Ischemic fasciitis: enhanced diagnostic resolution through clinical, histopathologic and radiologic correlation in 17 cases

Abstract

Ischemic fasciitis is a pseudosarcomatous nodule or mass resulting from sustained or repeated pressure and consequent ischemia of soft tissue. Fibrin and hemorrhage expand its hypocellular epicenter bordered by enlarged (atypical, ischemic) fibroblasts and reactive vascular prominence resulting in diagnostically important histologic zonation. Although classically in bedridden patients, ischemic fasciitis owing to posture-related intermittent pressure in ambulatory adults is not well characterized; there has not been a thorough review of its presentation in ambulatory patients in the dermatology/dermatopathology literature. This article reviews the clinical, pathologic and radiologic presentation of 17 cases of ischemic fasciitis diagnosed over a 14-year period. Eighty-six percent of the six cases submitted by non-dermatologists were limb girdle/trunk lesions averaging 6.7 cm in greatest diameter while 90% of the eleven lesions submitted by dermatologists were elbow and forearm lesions averaging 2.3 cm. In no case was the diagnosis anticipated pre-biopsy by clinician or radiologist. Dermatologists submitted the majority of cases. Because ischemic fasciitis may simulate soft tissue sarcoma clinically and histologically, diagnosis helps prevent overtreatment. Zonal histopathologic structure may be shown by any form of biopsy and should motivate correlation with available radiologic studies. Importantly, determining a history of postural pressure at the site confirms the histopathologic diagnosis and avoids unnecessary excision.

Solitary leg nodule in a young, physically active man

“…Lesions of IF present as nodules, sometimes tender. About 80% of cases arise on the girdle and trunk regions 1,3 . Yet, one review revealed IF to be more common on the elbow/forearm in ambulatory settings such as dermatology clinics.…”

“…Forearm lesions additionally had a smaller average diameter (2.8 cm) compared to girdle and trunk lesions (6.7 cm). Lesions on the forearm and a lesion on the foot correlated with a history of repetitive, intermittent pressure 3 . Very few cases have been reported on the lower extremities 1–5 …”

“…Malignant sarcomatous mimics of IF are more likely to exhibit greater cellularity and atypical mitoses. Although magnetic resonance imaging studies may highlight the zonation of IF, radiologic findings are overall not distinct from a necrotic abscess or sarcoma 3–5 …”

“…There have been no reports of malignant transformation, metastasis, or mortality associated with IF. Treatment is typically conservative excision to hasten resolution, treat symptoms, and ensure complete histologic examination of the entire lesion as malignant conditions are in the differential diagnosis 2,3 . Recurrence rates range from 2 to 10% 1,2 .…”

“…Recurrence rates range from 2 to 10% 1,2 . Partial biopsy may result in regression, which may be complete 3 . Regression has also been reported with activity or postural modification 3 …”