Cranial Fasciitis: A Systematic Review and Diagnostic Approach to a Pediatric Scalp Mass

A Rare Case of Infantile Myofibromatosis With Intra Cranial Involvement

Infantile myofibromatosis is a proliferative disorder occurring during infancy and early childhood, marked by the development of nodular or diffuse lesions consisting of various mesenchymal elements. Intracranial involvement is infrequently reported. Here, we present the case of a 3-year-old girl exhibiting a rare manifestation of IM with intracranial parenchymal involvement, displaying a histological pattern documented in existing literature on patients with infantile myofibromatosis. Subsequent MRI follow-up revealed no signs of recurrence.

Large Nodular Fasciitis of the Shoulder Presenting as Soft Tissue Sarcoma: A Case Report

CASE

This case report describes a patient who presented with clinical and radiographic features of a soft tissue sarcoma of the shoulder. Despite having a painless and relatively large mass, a biopsy and resection revealed nodular fasciitis (NF).

CONCLUSION

This is an unusual case of a painless 10 cm mass that histopathologically was diagnosed as NF in the upper extremity with proximity to the axillary nerve and posterior humeral circumflex vessels. The USP6 rearrangement was helpful in confirming the diagnosis. Careful clinical, radiographic, and pathologic correlation is necessary in diagnosing these relatively rare tumors. In cases where there are discordant findings, molecular markers can be very helpful.

Rare cardiac tumour-nodular fasciitis

Left ventricular tumour is a rare condition in children. The causes include vegetations, thrombus, and fibroma. 2-year-old asymptomatic female presented with an innocent heart murmur at 6 months of age. Subsequent follow-ups at 18 months of age showed left ventricular mass. Surgical pathology revealed "nodular fasciitis." This type of tumour has never been described in the heart before.

Nonsyndromic Craniofacial Disorders

We describe the investigation and management of select pediatric craniofacial disorders their recent advances. Positional plagiocephaly: The incidence of positional plagiocephaly has increased since the institution of the "safe to sleep" campaign to reduce sudden infant death syndrome. Positional plagiocephaly may be associated with underlying developmental delay. Nonsyndromic craniosynostosis: Treatment of nonsyndromic craniosynostosis depends on the age of the patient and the suture involved. Pediatric skull lesions: Management of skull lesions depends on histologic diagnosis. Some benign skull lesions are managed conservatively, whereas erosive and malignant lesions may require surgical excision, radiotherapy, chemotherapy, or multimodality treatment.

Small biopsies in the head and neck: Bone and soft tissue

Bone and soft tissue lesions in the head and neck encompass not only a broad morphologic spectrum but also significant inherent clinicopathologic overlap. Epidemiology, radiology, and location - similar to the diagnostic assessment in other sites - are especially important considerations in the context of an established mesenchymal proliferation. Herein, the approach towards diagnosis is stratified by morphology (spindle, sarcomatoid, epithelioid, round cell), cellular lineage (fibroblastic, nerve sheath, rhabdomyogenic), and tumor grade (benign, low- to high-grade malignant) as the basis of further immunohistochemical or molecular investigation.

Infantile Cranial Fasciitis: A Clinicopathologic Evaluation

OBJECTIVE

To investigate the clinicopathologic features, immunophenotype, molecular genetic changes, and differential diagnosis of cranial fasciitis (CF).

METHODS

The clinical manifestations, imaging, surgical technique, pathologic characteristics, special staining, and immunophenotype, as well as break-apart fluorescence in situ hybridization assay for USP6 of 19 CF cases were analyzed, retrospectively.

