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CASE REPORT
CytoJournal 2008,  5:14

Nodular fasciitis of the external ear masquerading as pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology


Department of Pathology, Maulana Azad Medical College, New Delhi, India

Date of Submission22-Aug-2008
Date of Acceptance20-Oct-2008
Date of Web Publication26-Nov-2008

Correspondence Address:
Shyama Jain
Department of Pathology, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1742-6413.44242

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 » Abstract 

Background: Nodular fasciitis (NF) is a benign myofibroblastic proliferation in soft tissue. The most common sites are extremities, followed by the trunk and head and neck region. It is infrequently seen in the post-auricular region of pinna. Case presentation: We present here an interesting case of a young male who had a swelling in the post-auricular region; on cytology, it was diagnosed as pleomorphic adenoma; however, biopsy revealed characteristic morphology of NF. Conclusion: The case highlights the potential pitfall of cytology in diagnosing NF, especially because of unusual site and morphologic overlap.


Keywords: Cytology, nodular fasciitis, pleomorphic adenoma, post-aural region


How to cite this article:
Jain D, Khurana N, Jain S. Nodular fasciitis of the external ear masquerading as pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology. CytoJournal 2008;5:14

How to cite this URL:
Jain D, Khurana N, Jain S. Nodular fasciitis of the external ear masquerading as pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology. CytoJournal [serial online] 2008 [cited 2017 Oct 18];5:14. Available from: http://www.cytojournal.com/text.asp?2008/5/1/14/44242


Nodular fasciitis (NF) was originally described by Konwaler et al. and is synonymous with pseudosarcomatous fasciitis. [1] These lesions are mostly located in the soft tissues of the forearm, followed by trunk and head and neck. [2] It is extremely rare in the external ear. Although there are a few histological reports on NF involving the post-auricular region, published cytological literature is too scanty, and NF may be confused with other neoplastic lesions of the salivary gland. [3,4]

We report here an interesting case of an adolescent boy who presented with a swelling in the post-auricular region; and on cytology, it was diagnosed as pleomorphic adenoma (PA); however, the histological diagnosis of classical NF was a surprise. The case is presented to highlight the diagnostic pitfall of cytology.


 » Case presentation Top


A 16-year-old adolescent boy presented with a swelling in the post-auricular region, slowly increasing in size for the past 6 weeks. On examination, the swelling was nontender, nonfluctuant, smooth, soft to firm with well-defined margins and measuring 1.5 cm in diameter. Clinical diagnosis of sebaceous cyst was considered, and the patient was referred for fine needle aspiration cytology (FNAC).


 » Cytological findings Top


FNA smears showed moderate cellularity comprising of predominantly dissociated round-to-plasmacytoid cells with central-to-eccentric nuclei, occasional binucleated cells, and few spindle cells. A fair number of spherical and linear deep magenta-colored stromal fragments surrounded by similar cells were also seen. The background was pale mucoid. There was no pleomorphism and necrosis; however, occasional typical mitosis was noticed [Figure 1]. A cytological diagnosis of PA was suggested, although a possibility of skin adnexal tumor was also considered as the swelling was involving the external ear.


 » Histological findings Top


Subsequently, total excision of the mass was performed for histological correlation. Gross examination showed a well-circumscribed, unencapsulated gray-white soft tissue mass measuring 1.5×1 cm in size. Histologically, the lesion comprised of proliferating but uniform-appearing plump fibroblasts arranged loosely in short fascicles, bundles, and vague storiform patterns. The background stroma was variably collagenous. Few mitotic figures and extravasated red blood cells were also noted [Figure 2]. In view of these findings, a histological diagnosis of nodular fasciitis of external ear was established.


 » Immunohistochemical studies Top


A panel of immunohistochemical (IHC) markers for cytokeratin (CK), epithelial membrane antigen (EMA), S-100, smooth muscle actin (SMA), and vimentin (Vim) was performed by Avidin-Biotin complex (ABC) method. On IHC study, CK, EMA, and S-100 were negative, and SMA and Vim were focally expressed, thus confirming the diagnosis of NF.

FNA smears reviewed after histological diagnosis of NF for the overlapping features of NF and PA [Table 1], [Figure 1] were found consistent with the final diagnosis of NF.


 » Discussion Top


Nodular fasciitis is a relatively common soft tissue tumor; it occurs more frequently than most other tumors or tumorlike lesions of fibrous tissue that develop in adults. [1] Although several mechanisms are proposed including reactive or inflammatory process, the pathogenesis of NF is still unknown. Antecedent trauma has been suggested as an inciting factor. [5] We did not find such history in our patient. Although the most common site is upper extremity, it may arise from the subcutaneous tissue, muscle, or fascia at any location in the body. [2] It is rare in the external ear and hence is usually not considered in the differential diagnosis (D/D) of lesions in the pinna. [6] Interestingly, cases in the head and neck region often involve dermal tissue [7] ; the present case also demonstrated dermal NF. Thompson et al. studied clinico-pathological features in the largest series of 50 cases of NF in the region of external ear, including 28 dermal variants. In the auricular area, it occurs most often in young patients. [6] Usually, the lesion is smooth and may present sometimes with superficial ulceration also. Since our patient had a mass lesion in the post-auricular region, it was diagnosed as benign mixed tumor of the salivary gland or skin based on cytomorphological features.

