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156
Nuchal-Type Fibroma
A Clinicopathologic Study of 52 Cases
Michal Michal, M.D.1
John F. Fetsch, M.D.2
Ondrej Hes, M.D.1
Markku Miettinen, M.D.2
BACKGROUND. Nuchal-type fibroma (NTF) usually arises in the posterior aspect of
the neck. Previously published reports describe only 11 cases and provide limited
clinicopathologic information.
METHODS. Fifty-two examples of NTF from 50 patients were analyzed from the files
of the Soft Tissue Registries of the Armed Forces Institute of Pathology in Wash-
1
Soft Tissue Tumor Registry, Department of Pathology, Faculty Hospital, Pilsen, Czech Republic.
2
Department of Soft Tissue Pathology, Armed
Forces Institute of Pathology, Washington, DC.
ington, DC, and the Faculty Hospital in Pilsen, Czech Republic.
RESULTS. The age of the patients ranged from 3 to 74 years (mean, 40 years). There
were 41 males and 9 females. Thirty-six NTFs were located in the posterior neck
region and 16 were from extranuchal sites. Two patients had had lesions excised
from both a nuchal and an extranuchal location. The mean greatest tumor dimension was 3.2 cm. Microscopically, all examples had a superficial (subcutaneous and
sometimes dermal) component and consisted of paucicellular, thick bundles of
lobulated collagen fibers with inconspicuous fibroblasts. Entrapped adipose tissue
and traumatic neuromalike nerve proliferations were typically present. Skeletal
muscle infiltration was also seen in a minority of cases. Eleven of 25 patients (44%)
for whom clinical information was available reportedly had diabetes. Gardner’s
syndrome was documented in one patient and was possibly present in two additional individuals. During follow-up, five patients had local recurrences, but none
of the recurrences were destructive and all were ultimately controlled by local
reexcision.
CONCLUSIONS. NTF is a rare, tumorlike accumulation of collagen that often affects
the posterior neck region but can also occur in a number of other sites. The process
has a strong association with diabetes and also appears to be linked to Gardner’s
syndrome. Local recurrence probably reflects the persistence of local or systemic
factors related to its pathogenesis. Cancer 1999;85:156 – 63.
© 1999 American Cancer Society.
KEYWORDS: nuchal-type fibroma, diabetes, Gardner’s syndrome, fibromatosis, diabetic scleredema.
Address for reprints: Markku Miettinen, M.D.,
Armed Forces Institute of Pathology, Soft Tissue
Department, 14th Street and Alaska Avenue, NW,
Washington, DC 20306-6000.
The opinions and assertions contained herein are
the expressed views of the authors and are not to
be construed as official or reflecting the views of
the Departments of the Army or Defense.
Received March 12, 1998; revision received June
26, 1998; accepted July 9, 1998.
© 1999 American Cancer Society
N
uchal-type fibroma (NTF) is a rare, tumorlike proliferation originally described by Enzinger and Weiss.1 This process chiefly occurs in the nuchal and interscapular regions of patients between ages
25 and 60 years. It consists of broad bundles of collagen with only a
few interspersed fibroblasts. The lesion is benign but has the potential
for recurrence.1 Only rare case reports and one clinicopathologic
series of nine cases have thus far been published.2,3 Involvement of an
extranuchal site has been reported on one previous occasion.4 We
describe the clinicopathologic features of 52 cases of nuchal-type
fibroma and demonstrate an association with diabetes and, to a lesser
extent, Gardner’s syndrome.
Nuchal-Type Fibroma/Michal et al.
157
TABLE 1
Antibodies Used in This Study of 52 Cases of NTF
Antibody specificity
Technique
Clone
Source
S-100 protein
␣-Smooth muscle actin
Muscle specific actin
EMAa
Vimentina
GFAP
SABC
SABC
SABC
SABC
SABC
SABC
Polyclonal
1A4
HHF-35
E29
V9
Polyclonal
Dakopatts, Glostrup, Denmark
Sigma, St. Louis, MO
Dakopatts
Dakopatts
Dakopatts
Dakopatts
NTF: nuchal-type fibroma; GFAP: glial fibrillary acidic protein; EMA: epithelial membrane antigen;
SABC: streptavidin-biotin-complex method.
a
Microwave-based antigen retireval used with these antigens.
