Rev. bras. ortop. vol.49 número1

w w w . r b o . o r g . b r

Case

Report

Nodular

fasciitis

in

finger

simulating

soft

tissue

malignancy

夽,夽夽

Soraya

Silveira

Monteiro,

Diva

Helena

Ribeiro,

Tatiane

Cantarelli

Rodrigues

_,

Gerson

Ferreira

Gontijo

Junior,

Kylza

Arruda,

Eloy

De

Avila

Fernandes

HospitaldoServidorPúblicoEstadual,SãoPaulo,SP,Brazil

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t

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e

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Articlehistory:

Received4February2013

Accepted9April2013

Keywords:

Fasciitis/radiography

Computedtomography

Magneticresonancespectroscopy

Softtissueneoplasms

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b

s

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Nodularfasciitis(NF)isararefibroblasticproliferativelesion,characterizedclinicallyasa

solitarymassofhardenedandslightlypainfulonpalpation,fastgrowingandnogender

preference.TheobjectiveofthisstudyistoreportthecaseofapatientwithNFinthird

fingeroflefthand,describethefindingsofplainradiography,computedtomographyand

magneticresonanceimagingandcorrelatewiththeliterature.SincethediagnosisofNFis

achallenge,beingnecessarytoconciliatetheclinical,radiologicalandpathological.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Fasciíte

nodular

em

quirodáctilo

que

simula

neoplasia

maligna

de

partes

moles

Palavras-chave:

Fasciíte/radiografia

Tomografiacomputadorizada

Espectroscopiaderessonância

magnética

Neoplasiasdetecidosmoles

r

e

s

u

m

o

Fasciítenodular(FN)éumalesãoproliferativafibroblásticarara,caracterizadaclinicamente

comoumamassasolitáriadeconsistênciaendurecida,poucodolorosaàpalpac¸ão,de

cresci-mentorápidoesempredilec¸ãoporsexo.Oobjetivodestetrabalhoérelatarocasodeuma

pacientecomFNnoterceiroquirodáctilodamãoesquerda,descreverosachadosda

radio-grafiasimples,tomografiacomputadorizadaeressonânciamagnéticaecorrelacionarcom

aliteratura.VistoqueodiagnósticodeFNéumdesafio,énecessárioconciliarosachados

clínicos,radiológicosepatológicos.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Todososdireitosreservados.

夽

Pleasecitethisarticleas:MonteiroSS,RibeiroDH,RodriguesTC,JuniorFGK,ArrudaG,FernandesEDeA.Fasciítenodularem

quirodác-tiloquesimulaneoplasiamalignadepartesmoles.RevBrasOrtop.2014;49:89–93.

夽夽

StudyconductedatHospitaldoServidorPúblicoEstadual,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:tcantarelli@gmail.com(T.C.Rodrigues).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

Nodularfasciitis(NF)isabenignsofttissueinjuryofunknown

etiology,1–4 _{characterizedby proliferation offibroblastsand}

often confused histologically with sarcomas, because of

its rapid growth, high cellularity and increased mitotic

activity.1,3,4

Thelesionsarecommonlysolitary,occurinadultsbetween

20and40yearsold,1–4_{andaffectanyregionofthebody.}1,5

Thisisaself-limitingdisease.2,3 _{Patients usuallyhave a}

history of rapid growth and nodulation, and may develop

numbnessorparesthesia.1–3,6

Its diagnosis is challenging and can be confused with

malignanttumors,becauseoftheaggressiveclinical

behav-iorassociatedwithimagingandhistologyfindings.1–3_Multiple

lesionsarerare,1,7_{aswellaslesionsinhandsandfeet,andvery}

rareinthefingers.8

Giventhisfact,wereportacaseofFNonthefinger,since

theknowledgeoftheappearanceoftheimagingstudiescan

avoidaggressiveinvasiveprocedures,sincethe histological

studywithoutimagemayleadtosuspicionofalesionwith

highaggressiveness.

Case

report

Patient, female, 45 yearsold, teacher,referringappearance

ofnodulationofrapidgrowthinthethirdleftfingerfortwo

years;painless,butwithlocaldiscomfort.Shedeniedtrauma

orprevioussurgery.Thephysicalexaminationshowedvolar

nodulationintheproximalphalanxofthethirdchirodactyl,

adheredtotheskinwithoutretractionorphlogisticsigns,and

measuringapproximately2cm.

Plainradiography(RX)revealedossificationofsofttissues

of the radial and flexor diaphyseal faces of the proximal

phalanx of the finger, with irregular and partially defined

contours, cortical erosion and lamellar periosteal reaction

proximalanddistaltothenodule,andincreasedvolumeand

densityofpartsoftheadjacentsofttissue(Fig.1).Computed

moreclearlythe ossification,extendingfrom the boneand

externally involvingthe corticalflexorcontiguous withthe

radial and flexor aspect nodulation (Fig. 2). MRI revealed

expansive formationon softparts oftheradialface ofthe

proximalphalanx,whichpromotedslightthinningofthe

cor-tical bone with intimate contact, and superiorly displaced

the extensor hood.Thelesion depictedthe iso/hypersignal

relative to muscle on T1, heterogeneous signal with mild

hypersignalon T2,andsignificant heterogeneous

enhance-ment toparamagnetic contrastmedium, associatedwitha

bonemarrowedemapattern(Fig.3).

The patient underwent surgical exeresis, and the

histopathological examination revealed fibrous

connec-tive tissue with neoformation and trabeculation, favoring

the diagnosis of NF. Five months later, MRI depicted only

fibrocicatricial changes in soft tissues, without significant

enhancementinthecontrastmedium(Fig.4).

