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The Journal of Foot & Ankle Surgery 51 (2012) 241–245

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The Journal of Foot & Ankle Surgery

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Pedal Occurrence of Nodular Fasciitis: A Case Report

Khurram Khan, DPM1, Kamran D. Farahani, DPM, MPH 2, Eric J. Roberts, DPM3,Anthony V. D’Antoni, PhD 4, Javier Cavazos, DPM5, Michael DellaCorte, DPM6

1Assistant Professor, New York College of Podiatric Medicine, New York, NY2Resident, Second Postgraduate Year, North Shore Long Island Jewish Health System, Forest Hills Hospital, Forest Hills, NY3Chief Resident, Third Postgraduate Year, North Shore Long Island Jewish Health System, Forest Hills Hospital, Forest Hills, NY4Director of Anatomy, New York College of Podiatric Medicine, New York, NY5 Private Practice, R.G.V. Footcare, P.A. McAllen, TX6Residency Director, North Shore Long Island Jewish Health System, Forest Hills Hospital, Forest Hills, NY

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:benignfasciitisneoplasmnoduletumor

Address correspondence to: Khurram Khan, DPMCollege of Podiatric Medicine, 53 East 124th Street N

E-mail address: Kkhan@nycpm.edu (K. Khan).

1067-2516/$ - see front matter � 2012 by the Americdoi:10.1053/j.jfas.2011.10.036

a b s t r a c t

Nodular fasciitis occurs primarily in the soft tissue structures of the upper extremities and, more rarely, in thelower extremities. This mass, although benign, can mimic certain sarcomas and is therefore important todifferentiate from more serious conditions. We report a case of nodular fasciitis of the foot in a healthy47-year-old male who presented with increasing pain and swelling in his right third digit of 3 monthsduration. Initial radiographs revealed an irregular contour to the proximal phalanx with increased soft tissuedensity. Magnetic resonance imaging and computed tomography scans were obtained that revealed a softtissue mass with bone erosion and fracture. Histologic analysis from a specimen obtained after excision of thelesion confirmed the diagnosis of hyalinizing nodular fasciitis. Nodular fasciitis in the foot can appearmalignant from the clinical and histopathologic findings but can be differentiated. A quick and accuratediagnosis of this benign process can prevent a treatment program unnecessarily dangerous to the patient.

� 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

Nodular fasciitis is a benign, hyperplastic mass that was firstdiscussed in 1951 by Stewart and Foote. In 1955, Konwaler et al (1)described the lesion as pseudosarcomatous fibromatosis in the firstpublication of 8 cases (2). The lack of case reports before 1951suggests the recent evolution of a new etiologic agent or a previousmisdiagnosis as malignancy (3). Histologically, this is a benignreactive fibroblastic lesion in the subcutaneous tissue that exhibitsrapid growth. These nodules are composed of immature fibroblastsand myofibroblasts in short, irregular bundles and are commonlyassociated with the deep fascia (4,5). The cause of nodular fasciitis isunknown but is believed to be triggered by local injury or a localinflammatory process (4). The lesions are generally small and soli-tary, arising commonly in the upper extremities of adults but canalso occur in the head and neck regions of infants and children. Thevolar aspect of the forearm has been reported as the most commonsite for this condition (2,6–9). Research has reported an occurrenceof 15% to 20% in the lower extremity, with fewer than 5% occurring inthe foot (10–12). It is found equally in men and women and typicallyoccurs in the age range of 20 to 50 years. The nodules can developrapidly within weeks and grows to a size of 1 to 2 cm. The most

, Assistant Professor, New Yorkew York, NY 10035.

an College of Foot and Ankle Surgeon

common clinical presentation is a rapidly growing mass that mighthave pain or tenderness on palpation. Nodular fasciitis can be sub-divided into several subtypes, depending on the location of thelesion. The most common subtype is subcutaneous, followed byintramuscular and fascial subtypes (5,11). Intravascular and intra-dermal lesions can appear in the rarer subtypes. The subcutaneoustype is 4 times more common than the other types (2). The diagnosisis usually made from the imaging and biopsy findings and histologicanalysis of the lesion.