MATERIALS AND METHODS
The records of the Soft Tissue Registries of the Armed
Forces Institute of Pathology in Washington, DC, and
the Faculty Hospital in Pilsen, Czech Republic, were
reviewed for surgical specimens diagnosed as fibromas involving nuchal and extranuchal sites. All hematoxylin and eosin–stained histologic sections were reviewed, and 52 cases corresponding to nuchal-type
fibromas1 were identified among approximately 1000
fibromas, including fibromas of tendon sheath; collagenous fibromas; calcifying aponeurotic fibromas; and
fibromas, not otherwise specified. Normal tissue from
the nuchal region of 10 randomly selected patients
was also studied for comparative purposes.
Immunohistochemical studies were performed on
formalin fixed, paraffin embedded tissue from 10
cases of NTF. Sections 5 ␮m thick were placed on
slides coated with 3-aminopropyltriethoxy-silane (Sigma, St. Louis, MO). Microwave-based epitope retrieval
in 10 mM citrate buffer (pH 6.0) was used prior to the
immunostaining procedure. The immunohistochemical reaction was visualized using the supersensitive
streptavidin-biotin-peroxidase complex (BioGenex,
San Ramon, CA). The color was developed with diaminobenzidine supplemented with hydrogen peroxide. The sections were lightly counterstained with
Mayer’s hematoxylin. The primary antibodies and
pretreatments are listed in Table 1.
RESULTS
Clinical Findings
The Soft Tissue archives of the Armed Forces Institute
of Pathology and the Faculty Hospital yielded 37 and
13 patients, respectively, who had NTF. There were 41
males (82%) and 9 females (18%). Two individuals had
two lesions each. The ages of patients ranged from 3 to
68 years (mean, 40 years) (Fig. 1). Thirty-six lesions
were located in the nuchal region and 16 affected
extranuchal sites. The NTFs in extranuchal locations
FIGURE 1.
Age and gender distribution is shown for 50 patients with
nuchal-type fibroma.
most often involved the back or scapular region (6
cases), shoulder (3 cases), and face (3 cases). However,
other sites of involvement were the left forearm, anterior neck, knee, and truncal region (1 case each).
Two patients with extranuchal NTF also had a separate lesion involving the nuchal region. The patients
typically presented with a history of a superficial mass
of long duration. Although the surgeons often described the lesions as subcutaneous in location, some
examples were noted to extend into deep soft tissue,
and on two occasions the periosteum of the skull was
reported to be involved.
A high proportion of the patients, 11 of 25 (44%)
with clinical information, were reported to have diabetes. One patient with a typical nuchal-type fibroma,
a man age 35 years, had Gardner’s syndrome. He had
known colonic adenomatosis, and his father and an
uncle had died of colonic carcinoma. The patient also
had multiple skin lesions on the face, one of which
was histologically verified as an epidermal inclusion
cyst. In addition, two other patients with NTFs had
possible Gardner’s syndrome. One of these, a male age
19 years with an NTF in the temporal region, had a
family history of colonic adenomatosis (uncle), 2 separate large extraabdominal desmoids involving both
thighs (15 cm and 14 cm in greatest dimension), and a
histologically verified epidermal inclusion cyst in the
left ankle. The other patient, a girl age 9 years, had an
NTF of 2.5 cm in the anterior aspect of the neck and 2
separate extraabdominal desmoids in the head and
neck region.
Macroscopic and Microscopic Features
Macroscopically, NTFs were poorly circumscribed
masses with a hard consistency and off-white color.
158
CANCER January 1, 1999 / Volume 85 / Number 1
FIGURE 2. Nuchal-type fibromas are characteristically paucicellular and
contain thick, haphazardly arranged collagen fibers (H & E, original magnification ⫻65).
FIGURE 3. In the central part of nuchal-type fibroma, the collagen fibers are
organized in several planes of section. The criss-crossing bundles of collagen
sometimes form well-developed lobules (H & E, original magnification ⫻125).
The mean greatest tumor dimension was 3.2 cm
(range, 1– 6 cm).
Microscopically, the process was paucicellular
and composed of thick, haphazardly arranged collagen fibers (Figs. 2,3). In the central parts of the lesions,
the collagen bundles often intersected and had a
vaguely lobular architecture. In small or recurrent examples with scarring, the lobulation was less conspicuous. The process was predominantly located in the
subcutis. However, in instances in which skin was part
FIGURE 4. Nuchal-type fibroma may involve skeletal muscle, as illustrated in
this example (H & E, original magnification ⫻150).
of the resection specimen, the dermis was often involved; and in most of 15 cases with “deep” clinical
extension, there was infiltration and entrapment of
the underlying skeletal muscle (Fig. 4).
