Articular nodular fasciitis of the right shoulder joint: report of an unusual case with focus on immunohistochemical differential diagnosis

The mesenchymal lesion nodular fasciitis (NF) can affect various sites of the body but usually arises in subcutaneous tissue or occasionally skeletal muscle. NF is not commonly known to arise in joints, and articular NF is extremely rare. Herein, we present a case of a 54-year-old woman with articular NF. No sign of recurrence was observed after surgical piecemeal removal with a suspected positive surgical margin. In our case, a differential diagnosis of NF, desmoid-type fibromatosis, and low-grade myofibroblastic sarcoma was considered. Stromal hyalinization, a characteristic of articular NF, made the diagnosis somewhat difficult, although typical NF morphology was present. Immunohistochemical analysis of α-smooth muscle actin, desmin, β-catenin, and protein gene product 9.5 expression along with close morphological examination provided a reliable distinction.     

Nodular fasciitis in the parotid gland: A case report and review of the literature

Nodular fasciitis (NF) is a benign, reactive lesion with a self‐limiting process. Because NF is rare in the parotid gland and has many cytological similarities to other benign or malignant tumors, cytological misinterpretation is common. The patient, a 30‐year‐old woman, had a painless mass in her right parotid gland. Fine needle aspiration cytology (FNAC) was performed. Spindle cells with basophilic and well‐demarcated cytoplasm were observed in a mucoid‐like background. The mucoid‐like substance was metachromatic and appeared to be the matrix of PA. Histopathologically, spindle‐shaped cells with intervening birefringent mature collagen were arranged in short irregular bundles. Prominent mucoid‐like matrixes as well as few infiltrating neutrophils and lymphocytes were found in the background. Lesional cells were positive for CD10 and β‐catenin in the cytoplasm, but negative for cytokeratin, the S‐100 protein, CD34, and neurofilament. Ultimately, this patient was diagnosed with NF. In FNAC of the parotid gland region, distinguishing NF from other real tumors is important for deciding treatment strategies. Diagn. Cytopathol. 2013;41:829–833. © 2013 Wiley Periodicals, Inc.     

Parosteal fasciitis of the clavicle

A rare case of parosteal fasciitis arising from the periosteum of the left clavicle in a 27-year-old woman is reported. Magnetic resonance imaging demonstrated the lesion surrounding the periosteum of the clavicle. The lesion was iso-intense with muscle on T(1)-weighted images and hyperintense on T(2)-weighted images. At surgery, the lesion was discovered to be densely adherent with the periosteum, and excised along with the periosteum. Histopathological examination revealed the proliferation of myofibroblasts in a vague storiform or short fascicular pattern. A large amount of extravasated erythrocytes, and a few lymphocytes were present in the matrix. There were some foci of abundant myxoid materials. Immunohistochemical study showed the cells to be positive for vimentin, alpha-smooth muscle actin and HHF35, but negative for desmin. There was no local recurrence at a 6 months postoperative follow up.     

Proliferative fasciitis of the forearm: Case report with immunohistochemical, ultrastructural and DNA ploidy studies and a review of the literature

A case of prollferative fasclitis arising In the left forearm of a 56-year-old man was examined. The lesion was preceded by blunt trauma, measured 1.5 times 1.3 times 1.0 cm, was poorly circumscribed and appeared white to light gray on the cut surface. Light microscopic examinations revealed that spindle cells and giant cells with one or two nuclei and abundant basophllic cytoplasm ware arranged without any organized patterns In collagenous stroma. Ultrastructurally, well-developed rough endoplasmic reticulum separated by varying amounts of fine to course fibrillar materials was detected in the giant cells. Only vimentin lmmunoreactivity was detected In both spindle and gtant cells. The Ki-67 labeling Index of spindle cells was 35% but that of giant cells was less than 5%, and this reflects the quiescent or slow-growing features of these giant cells in proliferative fasclitis. DNA content of the calls, which was examined by Image cytometry, demonstrated diploidy In both spindle (DNA Index = 1.01) and glant (DNA Index = 1.09) calls.     

