KE, Lattes R. Nodular (pseudosarcomatous) fasciitis, a nonrecurrent lesion: Clinicopathologic study of 134 cases. Cancer. 1982;49(8):1668e1678. 2. Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St Louis, MO: CV Mosby; 1998:167e176. 3. Hara H, Fujita I, Fukimoto T, Hanioka K, Akisue T, Kurosaka M. Nodular fasciitis of the hand in a young athlete. A case report. Ups J Med Sci. 2010;115(4):291e296. 4. Park JS, Park HB, Lee JS, Na JB. Nodular fasciitis with cortical erosion of the hand. Clin Orthop Surg. 2012;4(1):98e101. 5. Sano K, Hashimoto T, Kimura K, Ozeki S. A rare nodular fasciitis involving the finger: A case report. Hand (NY). 2009;4(3):327e329. 6. Coyle J, White LM, Dickson B, Ferguson P, Wunder J, Naraghi A. Magnetic resonance imaging characteristics of nodular fasciitis of the musculoskeletal system. Skeletal Radiol. 2013;42(7):975e982. 7. de Schepper AM, ed. Imaging of soft tissue tumors. 3rd ed. Berlin, Heidelberg: Springer; 2006:168e169. 8. Wirman JA. Nodular fasciitis, a lesion of myofibroblasts—An ultrastructural study. Cancer. 1976;38(6):2378e2389. 9. Rosai J, Ackermans LV. Rosai and Ackerman’s Surgical Pathology. 9th ed. St. Louis, MO: Mosby Elsevier; 2007:2244e2246. 10. Graham BS, Barrett TL, Goltz TW. Nodular fasciitis: response to intralesional corticosteroids. J Am Acad Dermatol. 1999;40(3): 490e492. 11. Neshida Y, Tsukushi S, Wasa J, Iwata Y, Kozawa E, Ishiquro N. Nodular fasciitis of the finger and hand: case report. J Hand Surg Am. 2010;35(7):1184e1186.
Vol. 39, December 2014
Multifocal Nodular Fasciitis of the Hand and Shoulder: Case Report Guruvardhan Kumar Kotha, MS, Venkatramana BJ, MS, Venkateshwar Reddy Maryada, MS, Harshad Jawalkar We report a case of nodular fasciitis occurring on the dorsum of the right middle finger, the dorsum of the right hand, and the right upper back associated with cortical erosions of the scapula. Ray amputation of the middle finger and marginal excision of the hand and periscapular masses were performed. There was no recurrence of the tumor at either site a year later. (J Hand Surg Am. 2014;39(12):2468e2471. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Bone erosions, dorsum of the middle finger, multiple sites, nodular fasciitis, hand and periscapular region.
N
growing benign soft tissue tumor. Often, it is clinically mistaken for a malignancy. It is common on the volar aspect of the forearm;1e4 multiple site occurrences are rare. We report a case of multisite nodular fasciitis occurring on the dorsum of the right middle finger, on the dorsum of the right hand, and on the right periscapular area to highlight the unusual presentation and to review the literature for various treatment options. ODULAR FASCIITIS IS A RAPIDLY
CASE REPORT A 30-year-old laborer presented with painful masses on the dorsum of her right middle finger and hand as well as her right periscapular area of 3 months From the Department of Orthopedics, Kamineni Institute of Medical Sciences, Narketplly, Andhra Pradesh, India. Received for publication December 12, 2013; accepted in revised form July 10, 2014. The authors are grateful to Dr. R.S. Murthy and Dr. Venkat Kishan of the Radiology Department and Dr. Seshagiri Rao of the Pathology Department, Kamineni Institute of Medical Sciences, for good histopathological images. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Dr. Guruvardhan Kumar V Kotha, Flat no 401a, Jaya Durga Towers, Door no. 6-4-11 to19, Bholakpur, Musheerabad, Secunderabad 500 080, India; e-mail: [email protected]. 0363-5023/14/3912-0019$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.07.023
2468
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
duration associated with numbness of the middle finger. She had a history of a thorn prick to the dorsum of the right hand 3 months prior to the appearance of the masses on the dorsum of the right middle finger and hand. She noted another mass on the right periscapular region one month after the appearance of the hand masses. The masses measured 6 3 cm on the middle ring finger, 4 3 cm on the hand (Fig. 1), and 10 8 cm on the shoulder. The masses were tender and firm. The mass on the middle finger had extended to the radial and ulnar borders of the finger. Both passive and active movements of the middle finger at the metacarpophalangeal joint were 0 to 20 of flexion. There was no active or passive movement at the proximal and distal interphalangeal joints of the middle finger. The hand and periscapular masses were in the subcutaneous plane and were not adherent to skin or tendons. There was no epitrochlear or axillary lymphadenopathy. There was loss of protective sensation in the middle finger. Radiographs showed increased soft tissue shadow over the dorsum of the middle finger and the dorsum of the hand, and cortical erosions of proximal phalanges and metacarpals of the middle and ring fingers (Fig. 2). Similar erosions were seen at the inferior angle of the right scapula (Fig. 3). Magnetic resonance imaging (MRI) showed a hypointense lesion arising in the subcutaneous plane on T1-weighted images and hyperintense signal on T2-weighted
MULTICENTRIC NODULAR FASCIITIS
2469
FIGURE 1: Nodular fasciitis on right middle finger and hand.
