Nodular fasciitis of the hand in a young athlete. A case report

Abstract

Nodular fasciitis is a rapidly growing mass, with high cellularity and mitotic activity, that can be both clinically and histologically misdiagnosed as a soft tissue sarcoma. Nodular fasciitis of the hand is an extremely rare condition. We report a 17-year-old male hand-ball player with nodular fasciitis in the dominant hand. The patient presented with a rapidly growing mass in his right hand and no history of major trauma. On physical examination, a painful mass measuring 2 cm in diameter was observed in the first web space. Magnetic resonance imaging (MRI) demonstrated a subcutaneous mass with isointensity on T1-weighted images and inhomogeneous high intensity on T2-weighted images. The lesion was inhomogeneously enhanced after intravenous administration of gadolinium. Moreover, thallium-201 scintigraphy showed high uptake at the early phase and no wash-out at the delayed phase. We performed an excisional biopsy. The mass was present subcutaneously and adhered to the interosseous muscle fascia. Although a pathological examination by frozen section during surgery showed a low-grade spindle cell sarcoma, the final histological diagnosis was nodular fasciitis. There was no evidence of local recurrence at the recent follow-up 2 years after the operation. We speculate that repeated small injuries as a result of sports activities played an important causative role in the nodular fasciitis.

Figure 1.

Radiographs of the right hand show an increase in soft tissue shadow in the first web space.

Figure 2.

On computed tomography, the 20 mm in diameter mass shows a lower density than the muscle, and its margins are comparatively clear.

Figure 3.

On magnetic resonance imaging (MRI), the mass has low intensity on T1-weighted images (A) and is heterogeneously hyperintense on T2-weighted images (B). After intravenous gadolinium, the mass is enhanced heterogeneously on T1-weighted images (C).

Figure 4.

Thallium-201 scintigraphy shows high uptake in the early phase and no wash-out on the delayed phase.

Figure 5.

On macroscopy, the solid mass measures 25 mm in diameter.

Figure 6.

A: The specimen shows vascular hyperplasia and infiltration of inflammatory cells (hematoxylin and eosin, ×100). B: The spindle cells formed S- or C- shaped fascicles in the highly cellular area (hematoxylin and eosin, ×200). C: In the poor cellular area, plump and spindle cells are present between the hyalinization of fibrous stroma (hematoxylin and eosin, ×200). D: little variation in size and shape of the nuclei. Mitotic activity ranges from 2 to 3 mitotic figures per 10 high-power fields, but atypical mitoses are hardly seen (hematoxylin and eosin, ×400).