RESULTS

The patients were 11 boys and 8 girls, aged 5 to 144 months, with a median age of 29 months. There were 5 cases (26.31%) in the temporal bone, 4 cases (21.05%) in the parietal bone, 3 cases (15.78%) in the occipital bone, 3 cases (15.78%) in the frontotemporal bone, 2 cases (10.52%) in the frontal bone, 1 case (5.26%) in the mastoid of middle ear, and 1 case (5.26%) in the external auditory canal. The main clinical manifestations were painless, with the presentation of masses that grew rapidly and frequently eroded the skull. There was no recurrence and no metastasis after the operation. Histologically, the lesion consists of spindle fibroblasts/myofibroblasts arranged in bundles, braided or atypical spokes. Mitotic figures could be seen, but not atypical forms. Immunohistochemical studies showed diffuse strong positive SMA and Vimentin in all CFs. These cells were negative for Calponin, Desmin, β-catenin, S-100, and CD34. The ki-67 proliferation index was 5% to 10%. Ocin blue-PH2.5 staining showed blue-stained mucinous features in the stroma. The positive rate of USP6 gene rearrangement detected by fluorescence in situ hybridization assay was about 10.52%, and the positive rate was not related to age. All patients were observed for 2 to 124 months and showed no signs of recurrence or metastasis.

CONCLUSIONS

In summary, CF was a benign pseudosarcomatous fasciitis that occurs in the skull of infants. Preoperative diagnosis and differential diagnosis were difficult. Computed tomography typing might be beneficial for imaging diagnosis, and pathologic examination might be the most reliable way to diagnose CF.

Extremely rare occurrence of multiple cranial fasciitis: A case report

Cranial fasciitis (CF) is a rare, rapidly growing, benign fibroproliferative lesion of the skull in the pediatric population. It is characterized by benign mesenchymal proliferation of spindle cells arranged as short, intersecting loose fascicles within a fibromyxoid stroma, and mostly appears as a single mass. A surgical excision with clear surgical margins is definitively curative for CF. Up to date only two cases with multiple CF have been reported in the literature. In this report, we describe a 1-year-old girl with multiple locations of CF, as the first case to be reported in the Turkish population. The radiological and morphological findings of our case were comparable with the observations of the two previous reports in the literature. Histopathological examination remains to be the gold-standard for differential diagnosis of CF, as the treatment of this lesion differs from other malignancies of the skull in the pediatric population.

Cranial fasciitis in children: clinicoradiology features and management

Background

Cranial fasciitis (CF) is a rare benign fibroproliferative lesion of the skull. To date, the summarized radiologic characteristics and the subtype of the disease have not been reported. our purpose was to summarize the characteristic clinicoradiology features and management of CF and to improve the knowledge of radiologists and clinicians.

Methods

We searched our institution’s database and retrieved the clinical and radiologic data of CF patients confirmed by histopathological examination. The clinicoradiology features and management of CF were analysed retrospectively.

Results

A total of 14 CF patients were included. A total of 85.7% of the patients presented with a painless, firm, nonmobile and single mass. Tenderness and multiple masses were found in 14.3% of the patients. The mass was clearly increased in 2 patients and gradually increased in 5 patients in the short term. We divided these patients into three types based on the CT characteristics. The characteristic features of type I (9 patients) presented as an expansive and osteolytic bone destruction with a soft tissue mass. Type II (2 patients) presented as a scalp mass with mild erosion of the outer skull plate. Type III (3 patients) presented as a scalp mass without skull destruction. All patients underwent surgical resection. For type I patients, craniectomy and cranioplasty were performed. For type II patients, complete excision of the scalp mass with local skull curettage was performed. For type III patients, complete excision of the scalp mass was performed. There were no cases of recurrence after follow-up.

Conclusions

CF usually presents as a painless, firm, nonmobile and single mass with a clear boundary. There are generally three types of MSCT findings: bone destruction with a soft tissue mass, a scalp mass with erosion of the skull and a scalp mass. Different management strategies should be utilized for the various types of CF.

