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Case Report |
1 Department of Radiology, Keck School of Medicine, University of Southern
California, LAC + USC Medical Center, 1200 N State St., Rm. 3550, Los Angeles,
CA 90033.
2 Department of Radiology, Keck School of Medicine, University of Southern
California, University Hospital, 1500 San Pablo St., Los Angeles, CA
90033.
Received September 23, 2003;
accepted after revision November 20, 2003.
Address correspondence to J. C. Pierce III
(jeromecp{at}usc.edu).
Introduction
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Elastofibromas have characteristic imaging findings on MRI and CT that allow a definitive diagnosis in most cases. Elastofibromas are typically located in the inferior subscapular region, deep in relation to the rhomboid major, serratus anterior, and latissimus dorsi muscles, and are bilateral in approximately 10% of cases. On CT, an elastofibroma appears as a poorly circumscribed soft-tissue mass with attenuation similar to that of muscle. Strands of lower density (attributed to fat) can be seen within the lesion. On MRI, the lesions show relatively low signal intensity (similar to muscle) on T1- and T2-weighted images. Interlaced fat is seen as strands of high signal intensity within these hypointense lesions [5, 6]. Enhancement after the administration of gadopentetate dimeglumine has been reported [7].
To our knowledge the positron emission tomography (PET) characteristics of elastofibromas have not been previously reported.
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A 69-year-old man presented with a left shoulder mass and left shoulder discomfort. Unenhanced CT scans of the chest followed by PET–CT hybrid images were obtained.
Unenhanced axial CT scans of the chest revealed a soft-tissue mass in the left inferior subscapular region. The mass was located just deep relative to the serratus anterior muscle, displacing the muscle laterally. The soft-tissue mass was oblong in shape, being longest in the superior–inferior plane. The attenuation of the lesion was similar to that of muscle. On closer inspection, we noted a similar but smaller soft-tissue lesion in a contralateral location.
PET–CT revealed a moderate degree of FDG accumulation within the subscapular masses. The hypermetabolism was more prominent in the left lesion (Fig. 1A, 1B, 1C, 1D). The maximum standardized uptake values for the left and right lesions were 1.88 and 1.52, respectively.
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The symptomatic left lesion was surgically excised by an orthopedic surgeon, and pathologic assessment was obtained. On gross examination, the lesion was firm and rubbery. Histologic assessment revealed fibroblastic proliferation with the accumulation of collagen and abnormal elastic fibers. The findings were diagnostic of elastofibroma dorsi (Fig. 1A, 1B, 1C, 1D).
An 83-year-old woman with a history of breast cancer presented to the PET center for metastatic workup, and PET–CT hybrid images were obtained.
PET–CT images of the 83-year-old woman revealed a poorly circumscribed, oblong, subscapular, soft-tissue mass located between the inferior tip of the scapula and the chest wall. The mass was similar in attenuation to muscle, with strands of lower density interspersed within the lesion. The location and the CT appearance of the lesion were characteristic of elastofibroma dorsi. On the PET portion of the study, a moderate degree of FDG radiotracer accumulation was noted in the mass (Fig. 2A, 2B). The calculated maximum standardized uptake value was 1.98.
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Biopsy of the lesion was not performed because the lesion was asymptomatic and the imaging features as well as the location of the mass were thought to be diagnostic of elastofibroma dorsi.
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In the 69-year-old man, the diagnosis of elastofibroma dorsi was not made on the initial CT of the chest. This led to further evaluation with PET–CT. The recognition of the characteristic imaging features of elastofibroma dorsi on the CT portion of this study enabled a preoperative diagnosis to be made. This was important because the presumptive diagnosis of elastofibroma dorsi affected surgical planning, and a wide surgical margin was not required. The lesion was removed because of symptomatology referable to the left shoulder. The patient's postoperative course was uneventful.
In the 83-year-old woman with a history of breast cancer, recognition of the classic CT features of elastofibroma dorsi was particularly important. Attributing the FDG hypermetabolism to metastatic disease would have caused unnecessary patient anxiety and may have led to an unnecessary surgical procedure or biopsy. In addition, the medical treatment of breast cancer patients with metastatic disease is different from that of patients in remission. Patients with metastatic disease are typically treated with hormonal or chemotherapy [8].
As the number of PET and PET–CT hybrid images obtained increases, more benign lesions with the potential for hypermetabolism are likely to be discovered. The two cases presented in this report show the potential for FDG hypermetabolism in elastofibromas. Knowledge of the typical location of elastofibromas and recognition of their characteristic CT appearance are helpful when encountering a hypermetabolic subscapular mass on PET–CT images.
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  K. D. Mortman, G. M. Hochheiser, E. M. Giblin, Y. Manon-Matos, and K. M. Frankel Elastofibroma Dorsi: Clinicopathologic Review of 6 Cases Ann. Thorac. Surg., May 1, 2007; 83(5): 1894 - 1897. [Abstract] [Full Text] [PDF]
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 J. E. Ochsner, S. A. Sewall, G. N. Brooks, and R. Agni Best Cases from the AFIP: Elastofibroma Dorsi RadioGraphics, November 1, 2006; 26(6): 1873 - 1876. [Full Text] [PDF]
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