乳腺结节性筋膜炎1例及文献复习

目的探讨乳腺结节性筋膜炎的临床病理特征。方法对1例乳腺结节性筋膜炎的临床表现、组织形态和免疫表型进行研究,并文献复习。结果该例肿块3cm×2cm,边界不清,向周围乳腺及脂肪组织浸润。肿块主要由梭形细胞组成,其中含少量破骨样巨细胞。梭形细胞表达Vim、SMA和MSA,破骨样巨细胞表达CD68(KP-1),未发现CK阳性细胞。结论结节性筋膜炎很少复发,也不转移,组织学形态易与一些良恶性肿瘤混淆,需做免疫组化检测以明确其性质。     

Nodular fasciitis in the submandibular gland

Nodular fasciitis (NF) is a benign, proliferative lesion of myofibroblasts. The most common site of the lesion is in the upper extremities or trunk. NF in the head and neck is next in frequency and is the most common site in infants and children. In adults, NF in the submandibular region is very rare. We report a case of a 53-year-old man with a submandibular mass, rapidly growing for 10 days. Cytologic findings revealed a few sheets or clusters of small, uniform spindle cells. The uniform spindle cells had centrally located round to ovoid nucleus, but there were no nuclear atypia and atypical mitosis. There were focally loose stroma but we could not find chondroid or myxoid components. A partial parotidectomy was performed. We describe a case of NF in the submandibular region, adjacent to the parotid gland and review the clinical, cytologic, histologic, and immunohistochemical features of NF.     

Necrotizing fasciitis caused by perforated appendicitis: a case report

Acute appendicitis is one of the most common causes of acute abdominal pain. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in diagnosis or treatment may result in increased risks of complications, such as perforation, which is associated with increased morbidity and mortality rates. Necrotizing fasciitis caused by perforated appendicitis is extremely rare. We herein report a case of 50-year-old man presenting with an appendiceal abscess in local hospital. After ten days of conservative treatment with intravenous antibiotics, the patient complained about pain and swelling of the right lower limb and computed tomography (CT) demonstrated a perforated appendix and gas and fluid collection extending from his retroperitoneal cavity to the subcutaneous layer of his right loin and right lower limb. He was transferred to our hospital and was diagnosed with necrotizing fasciitis caused by perforated appendicitis. Emergency surgery including surgical debridement and appendectomy was performed. However, the patient died of severe sepsis and multiple organ failure two days after the operation. This case represents an unusual complication of a common disease and we should bear in mind that retroperitoneal inflammation and/or abscesses may cause necrotizing fasciitis through lumbar triangles.     

Multiple metachronus proliferative fasciitis occurring in different anatomic regions: a case report and review of the literature

Proliferative fasciitis is a benign lesion that usually has a self-limited course and rarely recurs after excision. In the literature, the multifocal occurrence of PF in different anatomic sites has not been reported so far. In this report, we describe the clinical case of a 30-year-old woman with two metachronous proliferative fasciitis occurring firstly in the orbit and, after 18 months, in the forearm; we also review the available literature on this topic, outlining guidelines for therapy and the follow-up of these patients.     

Multicentric extra-abdominal ''myofibromatosis'' : report of a case with ultrastructural findings

A case of multicentric extra-abdominal fibromatosis, a rare entity, arising in a young female is presented. Three separate lesions developed in the same limb over a period of 11 years, one of which recurred on two occasions. Electron microscopy of the most recent tumour showed a predominance of myofibroblasts. The literature regarding extra-abdominal fibromatosis is reviewed and discussed. Redesignation of both abdominal and extra-abdominal fibromatoses as myofibromatoses is suggested.     

