Case Report
Nodular Fasciitis of the Breast: A Case and Literature Review Noduläre Fasziitis der Brust: Fallbericht und Literaturüberblick Introduction !
Nodular fasciitis is a benign fibroblastic proliferation in soft tissue that is most commonly found in the upper extremities, trunk, head, and neck region. Its occurrence in the breast has been rarely reported. The most characteristic features are the sudden appearance and rapid growth of a palpable lesion. Nodular fasciitis can clinically, radiologically, and histopathologically mimic a breast carcinoma. We present a case of nodular fasciitis of the breast and a review of the relevant literature.
Case report !
A 22-year-old woman presented with a 2month history of a palpable mass in the upper central portion of the left breast that developed after trauma. Two months earlier, she had fallen and bumped her left breast on the ground. Physical examination revealed a 2 cm mass located at the 12 o’clock position in her left breast. There was no associated axillary or supraclavicular lymphadenopathy. She had no medical or family history of malignancy. Ultrasonography and magnification mammography were performed. The ultra-
sound examination revealed a 10 × 10 × 7-mm, irregular, hypoechoic mass at the 12 o’clock position in the left breast that extended from the anterior border of the mammary zone to the premammary fat " Fig. 1). The hypoechoic mass had a layer (● spiculated margin and an echogenic halo with no acoustic shadowing. Vascularity adjacent to the mass was increased on color Doppler imaging. Magnification mammography on coned compression in the mediolateral oblique and craniocaudal projections showed a 15-mm, spiculated, irregular, isodense mass with no associated calcification in the same area as the ultra" Fig. 2). The imaging feasound lesion (● tures were considered as an intermediate suspicion of malignancy, and the lesion was assessed as category 4B according to the Breast Imaging Reporting and Data System (BI-RADS). An ultrasound-guided core needle biopsy of the lesion was performed with a 14gauge needle. This examination showed no evidence of malignancy and identified the lesion as a spindle cell proliferative lesion, suggestive of nodular fasciitis. The differential diagnoses included leiomyoma and fibromatosis, but the most likely diagnosis was thought to be nodular fasciitis.
Fig. 1 a Longitudinal ultrasonography shows a 10 × 10 × 7-mm, spiculated, irregular, hypoechoic mass with an echogenic halo at the 12 o’clock position in the left breast, extending from the anterior border of the mammary zone to the premammary fat layer. b Color Doppler imaging shows an increase in vascularity adjacent to the mass. Abb. 1 a Die Längssonografie zeigt eine 10 × 10 × 7-mm große spikulierte, ungleichmäßige, echoarme Raumforderung mit echoreichem Halo in der 12-Uhr-Position der linken Brust, die sich von der vorderen Grenze des mamillären Bereichs bis zur prämamillären Fettschicht hin erstreckt. b Das Farbdoppler-Bild zeigt eine Zunahme der Vaskularität angrenzend an die Raumforderung.
Although the core needle biopsy revealed a benign lesion, an ultrasound-guided, vacuum-assisted biopsy of the mass was performed for a more confirmative histopathologic diagnosis because of the discordance between the imaging and histological findings. In addition, percutaneous removal of the mass could alleviate the patient’s symptoms and accomplish both histological confirmation and treatment. Upon histopathological examination, a plump spindle cell proliferation of moderate cellularity with an irregular infiltrative margin was found; the proliferation was intermixed with scattered inflammatory cells and extravasated red blood cells. The tumor cells were arranged in short irregular bundles and fascicles in loosely textured stroma. Mitotic figures were seen (up to 4/10 HPF), but no atypical mitoses were observed. Immunohistochemically, the tumor cells were positive for α-smooth muscle actin and negative for S100 protein, CD34, and desmin, leading to a diagnosis of nodular fas" Fig. 3). ciitis (●
Fig. 2 Magnification and compression view shows a 15-mm, spiculated, irregular, isodense mass with no associated calcification in the same area as the ultrasound lesion. Abb. 2 Das Bild bei Vergrößerung und Kompression zeigt eine spikulierte, ungleichmäßige, isodense Raumforderung ohne assoziierte Kalzifikation an der gleichen Stelle der Ultraschall-Läsion.
