Nodular Fasciitis - Explained by a Soft Tissue Pathologist

A complete organized library of all my videos, digital slides, pics, & sample pathology reports is available here: kikoxp.com/posts/5084 (dermpath) & kikoxp.com/posts/5083 (bone/soft tissue sarcoma pathology).
A discussion of the histopathologic, clinical, and molecular features of nodular fasciitis.
Please check out my Soft Tissue Pathology & Dermatopathology survival guide textbooks: bit.ly/2Te2haB
This video is geared towards medical students, pathology or dermatology residents, or practicing pathologists or dermatologists. Of course, this video is for educational purposes only and is not formal medical advice or consultation.
Presented by Jerad M. Gardner, MD. Please subscribe to my channel to be notified of new pathology teaching videos.
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[@JMGardnerMD]

A complete organized library of all my videos, digital slides, pics, & sample pathology reports is available here: kikoxp.com/posts/5084 (dermpath) & kikoxp.com/posts/5083 (bone/soft tissue sarcoma pathology).

[@hinamaqbool8937]

Thankyou for being such a great teacher. Lots of prayers for you.

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[@TamNguyen-te1tk]

The way you emphasize the myxoid breakdown made me laugh out loud, even in the middle of the night. :D . Thank you very much!

[@piyalipodder6418]

Very useful video. I am a pathology resident from India, and soft tissue tumours appears to be the most confounding of all. So make more videos like this. It helps a lot.

[@shomaniv]

Dear Dr.Jerad Gardner, Thank you so much for your efforts in teaching...not only you make it interesting but at the same time you’re making us better diagnosticians and improving the patient management worldwide...learning through these videos has revolutionised the way we are learning ... you show so many slides and variations of any topic that it makes us more wiser in just couple of minutes which otherwise will take many years in real practice. Best wishes for you Sir. Regards

[@JMGardnerMD]

Thank you! I'm so glad I can help.

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you do not know how thankful i'm you r doing a very great job for the people of the pathology community at various levels.

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Thanks for the teaching. Im resident in pathology here in Brazil, and i find your videos very helpful and instructive.

[@shamsdarbar6492]

Thank you very much, your videos are great. I read the subject first and than I watch your videos which provide me with basis to be able to review some other pathologist lectures or conferences on youtube. your video helps a lot.

[@beelee87]

Thank you so much for the videos! I am slowly watching all your skin & soft tissue videos and they are invaluable!

[@JMGardnerMD]

Glad you like them! I also have 2 survival guide books on these topics. Soft tissue (written with Drs. Alisha Ware and Liz Montgomery): www.innovativepathologypress.com/product-page/survival-guide-to-soft-tissue-pathology. And dermpath (in press...will be out in August): www.innovativepathologypress.com/product-page/survival-guide-to-dermatopathology.

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As always, a very very good exposition!

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Very clear and amazing explanation. Thank you !

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Thank you very much Dr. Gardner; that's awesome!

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Very helpful. Concise and easy to understand and remember

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I am working in clinical patology in Sweden. The video is helpful.

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Great video! I can't wait for more.

[@Aashi429]

Very useful for residents, thanks

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Very helpful teaching sir.

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Wonderful explanation sir

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It's clear now.... Thank you ☺️ sir.

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Very helpful. Thanks

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Clear explanation.

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AOTA very good presentation I will suggest residents to see and get useful knowledge

[@user-mn2tg5fo7p]

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[@rabih10201]

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[@twotinysisters]

Superb sir

[@raginithapa833]

VERY NICE VIDEO

[@aakrutishah-5635]

Tysm for the video! How to differentiate Inflammatory myofibroblastic tumor from nodular fasciitis??

[@JMGardnerMD]

Video (IMT 101): kikoxp.com/posts/4255

[@frankrobert9199]

great

[@shomaniv]

Thank you Dr,Gardner....I often refer your videos whenever I want to study these often confusing topics. I wanted to ask a question which is as follows...is there a difference between myositis ossificans and the ossifying variant of NF or are they both same? Thanks and Regards, Nivedita

[@JMGardnerMD]

I think of them as essentially the same disease occurring at different sites/depths.

[@shomaniv]

@@JMGardnerMD Thank you so much for your kind reply...I have another small doubt sir...are there situations when pustular lesions and inflammatory vesicobullous lesions can be confused...like Dermatitis herpetiformes and AGEP? Thanks

[@JMGardnerMD]

Oh yes definitely. Pustules and blistering diseases can have overlapping features. A pustule is essentially a small blister (vesicles) filled with neutrophils.

[@shomaniv]

@@JMGardnerMD Thank you very much Dr.Gardner

[@bittu1857]

Amazing :)

[@GatlingHawk]

i had one of these. painfull af

[@LOLsaudi]

THE BEST

[@brirousseau7286]

How commonly do these occur in the breast? Are they likely to recede on their own, or do they require surgical removal?

[@JMGardnerMD]

Yes they do occur in the breast sometimes. But the only way to definitely make the diagnosis is to have a biopsy performed and looked at by a pathologist under the microscope As there are many other breast masses that could look just like nodular fasciitis clinically. They all present as a palpable mass (a lump you can feel with your fingers). If it is truly nodular fasciitis, then yes usually It will recede on its own eventually. Although sometimes the patient and surgeon decide to remove it upfront rather than to wait. If you are a patient with a mass in your breast, it is absolutely essential to see your doctor about it. It may be benign, but it’s important to have it worked up appropriately to be sure. They may send you for a mammogram and/or have you consult with a breast surgeon to decide if the mass is suspicious and needs a biopsy or can be watched and followed. Doctors who are experts in breast disease have specialized algorithms for figuring out how risky they think a breast mass is. But there is no way that a patient can know if their own breast mass is risky or not. So if you have a lump or mass, be sure to see your doctor as soon as possible so they can look into it. Do not just wait to see if it goes away on its own. Best wishes.