Discussion

FNisabenignlesionofunknownetiology,1,5 _butwith

possi-ble associationwithtrauma.1,3,7_{FNaffectseverybody part,}

and mostcommonly1,5 _{the upperextremity (48%), besides}

the trunk(20%),headand neck(17%),and lower extremity

(15%).1,2_{Itsoccurrenceisrareinhandsandfeet,andveryrare}

infingers.8

Themostaffectedagegroupis20–40years;FNalsoaffects

bothgenders.1,3 _{Symptomssuchasnumbness,paraesthesia}

and pain are infrequent,implying nervous compression.2,3

Multiplelesionsarerare.1,7_{Theaveragediameterofthelesion}

isabout2cm,andlargerlesionsareexceptional.1,3,7

Basedontheanatomicallocation,FNcanbedividedinto

threetypes: subcutaneous,intramuscular,and fascial.

Sub-cutaneous FN is three to10 times more frequent.1,2,4 _The

intramuscular typemoreperfectlysimulatesaneoplasmof

soft tissues.1 _{Intravascular and intradermal formsare rare}

subtypes.2

Fig.2–AxialsliceCTscanrevealstheossification(arrows)advancingfromtheboneandthatexternallyinvolvedthe corticalflexor(openarrows)contiguoustotheradialandflexoraspectnodulation.Thereconstructioninthecoronalplane (D)depictscontinuityofnodularlesionwithperiostealreaction(arrowheads)extendingtotheflexorside.

Accordingtothepredominanthistologiccomposition,FN

canbefibrous,myxoidorcellular.1,3,4_{Histologically,thislesion}

consistsoffibroblasts arrangedinshortbundlesand

fasci-clesscattered withina myxoid stroma, and may simulate

sarcoma.1,2,8_{Someauthorsbelievethattheamountandtype}

ofextracellularmatrixreflecttheageofthelesion:inearly

FN,predominatesthemyxoidcomponent;inmatureFN,the

fibrouscomponentismoreabundant.1,2,4_Thevarious

compo-nentscancoexistinthesame lesion,withcombinationsof

myxoid-cellular,andofcellular-fibroustypes,thataremore

commonthancombinationsofmyxoid-fibroustypes,

suggest-inghistologicaltransitionfrommyxoidtocellularand,later,

tofibroustype.1

ImagingstudiesmaybeusedtoevaluatepatientswithFN.

Thepresent studyshowssomeoftheimagechangestobe

characterizedandrecognized.RXshowsincreasedsofttissue.

Toourknowledge,thereisonlyonecaseintheliteraturethat

depictstheradiographicappearanceofthelesion,considering

itasnonspecific.8

OnCT,lesionsofFNusuallyappearasasuperficialmassof

softtissue,withdensitysimilartootherlesions,1_{well-defined,}

andthatcaninvadeanddestroyadjacentbone.7

At MRI, the appearance is nonspecific,1,2,7,8 _most

com-monlyiso/hyperintenseonT1andhyperintenseonT2,with

variedenhancementbyparamagneticcontrastbecauseofthe

differenthistologicaltypes.3,4_{Itisunknownwhichinfluences}

moredecisivelyinsignalintensity:thecellularityorcollagen.

Someauthorsadvocatethatmyxoidformspresent

hyperin-tensivityrelativetomuscleonT1,andtosubcutaneousfaton

T2;andthatfibrousformsarehypointensetothemuscleinall

sequences.Otherauthorsstatethatthelesionisisointenseto

muscleonT1,andtovenousstructuresonT2.1_The

hypercel-lularlesionspresentisointensesignaltomuscleonT1,and

arehyperintensetofatonT2.4

Because of the nonspecific findings, many differential

diagnoses can be proposed, including neuroma,

neurofi-broma,sarcoidosis,aggressivefibromatosis,dermatofibroma,

fibrosarcoma,andmalignantfibroushistiocytoma.2,3,7_Inthe

intramuscularlesions,onecanthinkofmyositisossificansin

earlystage.4 _{Giantcelltumorsofthetendonsheathcanbe}

differentiatedfromFNbyitsslowgrowthandbythefixation

ofthetumortothetendon.8_{Insomecases,thesimilarityin}

clinical and microscopicpresentationbetweenFN and

sar-coma makesdifficulttheestablishmentofadiagnosis,but

some clinicaland radiological features makethediagnosis

ofNFlesslikely,includinglesionsinpatientsover 70years

old,lesionslocatedinthehandsandfeet,orsimultaneous,

multiple,recurrentlesions,withperilesionaltissueedemaor

intralesionaldepositionofhemosiderininMRIstudies.2

Thephysicianmustobtainabiopsytoestablishadefinitive

diagnosis.2,8 _{Theexcision,usuallycurative,isthemainstay}

oftreatment,5 _{althoughintralesionalinfusionof}

corticoste-roidshasbeensuggestedbysomeauthors.2,6 _Theremaybe

Fig.3–MRIrevealsexpansiveformationonsoftpartsoftheradialfaceoftheproximalphalanxwithiso/hypersignal relativetomuscleonT1(AandC),mildhypersignalonT2(B),andsignificantheterogeneousenhancementtoparamagnetic contrastmedium(D);slightthinningofthecorticalbone(arrows),whichsuperiorlydisplacestheextensorhood

(arrowheads),associatedwithbonemarrowedemapattern.

of patients and being usually observed immediately after

excision.2,8

Insummary,FNcanbeinterpretedasamalignantlesion

becauseofitsrapidgrowthandaggressivehistologicalnature.

However,the correctdiagnosis can beestablishedby

com-bining the characteristics of the image, localization and

histology.1

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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