The sparsely scattered fibroblasts that were
present between the collagen fibers had a similar appearance in all cases. They had scant cytoplasm and
elongated, twisted, and tapered nuclei with a single
inconspicuous nucleolus. Entrapped islands of adipose tissue were seen in most cases (Fig. 5). In 47 of
the 52 cases, the NTFs contained entrapped peripheral
nerve twigs, sometimes exhibiting a splayed appearance similar to that of a traumatic neuroma (Fig. 6). In
15 cases, the lesions contained enlarged peripheral
nerves with perineurial fibrosis similar to that seen in
a Morton’s neuroma. A delicate network of elastic
fibers was often observed between the collagen fibers
(Fig. 7). Scant numbers of lymphocytes were present
in a minority of cases, but inflammatory features were
never prominent. The NTFs in extranuchal sites were
morphologically indistinguishable from the examples
involving the nuchal region.
Histologic examination of normal tissue from the
nuchal region showed thick collagen fibers in the deep
dermis reminiscent of those seen in NTF. However,
only the NTFs showed lobulation of the collagen fibers, encasement of adnexal structures, and extensive
involvement of the subcutis, resulting in a mass effect.
Also, neuromalike proliferations of the peripheral
nerves were not seen in any of the normal tissue
specimens.
Immunohistochemically, the intralesional fibro-
Nuchal-Type Fibroma/Michal et al.
FIGURE 5. Small, entrapped islands of adipose tissue were seen in almost
all cases of nuchal-type fibroma (H & E, original magnification ⫻150).
159
FIGURE 7. The lesions often contained a delicate web of elastic fibers that
usually ran parallel to the collagen fibers (H & E, original magnification ⫻150).
caused significant functional compromise, and all
were eventually successfully managed with local reexcision.
DISCUSSION
FIGURE 6. Nuchal-type fibromas often contain small nerves with haphazardly arranged fascicles, as seen in traumatic (amputation-type) neuroma (H &
E, original magnification ⫻150).
blastlike cells were consistently positive for vimentin,
but they were negative for actin, desmin, S-100 protein, glial fibrillary acidic protein, and epithelial membrane antigen. The proliferating neural elements were
S-100 protein positive.
Follow-Up
Of the 25 patients with follow-up information, 3 developed 1 recurrence, 1 had 2 recurrences, and another had 3 recurrences. None of the recurrences
Enzinger and Weiss first described NTF as a rare fibrous growth occurring chiefly in the interscapular
and paraspinal regions.1 Our series confirms many of
the originally described characteristics of NTF and
considerably expands on the clinical and histomorphologic characteristics of this tumorlike process.
NTFs are poorly circumscribed, paucicellular lesions that typically present in the posterior neck and
upper back regions. Compared with normal tissue
from the nuchal area, NTFs show similar thick collagen fibers. However, in NTF there is an expansion of
the collagenized dermis, often with focal lobular architecture, encasement of adnexa, effacement of the
subcutis with entrapped adipocytes, and, in some
cases, extension into the underlying skeletal muscle.
Thus, NTFs appear to represent a localized accentuation of the dense paucicellular, collagenous connective tissue that normally resides in these sites. Compared with true fibrous neoplasms, NTF is much less
cellular, suggesting that it represents a peculiar tumorlike reactive process. The tendency of some NTFs
to recur probably reflects the persistence of local or
systemic factors that initially triggered their development.
In many cases, NTFs contained a localized proliferation of nerve twigs, similar to that seen in traumatic
(amputation-type) neuromas; and in some cases,
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CANCER January 1, 1999 / Volume 85 / Number 1
there was also perineurial fibrosis, as seen in Morton’s
neuroma. These changes may be the result of repetitive minor trauma or a response by small nerves to the
local accumulation of collagen.
Of the 52 cases of NTF that we report, 16 examples
occurred in extranuchal soft tissue sites. Most of the
extranuchal tumors were located in the upper back
region, but facial, extremity, and other locations were
also encountered. Because the extranuchal lesions
were histologically indistinguishable from the nuchal
examples, we propose the designation “nuchal-type
fibroma (NTF)” to encompass all histologically similar
lesions irrespective of their site of origin.
Eleven of 25 patients (44%) in our series with
clinical data, and 1 previously reported patient with
NTF,2 had diabetes. The high incidence of diabetes in
this cohort strongly suggests a nonrandom association.