Dahl and Ackerman first documented the correlation between FNAC and histologically confirmed cases of NF. [8] Aydin et al. further supported its cytological diagnosis. [9] Morphologically on both cytology and histology, NF may be easily mistaken for malignant neoplasm of spindle cells, tumors of salivary gland and skin with similar morphology, leading to unnecessary surgical treatment. The wide spectrum of morphological patterns of PA often presents a potential for errors in cytological interpretations. [10] The common morphological features shared by both PA and NF are spindle and plasmacytoid cells with central-to-eccentric nuclei, clumps of intercellular stromal material, and myxoid background. Mitotic figures are frequent in most cases of NF but sparse in cases of PA. [3] The present case was misdiagnosed as PA based on cytomorphological overlap and occurrence at an unusual site. The smear in the present case was carefully compared and evaluated after the histological diagnosis of NF, for detailed morphological features of classical PA and NF [Table 1]. On review of the smears, an important feature was noticed - that the spindle and plasmacytoid cells had fuzzy cytoplasmic borders, one-to-multiple fragile cytoplasmic processes, and prominent nucleoli similar to ganglionlike cells of NF [Figures 1a-1c]. In contrast, cells in PA show well-demarcated cytoplasmic borders and indistinct nucleoli [Figure 1d], in addition to other features which are helpful in differentiating NF from PA [Table 1].

Spontaneous regression is known to occur in NF even without excision. Local recurrences are more frequent in these cases because of the difficulty in obtaining complete surgical excision around the ear; rarely, frequent recurrences may transform the lesion to fibrosarcoma. [6]

To conclude, preoperative cytological diagnosis of NF is important to avoid unnecessary surgery in most cases. Although site and overlapping morphology can mislead the cytologist, leading to a diagnostic pitfall, a careful evaluation of certain morphological features may help in making a definitive diagnosis of NF.


 » Competing interests Top


Authors do not have competing interests in this case.


 » Authors' contributions Top


DJ, assistant professor, collected the literature and helped in drafting of the manuscript.

NK, professor, helped in the histological evaluation of the case.

SJ, professor, helped in the final revision and approval of the version for publication.

All authors read and approved the final manuscript.

 
 » References Top

1.Konwaler BE, Keasbey L, Kaplan L. Subcutaneous pseudosarcomatous fibromatosis (fasciitis). Am J Clin Pathol 1955;25:241-52.  Back to cited text no. 1    
2.Shimizu S, Hashimoto H, Enjoji M. Nodular fasciitis: An analysis of 250 patients. Pathology 1984;16:161-6.  Back to cited text no. 2    
3.Saad RS, Takei H, Lipscomb J, Ruiz B. Nodular fasciitis of parotid region: A pitfall in the diagnosis of pleomorphic adenomas on fine needle aspiration cytology. Diagn Cytopathol 2005;33:191-4.  Back to cited text no. 3    
4.Mardi K, Sharma J, Kaur H. Nodular Fasciitis of the hand: A potential diagnostic pitfall in fine needle aspiration cytology. J Cytol 2007;24:197-8.  Back to cited text no. 4    Medknow Journal
5.Graham BS, Barrett TL, Goltz RW. Nodular fasciitis: Response to intralesional corticosteroids. J Am Acad Dermatol 1999;40:490-2.  Back to cited text no. 5    
6.Thompson LD, Fanburg-Smith JC, Wenig BM. Nodular fasciitis of the external ear region: A clinicopathologic study of 50 cases. Ann Diagn Pathol 2001;5:191-8.  Back to cited text no. 6    
7.Nishi SP, Brey NV, Sanchez RL. Dermal nodular fasciitis: Three case reports of the head and neck and literature review. J Cutan Pathol 2006;33:378-82  Back to cited text no. 7    
8.Dahl I, Akerman M. Nodular fasciitis: A correlative cytologic and histologic study of 13 cases. Acta Cytol 1981;25:215-23.   Back to cited text no. 8    
9.Aydin O, Oztuna V, Polat A. Three cases of nodular fasciitis: Primary diagnosis by fine needle aspiration cytology. Cytopathology 2001;12:346-7.  Back to cited text no. 9    
10.Boccato P, Altavilla G, Blandamura S. Fine needle aspiration biopsy of salivary gland lesions: A reappraisal of pitfalls and problems. Acta Cytol 1998;42:888-98.  Back to cited text no. 10    


    Figures

  [Figure 1], [Figure 2], [Figures 1a-1c], [Figure 1d]
 
 
    Tables

  [Table 1]

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