DOI: 10.1148/rg.271065065
Pathologic and MR Imaging Features of Benign Fibrous Soft-Tissue Tumors in Adults1
Philip A. Dinauer, MD,
Clark J. Brixey, MD,
Joel T. Moncur, MD,
Julie C. Fanburg-Smith, MD and
Mark D. Murphey, MD
1 From the Department of Diagnostic Radiology, Hospital of Saint Raphael, 1450 Chapel St, New Haven, CT 06511 (P.A.D.); Departments of Radiology (C.J.B., M.D.M.) and Pathology (J.T.M.), Walter Reed Army Medical Center, Washington, DC; Departments of Radiologic Pathology (M.D.M.) and Soft Tissue Pathology (J.C.F.), Armed Forces Institute of Pathology, Washington, DC; and Departments of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (P.A.D., M.D.M.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received April 17, 2006; revision requested May 1 and received June 7; accepted June 15. All authors have no financial relationships to disclose.
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Figure 1a. Subcutaneous fascia-based nodular fasciitis in the upper arm of a 38-year-old man. (a) Axial T1-weighted image shows a small nodule (arrow) localized to fascia on the lateral surface of the brachialis muscle. The lesion dimensions were 0.8 x 0.3 x 1.1 cm. (b) Photomicrograph (hematoxylineosin [H-E] stain) at low power demonstrates a well-circumscribed myxoid and spindle cell lesion (*) in fascia, centered between subcutaneous fat (A) and skeletal muscle (M).
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Figure 1b. Subcutaneous fascia-based nodular fasciitis in the upper arm of a 38-year-old man. (a) Axial T1-weighted image shows a small nodule (arrow) localized to fascia on the lateral surface of the brachialis muscle. The lesion dimensions were 0.8 x 0.3 x 1.1 cm. (b) Photomicrograph (hematoxylineosin [H-E] stain) at low power demonstrates a well-circumscribed myxoid and spindle cell lesion (*) in fascia, centered between subcutaneous fat (A) and skeletal muscle (M).
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Figure 2a. Fascia-based nodular fasciitis in the forearm of a 34-year-old woman with a clinical history of a palpable, rapidly enlarging mass. (a) Axial T1-weighted image shows a 3-cm mass (arrow) in the fascia along the radial aspect of the forearm. (b) Coronal short inversion time inversion recovery image shows linear extension of the lesion (arrows) superficially along the fascia. Although the lesion has nonspecific high signal intensity, nodular fasciitis should be the primary diagnostic consideration because of the lesion’s small size and forearm location and the patient’s age and clinical history.
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Figure 2b. Fascia-based nodular fasciitis in the forearm of a 34-year-old woman with a clinical history of a palpable, rapidly enlarging mass. (a) Axial T1-weighted image shows a 3-cm mass (arrow) in the fascia along the radial aspect of the forearm. (b) Coronal short inversion time inversion recovery image shows linear extension of the lesion (arrows) superficially along the fascia. Although the lesion has nonspecific high signal intensity, nodular fasciitis should be the primary diagnostic consideration because of the lesion’s small size and forearm location and the patient’s age and clinical history.
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Figure 3a. Fascia-based nodular fasciitis in the proximal forearm of a 44-year-old man. (a) Axial T1-weighted image shows a well-defined 1.1 x 1.4-cm mass (arrow) with signal that is nearly isointense to that of skeletal muscle. The mass is centered on the bicipital aponeurosis and overlies the pronator teres muscle. (b) Axial T2-weighted fat-suppressed fast SE image shows homogeneous high signal intensity in the lesion (arrow). (c) Coronal T1-weighted fat-suppressed image shows diffuse enhancement of the lesion (arrow). (d) Photomicrograph (H-E stain) at intermediate power shows alternating cellularity and foci of myxoid degeneration (M), classic features of nodular fasciitis.
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Figure 3b. Fascia-based nodular fasciitis in the proximal forearm of a 44-year-old man. (a) Axial T1-weighted image shows a well-defined 1.1 x 1.4-cm mass (arrow) with signal that is nearly isointense to that of skeletal muscle. The mass is centered on the bicipital aponeurosis and overlies the pronator teres muscle. (b) Axial T2-weighted fat-suppressed fast SE image shows homogeneous high signal intensity in the lesion (arrow). (c) Coronal T1-weighted fat-suppressed image shows diffuse enhancement of the lesion (arrow). (d) Photomicrograph (H-E stain) at intermediate power shows alternating cellularity and foci of myxoid degeneration (M), classic features of nodular fasciitis.
