Stanford School of Medicine
Surgical Pathology Criteria
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Nodular Fasciitis


  • Reactive soft tissue lesion composed of undulating bundles of loosely arranged fibroblasts and myofibroblasts

Diagnostic Criteria

  • Cells loosely arranged in C or S shaped bundles
    • May be storiform
  • Feathery or tissue culture-like appearance
    • Appears to have holes and tears in tissue
    • Stromal mucin accumulates in pools
  • Uniform elongate nuclei
    • No pleomorphism
    • Usually enlarged and vesicular
    • Pale, fine, even chromatin
    • Small nucleoli
  • Frequent normal mitotic figures
    • Abnormal mitotic figures very rare
  • Small thin walled blood vessels
    • May have an arborizing pattern
  • Extravasated blood cells
    • Hemosiderin and foamy macrophages rare
  • Scattered lymphocytes, frequently near periphery
  • Noncircumscribed, may infiltrate along fascial planes
  • Virtually always under 5 cm diameter
    • Usually under 3 cm
  • May occur from subcutis to skeletal muscle or periosteum
  • Occasional features, may be focal or predominant
    • Bone or cartilage formation
      • Most often in parosteal or cranial variants
      • Rarely may be seen focally in other sites
    • Vascular involvement
      • If prominent may be termed intravascular fasciitis
    • Hyalinization of stroma
      • May resemble keloid or desmoid fibromatosis
    • Multinuclear osteoclast-like giant cells
    • Cyst formation due to abundant mesenchymal mucin
    • Central necrosis and fibrin
  • Variants defined by location
    • Parosteal fasciitis
      • Forms metaplastic bone
      • Focal metaplastic bone may be seen rarely in lesions not near bones
      • Such lesions have been termed ossifying fasciitis or fasciitis ossificans
    • Intravascular fasciitis
      • Small to large veins and arteries may be involved
      • More often contains giant cells
      • Variable patterns
      • Typically extravascular nodular fasciitis with focal or extensive vascular involvement
      • Predominantly or exclusively intravascular
      • May extend through vessel and become multinodular
    • Cranial fasciitis
      • Most common in infants and children
      • Involves skull and soft tissue of scalp
      • May involve dura and meninges
      • Giant cells common
      • May have necrosis, bone formation
      • May be larger than 3 cm
    • Intramuscular fasciitis
      • Involves skeletal muscle
      • Damaged muscle fibers may have large hyperchromatic nuclei
      • Usually multinucleated
  • Richard L Kempson MD
    Robert V Rouse MD
    Department of Pathology
    Stanford University School of Medicine
    Stanford CA 94305-5342

    Original posting: March 1, 2008
    Last update: June 15, 2008


Supplemental studies


Muscle specific actin Positive
Smooth muscle actin Positive
S100 Negative
Desmin Negative
Beta-catenin Negative
ALK Negative
Keratin Negative
MyoD1 Negative
Myogenin Negative

Differential diagnosis

Proliferative Fasciitis Nodular Fasciitis
Ganglion-like cells present No ganglion-like cells
Clusters or linear arrangement of small vessels Vessels usually not clustered


Proliferative Myositis Nodular Fasciitis
Ganglion-like cells present No ganglion-like cells
No damage to muscle fibers resulting in a checkerboard pattern with lesional cells between patches of intact muscle Muscle fibers obliterated or damaged
Nodular fasciitis may occasionally involve muscle


Sarcomas (General) Nodular Fasciitis
Usually over 4 cm Rare over 5 cm
Frequent cellular pleomorphism No pleomorphism
Atypical mitotic figures common Atypical mitotic figures rare
Coarse, granular, irregular chromatin Fine, pale, even chromatin


Nodular Fasciitis Low Grade Fibromyxoid Sarcoma
Usually superficial Usually deep soft tissues
S and C shaped bundleslll of cells Alternating fibrous and myxoid areas with whorling
Small Usually large
Essentially never metastasizes Metastatic rate reported from 6-60%, probably closer to 10%
LGFS may contain areas indistinguishable from nodular fasciitis; both are composed of bland cells


Inflammatory Myofibroblastic Tumor Nodular Fasciitis
Frequently over 5 cm Rarely over 5 cm
Usually in children Rare in children
Frequently involves abdominal cavity Does not involve abdominal cavity
Variable patterns Usually loose pattern throughout
Prominent inflammatory cells Only scattered inflammatory cells


Nodular Fasciitis Fibroma of Tendon Sheath
Rare on hands Most on hands
Rapid growth Slow growth
Not circumscribed Circumscribed
Virtually no recurrences May recur
Although fibroma of tendon sheath is typically sclerotic and nodular fasciitis is typically not, there is sufficient variation in patterns to cause overlap. Most such lesions on the hands are labeled fibroma of tendon sheath.