Nodular fasciitis of parotid region: a pitfall in the diagnosis of pleomorphic adenomas on fine-needle aspiration cytology

Fine-needle aspiration cytology (FNAC) is routinely employed for the preoperative diagnosis of salivary gland lesions. Although most cases show morphologic features characteristic of specific entities, some lesions can be diagnostically challenging. We report two parotid aspirates, initially diagnosed as pleomorphic adenoma on FNA. The patients, a 33-yr-old white man, and a 24-yr-old white woman, presented with indurated lesions arising in the parotid gland region. The aspirates from both patients were markedly hypercellular. Smears showed a mixture of spindle cells with a well-demarcated cytoplasm showing occasional long cytoplasmic process; and cells with abundant cytoplasm with round to oval eccentric nuclei, giving the impression of plasmacytoid cells of pleomorphic adenoma. The nuclear chromatin was evenly distributed and finely granular with one or two occasional small nucleoli. Intermingled with the tumor cells were scattered neutrophils, eosinophils, and macrophages. Aggregates of spindle cells were also seen embedded in a mucoid background with occasional small tufts of a fibrillar mucoid stroma. These fibrillar tufts were magenta red in the Diff-Quik stain, giving the impression of matrix of pleomorphic adenoma. Both cases were later diagnosed on histologic examination as nodular fasciitis. Nodular fasciitis should be considered in the differential diagnosis of a mass arising in association with the parotid gland.     

A huge nodular fasciitis in parapharygneal space in a 7-year-old girl: a case report and review of literature

Nodular fasciitis (NF) is a benign and reactive fibroblastic growth extending from the superficial fascia into the subcutaneous tissue or muscle, with a morbidity of less than 20% in children. We report a case of a 7-year-old girl presented with a 3-month history of snore and mouth breathing. Image findings demonstrated a large soft-tissue mass in the right parapharyngeal space. The lesion was successfully eradicated by surgical removal. Pathological analysis established NF as the final diagnosis. Histopathological findings were notable for a reactive spindle-cell process composed of proliferative fibroblasts with extravasated red blood cells and interstitial edema. Immunohistochemical stains showed that the lesional cells were positive for smooth muscle actin (SMA), muscle-specific actin (HHF35), and epithelial membrane antigen (EMA), and negative for S100 protein. No clinical evidence of recurrence was noticed after 2 months of follow-up. Being the first report of NF in the parapharyngeal space of a child, this rare pediatric case points out the importance for otolaryngologists to keep NF in mind for differential diagnosis to avoid unnecessary wide resection.     

Fine needle aspiration cytology of nodular fasciitis of the breast

We report a case of nodular fasciitis (NF) of the breast, which was cytologically diagnosed as a spindle cell proliferation with undetermined malignant potential. Owing to small size of the lesion (5.9 × 3.7 × 4.1 mm), only fine needle aspiration (FNA) cytology was performed under ultrasound guidance. The FNA smears were cellular, rich in single/clustered spindle cells but mammary ductal epithelial/myoepithelial cells were absent. These cytologic findings suggested spindle cell growth of mesenchymal origin. Pattern‐less arrangement of spindle cells, heterogeneous composition of the stromal matrix, lack of nuclear/cellular atypia, occasional mitosis but no aberrant mitotic figures, and lymphocyte infiltration indicated reactive rather than neoplastic nature of the lesion. Nonetheless, lumpectomy was conducted because the possibility of neoplasm was not completely ruled out. The histologic diagnosis of the resected nodule was NF. FNA specimens were reviewed thoroughly in an attempt to define the key cytomorphologic features of NF that are important for the correct diagnosis. Differential diagnoses from the lesions that show similar cytologic pictures are discussed in detail. Although NF arising from the breast is rare, cytopathologists should be aware of its clinical and cytopathologic characteristics. Knowledge of the possibility of NF in the breast and its cytologic findings may help cytopathologists to discern its reactive, not neoplastic, characteristics of the lesion. If the referring surgeon is alerted NF as a possibility along with other differential diagnoses, close observation would become a management option. In‐depth discussion of cytologic features and a review of the pertinent literature are also included. Diagn. Cytopathol. 2015;43:222–229. © 2014 Wiley Periodicals, Inc.     

