Authors present a sixty year old female with a slow going painful scapular mass. Ultrasound showed a solid lesion that underwent evaluation with CT and MR. These techniques depicted a lenticular lesion located between the ribs, the serratus anterior and the rhomboid with strands of adipose tissue within it.
Our patient was a 60 year old woman with a slow going painful scapular mass. Thoracic X-ray with oblique view suggested the presence of a mass between the ribs and the scapula, without osseous destruction or matrix (Fig 1). Ultrasound showed a solid ovoid lesion, echogenic and homogeneous, measuring 5,3x 4,8x 2,2 cm (Fig 2). CT depicted lesion in the right scapular region, located between the ribs, the serratus anterior and the rhomboid, with strands of adipose tissue within it. Another lesion with the same structural characteristics, but smaller dimensions, was also identified in the left scapular area (Fig 3). MR was performed with T1 and T2 weighted sequences, with and without fat suppression, directed to the right scapular region. Images showed that the lesion was composed by soft tissue with intermediate signal and interlaced areas of signal intensity similar to the fat (Fig 4,5,6). Surgical excision was done and the pathologist confirmed the radiological hypothesis of Elastofibroma
Elastofibroma is a benign, tumorlike lesion more frequent in adult women. It’s a reactive lesion that usually arises between the inferior margin of the scapula and the posterior chest wall. This lesion has also been reported in infraolecranon region, ischial tuberosity, and over de great trocanter. Bilateral elastofibromas are not uncommon, occurring in 25% of the cases. Symptoms are usually pain and tumefaction [1, 2]. Chest radiographs may show a soft tissue mass overlying the ribs and elevating the lower end of the scapula. At US, elastofibroma dorsi has a peculiar multilayered appearance created by interspersed linear and curvilinear hypoechoic strands (fatty tissue) against an echogenic background (the fibroelastic bulk of the mass) [3]. CT depicts a lenticular mass in the typical localization, most of times with ill defined borders and linear low density streaking [4]. The lesion shows intermediate signal intensity on both T1 and T2 sequences, with interlaced areas of signal intensity similar to that of fat. Although these features are not pathognomonic, their presence in a subscapular lesion in an older patient suggests a presumptive diagnosis of elastofibroma [4, 5]. Differential diagnosis includes hemangioma, fibrosarcoma, liposarcoma, synovial sarcoma, desmoids and fibromatosis, At microscopy, the lesion consists primary of collagen and elastic fibers, scattered fibroblasts, and occasional lobules of adipose tissue [1, 2]. A unique histologic feature is the presence of enlarged, irregular, serrated elastic fibers that are hypereosinophilic [1, 2]. No treatment is necessary in asymptomatic lesions. In symptomatic patients excision is indicated. Local recurrence may occur when excision is incomplete. There no risk of malignant transformation [4,5]
Elastofibroma Dorsi
1. The provided X-ray reveals a widened soft tissue shadow in the subscapular area (between the scapula and chest wall), without significant bony destruction or apparent fracture signs.
2. Ultrasonography shows a solid lesion with linear and curvilinear hypoechoic bands intertwined with relatively hyperechoic fibrous tissue, forming a multilayered echo pattern.
3. On CT scans, the lesion appears as a fusiform or flat soft tissue mass beneath the scapula, primarily composed of soft tissue density, with strips or patches of fat density internally. Some parts of the lesion border are unclear, but it is still relatively distinguishable from surrounding muscle layers.
4. MRI findings show moderate signal intensity on T1- and T2-weighted images, containing high-signal strands resembling fat. The lesion is located between the lower margin of the scapula and the posterior chest wall and has an irregular lenticular shape.
Considering the patient’s age (60 years), localized pain, and the imaging findings, the following differential diagnoses are proposed:
1. Elastofibroma dorsi: Common in older females; typically located between the scapula and the chest wall. On CT/MRI, it usually shows interlaced fibrous tissue and fat bands.
2. Liposarcoma: May present with fatty components in soft tissue, often showing a noticeable mass effect. After contrast enhancement, it may exhibit complex enhancement patterns, so malignancy should be ruled out.
3. Fibroma or Fibrosarcoma: Mainly composed of fibrous tissue, may adhere to surrounding structures. Poorly defined margins are common, and T2-weighted MRI often shows mixed signal intensity.
4. Desmoid tumor (fibromatosis): Can also appear as fibrous lesions in soft tissue. These tend to be more aggressive and can recur locally.
Based on the patient’s age, sex, clinical symptoms (slow growth with pain), the typical subscapular location, and the characteristic imaging appearance of interlaced fibrous and fatty tissue,
the most likely diagnosis is
“Elastofibroma dorsi.”
If diagnostic uncertainty remains, a biopsy or surgical resection with pathological examination is recommended for confirmation.
1. Treatment Strategy:
‣ Elastofibroma dorsi is a benign lesion. If it causes no significant symptoms or functional problems, regular follow-up is typically advised with no specific intervention.
‣ In cases of persistent pain, motion restriction, or other discomfort, surgical excision can be considered as a primary treatment option. Indications for surgery include severe pain, functional impairment, or suspected malignancy.
‣ Complete surgical resection can reduce recurrence risk; however, partial resection or extensive involvement may be associated with a certain recurrence rate.
2. Rehabilitation and Exercise Prescription:
‣ Early Postoperative Period and Conservative Management: Focus on alleviating local pain and preventing functional impairments. Gentle active and passive range-of-motion exercises for the shoulder joint are recommended. If not operated on, instruct the patient to avoid excessive scapular protraction or heavy lifting.
‣ Progressive Exercise Protocol (FITT-VP Principle):
▸ Frequency: 3–4 times per week.
▸ Intensity: Based on pain level and muscle strength. Lower intensity is recommended initially (e.g., using a light-resistance band).
▸ Time: 10–20 minutes per session, gradually increasing to about 30 minutes.
▸ Type: Emphasize strengthening exercises for the shoulder joint and surrounding muscles, stretching of the shoulder and back, and aerobic activities. Examples include seated rowing, internal and external shoulder rotation exercises, and scapular retraction exercises.
▸ Progression: Increase resistance or duration gradually as pain subsides and strength improves. Additional exercises such as lateral raises or rowing with moderate resistance can be added when safe.
▸ Volume and Progress: Evaluate every 2–4 weeks and adjust accordingly, based on the patient’s tolerance and overall condition.
‣ Cautions: Patients with limited shoulder or thoracic mobility should warm up and stretch before and after exercise. In cases of marked pain or local swelling, suspend exercise and seek medical evaluation promptly.
This report is a reference for medical imaging analysis only and does not replace in-person consultations or professional medical diagnosis and treatment. If you have any questions or if your condition changes, please consult a specialist promptly.
Elastofibroma Dorsi