Desmoplastic Fibroblastoma Nodular Fasciitis, Hyalinized
Paucicellular Moderately cellular areas
No mucin Cystic mucin pools, tissue tears
Lacks S and C shaped bundles of cells S and C shaped bundles of cells
Mitotic figures absent or rare Mitotic figures may be numerous


Myositis Ossificans Nodular Fasciitis
Always involves muscle May involve muscle
Zonal osteoid and bone Focal bone formation


Intramuscular Myxoma Nodular Fasciitis
Very hypocellular Moderately cellular
No grouping of cells Undulating bundles of cells
No tissue culture appearance Tissue culture appearance with tears and spaces in tissue
Rare mitotic figures Frequent mitotic figures


Juxta-articular Myxoma Nodular Fasciitis
No grouping of cells Undulating bundles of cells
No tissue culture appearance Tissue culture appearance with tears and spaces in tissue
Rare mitotic figures Frequent mitotic figures


Inclusion Body Fibromatosis Nodular Fasciitis
Vast majority very young Uncommon in children
Vast majority in hands and feet Rare in hands and feet
Inclusions No inclusions


Benign Myxoid Nerve Sheath Tumors Nodular Fasciitis
Mitotic figures rare Mitotic figures frequent
S100 essentially always positive S100 negative


Plexiform Fibrohistiocytic Tumor Nodular Fasciitis
More mature collagenous stroma Loose, immature stroma
Small, dense nuclei Vesicular nuclei
Mitotic figures usually rare Mitotic figures frequent
Nodules of histiocytes frequent Foam cells and histiocytes infrequent
Plexiform rays of fibrous tissue Loose C and S shaped bundles of cells


Fibromatosis, Abdominal Desmoid and Extra-abdominal Desmoid Nodular Fasciitis
Usually dense collagenous stroma Collagenous stroma focal or rare
Linear fascicles of cells Undulating bundles of cells
Infrequent mitotic figures Frequent mitotic figures
Usually >3 cm Usually <4 cm
Beta-catenin 80-90% Beta-catenin negative


Nodular Fasciitis Myofibroma
Lacks biphasic pattern Biphasic nodular pattern
Lacks HPC-like vascular pattern Frequent HPC-like vascular pattern
Multiple lesions rare 25% of cases multifocal
Desmin variable Desmin negative


  • Uncommon in children and over age 65 years
    • Pediatric lesions more commonly in head and neck
  • Uncommon in lower extremity and hands
    • Does not involve abdominal cavity
  • Typically rapid growth
  • Rarely multiple
  • Recurrence following excision is very rare
    • Regression frequent even after partial excision


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  • Fletcher CDM, Unni KK, Mertens F. Pathology and Genetics of Tumours of Soft Tissue and Bone, World Health Organization Classification of Tumours 2002
  • Weiss SW, Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors, 5th edition, 2008
  • Allen PW.  Nodular fasciitis.  Pathology 1972 Jan;4(1):9-26
  • Bernstein KE, Lattes R.  Nodular (pseudosarcomatous) fasciitis, a nonrecurrent lesion: clinicopathologic study of 134 cases.  Cancer 1982 Apr 15;49(8):1668-78
  • Meister P, Buckmann FW, Konrad E.  Nodular fasciitis (analysis of 100 cases and review of the literature).  Pathol Res Pract 1978 Jun;162(2):133-65
  • Montgomery EA, Meis JM.  Nodular fasciitis. Its morphologic spectrum and immunohistochemical profile.  Am J Surg Pathol 1991 Oct;15(10):942-8
  • Shimizu S, Hashimoto H, Enjoji M.  Nodular fasciitis: an analysis of 250 patients.  Pathology 1984 Apr;16(2):161-6
  • Daroca PJ Jr, Pulitzer DR, LoCicero J 3rd.  Ossifying fasciitis.  Arch Pathol Lab Med 1982 Dec;106(13):682-5
  • Lauer DH, Enzinger FM.  Cranial fasciitis of childhood.  Cancer 1980 Jan 15;45(2):401-6 
  • Patchefsky AS, Enzinger FM.  Intravascular fasciitis: a report of 17 cases.  Am J Surg Pathol 1981 Jan;5(1):29-36
  • Patterson JW, Moran SL, Konerding H.  Cranial fasciitis.  Arch Dermatol 1989 May;125(5):674-8
  • Hutter R, Foote F, Francis K, et al.  Parosteal fasciitis.  A self-limited benign process that simulates a malignant neoplasm.  Am J Surg 1962; 104:800-12
  • el-Jabbour JN, Wilson GD, Bennett MH, Burke MM, Davey AT, Eames K.  Flow cytometric study of nodular fasciitis, proliferative fasciitis, and proliferative myositis.  Hum Pathol 1991 Nov;22(11):1146-9
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