Soft tissue
Fibroblastic / myofibroblastic
Ischemic fasciitis
Author: Jerad M. Gardner, M.D.
Last author update: 1 June 2013
Last staff update: 29 September 2020
Copyright: 2002-2023, PathologyOutlines.com, Inc.
PubMed Search: Ischemic fasciitis
Table of Contents
Definition / general | Epidemiology | Sites | Etiology | Case reports | Treatment | Clinical images | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Cytology description | Positive stains | Negative stains | Differential diagnosis | Additional referencesCite this page: Chaudhri, A. Ischemic fasciitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/softtissueischemicfasciitis.html. Accessed June 9th, 2023.
Definition / general
- Painless pseudosarcomatous fibroblastic proliferation in soft tissue overlying bony prominences subject to intermittent pressure-induced ischemia
- Also spelled "ischaemic"
- First described in 1992 as "atypical decubital fibroplasia" (Am J Surg Pathol 1992;16:708)
Epidemiology
- Occurs primarily in immobilized and physically impaired patients (i.e., wheelchair bound, bedridden), with mean age of presentation 70 - 90 years
- Also occurs in younger patients not debilitated (Am J Surg Pathol 2008;32:1546) or patients with physical disabilities (Path Int 1998;48:160, Int J Gynecol Pathol 2004;23:65)
- Patients present with painless mass slowly growing over 3 weeks to 6 months
Sites
- Shoulder, chest wall, sacrococcygeal region, greater trochanter
Etiology
- Similar to decubitus ulcers; pressure-induced ischemia causes mass-producing reactive process, but is insufficient to cause skin ulceration
Case reports
- 10 year old girl with firm palpable abdominal mass associated with a torso brace for scoliosis (Dermatol Online J 2012;18:9)
- 45 year old woman with post-mastectomy axillary mass (The Internet Journal of Pathology 2008;7:1)
- 55 year old man with hip mass (Case of the Week #64)
- 76 year old woman with thigh mass (Arch Pathol Lab Med 2004;128:e139)
Treatment
- Local excision is curative, although may recur due to continuation of underlying ischemia and injury
Clinical images
Contributed by Mark R. Wick, M.D.
Decubital
Gross description
- Usually 1 - 8 cm, poorly circumscribed, often myxoid
- Usually involves deep subcutis, may involve adjacent skeletal muscle and fascia
- Ulceration is uncommon (i.e. overlying skin is intact)
Microscopic (histologic) description
- Zonal pattern of central fibrinoid necrosis with uneven borders staining deep red / violet and prominent myxoid areas surrounded by ectatic, thin walled vessels and proliferating fibroblasts
- Endothelial cells may be atypical
- Fibroblasts have degenerative features with abundant, eosinophilic to amphophilic cytoplasm, enlarged nuclei with smudged chromatin and prominent nucleoli (resembling ganglion-like cells in proliferative fasciitis)
- Variable mitotic activity, but no atypical mitotic figures
- Fibrin thrombi are common within peripheral vessels, which may show fibrinoid necrosis and recanalization but no true vasculitis
- May have multivacuolated macrophages in myxoid zones mimicking lipoblasts
Microscopic (histologic) images
AFIP images
Cellular, fibrin rich proliferation centered on subcutaneous fibrous septum and extending into adjacent fat
Hyalinized focus with large ganglion-like cells, suggestive of proliferative fasciitis
Fibrin is adjacent to foci of ganglion-like cells in collagenous stroma
Contributed by Mark R. Wick, M.D.
Decubital
Case #64
Hip mass in 55 year old bedridden man
Images hosted on other servers:
Fibrinoid necrosis with few viable cells
Large nuclei with prominent nucleoli
Various images
Cytology description
- Spindled and ovoid cells with ample cytoplasm and occasional nuclear atypia (Acta Cytol 1997;41:598)
Differential diagnosis
- Epithelioid sarcoma: young adults on distal extremities, more cellular with central tumor cell necrosis, cells have eosinophilic cytoplasm, atypical mitotic figures, keratin+
- Myxofibrosarcoma: marked atypia, but no smudgy chromatin or fibrin thrombi; lacks zonation and degenerative features
- Myxoid liposarcoma: prominent plexiform vasculature and lipoblasts, small monotonous cells rather than larger myofibroblasts
- Proliferative fasciitis: younger patients, lesions not associated with pressure; zonation, myofibroblasts and fibroblasts with tissue culture type growth, also large ganglion cells
Additional references