Case Report

A 47-year-old Latin-American male presented with complaints ofpain and swelling in the right third toe that had begun 3 monthsearlier. The patient stated he was feeling severe discomfort at the endof the day and sometimes while resting. He denied any trauma to thearea and was taking over-the-counter anti-inflammatory medicationswithout improvement in pain or swelling. He denied all pertinentmedical and surgical history. The lower extremity physical examina-tion revealed a subdermal enlargement of the right third digit,dorsally. The lesionwasmobile and was painful on palpation andwithrange of motion. On physical examination using a 125-Hz tuning fork,5.07 10-g monofilament, and cotton swab, the patient’s neurovascularstatus was found to be intact with no deficits.

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Fig. 1. Transverse view of computed tomography (CT) scan with arrows identifyingmargins of soft tissue mass.

Fig. 2. Frontal view of computed tomography scan demonstrating soft tissue massencompassing third digit with deep plantar extension.

Fig. 3. T1-weighted magnetic resonance imaging scan showing evidence of corticalthinning and erosion of lateral proximal phalanx.

K. Khan et al. / The Journal of Foot & Ankle Surgery 51 (2012) 241–245242

The anteroposterior, lateral, and medial oblique radiographs of thepatient’s right foot had previously been ordered by his medical doctor.The report noted no fractures; however, an irregular contour of thethird proximal phalanxwith narrowing of the epiphysis was noted. Anincreased soft tissue density was located along the length of the digit.

At this point, it was decided to obtain a computed tomography (CT)scan owing to the irregularity of bone structures in proximity to themass. This revealed a soft tissue mass of the lateral aspect of theproximal phalanx of the third toe with cortical thinning of the lateral,central, and distal diaphysis (Fig. 1). No periosteal reaction or overtdestruction was noted. These findings suggested that a long-standingsoft tissue mass had placed pressure on the cortex. The position of themass was determined to extend plantarward and distally to the deeptransverse intermetatarsal ligament (Fig. 2).

A magnetic resonance imaging study was then performed toidentify the extent of the soft tissue mass. Frontal, coronal, andsagittal views of the right foot were obtained. Using a 3.0 Teslamagnet, T1, T2, and short T1 inversion recovery-weighted images wereobtained. On reviewing the previous CT scan, the musculoskeletalradiologist noted that the extrinsic thinning of the lateral, mid, anddistal diaphysis of the right third proximal phalanx was moreominous in appearance (Fig. 3). Additionally, this study revealeda transverse pathologic fracture of the third digit proximal phalanx.This was not detected on the previous CT scan, and the radiologistnoted that a pathologic fracture with erosive bone changes couldrepresent infiltration by tumor versus and an infectious process and

that the lesion now should be considered a possible malignancy(Fig. 4). The radiologist’s report mandated that surgical verification ofthe lesion must be done.

A 0.7 � 0.3 � 0.3-cm, full-thickness, soft-tissue biopsy was per-formed with a no. 15 blade, with a 4-mm bone biopsy of the proximalphalanx third digit on the right foot that was taken with a Jamshidineedle. The initial pathology results showed spindle cell proliferation.The difficulty in identifying benign spindle cell proliferation versusmalignant sarcoma led the initial pathologist to forward the specimento a university expert on malignant pathologies. The results of thisconsultation revealed the specimen to have a hyalinized matrix, shortrandomly distributed bands of myofibroblastic cells, and prominentmicrocystic change (Figs. 5 to 7). For this reason, the diagnosis was ofa benign hyalinizing nodular fasciitis and not spindle cell sarcoma.

Fig. 6. (A) Absence of articular cartilage with erosion. (B) Lacunae with osteocytes withinhaversian canals. Hematoxylin and eosin stain, original magnification �100.

Fig. 4. T1-weighted magnetic resonance imaging scan demonstrating soft tissue masswith plantar extension (A) and pathologic fracture of proximal phalanx (B).