Choi H Y et al. Nodular Fasciitis of … Ultraschall in Med 2015; 36: 290–291 · DOI http://dx.doi.org/10.1055/s-0034-1366340
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290
Fig. 3 a The tumor is composed of plump spindle cells arranged in short irregular bundles and fascicles. A small number of scattered inflammatory cells and extravasated red blood cells are also visible. b The tumor cells are positive for ą-smooth muscle actin. Abb. 3 a Der Tumor besteht aus plumpen Spindelzellen, die in kurzen irregulären Bündeln und Faszien zusammengefasst sind. Eine geringe Anzahl verteilter inflammatorischer Zellen und ausgetretener roter Blutkörperchen sind ebenfalls sichtbar. b Die Tumorzellen sind immunhistochemisch positiv für ą-Aktin glatter Muskeln.
Discussion !
Nodular fasciitis is a benign and reactive fibroblastic proliferation that is often mistaken for a sarcoma due to its rapid growth, cellularity, and mitotic activity. It commonly arises in the superficial or deep fascia of the soft tissue, mostly of the upper extremities, trunk, head, and neck regions. Reports of its occurrence in the breast exist but are rare. The most characteristic feature is a single, rapidly growing mass [Brown V et al. The Breast 2005; 14: 384 – 387]. It is reported to occur predominantly in young adults between the ages of 20 and 35 years. The male-female occurrence ratio is reportedly equal. Nodular fasciitis can be classified into 3 subtypes—subcutaneous, intramuscular, and fascial—according to the anatomic location. It can also be divided into 3 histological subtypes: myxoid, cellular, and fibrous. There is a close association between the microscopic appearance and the duration of the lesion. Old lesions are fibrous while recent cases reveal a myxoid type of lesion. The etiopathogenesis of nodular fasciitis is unknown. However, fibroblastic proliferation is believed to be triggered by local injury [Tulbah A et al. Breast J 2003; 9:223 – 225]. A history of trauma precedes such lesions in 10 – 15 % of patients [Brown V et al. The Breast 2005; 14: 384 – 387], but the cause is still not well known.
Nodular fasciitis of the breast is often clinically suspected as breast cancer because it forms a hard mass. Radiologically, mammography shows an irregular, often spiculated lesion, and ultrasonography indicates an infiltrative mass without a capsule. These imaging features are sufficient for the suspicion of breast carcinoma. Magnetic resonance imaging (MRI) findings vary depending on the histological subtype [Iwatani T et al. Breast cancer 2012; 19:180 – 182]. The myxoid and cellular types can appear hyperintense relative to muscle tissues on spin–echo T1-weighted MR images and hyperintense relative to surrounding fatty tissues on spin–echo T2-weighted MR images. Lesions with marked fibrous content appear as prominent low-signal intensity lesions relative to muscle tissues on all spin–echo sequences. Since there is no radiological appearance specific to this tumor, a histopathologic examination is necessary for an accurate diagnosis [Dahlstrom J et al. Australas Radiol 2001; 45:67 – 70]. The characteristic cytologic features for diagnosis include plump, immature, fibroblast-like spindle cells in myxoid material, chronic inflammatory cells, capillary proliferation, and vascular channels with extravasated red blood cells. The differential diagnoses of nodular fasciitis include fibromatosis, myofibroblastoma, granulation tissue, radial scars,
