Consultant Histopathologist, The Royal Oldham Hospital, Rochdale Road, Oldham, United Kingdom
2 Bon Secours Hospital at Barringtons,, Georges Quay, Limerick, Ireland
Corresponding author details:
Dr. John Coyne
The Royal Oldham Hospital, Rochdale Road Oldham, OL1 2JH
Copyright: © 2018 Coyne J. This is an openaccess article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Spontaneous regression of tumours is a well known but rare phenomenon. Tumour
regression has more usually been described in sporadic cases of skin, liver, testicular
and renal tumours.This report describes for the first time, the immunophenotype of the
dermal cellular infiltrateassociated with a case of regressing nodular fasciitis, suggesting an
immunologic mechanism for this often cited occurrence.
Cutaneous; Nodular Fasciitis; Regression
A 70-year-old man presented with a 10mm ulcerated lump on his scalp. A 3mm biopsy
was taken and microscopic examination showed a bland, spindle cell proliferation with
a fascicular pattern. The cells were elongated with tapering nuclei and displayed small
nucleoli; frequent normal mitoses were present (Figure 1). The stroma was mildly myxoid
and the lesion extended into the subcutaneous tissue. Immunohistochemistry showed
strong diffuse positivity for SMA and CD10 and a negative reaction with S100 protein,
HMB45, Mel A, p63, CK5/6, CKAE1/3, desmin and caldesmon. A moderate, focal and diffuse
lymphocytic infiltrate of CD3 and predominant CD8 positive lymphocytes was also present
(Figure 2). Occasional CD1a positive cells as well as a few CD68 positive histiocytes were
also a feature. Three weeks later the lesional area, which had clinically shrunk, was excised.
The biopsy showed no evidence of residual nodular fasciitis but the dermis was elastotic/
degenerated in appearance and contained a diffuse and follicular lymphocytic infiltrate
(Figure 3). Centrally, the follicles contained small numbers of CD21 positive reticulum cells;
the majority of the lymphocytes stained positively with CD3 and smaller numbers of CD20
positive cells were centrally present in most of the follicles. The T-cells were both CD4 and
CD8 positive in approximately equal numbers.Both CD56 and CD34 were negative.
Figure 1: Biopsy showing spindle cells with elongated tapering nuclei and displaying small nucleoli. Frequent normal mitoses were present
Figure 2: The excised specimen showing no evidence of residual nodular fasciitis. The dermis is elastotic and degenerated in appearance and contains a focal and diffuse lymphocytic infiltrate
Figure 3: A moderate, focal and diffuse lymphocytic infiltrate of CD3 and predominantly CD8 positive lymphocytes was also present
Nodular fasciitis is a reactive fibroblastic/myofibroblastic proliferation usually
occurring in the subcutaneous tissue. Dermal nodular fasciitis is a rare occurrence .
According to de Feraudy and Fletcher, 25% of cases arise in the head and neck area, as
did this case. Moreover, spontaneous regression is an unusual but well documented occurrence in nodular fasciitis . Its mechanism however, is not well
established. Shawn et al cite suggestions of regression by scarring2.
Yanagisawa and Okada, whilst acknowledging that the mechanism
is unclear at present, suggest that degeneration resulting from the
temporal transition from a myxoid to a fibrous morphology, may be
involved in the process . Other authors agree with this premise
and furthermore, report up regulation of genes encoding chemokines
and cytokines in nodular fasciitis, speculating that these lesions are
therefore poised to regress . This case also showed degenerative
features but with features of an immunological response. Nodular
fasciitis therefore illustrates an immunological mechanism of
regression with lesional CD4 and CD8 positive T lymphocytes, similar
to the pathogenesis of regression in benign lichenoid keratosis,
keratoacanthoma and halo nevus  atypical fibroxanthoma  and
also in a case of trichilemmal carcinoma with spontaneous regression
. Consequently, spontaneous regression of nodular fasciitis is
likely to be immunologically mediated and CD4 and CD8 lymphocytes
appear to mediate the process similar to other skin tumours .
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