Nodular Fasciitis Clinically Presenting as a Sarcoma Aristana Scourtas, Martha Bishop Pitman M.D., Ivan Chebib M.D.*
Nodular fasciitis is a benign proliferation of myofibroblasts of uncertain etiology, most commonly found on the upper extremities in patients 20–40 years of age.1,2 For-
merly known as “pseudosarcomatous fasciitis,” this rapidly growing, often well-circumscribed mass usually does not exceed 3 cm in diameter and generally resolves
Fig. 1. Nodular fasciitis on FNA and histology. A: Hypercellular sample of spindled fibroblasts with bland single intact cells in a background of myxoid stroma, with scattered inflammatory cells (Diff-Quik, 4003). B: Plump fibroblasts with prominent nucleoli and scattered lymphocytes (Papanicolaou, 6003). C: Single, ganglion-like fibroblasts with abundant cytoplasm and plump nuclei with background myxoid stroma (Diff-Quik, 4003). D: Typical storiform and short fascicles of myofibroblasts separated by myxoid microcysts. Note the lymphocytes and extravasated erythrocytes (Hematoxylin and eosin, 1003).
James Homer Wright Pathology Laboratories, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts *Correspondence to: Ivan Chebib, M.D., James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Department of Pathology, 55 Fruit Street, WRN2, Boston, MA 02114. E-mail: [email protected] Conflict of Interest: Nothing to report Received 16 July 2014; Accepted 6 October 2014 DOI: 10.1002/dc.23214 Published online 3 November 2014 in Wiley Online Library (wileyonlinelibrary.com).
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Diagnostic Cytopathology, Vol. 43, No 6
C 2014 WILEY PERIODICALS, INC. V
Diagnostic Cytopathology DOI 10.1002/dc
NODULAR FASCIITIS PRESENTING AS A SARCOMA
within a few months.1,3 The mass is most frequently subcutaneous; however, there are rare examples arising in intramuscular, fascial, or dermal locations.1 Recently, a 26-year-old male presented to the fineneedle aspiration (FNA) clinic with a firm 3 cm subcutaneous mass in the left upper arm, the site of a recent flu vaccine injection. An FNA biopsy of the left arm mass demonstrated a hypercellular smear composed of loosely cohesive groups of plump spindle cells with prominent single cell populations, some with ganglion-like cytomorphology. In the background, there was abundant myxoid stroma with intermixed chronic inflammatory cells. There were no atypical mitoses or necrosis (Fig. 1A–C). Overall, the features were reported as consistent with nodular fasciitis. The patient was followed for spontaneous resolution of the mass. However, the mass continued to grow rapidly. Magnetic resonance imaging of the mass showed a 5-cm contrast enhancing mass with small areas of necrosis, atypical for nodular fasciitis, and a soft tissue sarcoma could not be ruled out. Despite the cytopathologic diagno-
sis of nodular fasciitis and due to the continued concern for a sarcoma, the mass was subsequently excised 6 months after the initial diagnosis. The mass now measured 6.0 3 5.4 3 4.5 cm3. Histological analysis of the well-circumscribed mass showed spindled, tissue culturelike myofibroblasts arranged as short fascicles, storiform, and whorled, separated by myxoid microcysts. There were extravasated erythrocytes and scattered lymphocytes. Numerous mitotic figures were identified but there were no atypical mitoses or necrosis (Fig. 1D). No clonal abnormalities were found by cytogenetic analysis. The final diagnosis was nodular fasciitis.
References 1. Goldblum JR, Folpe AL, Weiss SW. Benign fibroblastic/myofibroblastic proliferations, including superficial fibromatoses. In: Goldblum JR, Folpe AL, Weiss SW, editors. Enzinger and Weiss’s Soft Tissue Tumors, Chapter 8, 6th ed., Philadelphia, OA: Elsevier, Saunders; 2014. p 188–255. 2. Allen PW. Nodular fasciitis. Pathology 1972;4:9–26. 3. Kong CS, Cha I. Nodular fasciitis: Diagnosis by fine needle aspiration biopsy. Acta Cytol 2004;48:473–477.