phyllodes tumor, sarcomatoid carcinoma, primary sarcoma, and metaplastic carcinoma. Nodular fasciitis can be differentiated from these entities by the cellularity, nuclear pleomorphism, collagen content, and growth pattern. Since most cases are diagnosed after surgical excision, the natural history of nodular fasciitis has not been well defined. However, spontaneous regression has been observed. The MRI, which was performed at 6 weeks from the onset of the symptoms, yielded normal results. Mammography performed at 6 months showed resolution of the lesion [Brown V et al. The Breast 2005; 14: 384 – 387]. Conservative management is appropriate if the lesion has a typical trauma-related clinical appearance, along with core biopsy results consistent with nodular fasciitis [Volkan O et al. Breast Care 2009; 4:401 – 402; Brown V et al. The Breast 2005; 14: 384 – 387]. If these criteria are not met, excisional biopsy should be performed, and no further treatment is necessary [Volkan O et al. Breast Care 2009; 4:401 – 402]. Recurrence following local excision is rare, and these tumors do not metastasize [Volkan O et al. Breast Care 2009; 4:401 – 402; Brown V et al. The Breast 2005; 14: 384 – 387]. In the current case, although nodular fasciitis was diagnosed on the basis of core needle biopsy along with a typical trauma-related clinical appearance, instead of conservative management, ultrasoundguided, vacuum-assisted, percutaneous excision of the lesion was performed. The procedure alleviated the patient’s symptoms and permitted a more confirmative histopathologic diagnosis without surgical excision. In summary, nodular fasciitis of the breast is a rare benign lesion that mimics breast cancer clinically, radiologically, and histopathologically. Because its clinical and radiological features are nonspecific, an exact diagnosis can only be made on histopathologic examination. Awareness of this benign entity obviates misdiagnoses and unnecessary surgical interventions. H. Y. Choi, S. M. Kim, M. Jang, B. L. Yun, H. S. Ahn, S. Y. Park, S. W. Kim, E. Y. Kang, Seongnam, Republic of Korea
Choi H Y et al. Nodular Fasciitis of … Ultraschall in Med 2015; 36: 290–291 · DOI http://dx.doi.org/10.1055/s-0034-1366340
291
Downloaded by: Universite Laval. Copyrighted material.
Case Report
Nodular Fasciitis of the Breast: A Case and Literature Review Noduläre Fasziitis der Brust: Fallbericht und Literaturüberblick Introduction !
Nodular fasciitis is a benign fibroblastic proliferation in soft tissue that is most commonly found in the upper extremities, trunk, head, and neck region. Its occurrence in the breast has been rarely reported. The most characteristic features are the sudden appearance and rapid growth of a palpable lesion. Nodular fasciitis can clinically, radiologically, and histopathologically mimic a breast carcinoma. We present a case of nodular fasciitis of the breast and a review of the relevant literature.
Case report !
A 22-year-old woman presented with a 2month history of a palpable mass in the upper central portion of the left breast that developed after trauma. Two months earlier, she had fallen and bumped her left breast on the ground. Physical examination revealed a 2 cm mass located at the 12 o’clock position in her left breast. There was no associated axillary or supraclavicular lymphadenopathy. She had no medical or family history of malignancy. Ultrasonography and magnification mammography were performed. The ultra-
sound examination revealed a 10 × 10 × 7-mm, irregular, hypoechoic mass at the 12 o’clock position in the left breast that extended from the anterior border of the mammary zone to the premammary fat " Fig. 1). The hypoechoic mass had a layer (● spiculated margin and an echogenic halo with no acoustic shadowing. Vascularity adjacent to the mass was increased on color Doppler imaging. Magnification mammography on coned compression in the mediolateral oblique and craniocaudal projections showed a 15-mm, spiculated, irregular, isodense mass with no associated calcification in the same area as the ultra" Fig. 2). The imaging feasound lesion (● tures were considered as an intermediate suspicion of malignancy, and the lesion was assessed as category 4B according to the Breast Imaging Reporting and Data System (BI-RADS). An ultrasound-guided core needle biopsy of the lesion was performed with a 14gauge needle. This examination showed no evidence of malignancy and identified the lesion as a spindle cell proliferative lesion, suggestive of nodular fasciitis. The differential diagnoses included leiomyoma and fibromatosis, but the most likely diagnosis was thought to be nodular fasciitis.
