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Case Report |
1 Department of Radiology, Faculty of Medicine, Atatürk University,
Erzurum, Turkey.
2 Department of Pathology, Faculty of Medicine, Atatürk University,
Erzurum, Turkey.
3 Department of Orthopedic Surgery, Faculty of Medicine, Atatürk
University, Erzurum, Turkey.
Received July 26, 2001;
accepted after revision October 23, 2001.
Address correspondence to P. Polat.
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In this article, we report the imaging findings of an unusual case of multiple nodular fasciitis located in the left knee and the left breast concomitantly in a 66-year-old woman.
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The sonogram of the left knee showed a well-defined hypoechoic mass lesion with lobular contours at the subcutaneous tissue of the left knee. On spin-echo T1-weighted MR imaging, the lesion showed low signal intensity relative to the muscle tissue (Fig. 2A). The internal structure of the lesion was homogeneous. Spin-echo T1-weighted MR imaging after IV gadolinium injection revealed moderate enhancement in the lesion (Fig. 2B). The lesion showed increased signal intensity on gradient-echo T2-weighted MR imaging (Fig. 2C). Histopathologic examination of the surgery material showed intense spindle cells, myxoid matrix, and vascular proliferation (Fig. 2D).
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In the breast, the finding of an opaque lesion with regular contours on mammography and the hypoechoic nature of the lesion relative to the surrounding fatty tissue on sonography in our patient suggested a benign lesion of the breast, such as fibroadenoma. However, fibroadenomas are primarily a disease of young women and are rare in the postmenopausal period. Papillary, medullary, mucinous (colloid), or well-circumscribed infiltrating ductal carcinoma also should be considered when a mass lesion with regular contours is detected in the breast in a patient after menopause, as in our patient. In reviewing the literature, we found that the imaging appearance of nodular fasciitis in the breast may mimic intraductal carcinoma [5]. Other than primary breast malignancies, fibrous lesions of the breast can be seen. They occur infrequently in the breast tissue. Pure fibrous lesions of the breast encompass reactive conditions such as scars and nodular fasciitis. Neoplastic entities, such as distinct benign mammary myofibroblastoma, locally aggressive fibromatosis, and rare true sarcomas, are other infrequently seen breast lesions of fibrous origin [6]. There are significant clinical, radiologic, and histologic overlap among reactive and neoplastic lesions, as well as with some nonfibrous lesions. Because no unique radiologic appearance of nodular fasciitis has been reported, the exact diagnosis can be made only by histopathologic findings.
Nodular fasciitis can be divided into the following three subtypes according to anatomic location: subcutaneous type, which is round or oval and is 3-10 times more common than the other subtypes; intramuscular type, seen in two of three patients, typically larger and therefore more often mimics a soft-tissue malignancy; and fascial type, which spreads along the superficial fascial planes and interlobular septa of the subcutaneous fat. These latter two lesions are less well circumscribed and often assume an irregular stellate appearance.
The higher fibrous components of the lesions make them hypoechoic relative to muscle when examined on sonography. The MR imaging findings also vary depending on the histologic characteristic of the nodular fasciitis. Mucoid or cellular types can be seen as hyperintense relative to muscle on spin-echo T1-weighted MR images and with high signal intensity relative to surrounding fatty tissue on spin-echo T2-weighted MR images. The lesions that have marked fibrous content are detected as prominent low-signal-intensity lesions relative to muscle on all spin-echo sequences. In our patient, we detected low signal intensity relative to muscle on T1-weighted MR images and increased signal intensity relative to subcutaneous fatty tissue on T2-weighted MR images. These findings can be attributed to both the myxoid and fibrous components of the lesion. The findings in our patient and the studies of other authors reveal no unique radiologic feature that is specific to nodular fasciitis.
In the differential diagnosis of nodular fasciitis located anywhere in the body except for breast tissue, desmoid tumors, soft-tissue sarcomas, neurofibromas, and myositis ossificans must be considered [7, 8]. The rapid growth rate of these lesions can simulate sarcomas. The differential diagnosis can be made only on the basis of histopathologic findings or clinical course evaluation. Nodular fasciitis may be confused both clinically and histologically with aggressive fibromatosis (desmoid tumor). Both are due to a proliferation of fibroblasts and are seen in many different patterns on imaging. Nodular fasciitis and aggressive fibromatosis may be differentiated only histologically on the basis of cellularity, collagen content, and growth pattern. The central increased signal intensity on T2-weighted MR imaging (due to extremely cellular central areas of proliferating fibroblasts and myofibroblasts in a myxoid stroma or extracellular matrix in myositis ossificans) can simulate nodular fasciitis both radiologically and histologically. CT shows a rim of mineralization around the lesion of myositis ossificans after 4-6 weeks.
Histologically, the lesion of nodular fasciitis is predominantly composed of plump immature fibroblasts that differ little in size and shape. The fibroblasts are arranged in characteristic short irregular bundles and fascicles accompanied by a dense reticulin meshwork and small amounts of mature birefringent collagen. A rich intervening myxoid matrix is present. This myxoid matrix is especially prominent early in the course of the lesion and becomes more cellular with time. Older lesions tend to have a fibrous histology and may be characterized by hyaline fibrosis [7].
Nodular fasciitis is a benign proliferation of fibrous tissue and must be considered in the differential diagnosis of soft-tissue tumors when a mass lesion is detected at a subcutaneous location. Nodular fasciitis can be multiple and may be seen in patients who are more than 60 years old, although this occurrence is rare. Nodular fasciitis reveals no unique imaging findings. The imaging appearances depend on the histologic features of nodular fasciitis.
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