K. Khan et al. / The Journal of Foot & Ankle Surgery 51 (2012) 241–245 243

Surgical resection of the soft tissue mass was subsequently per-formed. Using a dorsal linear incision, the mass was located superfi-cially on the dorsal aspect of the foot (Fig. 8). On exploration, it wasfound to extend deep into the third interspace with some encroach-ment onto the proximal phalanx. The mass was removed, and thesurrounding bone was scraped with a curette to remove any tumorremnants (Fig. 9). The mass measured 3.3 � 2.0 � 1.3 cm (Fig. 10). Anybleeding vessels were ligated, and the incision was closed withoutincident. Subsequent pathologic examination on the removed massshowed histologic features identical to those from the previousbiopsy, and the final diagnosis was consistent with nodular fasciitis(Fig. 11). The sutures were removed within 2 weeks, and the patienthad no pain or difficulty ambulating without assistive devices at thattime. The patient was followed up for a total of 3 months withoutcomplications. The authors attempted to interview the patient todiscuss long-term follow-up; however, he was unavailable.

Discussion

We have presented a rare case of pedal nodular fasciitis specificallylocated in the third proximal phalanx of the right foot. Although theprevalence of nodular fasciitis in the foot is extremely rare, physicians

Fig. 5. Transition zone (arrow) from myxoid to hyalinized matrix (A). Hematoxylin andeosin stain, original magnification �100.

must be aware of its existence when contemplating the differentialdiagnosis. Nodular fasciitis is a tumor-like fibroblastic proliferationthat is often misdiagnosed as a malignant lesion. The rapid growthwith rich cellularity, abundant mitotic figures, and the capacity to bepoorly circumscribed frequently cause this lesion to be misdiagnosedas several forms of benign and malignant neoplasms (1,2,4,7,8,13–15).The presence of collagen and reticular fibers, the tendency to recur,and the features of a larger, firmer, more deeply seated attachmentserve to distinguish sarcomas from nodular fasiciitis. For this reason,nodular fasciitis should be diagnosed as early as possible to rule outthe potential for a more serious condition.

Chromosome 15 has been identified in several cases of nodularfasciitis as the cytogenic abnormality. The region affected is involvedin the production of proteins specific to tissue repair (13). Reactive orinflammatory responses to trauma and induction by a myxoma-fibroma group of viruses in animals are 2 alternate etiologies;however, there is still no clear understanding of how this lesion isactivated (15).

A retrospective study performed in 1967 of 314 cases of nodularfasciitis demonstrated most nodules developed in the upper

Fig. 7. Cellular myxoid growth with peripheral hyalinization merging with surroundingdense fibrous tissue. (A) Cellular myxoid growth. (B) Hyalinization of spindle cells. (C)Dense fibrous tissue. Hematoxylin and eosin stain, original magnification �25.

Fig. 8. Appearance of mass on incision.

Fig. 10. Gross appearance and measurement of resected mass.

K. Khan et al. / The Journal of Foot & Ankle Surgery 51 (2012) 241–245244

extremity or on the trunk. Of the 314 cases analyzed, only 3 werefound on the foot (10). The greatest incidence was in the forearm(32%), although the lesion can occur in the fascia anywhere. Onlyslightly more than one half of the lesions (56%) were in the subcu-taneous fascia (10). Because the foot is the most important weight-bearing unit of the lower extremity, the patient will note any lesionthat interferes with its function sooner than in many other sites of thebody (16).

The lesion is usually first observed by the patient as a small noduleappearing without a definite history of trauma. Usually the patient isconcerned about the possibility of “cancer.” Many of the lesionsexhibit a duration of less than 1 week, but a few cases have beenreported to be present for up to 4 years’ duration (3,15–17).

The degree of pain must be evaluated. A history of pain only onweight bearing is compatible with benign tumors. In contrast,malignant tumors are associated with consistent pain that can wakethe patient at night (16).

Subtle microscopic differences can help distinguish this entityfrom other conditions. A working differential diagnosis is importantwhen treating with soft tissue masses, especially nodular fasciitis,which is diagnosed most often as fibrosarcoma (18).

Fig. 9. Appearance of third digit after removal of mass. Note, erosions of lateral cortex ofproximal phalanx.

Fibrosarcoma causes the most confusion; however, these massesare usually larger and longer standing than nodular fasciitis. Micro-scopically, fibrosarcomas exhibit pleomorphic nuclei, coarse andirregular chromatin, and atypical mitoses. These cells can exhibitwhat Stout termed the “herringbone pattern”: an arrangement of cellsto form fasciculated or intertwining bundles, giving the appearance ofa “fish bone” (6,7).