Fig. 1 a Longitudinal ultrasonography shows a 10 × 10 × 7-mm, spiculated, irregular, hypoechoic mass with an echogenic halo at the 12 o’clock position in the left breast, extending from the anterior border of the mammary zone to the premammary fat layer. b Color Doppler imaging shows an increase in vascularity adjacent to the mass. Abb. 1 a Die Längssonografie zeigt eine 10 × 10 × 7-mm große spikulierte, ungleichmäßige, echoarme Raumforderung mit echoreichem Halo in der 12-Uhr-Position der linken Brust, die sich von der vorderen Grenze des mamillären Bereichs bis zur prämamillären Fettschicht hin erstreckt. b Das Farbdoppler-Bild zeigt eine Zunahme der Vaskularität angrenzend an die Raumforderung.
Although the core needle biopsy revealed a benign lesion, an ultrasound-guided, vacuum-assisted biopsy of the mass was performed for a more confirmative histopathologic diagnosis because of the discordance between the imaging and histological findings. In addition, percutaneous removal of the mass could alleviate the patient’s symptoms and accomplish both histological confirmation and treatment. Upon histopathological examination, a plump spindle cell proliferation of moderate cellularity with an irregular infiltrative margin was found; the proliferation was intermixed with scattered inflammatory cells and extravasated red blood cells. The tumor cells were arranged in short irregular bundles and fascicles in loosely textured stroma. Mitotic figures were seen (up to 4/10 HPF), but no atypical mitoses were observed. Immunohistochemically, the tumor cells were positive for α-smooth muscle actin and negative for S100 protein, CD34, and desmin, leading to a diagnosis of nodular fas" Fig. 3). ciitis (●
Fig. 2 Magnification and compression view shows a 15-mm, spiculated, irregular, isodense mass with no associated calcification in the same area as the ultrasound lesion. Abb. 2 Das Bild bei Vergrößerung und Kompression zeigt eine spikulierte, ungleichmäßige, isodense Raumforderung ohne assoziierte Kalzifikation an der gleichen Stelle der Ultraschall-Läsion.
Choi H Y et al. Nodular Fasciitis of … Ultraschall in Med 2015; 36: 290–291 · DOI http://dx.doi.org/10.1055/s-0034-1366340
Downloaded by: Universite Laval. Copyrighted material.
290
Fig. 3 a The tumor is composed of plump spindle cells arranged in short irregular bundles and fascicles. A small number of scattered inflammatory cells and extravasated red blood cells are also visible. b The tumor cells are positive for ą-smooth muscle actin. Abb. 3 a Der Tumor besteht aus plumpen Spindelzellen, die in kurzen irregulären Bündeln und Faszien zusammengefasst sind. Eine geringe Anzahl verteilter inflammatorischer Zellen und ausgetretener roter Blutkörperchen sind ebenfalls sichtbar. b Die Tumorzellen sind immunhistochemisch positiv für ą-Aktin glatter Muskeln.
Discussion !
Nodular fasciitis is a benign and reactive fibroblastic proliferation that is often mistaken for a sarcoma due to its rapid growth, cellularity, and mitotic activity. It commonly arises in the superficial or deep fascia of the soft tissue, mostly of the upper extremities, trunk, head, and neck regions. Reports of its occurrence in the breast exist but are rare. The most characteristic feature is a single, rapidly growing mass [Brown V et al. The Breast 2005; 14: 384 – 387]. It is reported to occur predominantly in young adults between the ages of 20 and 35 years. The male-female occurrence ratio is reportedly equal. Nodular fasciitis can be classified into 3 subtypes—subcutaneous, intramuscular, and fascial—according to the anatomic location. It can also be divided into 3 histological subtypes: myxoid, cellular, and fibrous. There is a close association between the microscopic appearance and the duration of the lesion. Old lesions are fibrous while recent cases reveal a myxoid type of lesion. The etiopathogenesis of nodular fasciitis is unknown. However, fibroblastic proliferation is believed to be triggered by local injury [Tulbah A et al. Breast J 2003; 9:223 – 225]. A history of trauma precedes such lesions in 10 – 15 % of patients [Brown V et al. The Breast 2005; 14: 384 – 387], but the cause is still not well known.