A link between diabetes and tumorlike changes in
fibrous tissues has been established in the case of
scleredema.5–7 One patient subcategory affected by
this disorder is that of obese adults with maturityonset diabetes mellitus. The predisposed sites are the
skin and underlying soft tissues of the posterior neck,
upper back, and shoulders,6,7 but the process may also
involve the face, arms, chest, buttocks, and thighs, as
well as other locations.7 Histologically, diabetic scleredema is described as a poorly cellular hyperplasia of
the connective tissues, which goes beyond the limits
of the dermis and results in replacement of the subcutaneous tissues by coarse collagen fibers. This collagen excess results in marked thickening of the skin.7
One notable histologic feature is the entrapment of
skin adnexa and adipose tissue within the dense connective tissue. These findings suggest that diabetic
scleredema and NTF have some overlapping features.
However, diabetic scleredema is commonly a diffuse
or multifocal, indurative process that encompasses a
large anatomic region, whereas NTF typically manifests as a localized mass lesion.
Other fibrous lesions associated with diabetes include diabetic mastopathy and the so-called pedunculated lipofibroma. The former often contains a
perivascular lymphoid infiltrate and scattered, peculiar, epithelioid fibroblasts.8 –11 The latter is a benign,
tumorlike hyperplasia of fatty and fibrous tissue analogous to a large, fibroepithelial polyp.12
The increased deposition of collagen that is seen
in diabetes-associated fibrous lesions, such as scleredema and NTF, could result from increased collagen
synthesis, decreased collagen resorption, or a combination of the two. Increased collagen deposition appears to be mediated by a number of factors, among
them transforming growth factor-␤ (TGF-␤), a cyto-
kine that is often present at elevated levels in diabetics. TGF-␤ is believed to play a role in the fibrogenic
complications that occur in these patients. It also has
been implicated in other forms of tissue fibrosis that
are not associated with diabetes.13,14
Accumulation of collagen could also result from
impairment of the normal enzymatic degradation process due to increased cross-linking of collagen fibers
by diabetic, nonenzymatic glycosylation. Collagen resorption may also be impeded by mechanic factors,
such as extracellular matrix expansion due to the persistent leakage of anionic proteins from plasma as a
result of increased vascular permeability and the trapping of nonglycosylated proteins by glycosylated collagen.15,16 Finally, tissue ischemia due to microvascular disease could further contribute to a reduction in
the normal rate of collagen degradation.
A previously unpublished feature of NTF is its
occasional occurrence in the setting of Gardner’s syndrome. This disease shows a mendelian dominant
pattern of inheritance and is characterized by the association of colorectal adenomatosis with desmoid
fibromatosis, keratinous cysts, supernumerary teeth,
fibrous dysplasia of the skull, osteomas, and thyroid
carcinoma.17–25 In our series, one patient with NTF
had definitive evidence of Gardner’s syndrome, and
two other patients had one or more features of this
disease process. The association of NTF with Gardner’s syndrome might have been underestimated in
our series, because most cases were received in consultation with limited clinical information.
NTF should be distinguished from other fibrous
tumors and tumorlike conditions, especially the desmoid-type fibromatosis, circumscribed storiform collagenoma, connective tissue nevus, collagenous fibroma (desmoplastic fibroblastoma), elastofibroma,
and fibroma of tendon sheath (Table 2). Although two
of our patients who were clinically suspected of having
Gardner’s syndrome had both NTF and desmoid-type
fibromatosis, the lesions were separate, and there
were no transitional features suggesting the former to
be a degenerative or paucicellular variant of the latter.
In our experience, desmoid-type fibromatoses are
readily segregated from NTFs, given their predilection
for deep soft tissue, substantially greater cellularity,
and more prominent, mildly ectatic vessels.
Circumscribed storiform collagenoma (cutaneous
sclerotic fibroma) occurs both as a solitary tumor and
as a multifocal component of multiple hamartoma
syndrome (Cowden’s disease).26 –31 These lesions differ from NTFs by their dermal-based location, sharp
circumscription, whorled or storiform collagen pattern with prominent mucin-filled clefts, and absence
Nuchal-Type Fibroma/Michal et al.
161
TABLE 2
Comparison of the Clinical and Pathologic Features of Nuchal-Type Fibromas with Those of Other Fibrous Lesions
Most common
location(s)
Circumscription
Cellularity
Vascularity and
nature of vessels
Appearance of
collagen
Elastic fibers
Nuchal-type
fibroma
Collagenous fibroma
Fibroma of tendon sheath
Scar
Elastofibroma
Nuchal region
Shoulder girdle, extremities
Variable
No
Variable
Subscapular
chest wall
No
Very low
Very low
Yes, by macroscopic
appearance, but
microscopically
infiltrative
Increased but generally low
Low
Distal extremities, especially
the hand
Yes
Low to high
Variable
Low to moderate
Low
Bundles of fibers
Amorphous
Low to high
Moderate to high, with some
slitlike vessels
Amorphous
Abdominal wall,
shoulder girdle
Yes, by macroscopic
appearance, but
microscopically
infiltrative
Moderate
Moderate, mildly dilated
Amorphous
Amorphous
Amorphous
Scant
Scant or absent
Absent
Scant to absent
Abundant and
abnormal
Absent
of entrapped adipose tissue. They also lack the neural
proliferation commonly seen in NTF.
