Portal de Periódicos da CAPES

Bilateral Elastofibroma Dorsi

2011; Elsevier BV; Volume: 92; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2011.05.112

1552-6259

Ali Coşkun, Mehmet Yıldırım,

Oral and Maxillofacial Pathology

Elastofibroma dorsi is a slow-growing, noncapsulated, benign, solid, and soft tissue tumor. It is usually located in the infrascapular region, between the thorax wall and serratus anterior and latissimus dorsi. Although elastofibroma dorsi is usually unilateral, it is also bilateral in 10% of the cases. The pathogenesis of the lesion still remains unclear. Elastofibroma dorsi should be considered in differential diagnosis of soft tissue tumors due to their specific location. As it exhibits benign behavior, it should be surgically removed only in symptomatic patients. A case bilateral elastofibroma dorsi is described and presented. Elastofibroma dorsi is a slow-growing, noncapsulated, benign, solid, and soft tissue tumor. It is usually located in the infrascapular region, between the thorax wall and serratus anterior and latissimus dorsi. Although elastofibroma dorsi is usually unilateral, it is also bilateral in 10% of the cases. The pathogenesis of the lesion still remains unclear. Elastofibroma dorsi should be considered in differential diagnosis of soft tissue tumors due to their specific location. As it exhibits benign behavior, it should be surgically removed only in symptomatic patients. A case bilateral elastofibroma dorsi is described and presented. Elastofibroma dorsi (EFD) is a slow-growing, noncapsulated, rare, benign, solid, and soft tissue tumor with no well-defined boundaries, which is often observed in the subscapular region on the thorax wall [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The EFD is located between the thoracic wall and serratus anterior muscle and the muscles of rhomboid major and latissimus dorsi. An EFD prevalence rises to 24% and is often observed among women in the fourth to sixth decades. Although the EFD is usually unilateral, it is bilateral in 10% of the cases [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The EFD was first defined by Jarvi and Saxen in 1961 [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The pathogenesis of the lesion still remains unclear, although it was suggested that repetitive microtrauma by friction between the lower part of the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroelastic tissue [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Mortman K.D. Hochheiser G.M. Giblin E.M. Manon-Matos Y. Frankel K.M. Elastofibroma dorsi: clinicopathologic review of 6 cases.Ann Thorac Surg. 2007; 83: 1894-1897Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Chest roentgenograms, ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) are useful for diagnosis, with fine-needle aspiration biopsy, tru-cut, or incisional biopsy being performed to confirm the diagnosis; however, excisional biopsy should be preferred [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The common recommended treatment method for EFD is total surgical excision; nevertheless, it is also recommended to avoid surgery, particularly in asymptomatic lesions smaller than 5 cm. No recurrence has been detected in the literature, except for a postoperative case.A 50-year-old woman presented with a 6-months complaint of back pain, particularly aggravated with shoulder movements and swelling under the right scapula. Her laboratory tests were within normal limits. Her physical examination revealed a palpable mass in the right infrascapular region of approximately 7 × 6 cm. The detection of a second mass in the left subscapular region was made by thoracic CT, and the arm was re-examined in hyperabduction. The second mass was approximately 6 × 5 cm and was detected on the left. Her thoracic MRI examination revealed noncapsulated and ovoid masses of 7 × 6 × 4 cm on the right and 6 × 5 × 3 cm on the left side in the subscapular region between the rhomboid and latissimus dorsi muscle groups, which were isointense with the surrounding muscle tissues and contained linear hyperintense areas in its internal structure (Fig 1, Fig 2). Under general anesthesia, both masses were totally excised with bilateral posterolateral subscapular incision. The masses were macroscopically noncapsulated and rubberlike (Fig 3). During the 18-month postoperative follow-up, no complications, no local recurrence, and no restrained shoulder movements were identified.Fig 2Magnetic resonance image of the patient's chest coronal section. Two noncapsulated bilateral soft tissue masses (arrows).View Large Image Figure ViewerDownload (PPT)Fig 3Macroscopic view of the specimen.View Large Image Figure ViewerDownload (PPT)The histopathologic examination was reported as elastofibroma (Fig 4).Fig 4Microscopic view of the specimen. (Hematoxylin-eosin stain, X200.)View Large Image Figure ViewerDownload (PPT)CommentAn EFD is a rare benign tumor of the connective tissue. The EFD typically appears in the subscapular region. In addition, elastofibroma cases have been reported in different regions, such as the axilla, tuberositas ischii, trochanter major, elbows, stomach, rectum, omentum, eyes, hands, and feet [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar].The