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Case Note

Case Note: Two Subcutaneous Nodules

History

A 61-year-old gentleman with no significant past medical history presented with two subcutaneous nodules that had been present on the right flank for over 10 years. He reports that the lesions have been slowly enlarging but are asymptomatic. At this point, due to their size, he would like to have them removed.

Initial evaluation

Physical examination revealed two adjacent subcutaneous nodules of the superior and inferior aspect of the right flank respectively (Figure 1).

  • The upper lesion measured approximately 8 cm and was rubbery and movable
  • The lower lesion measured approximately 5 cm and was similarly rubbery and movable

 

  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

Prior to histopathalogic identification, a presumptive diagnosis of lipoma was made and excision pursued.

Initial Treatment

A window of skin was excised above each lesion. A search for the largest lesion first failed to reveal the lesion in the fat, but it was palpably deeper. A small knick was made through superficial muscle and a large firm white mass was extruded (Figure 2). When cut, mucin was expressed. Although the lesion was movable and compressible, it clearly had deep attachments. The lesion was cut - satisfactorily debulking it - and the skin closed (Figure 3).

 

  • Image 1
    Image 1
  • Image 2
    Image 2.

Follow-up evaluation strategy

It was decided to delay removal of the second lesion until histopathologic identification of the mass could be performed. Pathology revealed an elastofibroma. In this case, what seemed to be an obvious common lipoma was in fact arare elastofibroma, made all the more unusual by its location off the scapula.

General discussion

This is a rare reactive tumor-like growth typically seen in the subscapular region, arising in the connective tissue between the lower end of the scapula and the chest wall. Usually, these lesions measure between 5-10 cm and are thought to be a reactive process from friction. They are harmless but persistent, and if troubling to the patient, are cured by surgical excision.

Although elastofibroma dorsi is regarded as uncommon, a prevalence rate of 2% in people over 60 years has been reported in a CT study,1 and one autopsy study found a prevalence of 24% in women and 11% in men.2

Imaging studies can be useful for diagnosis - ultrasound can show an alternating pattern of fasciculated type or laminar, hypo-and hyperechoic lines parallel to the chest wall, and the Doppler signal is usually negative, demonstrating the absence of intrinsic vascularity. These data are usually sufficient to make a diagnosis.3-5

Further reading

Demis DJ: Clinical Dermatology. J.B.Lippincott Company. Philadelphia. U.S.A. 19th revision edition. (1998).

Muramatsu K, Ihara K, Hashimoto T, Seto S, et al. Elastofibroma dorsi: Diagnosis and treatment. J Shoulder Elbow Surg. 2007;16(5):591-5.

Hayes AJ, Alexander N, Clark MA, Thomas JM.. Elastofibroma: a rare soft tissue tumour with a pathognomonic anatomical location and clinical symptom. Eur J Surg Oncol. 2004;30(4):450-3.

Parratt MT, Donaldson JR, Flanagan AM, et al. Elastofibroma dorsi: management, outcome and review of the literature. J Bone Joint Surg Br. 2010;92(2):262-6.

 

References

  1. Brandser EA, Goree JC, El-Khoury GY. Elastofibroma dorsi: prevalence in an elderly patient population as revealed by CT. AJR Am J Roentgenol. 1998;171:977-80.
  2. Järvi OH, Länsimies PH. Subclinical elastofibroma in the scapular region in an autopsy series. Acta Pathol Microbiol Scand A. 1975;83:87-108.
  3. Cavallasca JA, Sohn DI, Borgia AR, et al. Elastofibroma dorsi: revisión de 4 casos. Reumatol Clin. 2012; 8(6):358-36.
  4. Battaglia M, et al. Imaging patterns in elastofibroma dorsi. Eur J Radiol. 2009;72:16-21.
  5. Bianchi S, Martinoli C, Abdelwahab IF, et al. Elastofibroma dorsi: sonographic findings. AJR Am J Roentgenol. 1997;169:1113-5.

 

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