FIGURE 3: Radiograph shows erosions at the inferior angle of right scapula.
FIGURE 2: Radiograph shows cortical erosions of middle and ring finger proximal phalanges and metacarpals.
images of the middle finger, the hand, and the right periscapular region (Fig. 4). The tumor on the dorsum of the middle finger was adherent to the neurovascular bundle. An incisional biopsy from both the hand and the periscapular masses indicated nodular J Hand Surg Am.
r
fasciitis. Biopsy specimens were not sent for culture because the clinical examination, the normal blood investigations (complete blood picture, erythrocyte sedimentation rate, and C-reactive protein), the MRI, and the intra-operative findings were not suggestive of infection. All 3 lesions showed similar histological features of spindle cell growth, vascular hyperplasia, and lymphocyte infiltration. The spindle cells formed Sor C-shaped fascicles in the highly cellular area (Fig. 5). In the hypocellular area, plump and spindle cells were present between the hyalinization of fibrous stroma. There was little variation in the size and shape of the nuclei. There were 2 to 3 mitotic figures per 10 high-power fields without any atypical mitoses. In view of the adhesions to the digital neurovascular bundle and the digital tendons, ray amputation of the middle finger was performed. Marginal excision was performed for the hand and periscapular masses. Margins of all the excised masses were free of tumor. At 1-year follow-up there was no recurrence of the tumor either on the hand or shoulder on clinical examination. Vol. 39, December 2014
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MULTICENTRIC NODULAR FASCIITIS
FIGURE 4: On MRI, the mass has low intensity on T1-weighted images and is heterogeneously hyperintense on T2 weighted images. A Middle finger. B Hand. C Scapula.
DISCUSSION Nodular fasciitis is a benign reactive soft tissue tumor reported by Konwaler et al as a subcutaneous pseudosarcomatous fibromatosis.3,4 It is benign but has rapid proliferation of fibroblasts and myoblasts, which mimics a malignant tumor. Etiology is unknown but is attributed to injury or infection.3,4 It is a self-limiting reactive growth and is not neoplastic.1 It commonly occurs in patients between the ages of 20 and 40 years. The common sites of occurrence are the upper extremity (48%), trunk (20%), head and neck (17%), and lower extremity (15%). Nodular fasciitis is rare in the hands and feet.4,5 It most commonly occurs on the volar aspects of the upper limb and rarely is seen dorsally.3,4 Park et al reported a case of nodular fasciitis on dorsoradial aspect of the thumb.4 J Hand Surg Am.
r
Clinically, the lesions are oval to round, rapidly grow over 1 to 3 months, and cause pain and tenderness. The differential diagnoses for nodular fasciitis in the hand includes deep fungal infection, giant cell tumor of tendon sheath, desmoid tumors, fibromatosis, high grade pleomorphic sarcoma, dermatofibrosarcoma protuberans, and fibrosarcoma. Incisional biopsy is usually recommended for a definitive diagnosis.4 Plain radiographs show the soft tissue mass with or without cortical erosions of the underlying bones. MRI features of nodular fasciitis depend on its histological composition. An immature nodular fasciitis lesion has a myxoid matrix rich in acid mucopolysaccharide. Mature lesions have a more fibrous appearance microscopically. The 3 types of nodular fasciitis are myxoid, cellular, and fibrous. Myxoid Vol. 39, December 2014
MULTICENTRIC NODULAR FASCIITIS
FIGURE 5: Histopathological examination shows spindle cells forming S- or C-shaped fascicles.
