From the Department of Orthopedics, Kamineni Institute of MedicalAndhra Pradesh, India.

Received for publication December 12, 2013; accepted in revised f

The authors are grateful to Dr. R.S. Murthy and Dr. Venkat KishDepartment and Dr. Seshagiri Rao of the Pathology Department, KMedical Sciences, for good histopathological images.

No benefits in any form have been received or will be receiveindirectly to the subject of this article.

Corresponding author: Dr. Guruvardhan Kumar V Kotha, Flat nTowers, Door no. 6-4-11 to19, Bholakpur, Musheerabad, Secunderae-mail: drguru.gmc@gmail.com.

0363-5023/14/3912-0019$36.00/0http://dx.doi.org/10.1016/j.jhsa.2014.07.023

2468 r � 2014 ASSH r Published by Elsevier, In

SCIENTIFIC ARTICLE

Multifocal Nodular Fasciitis of the

Hand and Shoulder: Case Report

Guruvardhan Kumar Kotha, MS, Venkatramana BJ, MS, Venkateshwar Reddy Maryada, MS,Harshad Jawalkar

We report a case of nodular fasciitis occurring on the dorsum of the right middle finger, thedorsum of the right hand, and the right upper back associated with cortical erosions of thescapula. Ray amputation of the middle finger and marginal excision of the hand and peri-scapular masses were performed. There was no recurrence of the tumor at either site a yearlater. (J Hand Surg Am. 2014;39(12):2468e2471. Copyright� 2014 by the American Societyfor Surgery of the Hand. All rights reserved.)Key words Bone erosions, dorsum of the middle finger, multiple sites, nodular fasciitis, handand periscapular region.

N ODULAR FASCIITIS IS A RAPIDLY growing benignsoft tissue tumor. Often, it is clinicallymistaken for a malignancy. It is common on

the volar aspect of the forearm;1e4 multiple site oc-currences are rare.

We report a case of multisite nodular fasciitisoccurring on the dorsum of the right middle finger, onthe dorsum of the right hand, and on the right peri-scapular area to highlight the unusual presentationand to review the literature for various treatmentoptions.

CASE REPORTA 30-year-old laborer presented with painful masseson the dorsum of her right middle finger and handas well as her right periscapular area of 3 months

Sciences, Narketplly,

orm July 10, 2014.

an of the Radiologyamineni Institute of

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o 401a, Jaya Durgabad 500 080, India;

c. All rights reserved.

duration associated with numbness of the middlefinger. She had a history of a thorn prick to thedorsum of the right hand 3 months prior to theappearance of the masses on the dorsum of the rightmiddle finger and hand. She noted another masson the right periscapular region one month after theappearance of the hand masses.

The masses measured 6 � 3 cm on the middle ringfinger, 4 � 3 cm on the hand (Fig. 1), and 10 � 8 cmon the shoulder. The masses were tender and firm.The mass on the middle finger had extended to theradial and ulnar borders of the finger. Both passiveand active movements of the middle finger at themetacarpophalangeal joint were 0� to 20� of flexion.There was no active or passive movement at theproximal and distal interphalangeal joints of themiddle finger. The hand and periscapular masseswere in the subcutaneous plane and were not adherentto skin or tendons. There was no epitrochlear oraxillary lymphadenopathy. There was loss of pro-tective sensation in the middle finger.

Radiographs showed increased soft tissue shadowover the dorsum of the middle finger and the dorsumof the hand, and cortical erosions of proximal pha-langes and metacarpals of the middle and ring fingers(Fig. 2). Similar erosions were seen at the inferiorangle of the right scapula (Fig. 3). Magnetic reso-nance imaging (MRI) showed a hypointense lesionarising in the subcutaneous plane on T1-weightedimages and hyperintense signal on T2-weighted

FIGURE 1: Nodular fasciitis on right middle finger and hand.

FIGURE 2: Radiograph shows cortical erosions of middle andring finger proximal phalanges and metacarpals.

FIGURE 3: Radiograph shows erosions at the inferior angle ofright scapula.

MULTICENTRIC NODULAR FASCIITIS 2469

images of the middle finger, the hand, and the rightperiscapular region (Fig. 4). The tumor on the dorsumof the middle finger was adherent to the neuro-vascular bundle. An incisional biopsy from both thehand and the periscapular masses indicated nodular

J Hand Surg Am. r Vol

fasciitis. Biopsy specimens were not sent for culturebecause the clinical examination, the normal bloodinvestigations (complete blood picture, erythrocytesedimentation rate, and C-reactive protein), the MRI,and the intra-operative findings were not suggestiveof infection.

All 3 lesions showed similar histological featuresof spindle cell growth, vascular hyperplasia, andlymphocyte infiltration. The spindle cells formed S-or C-shaped fascicles in the highly cellular area(Fig. 5). In the hypocellular area, plump and spindlecells were present between the hyalinization offibrous stroma. There was little variation in the sizeand shape of the nuclei. There were 2 to 3 mitoticfigures per 10 high-power fields without any atypicalmitoses.

In view of the adhesions to the digital neuro-vascular bundle and the digital tendons, ray ampu-tation of the middle finger was performed. Marginalexcision was performed for the hand and periscapularmasses. Margins of all the excised masses were freeof tumor.

At 1-year follow-up there was no recurrence of thetumor either on the hand or shoulder on clinicalexamination.

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FIGURE 4: On MRI, the mass has low intensity on T1-weighted images and is heterogeneously hyperintense on T2 weighted images.A Middle finger. B Hand. C Scapula.