Cranial Fasciitis in Children: Expanding the Spectrum of USP6-Associated Clonal Transient Neoplasms

Background: Cranial fasciitis (CF) is a benign (myo)fibroblastic proliferation of children. Typical presentation consists of a rapidly growing solitary mass on the temporal or parietal cranium in the first 2 years of age. CF is characterized by a rapid growth followed by a relative slowdown and even growth arrest. The finding of somatic USP6 gene rearrangements demonstrating clonality in CF together with its clinical behavior places it in the category of diseases recently termed "transient neoplasia."Methods: Histological, immunohistochemical, and molecular findings of 18 patients with CF were retrospectively studied.Results: The tumor typically presented as a painless rapidly enlarging mass in the temporal region. Sixty-six percent of the cases harbored USP6 gene rearrangement. Nine patients were treated with gross total resection (GTR) and 9 with subtotal tumor resection (STR). Two patients treated with GTR had recurrence. Five patients treated with STR had progression-free disease for at least 10 months after surgery and in four patients the tumor regressed spontaneously a median 16 months after surgery.Conclusions: In this largest series to date, we reported the clinicopathological, immunohistochemical, and molecular findings of 18 pediatric cases of CF with emphasis on the clinical growth pattern of these tumors.

Update on MR Imaging of Soft Tissue Tumors of Head and Neck

This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.

Craniofacial fasciitis of the face: Case report and review of the recent literature

INTRODUCTION

Craniofacial fasciitis (CFFF) an uncommon, benign pseudosarcomatous proliferation of unknown etiology that occurs almost exclusively in children less than 6 years old. CFF lesions occur most frequently in the deep fascial layers and the periosteal layer of the calvarium, resulting in a rapidly enlarging scalp mass with potential underlying bony erosion. Presentation of CFF on the midface is rare.

OBJECTIVE

The objective of this report is to describe a case of paranasal CFF involving the nasolacrimal duct in an infant and perform a literature review of cases of CFF of the midface in children.

METHODS

A literature review of children ≤18 years old who were diagnosed with CFF of the midface was performed. A single case report is presented.

RESULTS

A 7-month-old girl presented with a rapidly enlarging facial mass with edema, epiphora, difficulty breathing, and issues with feeding. She underwent urgent biopsy which revealed spindle cells with fibrous background. Patient was diagnosed with paranasal CFF based on clinical presentation and pathology report. She subsequently underwent near complete surgical excision. Patient is doing well with no progression of disease with follow up MRI revealing minimal residual disease in the nasal cavity. Review of the literature identified 4 additional cases of CFF of the midface which presented on sites including the mandible, frontonasal region, nasal process of the maxilla, and orbit/maxilla. The patient in this case is the first presentation of CFF involving the nasolacrimal duct. Lesions presented anywhere from 2 days to 3 months prior to treatment, and immunohistochemistry was positive for either vimentin or beta-catenin. Interestingly, all cases in this series occurred within the first year of life and were treated with complete or near complete resection with no evidence of recurrence.

CONCLUSION

Although CFF is a rare diagnosis, it should be considered in the evaluation and treatment of soft-tissue masses of the midface in children. Surgical excision is curative and there appears to be a low rate of recurrence based on the small series presented in literature.

USP6 Gene Rearrangement by FISH Analysis in Cranial Fasciitis: A Report of Three Cases

Cranial fasciitis (CF) is an uncommon benign myofibroblastic proliferation involving the soft and hard tissues of the cranium. It typically occurs in the pediatric population with a male predilection (male-to-female ratio 1.5:1). The clinical presentation is usually a rapidly expanding, painless nodule. Bone erosion may be appreciated radiographically. Histopathologic sections of CF show plump, fibroblast-like cells with pale, oval shaped nuclei and prominent nucleoli in a fibrous or myxoid background. Growth is self-limited and surgical excision is considered curative. Due to these features, CF is thought to be a variant of nodular fasciitis (NF). As with NF, CF may mimic a sarcomatous process and pose a diagnostic challenge to clinicians and pathologists alike. Erickson-Johnson et al. identified rearrangements of the ubiquitin-specific protease 6 (USP6) gene in 44 of 48 cases of NF. MYH9 was the fusion partner in 12 of these cases. To date, the molecular profile of CF has not been studied. Here we present the molecular findings in three cases of CF identified at our institution. Each case was subjected to fluorescence in-situ hybridization with appropriate negative controls. Two of three cases were positive for the USP6 gene rearrangement. The third case failed to hybridize, likely related to nucleic acid damage secondary to decalcification. Negative controls did not demonstrate the genetic rearrangement. These findings warrant further investigation of the USP6 gene rearrangement in CF, as it may prove helpful as a diagnostic adjunct in challenging cases.