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Figure 3c. Fascia-based nodular fasciitis in the proximal forearm of a 44-year-old man. (a) Axial T1-weighted image shows a well-defined 1.1 x 1.4-cm mass (arrow) with signal that is nearly isointense to that of skeletal muscle. The mass is centered on the bicipital aponeurosis and overlies the pronator teres muscle. (b) Axial T2-weighted fat-suppressed fast SE image shows homogeneous high signal intensity in the lesion (arrow). (c) Coronal T1-weighted fat-suppressed image shows diffuse enhancement of the lesion (arrow). (d) Photomicrograph (H-E stain) at intermediate power shows alternating cellularity and foci of myxoid degeneration (M), classic features of nodular fasciitis.
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Figure 3d. Fascia-based nodular fasciitis in the proximal forearm of a 44-year-old man. (a) Axial T1-weighted image shows a well-defined 1.1 x 1.4-cm mass (arrow) with signal that is nearly isointense to that of skeletal muscle. The mass is centered on the bicipital aponeurosis and overlies the pronator teres muscle. (b) Axial T2-weighted fat-suppressed fast SE image shows homogeneous high signal intensity in the lesion (arrow). (c) Coronal T1-weighted fat-suppressed image shows diffuse enhancement of the lesion (arrow). (d) Photomicrograph (H-E stain) at intermediate power shows alternating cellularity and foci of myxoid degeneration (M), classic features of nodular fasciitis.
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Figure 4a. Painful intramuscular nodular fasciitis in the upper arm of a 46-year-old woman. (a) Axial T2-weighted image shows a 3 x 3.5-cm hyperintense mass in the medial triceps. The mass has lower signal intensity along its periphery (arrow). (b) Coronal gadolinium-enhanced T1-weighted image shows peripheral enhancement of the lesion, with no appreciable enhancement in the predominantly myxoid center. (c) The nodule was exposed and removed with marginal excision after surgical dissection through the long head of the triceps. (d) Photomicrograph (H-E stain) shows fascia (lower left) with typical myxoid degeneration (M) predominantly in the central portion of the lesion. Note the peripheral parallel vessels at the interface between the fascia and the lesion.
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Figure 4b. Painful intramuscular nodular fasciitis in the upper arm of a 46-year-old woman. (a) Axial T2-weighted image shows a 3 x 3.5-cm hyperintense mass in the medial triceps. The mass has lower signal intensity along its periphery (arrow). (b) Coronal gadolinium-enhanced T1-weighted image shows peripheral enhancement of the lesion, with no appreciable enhancement in the predominantly myxoid center. (c) The nodule was exposed and removed with marginal excision after surgical dissection through the long head of the triceps. (d) Photomicrograph (H-E stain) shows fascia (lower left) with typical myxoid degeneration (M) predominantly in the central portion of the lesion. Note the peripheral parallel vessels at the interface between the fascia and the lesion.
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Figure 4c. Painful intramuscular nodular fasciitis in the upper arm of a 46-year-old woman. (a) Axial T2-weighted image shows a 3 x 3.5-cm hyperintense mass in the medial triceps. The mass has lower signal intensity along its periphery (arrow). (b) Coronal gadolinium-enhanced T1-weighted image shows peripheral enhancement of the lesion, with no appreciable enhancement in the predominantly myxoid center. (c) The nodule was exposed and removed with marginal excision after surgical dissection through the long head of the triceps. (d) Photomicrograph (H-E stain) shows fascia (lower left) with typical myxoid degeneration (M) predominantly in the central portion of the lesion. Note the peripheral parallel vessels at the interface between the fascia and the lesion.
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Figure 4d. Painful intramuscular nodular fasciitis in the upper arm of a 46-year-old woman. (a) Axial T2-weighted image shows a 3 x 3.5-cm hyperintense mass in the medial triceps. The mass has lower signal intensity along its periphery (arrow). (b) Coronal gadolinium-enhanced T1-weighted image shows peripheral enhancement of the lesion, with no appreciable enhancement in the predominantly myxoid center. (c) The nodule was exposed and removed with marginal excision after surgical dissection through the long head of the triceps. (d) Photomicrograph (H-E stain) shows fascia (lower left) with typical myxoid degeneration (M) predominantly in the central portion of the lesion. Note the peripheral parallel vessels at the interface between the fascia and the lesion.
