Imaging study findings in elastofibroma dorsi

doi:10.1016/j.jbspin.2004.04.006

Joint Bone Spine

Volume 71, Issue 6, November 2004, Pages 536-541

https://doi.org/10.1016/j.jbspin.2004.04.006 Get rights and content

Abstract

Elastofibroma dorsi is a tumor or pseudotumor typically located under the tip of the scapula. It is far from uncommon in older individuals. The mass contains both fibrous tissue and fatty tissue. Imaging studies can provide the definite diagnosis in many cases. Computed tomography (CT) and magnetic resonance imaging (MRI) are particularly effective, as they visualize the characteristic layered pattern of fatty tissue (low-density by CT, high-signal on T1 images and intermediate signal on T2 images by MRI) and fibrous tissue (similar to muscle in terms of density by CT and signal intensity by MRI). To a lesser extent, plain radiographs and ultrasonography identify a number of suggestive features (location and layered structure). When the lesion exhibits typical imaging features and produces no symptoms, as is usually the case, further investigations are probably unnecessary.

Introduction

Elastofibroma is a benign tumor or pseudotumor whose distinctive histological features and anatomic location can be readily recognized by imaging studies. The appearance by magnetic resonance imaging (MRI) and computed tomography (CT) is often typical, obviating the need for a biopsy [1]. Ultrasonography and plain radiography may also contribute to the diagnosis. However, physicians should be aware of the clinical manifestations, as these are often virtually pathognomonic, so that imaging studies merely serve to confirm the diagnosis.

Section snippets

Histological features

As indicated in the initial description by Järvi and Saxén [2], elastofibromas exhibit a characteristic structure in which streaks of fatty tissue alternate with strands of fibrous tissue (Fig. 1). This structure reflects the genesis of elastofibromas, which involves overproduction of collagenous connective tissue alternating with deposition of fat [3], [4]. The hypertrophic fibrous tissue contains fibrillar material whose staining affinities are identical to those of elastin fibers

Epidemiology

Elastofibromas are slow-growing lesions that develop in a highly characteristic anatomic location. Their prevalence is relatively high among older individuals. Nagamine et al. [4] reported a study of 170 cases in the Okinawa area of Japan, whereas most of the other publications report single cases [5], [6], [7], [8], [9], [10], [11] or small series of two to five cases [12], [13], [14], [15], [16], [17]. The highly distinctive features of elastofibroma were documented consistently in all these

Clinical features and treatment

The lesions are asymptomatic in over 50% of the cases [4], [11], [19]. When symptoms are present, they are usually mild, consisting of a swelling, clunking of the scapula on moving the shoulder, or moderate pain; severe pain is uncommon [4], [19], [21], [23]. A wait-and-see approach is appropriate in patients with no symptoms. When the symptoms are sufficiently bothersome to warrant surgery, marginal resection is sufficient, as recurrences are exceedingly rare [17] and malignant transformation

Pathogenesis

The location of elastofibromas and their predominance among older individuals militate against a neoplastic mechanism and strongly suggest a reactive process in response to rubbing of the scapula against the ribs [3], [11]. The reactive process combines a hyperplastic response, degeneration of collagen fibers, and overproduction of immature elastic tissue derived from fibroblasts [23]. Genetic factors may also be involved, as high prevalences of elastofibroma have been noted in specific

Magnetic resonance imaging

MRI is undoubtedly the investigation of choice, as it clearly shows the alternating pattern of fibrous tissue and fatty tissue, as well as the highly characteristic location of the mass (Fig. 2). The margins may be sharp or indistinct [17] and the mass itself is heterogeneous. On T1-weighted and T2-weighted sequences, the fibrous tissue produces low-intensity signal nearly identical to that generated by the muscle. The low signal on T2 images is ascribable to the scarcity of cells and abundance

Computed tomography

The findings are the same as with MRI: the mass may have indistinct or sharp contours [13] and is composed of fibrous tissue having the same density as muscles alternating with streaks of tissue of fat density [1], [9], [10], [12], [21] (Fig. 4). After injection of an iodinated contrast agent, the density of the mass remains virtually unchanged [14].