Three Skulls Dating from the French Revolutionary Years Diagnosed with Tinea Capitis: A Paleopathologic Approach

The Musée Dupuytren was a Parisian pathology museum established in 1835. This museum hosted 3 skulls with severe craniofacial lesions initially tagged as aggressive forms of tinea capitis. The aim of this study was to investigate these specimens and discuss the initial diagnosis. Historical investigations were conducted based on the biographic data from the tags of the 3 skulls and entries on the catalog of the museum. Age was determined using dentition and the patency of cranial base synchondroses. The computed tomography scans were performed using standard medical devices. The 3 skulls were from the late 18th to early 19th century. Skull № 1 was a 5-year-old child and presented with microcephaly and extensive vault osteolysis compatible with an aggressive benign lesion, a malignant tumor, or a chronic infection. Skull № 2 was a 12- to 18-year-old teenager and presented with symmetrical porotic hyperostosis compatible with undernutrition and various hematologic conditions causing prolonged anemia, but also with chronic inflammation and/or infection. Skull № 3 was also from a 12- to 18-year-old teenager and presented with focal temporal osteolysis compatible with an aggressive benign or a low-grade malignant temporal soft-tissue lesion or with chronic infection. These skulls contribute to the understanding of the concept of tinea in the 19th century. They are furthermore windows on the sanitary and social conditions in Paris in the years following the French revolution and during the Napoleonian wars.

Novel presentation of cranial fasciitis of the mandible: Case report and literature review

Cranial fasciitis (CF) is a rare benign fibroblastic lesion of the scalp, most commonly affecting the pediatric population. The authors conducted a literature review and include a summary of reported cases of CF. CF is most commonly located in the parietal and temporal regions of the skull. The majority of cases are found in males and in children under a few years of ago. We describe the clinical, pathological and radiological findings of the first reported case of CF of the mandible. In this case, the patient was a 12 month-old male who presented with a one-month history of a rapidly enlarging mass along his left mandibular ramus. Treatment of CF involves surgical resection and has a low rate of recurrence. The patient in question was managed surgically with no complications and has not had any evidence of disease recurrence.

Infantile cranial fasciitis: case-based review and operative technique

BACKGROUND

Cranial fasciitis (CF) is an uncommon benign primary lesion of the skull that typically affects the pediatric age group. Due to the rarity of CF, no prospective studies exist. Earliest description of this condition dates to 1980. The limited scientific and clinical literature regarding CF is dominated by case reports. For these reasons, questions pertaining to the true incidence, genetic risk factors, prognosis, and long-term outcome remain unanswered.

DISCUSSION

Clinically, CF presents as a firm, painless, growing scalp mass that is typically not considered in the differential diagnosis. Preoperative pathognomonic signs and symptoms are absent, and imaging features are often nonspecific. Treatment is typically through complete surgical resection, at which time histopathological examination confirms the diagnosis of CF. Reconstruction of the skull defect in the child is critical. Autograft techniques help maintain a rigid construct that integrates with the native skull while preserving its continued ability to grow. Generally, a good outcome is observed with complete resection.

EXEMPLARY CASE

We report a case of CF in an infant with emphasis on operative nuances and early follow-up results.

CONCLUSION

CF is a rare fibroproliferative disease that has a poorly defined incidence and long-term follow-up. Due to its locally invasive nature and nonspecific presentation, CF is often difficult to differentiate from malignancies and infections. Complete surgical resection is the best approach for diagnosis and cure. Its occult clinical presentation often allows it to achieve considerable growth, leaving a sizeable skull defect following resection. Since CF presents in the pediatric population, allograft reconstruction is preferred over titanium mesh or other synthetic materials to allow osseous integration and continued uninterrupted skull growth.