pathogenesis of the EFD still remains unclear. It has been suggested that repetitive microtrauma by friction between the lower part of the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroblastic tissue [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Mortman K.D. Hochheiser G.M. Giblin E.M. Manon-Matos Y. Frankel K.M. Elastofibroma dorsi: clinicopathologic review of 6 cases.Ann Thorac Surg. 2007; 83: 1894-1897Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Although this view has been supported by the higher elastofibroma dorsi prevalence particularly among individuals who work at hard manual labor, the EFD may also be observed in those who have never worked in hard manual labor jobs and in different locations. Detection of new cases in different regions has led to hypotheses, such as reactive fibromatosis, degeneration due to vascular deficiency, elastotic degeneration, genetic disposition, hereditary enzymatic defect, or systematic involvement [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Perhaps, multiple factors might account for the etiopathogenesis. Our patient had no findings that suggested a genetic disposition or enzyme defect, and no history of working with muscle force.Although usually unilateral, the EFD is bilateral in 10% of the cases and is most commonly located in the infrascapular region, between the thorax wall and serratus anterior muscle and the muscles of the rhomboid major and latissimus dorsi. Although a prevalence of 2% has been reported in the thoracic CT examinations on an asymptomatic elderly population, the rate has risen to 24% in autopsy studies [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. It is often observed among women in the fourth to sixth decades. Its prevalence among women has been reported to be 8 to 13 times higher than men [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The reason behind the higher prevalence among women is still unclear. Our case was a 50-year-old housewife.The symptoms in the EFD depend on the size and location of the lesion. Patients often present with complaints of pain that aggravates with shoulder movements, swelling in the infrascapular region, snapping of the scapula, and chronic back pain. A good physical examination can detect the mass under the scapula, with 50% of cases being asymptomatic or having mild complaints. Therefore, a rather long time may pass from the onset of complaints until treatment. Large lesions might elevate scapula simulating scapula alata.Except for increased signals in the soft tissue and elevated scapula, no specific changes are observed in conventional chest roentgenograms. An ultrasound is a quick and inexpensive diagnostic method in experienced hands. An ultrasound shows in the echogenic fibroblastic background a mass that contains a lipid tissue in the form of scattered linear and curvilinear hypoechoic lines, and a multilayered appearance is characteristic of the EFD. The CT scan reveals a heterogeneous soft tissue mass with muscular density, which contains low-density linear areas depending on the lipid tissue. It is hard to discriminate it from the surrounding muscles. The MRI is the most useful noninvasive diagnostic method. An MRI shows a soft tissue mass containing linear opacities of the lipid tissue with muscular density [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar].Typical localization, female gender, and bilaterality in elderly patients support a possible EFD diagnosis. In such cases, clear findings in the imaging methods should prevent biopsy. Imaging methods may not always be sufficient to diagnose elastofibroma dorsi. Biopsy can be performed to confirm the diagnosis and to eliminate malignity in asymptomatic patients who do not require surgical treatment. Fine needle aspiration biopsy is not recommended due to the hypocellular structure of the tumors [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Open biopsy, or at least, core needle biopsy are needed to obtain sufficient tissue samples [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Differential diagnosis should consider distinctive lipoma, hemangioma, metastatic or primary sarcoma, desmoid tumor, neurofibroma, cicatricial fibroma, fibrous histiocytoma, fibromatosis, and fibrolipoma.Incidentally diagnosed asymptomatic lesions do not need to be surgically removed because no malign transformations have been reported so far. Surgical excision is indicated in symptomatic patients. Unnecessary large and radical resections should be avoided in such patients as marginal resections would be enough. Radiotherapy may be an option particularly in unresectable cases due to their localizations [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. In the postoperative period, the shoulder area will be immobilized for approximately 1 week due to the drainage and compression of the wound, which helps prevent seroma formation. In our patient, we totally excised the masses by bilateral subscapular incision. Having completed her 30-month follow-up, our patient has exhibited no physical and radiologic findings in favor of recurrence.Consequently, a rare and benign soft tissue tumor mostly observed in the subscapular regions of elderly patients, the EFD should be considered in patients with