The chameleon in the neck: Nodular fasciitis mimicking malignant neck mass of unknown primary

INTRODUCTION: Difficulties with the correct diagnosis and treatment of nodular fasciitis in head and neck region has been reported in the literature. Nodular fasciitis was mistaken for sarcoma, papillary thyroid carcinoma, Burkitt's lymphoma, pleomorphic adenoma, or as a vascular lesion. PRESENTATION OF CASE: We present a patient with a single node in the neck with accelerated growth, which clinically appeared as a malignant epithelial tumor with unknown primary. The en bloc removal of the tumor and selective neck dissection was performed with bilateral tonsillectomy and biopsy of the tongue base. The histopathology revealed the tumor to be nodular fasciitis. No malignant cells were detected. DISCUSSION: Due to very rapid growth, its rich cellularity and high mitotic activity, nodular fasciitis can be mistaken as a malignant tumor. Trauma and/ or infection is advocated to be a trigger for the formation of nodular fasciitis, although the exact aetiopathogenesis still remains unknown. Our patient admitted to regularly practicing martial arts with his opponent performing a specific combat maneuver applying pressure into the neck and submental region, which might have triggered the formation of the nodular fasciitis. CONCLUSION: Nodular fasciitis is a benign and often overlooked diagnosis in the head and neck region, that can be misinterpreted as a malignant tumor both clinically and histologically. A comprehensive medical history may help to avoid unnecessary radical treatment. If a malignancy cannot be confidently ruled out, the en bloc resection of the tumor with selective neck dissection may offer a safe option with low morbidity. (C) 2012 Surgical Associates Ltd. Published by Elsevier Ltd.