2471
Graham et al reported complete regression of a 5-cm lesion on the volar aspect of the forearm following intralesional corticosteroid injection.10 Marginal excision is the treatment of choice for a rapidly growing tumor.5 Yoshihiro et al reported 4 cases of nodular fasciitis; 2 cases (4 3 cm on the hypothenar aspect of the hand and 1.5 1.5 cm on the index finger) were excised for their rapid growth, and the other 2 (2 1 cm on the volar aspect of the interphalangeal joint of the thumb and 2 2 cm on the volar aspect of the metacarpophalangeal joint of the thumb) showed partial regression over one year.11 Recurrence is low (1% to 2%) and is due to incomplete excision.4 REFERENCES
and cellular lesions are iso- to hyperintense to skeletal muscle on T1-weighted images and iso- to hyperintense to fat on T2-weighted images. Fibrous lesions are markedly hypointense on T1 and T2 images.6,7 As these tumors usually show nonspecific MRI features, soft tissue sarcoma cannot be excluded. Microscopically, these lesions are characterized by a cellular spindle cell growth in a loosely textured mucoid matrix with lymphocytic infiltration and extravasations of red blood cells. An important diagnostic finding is the presence of undulating wide bands of collagen lined on the side of spindle cells. The high cellularity of the lesion and the presence of mitotic figures are responsible for the frequent confusion of this lesion with sarcoma. Atypical hyperchromatic nuclei have never been seen in nodular fasciitis.8,9 Ultrastructurally and immunohistochemically, the proliferating spindle cells have features of myofibroblasts. The DNA pattern is always diploid.9 Observation, intralesional steroids, and marginal excision are treatment options for nodular fasciitis.
J Hand Surg Am.
r
1. Bernstein KE, Lattes R. Nodular (pseudosarcomatous) fasciitis, a nonrecurrent lesion: Clinicopathologic study of 134 cases. Cancer. 1982;49(8):1668e1678. 2. Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St Louis, MO: CV Mosby; 1998:167e176. 3. Hara H, Fujita I, Fukimoto T, Hanioka K, Akisue T, Kurosaka M. Nodular fasciitis of the hand in a young athlete. A case report. Ups J Med Sci. 2010;115(4):291e296. 4. Park JS, Park HB, Lee JS, Na JB. Nodular fasciitis with cortical erosion of the hand. Clin Orthop Surg. 2012;4(1):98e101. 5. Sano K, Hashimoto T, Kimura K, Ozeki S. A rare nodular fasciitis involving the finger: A case report. Hand (NY). 2009;4(3):327e329. 6. Coyle J, White LM, Dickson B, Ferguson P, Wunder J, Naraghi A. Magnetic resonance imaging characteristics of nodular fasciitis of the musculoskeletal system. Skeletal Radiol. 2013;42(7):975e982. 7. de Schepper AM, ed. Imaging of soft tissue tumors. 3rd ed. Berlin, Heidelberg: Springer; 2006:168e169. 8. Wirman JA. Nodular fasciitis, a lesion of myofibroblasts—An ultrastructural study. Cancer. 1976;38(6):2378e2389. 9. Rosai J, Ackermans LV. Rosai and Ackerman’s Surgical Pathology. 9th ed. St. Louis, MO: Mosby Elsevier; 2007:2244e2246. 10. Graham BS, Barrett TL, Goltz TW. Nodular fasciitis: response to intralesional corticosteroids. J Am Acad Dermatol. 1999;40(3): 490e492. 11. Neshida Y, Tsukushi S, Wasa J, Iwata Y, Kozawa E, Ishiquro N. Nodular fasciitis of the finger and hand: case report. J Hand Surg Am. 2010;35(7):1184e1186.
Vol. 39, December 2014