[@ncorry8491]

Thanks again another fantastic video. I was wondering about the term stellate cells @3:10, does it mean the cells are becoming less spindles and more triangle like? Could you perhaps do a short video on stellate cells in general, googling Stellate shows images of hepatic stellate cells. Sorry to be a pain , maybe you could do a mini series on morphological descriptive terms?

[@ncorry8491]

I see this is already covered in your proliferative fascitis video!

[@JMGardnerMD]

Yes I regard stellate as meaning triangular cells. Not truly star shaped as the term implies.

[@drsuryakumarbera4273]

Thank you for such a beautiful presentation as always. We Pathologists are eternally indebted to you for all your endeavours of spreading knowledge. It really inspires us. Just one point I would like to ask. They say Nodular fascitis is rarely associated with any known recent or past trauma but proliferative fascitis is more commonly may be traced to history of trauma. So proliferative fascitis and myositis are reactive proliferation and nodular fascitis is transient neoplasm as it is associated with the recurrent translocation of t(17:22) resulting in MYH9 and USP 6 fusion, as u mentioned. Then, how they are related to each other? Are they totally different entities apart from being the namesake? Regards. Dr Surya Kumar Bera India

[@JMGardnerMD]

I don’t know the answer to that for sure. Some cases of proliferative fasciitis are trauma related but I don’t think all of them are. And they definitely have a background that resembles nodular fasciitis but I’m still unclear as to the molecular findings.

[@SOURAVEMEL]

I just had one of these removed from my foot.

[@aakrutishah-5635]

I had a case with spindle cell proliferation in oral cavity..like a huge 4-5 cm pedunculated mass.. showing few mitotic figures…was SMA, desmin positive… negative for CK, p63, p40 (did those because Sarcomatoid carcinoma was one of my 1st differentials considering oral cavity having spindle cell looking picture), CD34, S100, Myogenin, MyoD1, h caldesmon, b catenin everything negative… was really wondering what lesion could this be? Myofibroblastic origin (but desmin positive??) ..May be IMFT??? Not smooth muscle tumor ( because h caldesmon was negative) … how often have you seen nodular fasciitis in oral cavity..growing like a proper peductulated mass??? Also how extractly do u score Ki 67 positivity??

[@JMGardnerMD]

I have not seen nodular fasciitis present that way to my recollection. But I suppose it is possible. Desmin is usually negative in Myofibroblastic lesions but sometimes can be positive. I don’t use caldesmon very often, but I don’t think it is a perfect discriminator between smooth muscle and myofibroblasts. I usually use H&E morphology as most important feature to distinguish between smooth muscle and myofibroblastic. I don’t know how to meaningfully score Ki- 67 for nodular Fasciitis (or most soft tissue tumors) therefore I rarely use it for spindle cell tumors. Because I don’t know what the results actually mean. One exception is when I see a tumor that has a lot of pleomorphism but no we’re very few mitoses and I am thinking that it might be a benign tumor with degenerative nuclear atypia mimicking malignancy. Sometimes I will do Ki- 67 in that setting and then, if it is very low, that makes me feel reassured that it may be a benign tumor. But I am only using it as an additional tool on top of my H&E impression and other work up. I don’t rely on that stain by itself for diagnosis in soft tissue pathology. And for tumors with many mitoses I don’t see the point of doing Ki-67 because I already know that it will be high.!Sometimes I see pathologist do Ki-67 stain on high-grade sarcomas with numerous mitoses and necrosis…that seems totally pointless to do that as I know it will be highly proliferative already just by looking at H&E.

[@aakrutishah-5635]

I completely agree that you most of the times give your diagnosis based on h & e… meaning I really struggle with soft tissue lesions.. all almost looks same.. spindle cell lesions with fascicles… few features here & there.. and this makes soft tissue lesions most difficult for me… but you are really really a great, experienced pathologist.. like most of the times, for your cases, you give diagnosis based on H & E ..That’s a great great skill!😍

[@aakrutishah-5635]

Are there any specific ihc marker to distinguish smooth muscles & Myofibroblasts??

[@oldmanlolipawp5809]

Came from dr.Sandra Lee :)

[@user-rf8xh2jy2e]

What dose plump spindle cell mean?

[@JMGardnerMD]

Nuclei are thick or wide (opposite of thin). Sometimes they have more cytoplasm too. I’m sorry I don’t have the right words to explain. French pathologists sometimes use “joufflu” (“chubby” in English) for cells that I would describe as “plump”. Does that help?

[@ddscanine]

What's meant by 'transient neoplasm'? ... can neoplasms be transient or self-limiting in any aspect?! It will no longer be regarded as neoplasms then!

[@JMGardnerMD]

That's a great question! It sounds crazy, right? It's a paradox that is hard to wrap one's mind around. But we do see other neoplasms that grow and then regress (e.g. - keratoacanthoma, infantile hemangioma). We try to put neoplasms into simple easy to understand boxes, but the more we study them, the more we realize that they are a lot more complicated than they may seem at first! Here's a paper that addresses the idea of transient neoplasia in regards to nodular fasciitis: www.ncbi.nlm.nih.gov/pubmed/21826056