CT is less sensitive than MRI for visualizing the streaks of fatty tissue, so that the elastofibroma may be seen as a nearly homogeneous mass whose

Ultrasonography

Ultrasonography shows an abnormal mass of tissue in a location typical for elastofibroma. Technological improvements have improved the ability of ultrasonography to visualize the typical layered structure. Typically, an alternating pattern of hyperechoic and hypoechoic lines that are roughly parallel to the chest wall is seen in all or part of the mass [12], [26] (Fig. 5).

Plain radiography

Although the value of plain radiography for the diagnosis of elastofibroma has been described as limited [21], the finding of a tissue mass that lifts the inferior pole of the scapula away from the ribs is highly suggestive. In addition, plain radiographs show that there are no bone abnormalities adjacent to the mass. In addition, high-quality plain radiographs may show linear streaks of tissue having the density of fat [10], [12] (Fig. 6).

Conclusion

The diagnosis of elastofibroma is readily established provided the physician is familiar with the typical features and seeks them routinely. A mass composed of alternating strands of fatty and fibrous tissue is pathognomonic if it is located at the inferior pole of the scapula. Thus, the definitive diagnosis can be made by MRI (the investigation of choice), CT, or even ultrasonography or plain radiography. A bilateral distribution is an additional argument in favor of elastofibroma.

The clinical

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Cited by (64)