Nodular fasciitis of the breast is often clinically suspected as breast cancer because it forms a hard mass. Radiologically, mammography shows an irregular, often spiculated lesion, and ultrasonography indicates an infiltrative mass without a capsule. These imaging features are sufficient for the suspicion of breast carcinoma. Magnetic resonance imaging (MRI) findings vary depending on the histological subtype [Iwatani T et al. Breast cancer 2012; 19:180 – 182]. The myxoid and cellular types can appear hyperintense relative to muscle tissues on spin–echo T1-weighted MR images and hyperintense relative to surrounding fatty tissues on spin–echo T2-weighted MR images. Lesions with marked fibrous content appear as prominent low-signal intensity lesions relative to muscle tissues on all spin–echo sequences. Since there is no radiological appearance specific to this tumor, a histopathologic examination is necessary for an accurate diagnosis [Dahlstrom J et al. Australas Radiol 2001; 45:67 – 70]. The characteristic cytologic features for diagnosis include plump, immature, fibroblast-like spindle cells in myxoid material, chronic inflammatory cells, capillary proliferation, and vascular channels with extravasated red blood cells. The differential diagnoses of nodular fasciitis include fibromatosis, myofibroblastoma, granulation tissue, radial scars,
phyllodes tumor, sarcomatoid carcinoma, primary sarcoma, and metaplastic carcinoma. Nodular fasciitis can be differentiated from these entities by the cellularity, nuclear pleomorphism, collagen content, and growth pattern. Since most cases are diagnosed after surgical excision, the natural history of nodular fasciitis has not been well defined. However, spontaneous regression has been observed. The MRI, which was performed at 6 weeks from the onset of the symptoms, yielded normal results. Mammography performed at 6 months showed resolution of the lesion [Brown V et al. The Breast 2005; 14: 384 – 387]. Conservative management is appropriate if the lesion has a typical trauma-related clinical appearance, along with core biopsy results consistent with nodular fasciitis [Volkan O et al. Breast Care 2009; 4:401 – 402; Brown V et al. The Breast 2005; 14: 384 – 387]. If these criteria are not met, excisional biopsy should be performed, and no further treatment is necessary [Volkan O et al. Breast Care 2009; 4:401 – 402]. Recurrence following local excision is rare, and these tumors do not metastasize [Volkan O et al. Breast Care 2009; 4:401 – 402; Brown V et al. The Breast 2005; 14: 384 – 387]. In the current case, although nodular fasciitis was diagnosed on the basis of core needle biopsy along with a typical trauma-related clinical appearance, instead of conservative management, ultrasoundguided, vacuum-assisted, percutaneous excision of the lesion was performed. The procedure alleviated the patient’s symptoms and permitted a more confirmative histopathologic diagnosis without surgical excision. In summary, nodular fasciitis of the breast is a rare benign lesion that mimics breast cancer clinically, radiologically, and histopathologically. Because its clinical and radiological features are nonspecific, an exact diagnosis can only be made on histopathologic examination. Awareness of this benign entity obviates misdiagnoses and unnecessary surgical interventions. H. Y. Choi, S. M. Kim, M. Jang, B. L. Yun, H. S. Ahn, S. Y. Park, S. W. Kim, E. Y. Kang, Seongnam, Republic of Korea
Choi H Y et al. Nodular Fasciitis of … Ultraschall in Med 2015; 36: 290–291 · DOI http://dx.doi.org/10.1055/s-0034-1366340
291
Downloaded by: Universite Laval. Copyrighted material.
Case Report
