We describe the case of a 20-year-old rower presenting with an uncommon condition of Proliferative Myositis (PM) affecting the Latissimus Dorsi (LD). PM is a rare, benign tumour infrequently developing in the upper back. Its rapid growth and firm consistency may mistake it for sarcoma at presentation. Therefore, careful multidisciplinary work-up is crucial, and should involve appropriate radiological and histopathological investigations. Here, we propose the aetiology of LD PM to be persistent myotrauma induced by repetitive rowing motions. Symptoms and rate of progression ultimately determine the management which includes surveillance and/or conservative resection. There have been no documented cases of recurrence or malignant transformation

Beggan, C.

Bennett, Michael W.

Larkin, J.

McHugh, Nathaniel

Moloney, Fiachra

Ryan, D. J.

Tevlin, R.

Irish Universities

Proliferative myositis of the Latissimus Dorsi presenting in a 20-year-old male athlete

Cork Open Research Archive

UCC Library and UCC researchers have made this item openly available.Please let us know how this has helped you. Thanks!Title Proliferative myositis of the Latissimus Dorsi presenting in a 20-year-old male athleteAuthor(s) McHugh, Nathaniel; Tevlin, R.; Beggan, C.; Ryan, D. J.; Larkin, J.;Moloney, Fiachra; Bennett, Michael W.Publication date 2017-08Original citation McHugh, N., Tevlin, R., Beggan, C., Ryan, D., Larkin, J., Moloney, F.,Bennett, M. and Kelly, J. (2017) ‘Proliferative myositis of the latissimusdorsi presenting in a 20-year-old male athlete’, Irish Medical Journal,110(7), 605 (6pp). doi: 10147/622530Type of publication Article (peer-reviewed)Link to publisher'sversionhttp://dx.doi.org/10147/622530Access to the full text of the published version may require asubscription.Rights © 2017, Irish Medical Journal. All rights reserved.Item downloadedfromhttp://hdl.handle.net/10468/5888Downloaded on 2019-12-02T14:30:39ZProliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]Proliferative myositis of the latissimus dorsi presentingin a 20-year-old male athleteN Mc Hugh , R Tevlin , C Beggan , D J. Ryan , J Larkin , F Moloney , M W. Bennett , J KellyDepartment of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, IrelandDepartment of Histopathology, Cork University Hospital, Wilton, Cork, IrelandDepartment of Radiology, Cork University Hospital, Wilton, Cork, IrelandUniversity College Cork School of Medicine, Cork University Hospital, Wilton, Cork, IrelandAbstractWe describe the case of a 20-year-old rower presenting with an uncommon condition ofProliferative Myositis (PM) affecting the Latissimus Dorsi (LD). PM is a rare, benign tumourinfrequently developing in the upper back. Its rapid growth and firm consistency may mistake itfor sarcoma at presentation. Therefore, careful multidisciplinary work-up is crucial, and shouldinvolve appropriate radiological and histopathological investigations. Here, we propose theaetiology of LD PM to be persistent myotrauma induced by repetitive rowing motions. Symptomsand rate of progression ultimately determine the management which includes surveillance and/orconservative resection. There have been no documented cases of recurrence or malignanttransformation. 1 1 2 3 4 3 2 11234       This Month Archive Subscribe For Authors About Us My CPDHosted Content HomeProliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]IntroductionProliferative Myositis (PM) is a rare, benign tumour easily mistaken for sarcoma at presentation. Here, wepropose that LD PM developed following repetitive rowing-induced myotrauma in a young male.Case ReportA 20-year-old male presented with an unresolving, tender subcutaneous mass on his chest wall ofsudden development five months prior. Overlying skin unchanged. No history of trauma. However, thepatient described rowing competitively in the previous months. No systemic disturbances. Clinicalexamination revealed a firm, discrete, deeply-seated solitary 2cm mass attached to underlying LD butuntethered to overlying skin. Ultrasound demonstrated an intramuscular mass, warranting further imaging.MRI subsequently visualised a poorly-defined 29x19x12mm mass within the LD, abutting superficialfascia but with no subcutaneous fat extension (Figure 1).T2-weighted sequencing hyper-intensified thelesion, indicating oedematous tissue. An urgent trucut biopsy was obtained to diagnose/out-rulesuspected sarcoma.Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]Histopathological examination revealed irregular cores of fibroconnective tissue displaying a spindle cellproliferation. The cells were plump, uniform and spindle to stellate without significant nuclearpleomorphism/atypia. Admixed was a population of ganglion-like giant cells with abundant basophiliccytoplasm, eccentric vesicular nuclei and prominent nucleoli (Figure 2). High power magnificationdemonstrated the co-existence of spindle and stellate fibroblasts and ganglion-like myofibroblasts.Spindle cells were CD68(+) and smooth muscle antigen(+) (supporting a fibroblastic process) andnegative for desmin, beta-catenin and s100. Therefore, sarcoma or desmoid-type fibromatosis wasunlikely. The constellation of findings was consistent with PM.Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]DiscussionPM is a rare, benign tumour easily confused with sarcoma at presentation due to its rapid growth withinthe skeletal muscle of predominantly middle-aged patients . The median age of onset is 50 years withmales slightly more affected than females . Areas most commonly affected include the head, neck andupper extremities . The rapid growth is commonly painful, however, lymphadenopathy and inflammationare usually absent .Although the aetiology of PM remains unknown, several theories have been proposed including musculartrauma . Enzinger reported two cases discovered in mailmen who had complained of mailbag-inducedmuscle irritation preceding the development of the lesions . As mentioned, our patient was a competitiverower who sustained repeated strain on his LD, supporting this theory. Alternative theories include localischemia and paracrine myopathy .Following thorough history and examination, radiographic investigations are warranted. Ultrasonographyis a valuable initial approach . Pathognomonic findings on ultrasound include what has been described asa "Scaffolding" pattern in which hypoechoic geometric lines within dense, hyperechoic muscle arevisualised . Additional imaging modalities include CT and MRI. A poorly demarcated intramuscular lessonwith irregular borders is typically demonstrated by CT. MRI appearances vary according to sequence.1,211,33,42-51444Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]Hypointense/isointense lesions are generally demonstrated by T1-weighted sequencing whereas T2-weighted sequences may reveal strongly hyper-intensification. This is suggestive of inflammation , aswas the case with our patient.Definitive diagnosis is made histopathologically. Tissue can be obtained by fine needle aspiration orincisional biopsy, aiming to visualise the characteristic "checkerboard" pattern of myofibroblasts infiltratingsurrounding healthy muscle, ganglion-like basophilic giant cells and a lack of atypical mitosis .Macroscopically, the lesions are frequently poorly-demarcated, appearing as an area of white scar-likeinduration of muscle.  Diagnostically, PM falls within a spectrum of benign myofibroblastic tumour-likelesions, including modular fasciitis and proliferative fasciitis .Symptoms and rate of progression determine management of PM. Surveillance is the preferred optionwith reports suggesting PM tends to spontaneously regress, often with complete resolution achievedwithin months. If the tumour progresses, causes functional impairment or becomes cosmeticallydistressing, conservative surgical excision is recommended . There is currently no role for radicalresection as there have been no documented cases of recurrence or malignant transformationConflict of Interest:The authors declare that there is no conflict of interests.CorrespondenceNathaniel Mc Hugh, Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton,Cork, IrelandReferences1. Enzinger, F.M. & Dulcey, F. Proliferative myositis. Report of thirty-three cases. Cancer 20, 2213-2223(1967).2. Kunze, B., von Weyhern, C. & Kluba, T. Myositis proliferans: diagnosis and therapy of apseudosarcomatous soft tissue lesion. Musculoskeletal surgery 95, 255-257 (2011).3. Fauser, C., Nahrig, J., Niedermeyer, H.P. & Arnold, W. Proliferative myositis: a rare pseudomalignanttumor of the head and neck. Archives of otolaryngology--head & neck surgery 134, 437-440 (2008).4. Colombo, J.R., Dagher, W. & Wein, R.O. Benign proliferative myositis of the sternohyoid muscle:review and case report. American journal of otolaryngology 36, 87-89 (2015).5. Pagonidis, K., Raissaki, M. & Gourtsoyiannis, N. Proliferative myositis: value of imaging. Journal ofcomputer assisted tomography 29, 108-111 (2005).6. Kato, K., Ehara, S., Nishida, J. & Satoh, T. Rapid involution of proliferative fasciitis. Skeletal radiology53,4,5162-52-5.:Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journalfile:///nas.ucc.ie/...d Versions/Proliferative myositis of the latissimus dorsi presenting in a 20-year-old male athlete – Irish Medical Journal.html[27/04/2018 09:51:27]33, 300-302 (2004).(P605)This Month  Archive  Subscribe  For Authors  About Us  My CPD  Hosted Content  HomeTheme by Tyler Moore

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Proliferative myositis of the Latissimus Dorsi presenting in a 20-year-old male athlete

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