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Figure 5a. Fibroma of the tendon sheath in the hand of a 39-year-old woman. (a) Axial T2-weighted fast SE image shows a low-signal-intensity mass on the volar aspect of the thumb (arrow). The lesion has signal isointense to that of skeletal muscle. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted fast SE image shows that the heterogeneously enhanced lesion involves the flexor pollicis longus tendon (arrow), which is anteriorly displaced.
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Figure 5b. Fibroma of the tendon sheath in the hand of a 39-year-old woman. (a) Axial T2-weighted fast SE image shows a low-signal-intensity mass on the volar aspect of the thumb (arrow). The lesion has signal isointense to that of skeletal muscle. (b) Axial gadolinium-enhanced fat-suppressed T1-weighted fast SE image shows that the heterogeneously enhanced lesion involves the flexor pollicis longus tendon (arrow), which is anteriorly displaced.
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Figure 6a. Fibroma of the tendon sheath in the foot of a 26-year-old woman. (a) Short-axis T2-weighted image depicts a mass, dorsal to the third metatarsal bone of the right foot, with signal that is hypointense to that of skeletal muscle. The anatomic location and signal intensity of the lesion are suggestive of a fibroma or giant cell tumor of the tendon sheath. (b) Photomicrograph (H-E stain) at high power shows a well-delineated mass that is hypocellular and contains a dense collagenous matrix that surrounds a slitlike vessel (arrow) and scattered spindle-shaped fibroblasts.
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Figure 6b. Fibroma of the tendon sheath in the foot of a 26-year-old woman. (a) Short-axis T2-weighted image depicts a mass, dorsal to the third metatarsal bone of the right foot, with signal that is hypointense to that of skeletal muscle. The anatomic location and signal intensity of the lesion are suggestive of a fibroma or giant cell tumor of the tendon sheath. (b) Photomicrograph (H-E stain) at high power shows a well-delineated mass that is hypocellular and contains a dense collagenous matrix that surrounds a slitlike vessel (arrow) and scattered spindle-shaped fibroblasts.
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Figure 7a. Hypertrophic scar in the foot of a 37-year-old woman. (a, b) Sagittal T1-weighted image (a) and short inversion time inversion recovery image (b) demonstrate an elongated low-signal-intensity mass (*) that has arisen in the skin on the plantar aspect of the foot. (c) Photomicrograph (H-E stain) at low power shows the dense collagenous content of the lesion, which accounts for its low signal intensity in a and b; a disorganized spindled fibroblastic cell proliferation oriented in a predominantly horizontal direction, deep to the epidermis (E); vertically oriented vessels (*); and the absence of thick keloid-like collagenous bands.
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Figure 7b. Hypertrophic scar in the foot of a 37-year-old woman. (a, b) Sagittal T1-weighted image (a) and short inversion time inversion recovery image (b) demonstrate an elongated low-signal-intensity mass (*) that has arisen in the skin on the plantar aspect of the foot. (c) Photomicrograph (H-E stain) at low power shows the dense collagenous content of the lesion, which accounts for its low signal intensity in a and b; a disorganized spindled fibroblastic cell proliferation oriented in a predominantly horizontal direction, deep to the epidermis (E); vertically oriented vessels (*); and the absence of thick keloid-like collagenous bands.
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Figure 7c. Hypertrophic scar in the foot of a 37-year-old woman. (a, b) Sagittal T1-weighted image (a) and short inversion time inversion recovery image (b) demonstrate an elongated low-signal-intensity mass (*) that has arisen in the skin on the plantar aspect of the foot. (c) Photomicrograph (H-E stain) at low power shows the dense collagenous content of the lesion, which accounts for its low signal intensity in a and b; a disorganized spindled fibroblastic cell proliferation oriented in a predominantly horizontal direction, deep to the epidermis (E); vertically oriented vessels (*); and the absence of thick keloid-like collagenous bands.
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Figure 8a. Subscapular elastofibroma. (a) Gross specimen resected from an 81-year-old woman shows an admixture of fibrous tissue (white) with fat (yellow). (b) Low-power photomicrograph (H-E stain) demonstrates fibromyxoid stroma with fat infiltration (white) and scattered elastic fibers (bright red).