chronic back pain. When it is detected unilaterally, necessary further examinations should be performed by considering that it may be bilateral. Thus, in bilateral cases, patients should be spared from the risk of a second operation by operating on both sides in a single session. Elastofibroma dorsi (EFD) is a slow-growing, noncapsulated, rare, benign, solid, and soft tissue tumor with no well-defined boundaries, which is often observed in the subscapular region on the thorax wall [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The EFD is located between the thoracic wall and serratus anterior muscle and the muscles of rhomboid major and latissimus dorsi. An EFD prevalence rises to 24% and is often observed among women in the fourth to sixth decades. Although the EFD is usually unilateral, it is bilateral in 10% of the cases [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The EFD was first defined by Jarvi and Saxen in 1961 [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The pathogenesis of the lesion still remains unclear, although it was suggested that repetitive microtrauma by friction between the lower part of the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroelastic tissue [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Mortman K.D. Hochheiser G.M. Giblin E.M. Manon-Matos Y. Frankel K.M. Elastofibroma dorsi: clinicopathologic review of 6 cases.Ann Thorac Surg. 2007; 83: 1894-1897Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Chest roentgenograms, ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) are useful for diagnosis, with fine-needle aspiration biopsy, tru-cut, or incisional biopsy being performed to confirm the diagnosis; however, excisional biopsy should be preferred [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The common recommended treatment method for EFD is total surgical excision; nevertheless, it is also recommended to avoid surgery, particularly in asymptomatic lesions smaller than 5 cm. No recurrence has been detected in the literature, except for a postoperative case. A 50-year-old woman presented with a 6-months complaint of back pain, particularly aggravated with shoulder movements and swelling under the right scapula. Her laboratory tests were within normal limits. Her physical examination revealed a palpable mass in the right infrascapular region of approximately 7 × 6 cm. The detection of a second mass in the left subscapular region was made by thoracic CT, and the arm was re-examined in hyperabduction. The second mass was approximately 6 × 5 cm and was detected on the left. Her thoracic MRI examination revealed noncapsulated and ovoid masses of 7 × 6 × 4 cm on the right and 6 × 5 × 3 cm on the left side in the subscapular region between the rhomboid and latissimus dorsi muscle groups, which were isointense with the surrounding muscle tissues and contained linear hyperintense areas in its internal structure (Fig 1, Fig 2). Under general anesthesia, both masses were totally excised with bilateral posterolateral subscapular incision. The masses were macroscopically noncapsulated and rubberlike (Fig 3). During the 18-month postoperative follow-up, no complications, no local recurrence, and no restrained shoulder movements were identified. The histopathologic examination was reported as elastofibroma (Fig 4). CommentAn EFD is a rare benign tumor of the connective tissue. The EFD typically appears in the subscapular region. In addition, elastofibroma cases have been reported in different regions, such as the axilla, tuberositas ischii, trochanter major, elbows, stomach, rectum, omentum, eyes, hands, and feet [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar].The pathogenesis of the EFD still remains unclear. It has been suggested that repetitive microtrauma by friction between the lower part of the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroblastic tissue [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Mortman K.D. Hochheiser G.M. Giblin E.M. Manon-Matos Y. Frankel K.M. Elastofibroma dorsi: clinicopathologic review of 6 cases.Ann Thorac Surg. 2007; 83: 1894-1897Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Although this view has been supported by the higher elastofibroma dorsi prevalence particularly among individuals who work at hard manual labor, the EFD may also be observed in those who have never worked in hard manual labor jobs and in different locations. Detection of new cases in different regions has led to hypotheses, such as reactive fibromatosis, degeneration due to vascular deficiency, elastotic degeneration, genetic disposition, hereditary enzymatic defect, or systematic involvement [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Perhaps, multiple factors might account for the etiopathogenesis. Our patient had no findings that suggested a genetic disposition or enzyme defect, and no history of working with muscle force.Although usually unilateral, the EFD is bilateral in 10% of the cases and is most commonly located in the infrascapular region, between the thorax wall and serratus anterior muscle and the muscles of the rhomboid major and latissimus dorsi. Although a prevalence of 2% has been reported in the thoracic CT examinations on an asymptomatic elderly population, the rate has