Liposarcomas can be distinguished from nodular fasciitis on clin-ical examination and by the gross and microscopic appearance.Clinically, these lesions are large, rarely exist in the subcutaneoustissues, and are slow growing. Histologically, vacuolated lipoblasts,and the abundance of plexiform thin-walled capillaries are evidenceagainst a diagnosis of nodular fasciitis, because these capillaries arenever as prominent as in liposarcomas (6,18).

Neurofibromas can also simulate nodular fasciitis. It is possible fornerve fibers to become entangled in nodular fasciitis; however, theproliferation of nerve fiber elements, sharply twisted spindle-shapednuclei, and wire-like bundles of collagen with small roundlymphocyte-like cells are all elements of neurofibromas (6,18).

Neurofibrosarcoma, also known as malignant schwannoma andneurosarcoma, is another distinct diagnostic challenge for thepathologist. This form of cancer arises from the connective tissuesurrounding nerves. Approximately 50% of cases have a coexistingdiagnosis of neurofibromatosis. Histologically, the pathologist mightfind evidence of adjacent neurofibromas or tissues of nerve sheath

Fig. 11. Cellular myxoid area with haphazard growth pattern (A) showing areas of spindlecell proliferation with hyalinization and myxoid changes (arrows); bland cells withoutalteration of nuclear/cytoplastic ratio, pleomorphs, and/or significant mitotic activity. Nocytologic atypia seen. Hematoxylin and eosin stain, original magnification �100.

K. Khan et al. / The Journal of Foot & Ankle Surgery 51 (2012) 241–245 245

origin. These clinical and histologic features of neurofibrosarcomahelp differentiate this malignant condition from nodular fasciitis(6,18,19).

Magnetic resonance imaging has soft tissue specificity that allowsfor the extension of the mass to be evaluated. The mass presents ina well-defined, round, or oval shape (20,21). Intramuscular subtypesappear heterogenous and hyperintense to skeletal muscle on T1-weighted images and relatively homogeneous, with a hyperintensesignal to subcutaneous fat on T2-weighted images (20–22). Subcuta-neous subtypes are typically more fibrous than the intramuscular andare hypointense to skeletal muscle on all sequences (20–22). CTcan beused for patients who cannot undergo magnetic resonance imagingand is useful in identifying calcifications or suspected boneinvolvement.

Although imaging studies are helpful in the diagnosis, a biopsy isnecessary to definitively identify themass. Microscopic findings are ofgreat importance because the histopathologic findings have so oftendeceived the pathologist into thinking that the specimen is a type ofa malignant tumor. This case was more advanced, as stated in the finalpathology report, owing to the prominent hyalinization and cysticchanges.

The lesion is quite characteristic histologically; however, thevariation in its growth pattern cause difficulty in interpretation. Stout(7), in 1961, believed that the lesion’s characteristic features alsoincluded invasion of adjacent tissue and large number of mitoticfigures. Price et al (17), later in 1961, reported a pathologic analysis of65 cases that enumerated 5 features common to all the nodules:nodular proliferation of plump to spindle-shaped fibroblasts, whichtend to be larger than normal; a stromal network of cell processes andfibers with a myxoid or serous intercellular ground substance;a vascular component of well-formed, radially arranged capillariessuggestive of a reparative process; few lymphocytes and othermononuclear cells in all cases, with multinucleated giant cells in onehalf the cases; and involvement of the superficial or deep fascia in allpatients (17). Hutter et al (23), 1 year later in 1962, observed that thenodules had finger-like extensions into surrounding tissue similar tothat seen in invasive cancer. Descriptions such as these explain howthe tumor is so often mistaken for a malignancy (23).

The treatment of nodular fasciitis is local excision of the lesion. Arecurrence rate of 1% to 2% has been reported after excision, althoughsome investigators have reported that even incompletely excisedlesions do not recur (9,20). For this reason, any recurrence afterresection should lead the clinician to seek a possible alternativediagnosis. It is for this reason that a quick and accurate diagnosis of

nodular fasciitis can rule out a host of more serious, malignantdiseases.

Acknowledgment

The authors thank Dwayne Breining, MD, Director of Pathology(North Shore Long Island Jewish–Forest Hills Hospital) for thephotomicrographs and descriptions and Joseph Santi, DPM, andAlbert Samandarov, DPM, for initial investments in this publication.

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