2470 MULTICENTRIC NODULAR FASCIITIS

DISCUSSIONNodular fasciitis is a benign reactive soft tissue tumorreported by Konwaler et al as a subcutaneous pseu-dosarcomatous fibromatosis.3,4 It is benign but hasrapid proliferation of fibroblasts and myoblasts,which mimics a malignant tumor. Etiology is un-known but is attributed to injury or infection.3,4 It is aself-limiting reactive growth and is not neoplastic.1 Itcommonly occurs in patients between the ages of 20and 40 years. The common sites of occurrence are theupper extremity (48%), trunk (20%), head and neck(17%), and lower extremity (15%). Nodular fasciitisis rare in the hands and feet.4,5 It most commonlyoccurs on the volar aspects of the upper limb andrarely is seen dorsally.3,4 Park et al reported a case ofnodular fasciitis on dorsoradial aspect of the thumb.4

J Hand Surg Am. r Vol

Clinically, the lesions are oval to round, rapidly growover 1 to 3 months, and cause pain and tenderness.

The differential diagnoses for nodular fasciitis in thehand includes deep fungal infection, giant cell tumorof tendon sheath, desmoid tumors, fibromatosis, highgrade pleomorphic sarcoma, dermatofibrosarcomaprotuberans, and fibrosarcoma. Incisional biopsy isusually recommended for a definitive diagnosis.4

Plain radiographs show the soft tissue mass with orwithout cortical erosions of the underlying bones.MRI features of nodular fasciitis depend on its his-tological composition. An immature nodular fasciitislesion has a myxoid matrix rich in acid mucopoly-saccharide. Mature lesions have a more fibrousappearance microscopically. The 3 types of nodularfasciitis are myxoid, cellular, and fibrous. Myxoid

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FIGURE 5: Histopathological examination shows spindle cellsforming S- or C-shaped fascicles.

MULTICENTRIC NODULAR FASCIITIS 2471

and cellular lesions are iso- to hyperintense to skeletalmuscle on T1-weighted images and iso- to hyperin-tense to fat on T2-weighted images. Fibrous lesionsare markedly hypointense on T1 and T2 images.6,7

As these tumors usually show nonspecific MRI fea-tures, soft tissue sarcoma cannot be excluded.

Microscopically, these lesions are characterized bya cellular spindle cell growth in a loosely texturedmucoid matrix with lymphocytic infiltration and ex-travasations of red blood cells. An important diag-nostic finding is the presence of undulating wide bandsof collagen lined on the side of spindle cells. The highcellularity of the lesion and the presence of mitoticfigures are responsible for the frequent confusion ofthis lesion with sarcoma. Atypical hyperchromaticnuclei have never been seen in nodular fasciitis.8,9

Ultrastructurally and immunohistochemically, theproliferating spindle cells have features of myofibro-blasts. The DNA pattern is always diploid.9

Observation, intralesional steroids, and marginalexcision are treatment options for nodular fasciitis.

J Hand Surg Am. r Vol

Graham et al reported complete regression of a 5-cmlesion on the volar aspect of the forearm followingintralesional corticosteroid injection.10 Marginal ex-cision is the treatment of choice for a rapidlygrowing tumor.5 Yoshihiro et al reported 4 cases ofnodular fasciitis; 2 cases (4 � 3 cm on the hypoth-enar aspect of the hand and 1.5 � 1.5 cm on theindex finger) were excised for their rapid growth, andthe other 2 (2 � 1 cm on the volar aspect of theinterphalangeal joint of the thumb and 2 � 2 cm onthe volar aspect of the metacarpophalangeal joint ofthe thumb) showed partial regression over one year.11

Recurrence is low (1% to 2%) and is due to incom-plete excision.4

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1. Bernstein KE, Lattes R. Nodular (pseudosarcomatous) fasciitis, anonrecurrent lesion: Clinicopathologic study of 134 cases. Cancer.1982;49(8):1668e1678.

2. Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St Louis, MO:CV Mosby; 1998:167e176.

3. Hara H, Fujita I, Fukimoto T, Hanioka K, Akisue T, Kurosaka M.Nodular fasciitis of the hand in a young athlete. A case report. UpsJ Med Sci. 2010;115(4):291e296.

4. Park JS, Park HB, Lee JS, Na JB. Nodular fasciitis with corticalerosion of the hand. Clin Orthop Surg. 2012;4(1):98e101.

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6. Coyle J, White LM, Dickson B, Ferguson P, Wunder J, Naraghi A.Magnetic resonance imaging characteristics of nodular fasciitis of themusculoskeletal system. Skeletal Radiol. 2013;42(7):975e982.

7. de Schepper AM, ed. Imaging of soft tissue tumors. 3rd ed. Berlin,Heidelberg: Springer; 2006:168e169.

8. Wirman JA. Nodular fasciitis, a lesion of myofibroblasts—Anultrastructural study. Cancer. 1976;38(6):2378e2389.

9. Rosai J, Ackermans LV. Rosai and Ackerman’s Surgical Pathology.9th ed. St. Louis, MO: Mosby Elsevier; 2007:2244e2246.

10. Graham BS, Barrett TL, Goltz TW. Nodular fasciitis: response tointralesional corticosteroids. J Am Acad Dermatol. 1999;40(3):490e492.

11. Neshida Y, Tsukushi S, Wasa J, Iwata Y, Kozawa E, Ishiquro N.Nodular fasciitis of the finger and hand: case report. J Hand Surg Am.2010;35(7):1184e1186.

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