Diagnostic Cytopathology, Vol. 43, No 6
489
Nodular fasciitis is a benign proliferation of myofibroblasts of uncertain etiology, most commonly found on the upper extremities in patients 20–40 years of age.1,2 For-
merly known as “pseudosarcomatous fasciitis,” this rapidly growing, often well-circumscribed mass usually does not exceed 3 cm in diameter and generally resolves
Fig. 1. Nodular fasciitis on FNA and histology. A: Hypercellular sample of spindled fibroblasts with bland single intact cells in a background of myxoid stroma, with scattered inflammatory cells (Diff-Quik, 4003). B: Plump fibroblasts with prominent nucleoli and scattered lymphocytes (Papanicolaou, 6003). C: Single, ganglion-like fibroblasts with abundant cytoplasm and plump nuclei with background myxoid stroma (Diff-Quik, 4003). D: Typical storiform and short fascicles of myofibroblasts separated by myxoid microcysts. Note the lymphocytes and extravasated erythrocytes (Hematoxylin and eosin, 1003).
James Homer Wright Pathology Laboratories, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts *Correspondence to: Ivan Chebib, M.D., James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Department of Pathology, 55 Fruit Street, WRN2, Boston, MA 02114. E-mail: [email protected] Conflict of Interest: Nothing to report Received 16 July 2014; Accepted 6 October 2014 DOI: 10.1002/dc.23214 Published online 3 November 2014 in Wiley Online Library (wileyonlinelibrary.com).
488
Diagnostic Cytopathology, Vol. 43, No 6
C 2014 WILEY PERIODICALS, INC. V
Diagnostic Cytopathology DOI 10.1002/dc
NODULAR FASCIITIS PRESENTING AS A SARCOMA
within a few months.1,3 The mass is most frequently subcutaneous; however, there are rare examples arising in intramuscular, fascial, or dermal locations.1 Recently, a 26-year-old male presented to the fineneedle aspiration (FNA) clinic with a firm 3 cm subcutaneous mass in the left upper arm, the site of a recent flu vaccine injection. An FNA biopsy of the left arm mass demonstrated a hypercellular smear composed of loosely cohesive groups of plump spindle cells with prominent single cell populations, some with ganglion-like cytomorphology. In the background, there was abundant myxoid stroma with intermixed chronic inflammatory cells. There were no atypical mitoses or necrosis (Fig. 1A–C). Overall, the features were reported as consistent with nodular fasciitis. The patient was followed for spontaneous resolution of the mass. However, the mass continued to grow rapidly. Magnetic resonance imaging of the mass showed a 5-cm contrast enhancing mass with small areas of necrosis, atypical for nodular fasciitis, and a soft tissue sarcoma could not be ruled out. Despite the cytopathologic diagno-
sis of nodular fasciitis and due to the continued concern for a sarcoma, the mass was subsequently excised 6 months after the initial diagnosis. The mass now measured 6.0 3 5.4 3 4.5 cm3. Histological analysis of the well-circumscribed mass showed spindled, tissue culturelike myofibroblasts arranged as short fascicles, storiform, and whorled, separated by myxoid microcysts. There were extravasated erythrocytes and scattered lymphocytes. Numerous mitotic figures were identified but there were no atypical mitoses or necrosis (Fig. 1D). No clonal abnormalities were found by cytogenetic analysis. The final diagnosis was nodular fasciitis.
References 1. Goldblum JR, Folpe AL, Weiss SW. Benign fibroblastic/myofibroblastic proliferations, including superficial fibromatoses. In: Goldblum JR, Folpe AL, Weiss SW, editors. Enzinger and Weiss’s Soft Tissue Tumors, Chapter 8, 6th ed., Philadelphia, OA: Elsevier, Saunders; 2014. p 188–255. 2. Allen PW. Nodular fasciitis. Pathology 1972;4:9–26. 3. Kong CS, Cha I. Nodular fasciitis: Diagnosis by fine needle aspiration biopsy. Acta Cytol 2004;48:473–477.
Diagnostic Cytopathology, Vol. 43, No 6
489