Connective tissue nevi are generally regarded as
hamartomatous accumulations of collagen with variable (decreased, normal, or increased) amounts of
elastic tissue. These lesions usually present as slightly
elevated, small dermal nodules that may cluster to
form one or more plaques.32–34 Whereas some authors
propose segregation of these lesions based on the
relative amount of each connective tissue component,
others see no clear advantage to this approach. Connective tissue nevi may be hereditary, as seen with
Buschke–Ollendorf syndrome (connective tissue nevi
with osteopoikilosis), familial cutaneous collagenoma
(multiple connective tissue nevi of the collagen type
symmetrically distributed on the trunk and upper
arms), and tuberous sclerosis (collagen nevus/
shagreen patch in association with other abnormalities, including gliomas, rhabdomyomas, angiomyolipomas, and cutaneous angiofibromas). These lesions
differ histologically from NTFs in that they are generally smaller, more superficial, and less permeative and
lack deep subcutaneous extension.
Collagenous fibroma (desmoplastic fibroblastoma) is a benign soft tissue tumor with a wide anatomic distribution, predominance in males, and peak
incidence in the fifth and sixth decades of life.35 This
process predominantly affects the subcutis, although
fascial involvement is common and muscle is affected
in approximately 20% of cases. Collagenous fibromas
differ from NTFs in several respects. First, at low magnification, the lesions often appear well marginated,
though on closer inspection entrapment of adipocytes
and other structures is common. Second, the tumors
Desmoid-type
fibromatosis
contain moderate numbers of bland, stellate, and
spindled fibroblasts embedded in a more homogeneous collagenous or myxocollagenous matrix.35–37
Elastofibroma generally presents as an ill-defined
mass involving the infrascapular chest wall of middleaged and elderly adults.38,39 Microscopically, this process consists of an admixture of intertwining collagen
fibers, fragmented elastic fibers, and scattered fibroblasts. The elastic fibers are best seen with an elastic
stain (e.g., Verhoeff’s or Gomori’s stains) and have a
characteristic appearance with a central core and peripherally radiating (spokelike) filaments; a structural
resemblance to chenille fibers or pipe cleaners has
been noted. NTFs are less cellular than elastofibromas
and contain only a delicate network of thin, elastic
fibers of normal width, aligned parallel to the collagen
fibers.
Fibroma of tendon sheath occurs mainly in the
distal extremities and presents as a discrete, often
lobulated nodule that is generally attached to the surface of a tendon.40,41 Among the more than 1000 “fibromas” on file in the Soft Tissue Registry of the
Armed Forces Institute of Pathology, this is the most
common subtype, accounting for approximately 40%
of all cases. It differs clinically from the nuchal-type
fibroma in its anatomic distribution, tendency to involve deeper soft tissues, and predilection for younger
patients, with a peak incidence in the third decade of
life. Histologically, it is better marginated, often with
peripheral cleftlike vascular spaces, and much more
cellular, with early stages often resembling nodular
fasciitis or fibrous histiocytoma. In addition, it has
more homogeneous, amorphous collagen than nuchal-type fibroma.
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CANCER January 1, 1999 / Volume 85 / Number 1
Because NTFs often contain some entrapped subcutaneous fat, one might also consider a fibrolipoma
in the differential diagnosis. The latter tumor type can
be seen in the upper back and nuchal region, but it
differs from NTF in several ways. First, subcutaneous
fatty tumors are usually better marginated and generally do not exhibit substantial dermal involvement.
Second, they typically contain more abundant adipose
tissue. Finally, the collagenous element often contains
more abundant fibroblasts.
In conclusion, our series of 50 patients with 52
NTFs indicated the following: These lesions have a
predilection for the posterior neck, but they may
also involve other soft tissue sites, such as the upper
back, shoulder, and facial regions. The designation
we have adopted is in keeping with this observation.
The process typically presents as a mass lesion and
represents a nonneoplastic, tumorlike accumulation
of collagen. A frequent association with diabetes
and a weaker link to Gardner’s syndrome are documented.
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