Elastofibroma dorsi: 8 case reports and a literature review
© Springer-Verlag Italia 2008
Received: 28 July 2007
Accepted: 29 December 2007
Published: 13 March 2008
A series of 8 cases of elastofibroma is reported, and the clinical, pathological and imaging features and different therapeutic modalities are reviewed. On this basis, we suggest an algorithm for the diagnosis and treatment of elastofibroma. Briefly, marginal excision is the treatment of choice in symptomatic patients, while followup appears to be a good solution in asymptomatic ones.
Elastofibroma dorsi is a rare pseudotumor developing in a highly characteristic anatomical location. In fact, it is usually localized anterior to the inferior pole of the scapula and the serratus anterior muscle over the ribs of the thoracic cage. Very rarely, elastofibroma is found in other sites, such as the tip of the elbow, near the ischial tuberosities, the deltoid muscle, foot, inguinal region, orbits, stomach, greater omentum and the intraspinal spaces [1–10]. It is relatively frequent among elderly women, with a mean age at onset of 70 years. It is bilateral in 10% of cases [1, 8, 10].
We reported a series of eight patients affected by elastofibroma. We discuss the clinical and radiological features and treatment modalities and review the literature concerned.
Seven women and one man of mean age 61 years (range, 47–82 year) were treated for elastofibroma during the period from 2000 to 2004 (1). All had unilateral lesions except one woman who had bilaterla masses. Every case was studied with radiography, ultrasound, computed tomography (CT) and gadolinium (MRI) enhanced magnetic versonance imaging. The patients were divided into 2 groups: asymptomatic (2 cases) and symtomatic (6 cases).
Clinical characteristics of 8 patients with elstofibroma
Elastofibroma is a rare lesion. In fact most publications [1–6, 8–10] reported either a single case or a small series of 2–7 cases, except for Nagamine et al.  who reported a study of 170 cases. These lesions tend to be slowly growing and asymptomatic in more than 50% of the cases. When symptoms are present, they are typical, consisting of local scapular swelling and a clunking sensation during abduction and adduction of the shoulder, with pain of moderate or, rarely, severe entity [2, 3, 5].
The location of elastofibromas and its incidence among older individuals may be related to the natural existence of fibro-elastic tissue in this region and suggests a reactive process in response to friction of the scapula against the ribs [2, 3, 10]. Alternatively, the genesis of elastofibroma is thought to involve an overproduction of the collagenous connective tissue with a degeneration of the collagen fibres and an overproduction of immature elastic tissue, derived from fibroblasts, alternating with deposition of hyperplastic fat [2, 8, 10]. Genetic factors may also be involved [2, 8, 10].
Elastofibroma exhibits a characteristic structure where streaks of fatty tissue are alternated with strands of fibrous tissue. The hypertrophic fibrous tissue contains fibrillated material with identical staining affinities to that of necrotic fibrous tissue, muscle, and fat (Fig. 3).
Concerning the modalities of treatment, controversy is reported in the literature. Marginal excision has been suggested because it carries a low recurrence risk [1, 5, 8–10], and no malignant transformation has been reported. Guha and Reja  mentioned the marginal surgical excision for these lesions and reported only one case of recurrence after the excision; another case was successfully treated with radiotherapy. Malghem et al.  adopted a wait and see approach in asymptomatic patients: since these patients did not develop symptoms, the authors concluded that elastofibroma is an ungrowing lesion after the diagnosis.
Considering these reports, we suggest a diagnostic and therapeutic algorithm for elastofibroma (Fig. 4). In case of a scapular region mass in an elderly woman, radiography, ultrasound and MRI with gadolinium enhancement are required. If the patient is asymptomatic and there is no enhancement on MRI, clinical follow-up is sufficient. On the other hand, in symptomatic patients with no enhancement, marginal excision of the mass is necessary. Marginal excision is also indicated in the absence of symptoms in the presence of enhancement on MRI. We recommend biopsy to rule out sarcoma when both symptoms and MRI enhancement are present.
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