Elastofibroma dorsi: Diagnosis and follow-up in primary care
2023, Semergen
Presentar una serie de pacientes con elastofibroma dorsi (ED) para recordar la patología y justificar su manejo diagnóstico y terapéutico en el ámbito de la atención primaria.
Estudio retrospectivo observacional y longitudinal de 12 pacientes con 18 ED. Se analizaron las características epidemiológicas, clínicas y de imagen. Los resultados del tratamiento se evaluaron atendiendo al dolor (escala EVA), la función del hombro (escala de Constant y Murley) y la calidad de vida (escala EuroQol-5 dimension [EQ-5D]). El tiempo medio de seguimiento de los casos fue de 60,5 meses (5 años, RIC: 1-161 meses).
Seis pacientes fueron hombres y seis fueron mujeres, con edad media al diagnóstico de 59 años. El diagnóstico de sospecha en todos los casos fue clínico y de imagen. Solo tres precisaron intervención quirúrgica. Los resultados de todos fueron satisfactorios.
Tanto el diagnóstico como la indicación del tratamiento de un ED puede hacerse en el ámbito de la atención primaria. En los casos típicos, que son mayoría, la historia clínica y una ecografía permiten un diagnóstico de certeza. La indicación terapéutica conservadora o quirúrgica depende de la decisión del paciente informado. Cuando existen dudas diagnósticas o el paciente desea la resección quirúrgica de la tumoración, habría que derivar al paciente al especialista hospitalario.
To present a series of patients with elastofibroma dorsi (ED) in order to recall the pathology and justify its diagnostic and therapeutic management in the primary care setting.
Retrospective observational and longitudinal study of 12 patients with 18 ED. Epidemiological, clinical and imaging characteristics were analysed. Treatment outcomes were assessed in terms of pain (VAS scale), shoulder function (Constant and Murley scale) and quality of life (EuroQol-5 dimension scale, EQ-5D). The mean follow-up of the cases was 60.5 months (5 years, range 1-161 months).
Six patients were male and six were female, with a mean age at diagnosis of 59 years. The diagnosis of suspicion in all cases was based in clinical and imaging findings. Only three required surgery. The results of all were satisfactory.
Both the diagnosis and the indication for treatment of an ED can be made in the primary care setting. In typical cases, which are the majority, the clinical history and an ultrasound study allow a diagnosis of certainty. The indication for conservative or surgical treatment depends on the informed patient. When there are diagnostic doubts or the patient wishes surgical resection of the tumour, the patient should be referred to a hospital specialist.
Prevalence of elastofibroma dorsi on CT: Is it really an uncommon entity?
2019, Acta Orthopaedica et Traumatologica Turcica
The aim of this study was to determine the prevalence, demographic data of elastofibroma dorsi (ED) in adult population who had undergone chest CT examination and to discuss clinical, and radiological presentations, and treatment options of ED.
We retrospectively reviewed 4074 chest CT examinations for ED from July 2014 to April 2015. Lesion size, side, and patient demographics were analyzed for positive cases of ED. The initial radiology reports of patients with ED were also reviewed.
Of the 4074 patients, 111 patients (2.73%) (77 women and 34 men; mean age: 68.2 years; range: 35–91 years) had a total of 168 ED. The females had a 1.96 -fold higher prevalence of ED than the males (OR, 1.96; 95% CI, 1.481–2.59). The mean lesion thickness was found to be significantly greater in the female patients compared with the male patients (p = 0.001). The prevalence of the disease was estimated to be 4.98 times higher in patients aged 65 years or older (CI 95%, 3.25–7.36). In 111 ED patients, the lesions were only noted in 9 patients' initial radiology report.
Here, we present a prevalence study with the largest population in the literature concerning ED. Our study shows that ED is not as uncommon as previously thought and should be especially suspected in females and older age groups.
Level IV, Diagnostic Study.
Elastofibroma dorsi: Clinical evaluation of 61 cases and review of the literature
2017, Acta Orthopaedica et Traumatologica Turcica
Elastofibroma dorsi (ED) is a rare, benign, soft tissue tumor typically located between inferior corner of scapula and posterior chest wall causing mass, scapular snapping, and pain. When classic symptoms and localization are present, it is diagnosed without biopsy and treated with marginal resection. This study retrospectively analyzed patients operated on for ED to evaluate presenting symptoms, tumor size, complications, and clinical results, and to suggest optimal treatments.
This study included 51 patients who underwent surgery for ED in 2 different clinics between 2005 and 2015. Patient age, gender, profession, side affected, symptoms, average duration of symptoms, and tumor size were researched. Radiological examinations of patients were evaluated. Patients with lesions larger than 5 cm in size were operated on. Postoperative complications, recurrence, and functional results were evaluated using Constant score and compared to preoperative values.