risen to 24% in autopsy studies [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. It is often observed among women in the fourth to sixth decades. Its prevalence among women has been reported to be 8 to 13 times higher than men [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The reason behind the higher prevalence among women is still unclear. Our case was a 50-year-old housewife.The symptoms in the EFD depend on the size and location of the lesion. Patients often present with complaints of pain that aggravates with shoulder movements, swelling in the infrascapular region, snapping of the scapula, and chronic back pain. A good physical examination can detect the mass under the scapula, with 50% of cases being asymptomatic or having mild complaints. Therefore, a rather long time may pass from the onset of complaints until treatment. Large lesions might elevate scapula simulating scapula alata.Except for increased signals in the soft tissue and elevated scapula, no specific changes are observed in conventional chest roentgenograms. An ultrasound is a quick and inexpensive diagnostic method in experienced hands. An ultrasound shows in the echogenic fibroblastic background a mass that contains a lipid tissue in the form of scattered linear and curvilinear hypoechoic lines, and a multilayered appearance is characteristic of the EFD. The CT scan reveals a heterogeneous soft tissue mass with muscular density, which contains low-density linear areas depending on the lipid tissue. It is hard to discriminate it from the surrounding muscles. The MRI is the most useful noninvasive diagnostic method. An MRI shows a soft tissue mass containing linear opacities of the lipid tissue with muscular density [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar].Typical localization, female gender, and bilaterality in elderly patients support a possible EFD diagnosis. In such cases, clear findings in the imaging methods should prevent biopsy. Imaging methods may not always be sufficient to diagnose elastofibroma dorsi. Biopsy can be performed to confirm the diagnosis and to eliminate malignity in asymptomatic patients who do not require surgical treatment. Fine needle aspiration biopsy is not recommended due to the hypocellular structure of the tumors [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Open biopsy, or at least, core needle biopsy are needed to obtain sufficient tissue samples [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Differential diagnosis should consider distinctive lipoma, hemangioma, metastatic or primary sarcoma, desmoid tumor, neurofibroma, cicatricial fibroma, fibrous histiocytoma, fibromatosis, and fibrolipoma.Incidentally diagnosed asymptomatic lesions do not need to be surgically removed because no malign transformations have been reported so far. Surgical excision is indicated in symptomatic patients. Unnecessary large and radical resections should be avoided in such patients as marginal resections would be enough. Radiotherapy may be an option particularly in unresectable cases due to their localizations [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. In the postoperative period, the shoulder area will be immobilized for approximately 1 week due to the drainage and compression of the wound, which helps prevent seroma formation. In our patient, we totally excised the masses by bilateral subscapular incision. Having completed her 30-month follow-up, our patient has exhibited no physical and radiologic findings in favor of recurrence.Consequently, a rare and benign soft tissue tumor mostly observed in the subscapular regions of elderly patients, the EFD should be considered in patients with chronic back pain. When it is detected unilaterally, necessary further examinations should be performed by considering that it may be bilateral. Thus, in bilateral cases, patients should be spared from the risk of a second operation by operating on both sides in a single session. An EFD is a rare benign tumor of the connective tissue. The EFD typically appears in the subscapular region. In addition, elastofibroma cases have been reported in different regions, such as the axilla, tuberositas ischii, trochanter major, elbows, stomach, rectum, omentum, eyes, hands, and feet [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The pathogenesis of the EFD still remains unclear. It has been suggested that repetitive microtrauma by friction between the lower part of the scapula and the thoracic wall may cause the reactive hyperproliferation of fibroblastic tissue [1Fibla J. Molins L. Marco V. Perez J. Vidal G. Bilateral elastofibroma dorsi.Joint Bone Spine. 