Stanford School of Medicine
Surgical Pathology Criteria
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Ischemic Fasciitis

Definition

  • Reactive process composed of large ganglion-like cells, fibroblasts and myofibroblasts set in a myxoid stroma usually occurring at areas of pressure over bone

Alternate / Historical Names

  • Atypical decubital fibroplasia

Diagnostic Criteria

  • Usually poorly circumscribed, non-ulcerated mass
    • May be larger than other fasciitis lesions
      • Range 1-9 cm
  • Most often in areas of chronic pressure
    • Usually shoulder or hip
  • Central zone of necrotic fat and/or cystic fibrinoid necrosis surrounded by vessels and proliferating fibroblasts
    • Hemosiderin and hemorrhage frequent
    • Inflammation frequent
      • Usually chronic, occasionally acute
  • Fibrin may be prominent in degenerate areas or in vessels
  • Ganglion-like cells may be present in surrounding tissue
    • May surround vessels
    • Large nuclei may be irregular
    • Chromatin may be dense and smudged
    • Prominent nucleoli
    • Basophilic to amphophilic cytoplasm
    • Mitotic figures may be frequent but atypical figures very rare

    • Richard L Kempson MD
    Robert V Rouse MD
    Department of Pathology
    Stanford University School of Medicine
    Stanford CA 94305-5342

    Original posting: March 8, 2008
    Last update: December 30, 2008

 

Supplemental studies

Immunohistology

  • Ganglion-like cells may stain for actin, desmin, CD68 or CD34

Differential diagnosis

 

  • Ischemic Fasciitis shares histologic features with and could be considered a variant of Proliferative Fasciitis
    • They are defined by location, association with fat necrosis and clinical presentation.
      • Advanced age and location near limb girdles favor ischemic fasciitis
      • Young age and location on extremities favor proliferative fasciitis
    • Both are benign

 

Sarcoma, NOS Ischemic Fasciitis
Generally more cellular Generally less cellular
May show clear cytologic malignancy No clear cytological malignancy
May have atypical mitotic figures Atypical mitotic figures rare
Fat necrosis uncommon Fat necrosis characteristic

 

Myxoid Liposarcoma Ischemic Fasciitis
Little pleomorphism May be pleomorphic
Arborizing vascular pattern Granulation tissue but lacks arborizing pattern

 

Epithelioid Sarcoma Ischemic Fasciitis
Usually extremities of young patient Usually shoulder or hip of elderly patient
Usually brightly eosinophilic cytoplasm Cytoplasm usually basophilic or amphophilic
Keratin positive Keratin negative
Both are frequently CD34 positive

 

Myxofibrosarcoma Ischemic Fasciitis
Cytologically atypical to malignant No clear cytologic malignancy
Frequent atypical mitotic figures Atypical mitotic figures rare
Fat necrosis and fibrin rare Fat necrosis and fibrin characteristic
CD34 negative May be CD34 positive

Clinical

  • Most patients elderly, immobilized
    • May also be seen without history of immobilization
  • Usually on hips or shoulders
  • Mass lesion usually without ulceration
  • May recur
    • No destructive or aggressive recurrences
    • No metastases

Bibliography

  • Kempson RL, Fletcher CDM, Evans HL, Henrickson MR, Sibley RS. Tumors of the Soft Tissues, Atlas of Tumor Pathology, AFIP Third Series, Fascicle 30, 2001
  • 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
  • Baldassano MF, Rosenberg AE, Flotte TJ.  Atypical decubital fibroplasia: a series of three cases.  J Cutan Pathol 1998 Mar;25(3):149-52
  • Montgomery EA, Meis JM, Mitchell MS, Enzinger FM. Atypical decubital fibroplasia. A distinctive fibroblastic pseudotumor occurring in debilitated patients. Am J Surg Pathol. 1992 Jul;16(7):708-15.
  • Perosio PM, Weiss SW. Ischemic fasciitis: a juxta-skeletal fibroblastic proliferation with a predilection for elderly patients. Mod Pathol. 1993 Jan;6(1):69-72.
  • Liegl B, Fletcher CD. Ischemic fasciitis: analysis of 44 cases indicating an inconsistent association with immobility or debilitation. Am J Surg Pathol. 2008 Oct;32(10):1546-52.
 
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