Nodular Fasciitis in a One-Year-Old Male: A Diagnostic Dilemma

Abstract

A one-year-old boy presented with an initially painless, left supra-auricular mass that rapidly enlarged from < 1 cm to 3 cm (widest diameter) in a two-month period. Sarcoma was initially considered over an inflammatory process as the mass was non-responsive to antibiotic therapy. Fine-Needle Aspiration Cytology (FNAC) and High-Resolution Computed Tomography (HRCT) with contrast revealed benign cytologic and radiologic findings making nodular fasciitis the primary impression. The patient eventually underwent complete surgical excision of the left supra-auricular mass. Histopathologic findings then showed a stroma rich in collagen and myxoid ground substance and loose array of short S-shaped fascicle cells with scattered lymphocytes, macrophages and red blood cells consistent with nodular fasciitis. Conclusion: Nodular fasciitis is a rare benign myofibroblastic soft tissue tumor which typically presents as a rapidly progressive nodular lesion in the head and neck region of the young pediatric age group. Cytopathologic recognition with FNA is a challenge. The gold standard of treatment is still surgical and in most reported cases, curative. More importantly, early clinical recognition and correlation with radiologic and histopathologic appearance is very important to avoid unnecessary work-ups and over-treatment.

Cervical nodular fasciitis in a 17-month-old child

“…Its precise incidence is unknown,6 but it is a rarely diagnosed entity8 9 especially in children—fewer than 20% of cases occur under the age of 20-years-old 1 3 10. It is more common in young adults between 20 and 40 years old,1–3 5 6 without gender preference 2 5 11 12.…”

“…Some believe that the unusual proliferation of myofibroblasts is triggered by local injury or inflammatory process 5 6 8 9 12. However, only a minority of cases (10–15%) report local trauma2 5 6 11 and it remains unclear why there are not more lesions in the inferior limbs, more prone to trauma in children 6 11…”

“…Imaging features can help characterise the lesion and the surrounding anatomy but are also unspecific and, most of the times, insufficient to make the correct diagnosis or differentiate it from malignant lesions 9 10 13. Ultrasound generally reveals a well circumscribed, isoechoic or hipoechoic heterogeneous mass, with substantial colour Doppler arterial flow.…”

“…NF accounts for 0.025% of all pathological diagnosis, with less than 4% of those occurring in children aged 0–9 years1 2 Its cytomorphology is rather characteristic, making it possible to recognise these lesions in fine needle aspirates by an experienced pathologist 8 9. Histologically it is characterised by a myxoid stroma with high cellularity of immature appearing fibroblasts.…”