2007; 74: 194-196Crossref PubMed Scopus (19) Google Scholar, 2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Mortman K.D. Hochheiser G.M. Giblin E.M. Manon-Matos Y. Frankel K.M. Elastofibroma dorsi: clinicopathologic review of 6 cases.Ann Thorac Surg. 2007; 83: 1894-1897Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Although this view has been supported by the higher elastofibroma dorsi prevalence particularly among individuals who work at hard manual labor, the EFD may also be observed in those who have never worked in hard manual labor jobs and in different locations. Detection of new cases in different regions has led to hypotheses, such as reactive fibromatosis, degeneration due to vascular deficiency, elastotic degeneration, genetic disposition, hereditary enzymatic defect, or systematic involvement [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Perhaps, multiple factors might account for the etiopathogenesis. Our patient had no findings that suggested a genetic disposition or enzyme defect, and no history of working with muscle force. Although usually unilateral, the EFD is bilateral in 10% of the cases and is most commonly located in the infrascapular region, between the thorax wall and serratus anterior muscle and the muscles of the rhomboid major and latissimus dorsi. Although a prevalence of 2% has been reported in the thoracic CT examinations on an asymptomatic elderly population, the rate has risen to 24% in autopsy studies [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. It is often observed among women in the fourth to sixth decades. Its prevalence among women has been reported to be 8 to 13 times higher than men [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. The reason behind the higher prevalence among women is still unclear. Our case was a 50-year-old housewife. The symptoms in the EFD depend on the size and location of the lesion. Patients often present with complaints of pain that aggravates with shoulder movements, swelling in the infrascapular region, snapping of the scapula, and chronic back pain. A good physical examination can detect the mass under the scapula, with 50% of cases being asymptomatic or having mild complaints. Therefore, a rather long time may pass from the onset of complaints until treatment. Large lesions might elevate scapula simulating scapula alata. Except for increased signals in the soft tissue and elevated scapula, no specific changes are observed in conventional chest roentgenograms. An ultrasound is a quick and inexpensive diagnostic method in experienced hands. An ultrasound shows in the echogenic fibroblastic background a mass that contains a lipid tissue in the form of scattered linear and curvilinear hypoechoic lines, and a multilayered appearance is characteristic of the EFD. The CT scan reveals a heterogeneous soft tissue mass with muscular density, which contains low-density linear areas depending on the lipid tissue. It is hard to discriminate it from the surrounding muscles. The MRI is the most useful noninvasive diagnostic method. An MRI shows a soft tissue mass containing linear opacities of the lipid tissue with muscular density [2Muramatsu K. Ihara K. Hashimoto T. Seto S. Taguchi T. Elastofibroma dorsi: diagnosis and treatment.J Shoulder Elbow Surg. 2007; 16: 591-595Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar]. Typical localization, female gender, and bilaterality in elderly patients support a possible EFD diagnosis. In such cases, clear findings in the imaging methods should prevent biopsy. Imaging methods may not always be sufficient to diagnose elastofibroma dorsi. Biopsy can be performed to confirm the diagnosis and to eliminate malignity in asymptomatic patients who do not require surgical treatment. Fine needle aspiration biopsy is not recommended due to the hypocellular structure of the tumors [4Kourda J. Ayadi-Kaddour A. Merai S. Hantous S. Miled K.B. Mezni F.E. Bilateral elastofibroma dorsi A case report and review of the literature.Orthop Traumatol Surg Res. 2009; 95: 383-387Crossref PubMed Scopus (23) Google Scholar, 5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Open biopsy, or at least, core needle biopsy are needed to obtain sufficient tissue samples [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. Differential diagnosis should consider distinctive lipoma, hemangioma, metastatic or primary sarcoma, desmoid tumor, neurofibroma, cicatricial fibroma, fibrous histiocytoma, fibromatosis, and fibrolipoma. Incidentally diagnosed asymptomatic lesions do not need to be surgically removed because no malign transformations have been reported so far. Surgical excision is indicated in symptomatic patients. Unnecessary large and radical resections should be avoided in such patients as marginal resections would be enough. Radiotherapy may be an option particularly in unresectable cases due to their localizations [5Daigeler A. Vogt P.M. Bush K. et al.Elastofibroma dorsi-differential diagnosis in chest wall tumors.World J Surg Oncol. 2007; 5: 1-15Crossref PubMed Scopus (65) Google Scholar]. In the postoperative period, the shoulder area will be immobilized for approximately 1 week due to the drainage and compression of the wound, which helps prevent seroma formation. In our patient, we totally excised the masses by bilateral subscapular incision. Having completed her 30-month follow-up, our patient has exhibited no physical and radiologic findings in favor of recurrence. Consequently, a rare and benign soft tissue tumor mostly observed in the subscapular regions of elderly patients, the EFD should be considered in patients with chronic back pain. When it is detected unilaterally, necessary further examinations should be performed by considering that it may be bilateral. Thus, in bilateral cases, patients should be spared from the risk of a second operation by operating on both sides in a single session.