Intravascular fasciitis of the hip joint in a postpartum female: misdiagnosed as low grade fibromyxoid sarcoma

Intravascular fasciitis is a special type of nodular fasciitis. It is an uncommon lesion. We report here the first case of intravascular fasciitis involving the deep muscle of the hip joint. The female, postpartum patient presented with a large, firm, painless tumoral mass in the anterolateral muscles of the right hip. The diagnosis of intravascular fasciitis was difficult because of the large size and location of the lesion. The false positive immunohistochemistry for MUC4 initially caused our team to misdiagnose the intravascular fasciitis as a low grade malignant fibromyxoid sarcoma. Our case adds to the literature on intravascular fasciitis. Since the operation about 20 months prior, the tumor in this case has not recurred.     

Eosinophilic fasciitis ultrastructural study of an early biopsied case

Summary A 55-year-old woman with eosinophilic fasciitis was biopsied 8 weeks after the onset of her illness. Under the electron microscope the changes were almost exclusively located in the fascia with many active fibroblasts, accumulation of protocollagen fibrils (10–50 Å diameter), elastic fibre remodelling and numerous degranulating mast cells. The inflammatory infiltrate was dense and mostly composed of lymphocytes and plasma cells, with 16% eosinophils.The connective tissue changes may be part of a healing process following microinjury of the fascia. However, large numbers of lymphocytes and plasma cells are unusual in the healing process and are more common in the cellular reaction of morphea. Nevertheless, the absence of macrophages in subcutaneous fat, together with large number of eosinophils in the fascia may be considered to be distinctive features of eosinophilic fasciitis.     

Fine-needle aspiration of nodular hidradenoma: A case report

A case of nodular hidradenoma presenting on the forearm of a 36 year old woman is reported. The diagnosis was made on fine-needle aspiration biopsy (FNAB). The cytologic features of the lesion are described. This is the first case to be diagnosed cytologically. Diagn Cytopathol 1996;15:395–397. © 1996 Wiley-Liss, Inc.     

Case of mesenchymal tumor with the PPP6R3‐USP6 fusion,possible nodular fasciitis with malignant transformation

Nodular fasciitis (NF) is a self‐limiting benign disease that is characterized by rapid proliferation of fibroblastic and myofibroblastic cells. The characteristic gene fusion containing the USP6 gene is a genetic hallmark of NF and MYH9‐USP6 is the most frequent fusion, suggesting that NF is not a reactive condition but a neoplastic disease. Malignant transformation of NF has been reported rarely as a single case associated with the PPP6R3‐USP6 fusion. Here we report a case of soft part tumor of which the histological feature was a typical NF but showed aggressive and non‐regressing growth with local invasion. Targeted RNA sequencing and fluorescence in situ hybridization analysis identified PPP6R3‐USP6 with gene amplification. These findings indicate that the present case is the second case of malignant NF, and we suggest potential malignant transformation in certain NF cases.     

Sarcomatoid carcinoma of the pancreas: A case report with immunohistochemical study

Sarcomatoid carcinoma of the pancreas is an uncommon neoplasm. The immunohistochemical characteristics of this unique type of pancreatic tumor were studied. Histologically, there was diffuse proliferation of atypical spindle cells that had hyperchromatic, short, spindle-shaped nuclei and pale cytoplasm. A few tiny foci of small tubular structures were seen in connection with the atypical spindle-shaped cells. Immunohistochemical examination showed that the spindle cells were positive for epithelial cell markers (cytokeratin AE3, cytokeratin AE1, epithelial membrane antigen) and DF3 (MUC1 apomucin-related antigen (ARA)), and were negative for markers such as vimentin, desmin, neuron-specific enolase, and myoglobin. DF3 antigen is known to be expressed in invasive ductal carcinoma of the pancreas and liver, as well as of the breast. Other MUC1-ARA (MY.1E12, MUC1 glycoprotein, HMFG-1, HMFG-2) and anti-CA19-9 were also detected in the present case. Thus, this tumor was diagnosed as anaplastic carcinoma (sarcomatoid carcinoma).