A total of 61 operated lesions of 51 patients clinically and radiologically diagnosed with ED were retrospectively evaluated. Average length of time patient experienced symptoms was 11.21 months. Lesions in 19 (37.2%) patients were bilateral, 10 of which were symptomatic and larger than 5 cm in size, meeting indication for surgery. Average lesion diameter was 8.7 cm. Average follow-up was 26.89 months. Average of preoperative Constant score of 67.28 subsequently increased to 92.88 (p < 0.05). Seroma and hematoma were observed in 11.5% of patients.
Generally, good clinical results can be obtained with marginal resection without requiring a biopsy, considering classic complaints and radiological appearance of ED.
Level IV, Therapeutic study.
Elastofibroma dorsi: A case report of extra-osseous uptake of <sup>99m</sup>Tc-HMDP
2015, Medecine Nucleaire
L’élastofibrome dorsal est une tumeur des tissus mous de la femme âgée majoritairement localisée dans la région subscapulaire. Cette tumeur est bien connue des médecins nucléaires pour être modérément hypermétabolique en TEP/TDM au ¹⁸F-FDG. Nous rapportons le cas d’une patiente de 64 ans adressée pour un bilan d’extension initial osseux d’un cancer du sein. Dans un contexte d’hyperparathyroïdie primaire, la scintigraphie osseuse révéla une accumulation de ^99mTc-HMDP au sein d’un élastofibrome subscapulaire droit. Le diagnostic fut confirmé par IRM. Après chirurgie parathyroïdienne et mammaire, le contrôle de la scintigraphie osseuse ne retrouvait aucune anomalie dans la région subscapulaire droite.
Elastofibroma dorsi is a soft tissue tumor occurring most frequently in the subscapular region in elderly women. It is well known in ¹⁸F-FDG PET/CT to be moderately hypermetabolic. We report the case of a 64-year-old woman referred for the bone staging of her breast cancer. In the context of primary hyperparathyroidism (parathyroid adenoma), the Tc-99m-bisphosphonate bone scintigraphy revealed a right subscapular elastofibroma dorsi uptake. The diagnosis was confirmed by MRI. After parathyroidectomy and mastectomy the second bone scan exhibited complete disappearance of this uptake when calcium and PTH blood rates were normal.
An unusual cause of shoulder pain
2015, Indian Journal of Rheumatology
Dorsi elastofibroma. About 14 cases, and review of the literature
2014, Annales de Chirurgie Plastique Esthetique
L’élastofibrome dorsal est une tumeur bénigne siégeant le plus souvent au niveau des tissus mous périscapulaires de la paroi thoracique postérieure. Nous rapportons une série rétrospective de 14 cas d’élastofibromes dorsaux, chez neuf patients, pris en charge en chirurgie plastique, viscérale et orthopédique. L’âge moyen était de 67 ans. Cinq patients présentaient des lésions bilatérales. Toutes les lésions siégeaient dans la région sous-scapulaire. Neuf lésions ont été retirées chirurgicalement et six épaules sont asymptomatiques après la chirurgie. L’élastofibrome dorsal est une lésion rare, d’évolution lente. On le trouve le plus souvent chez les patients d’âge mûr. L’étiopathogénie de cette lésion est pour l’instant mal définie. L’imagerie par scanner ou IRM permet de poser le diagnostic d’élastofibrome dorsal, et peut permettre, dans les cas asymptomatiques et typiques, d’éviter la biopsie et la chirurgie. Seuls les cas symptomatiques doivent être opérés.
Elastofibroma dorsi is a benign tumor which usually occurs at the inferior angle of the scapula. We retrospectively reviewed 14 cases of elastofibroma dorsi, in nine patients. The patients were hospitalized in the departments of plastic surgery, orthopedic surgery or visceral surgery. Mean age was 67 years. The location of the lesions (bilateral in five patients) was typical, in the thoracoscapular region. Nine lesions were removed surgically, six shoulders were asymptomatic after surgery. Elastofibroma is a rare, slow-growing lesion. It occurs in connective tissue of the infrascapular region of elderly patients. The pathogenesis of the lesion still remains unclear. MRI and computed tomography are useful for assessment of elastofibroma dorsi, and can potentially help avoid the need for unnecessary biopsy and surgery, especially in the asymptomatic patient. It should be surgically removed only in symptomatic patients.

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ReviewImaging study findings in elastofibroma dorsi

Abstract

Introduction

Section snippets

Histological features

Epidemiology

Clinical features and treatment

Pathogenesis

Magnetic resonance imaging

Computed tomography

Ultrasonography

Plain radiography

Conclusion

Eur J Surg Oncol

Pseudotumeurs des parties molles

Encycl Méd Chir, Radiodiagnostic–Neuroradiologie–Appareil locomoteur

Elastofibroma dorsi

Acta Pathol Microbiol Scand

Subclinical elastofibromas in the scapular region in an autopsy series

Acta Pathol Microbiol Scand

Elastofibroma in Okinawa. A clinicopathologic study of 170 cases

Cancer

Elastofibroma: chest wall pseudotumor

Radiology

Case report 583

Skeletal Radiol

MR appearance of bilateral periscapular elastofibromas

J Comput Assist Tomogr

Elastofibroma dorsi: CT, MR and pathologic study in a new case

JBR-BTR

Elastofibrome sous-scapulaire: diagnostic IRM

Rev Im Med