What is the management approach for elastofibroma?

Management of Elastofibroma

For elastofibroma dorsi, a conservative "watch and wait" approach is the recommended first-line management strategy, with surgical excision reserved exclusively for symptomatic patients or those with large lesions causing functional impairment. 1, 2, 3

Initial Management Strategy

Conservative observation is the standard of care for asymptomatic elastofibroma dorsi, regardless of tumor size. 1, 2 This approach is justified because:

• Elastofibroma dorsi is a benign pseudo-tumor with no malignant potential 2
• Surgical excision carries a significant complication rate of 10-43%, primarily hematoma and seroma formation 4, 5
• No recurrence has been documented after complete excision, indicating these lesions are stable when left in situ 5, 3

Diagnostic Workup

CT scan is the preferred imaging modality for preoperative assessment, showing the highest correlation with actual pathological tumor size (r=0.819) compared to ultrasound (r=0.421). 3 MRI can also be used effectively for diagnosis and characterization. 1, 2

Percutaneous biopsy should be performed to confirm diagnosis and exclude soft tissue sarcoma before committing to conservative management, particularly for lesions >5 cm in diameter. 2 The characteristic subscapular location between the inferior scapular angle and posterior thoracic wall is highly suggestive of elastofibroma. 4, 2

Indications for Surgical Intervention

Surgery should be offered when patients experience:

• Significant pain or discomfort during shoulder movements 5, 3
• Clunking sensation or snapping with scapular motion 5, 2
• Localized swelling causing cosmetic concerns or functional limitation 5
• Large tumor size (typically >8 cm) even if minimally symptomatic 3

Approximately 46-54% of patients with elastofibroma present with symptoms warranting consideration of surgery. 5

Surgical Technique

When surgery is indicated, marginal excision through a muscle-sparing approach is the standard technique. 3 Key technical considerations include:

• Complete tumor excision with marginal resection is curative with no documented recurrences 5, 3
• Muscle-sparing approaches minimize morbidity while achieving complete resection 3
• Suction drainage should be maintained for >7 days postoperatively to prevent hematoma/seroma formation 4
• Careful wound observation and surgical techniques to facilitate wound margin adhesion reduce complications 4

Risk Factors for Postoperative Complications

BMI >25 is an independent risk factor for postoperative morbidity (OR 8.71, P=0.024). 3 Additional risk factors include:

• Larger tumor diameter correlates with higher hematoma risk (P=0.02) 4
• Antiplatelet medications increase drainage time (P=0.006) and complication rates (P=0.038) 3
• Longer operative times occur in patients with BMI >25 (P=0.048) 3

Follow-Up Protocol

An "open-door" follow-up policy is appropriate after surgical excision, given the benign nature and absence of recurrence after complete resection. 3 For conservatively managed patients, periodic clinical assessment is reasonable, though no formal surveillance protocol exists given the stable natural history. 1, 2

Common Pitfalls to Avoid

• Do not proceed directly to surgery without tissue diagnosis, as soft tissue sarcomas can present similarly in the subscapular region 2
• Avoid recommending surgery for asymptomatic patients solely based on tumor size, as complications may exceed benefits 1, 2
• Do not discontinue drainage prematurely (<7 days), as this significantly increases hematoma/seroma risk 4
• Bilateral lesions occur in 16-17% of cases—always image the contralateral side 5, 2