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Figure 8b. Subscapular elastofibroma. (a) Gross specimen resected from an 81-year-old woman shows an admixture of fibrous tissue (white) with fat (yellow). (b) Low-power photomicrograph (H-E stain) demonstrates fibromyxoid stroma with fat infiltration (white) and scattered elastic fibers (bright red).
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Figure 9a. Subscapular elastofibroma in a 57-year-old woman. (a) Axial T1-weighted image of the left upper back shows a lenticular mass (arrow), deep to the latissimus dorsi and serratus anterior muscles (arrowhead), that contains hyperintense linear streaks of entrapped fat. (b) T2-weighted fast SE image without fat suppression depicts the lesion (arrow) with signal predominantly isointense to that of skeletal muscle.
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Figure 9b. Subscapular elastofibroma in a 57-year-old woman. (a) Axial T1-weighted image of the left upper back shows a lenticular mass (arrow), deep to the latissimus dorsi and serratus anterior muscles (arrowhead), that contains hyperintense linear streaks of entrapped fat. (b) T2-weighted fast SE image without fat suppression depicts the lesion (arrow) with signal predominantly isointense to that of skeletal muscle.
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Figure 10a. Palmar fibromatosis in a 44-year-old woman. (a) Sagittal T1-weighted image depicts a 1-cm-long fusiform lesion (arrowhead) along the palmar aponeurosis at the level of the distal fifth metacarpal. (b) Axial T2-weighted MR image shows low signal intensity in the lesion (arrowhead), which is superficial to the flexor tendon (arrow). (c) High-power photomicrograph (H-E stain) shows a relatively hypocellular, infiltrative aponeurotic tumor composed of fibroblasts, elongated vessels, and extracellular keloidal collagen (arrows).
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Figure 10b. Palmar fibromatosis in a 44-year-old woman. (a) Sagittal T1-weighted image depicts a 1-cm-long fusiform lesion (arrowhead) along the palmar aponeurosis at the level of the distal fifth metacarpal. (b) Axial T2-weighted MR image shows low signal intensity in the lesion (arrowhead), which is superficial to the flexor tendon (arrow). (c) High-power photomicrograph (H-E stain) shows a relatively hypocellular, infiltrative aponeurotic tumor composed of fibroblasts, elongated vessels, and extracellular keloidal collagen (arrows).
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Figure 10c. Palmar fibromatosis in a 44-year-old woman. (a) Sagittal T1-weighted image depicts a 1-cm-long fusiform lesion (arrowhead) along the palmar aponeurosis at the level of the distal fifth metacarpal. (b) Axial T2-weighted MR image shows low signal intensity in the lesion (arrowhead), which is superficial to the flexor tendon (arrow). (c) High-power photomicrograph (H-E stain) shows a relatively hypocellular, infiltrative aponeurotic tumor composed of fibroblasts, elongated vessels, and extracellular keloidal collagen (arrows).
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Figure 11a. Plantar fibromatosis along the aponeurosis superficial to the flexor digitorum brevis muscle. (a) Short-axis T1-weighted image shows a lesion (arrow) with foci of intermediate signal intensity corresponding to cellular areas and foci of low signal intensity corresponding to collagenous areas (arrowheads). (b) Sagittal short inversion time inversion recovery MR image shows the lesion (large arrow) with heterogeneous signal intensity and linear extension (small arrow) along the plantar aponeurosis (arrowheads). (c) Incision through the plantar surface of the foot reveals a firm, glistening nodule (arrows) of the medial plantar aponeurosis.
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Figure 11b. Plantar fibromatosis along the aponeurosis superficial to the flexor digitorum brevis muscle. (a) Short-axis T1-weighted image shows a lesion (arrow) with foci of intermediate signal intensity corresponding to cellular areas and foci of low signal intensity corresponding to collagenous areas (arrowheads). (b) Sagittal short inversion time inversion recovery MR image shows the lesion (large arrow) with heterogeneous signal intensity and linear extension (small arrow) along the plantar aponeurosis (arrowheads). (c) Incision through the plantar surface of the foot reveals a firm, glistening nodule (arrows) of the medial plantar aponeurosis.
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Figure 11c. Plantar fibromatosis along the aponeurosis superficial to the flexor digitorum brevis muscle. (a) Short-axis T1-weighted image shows a lesion (arrow) with foci of intermediate signal intensity corresponding to cellular areas and foci of low signal intensity corresponding to collagenous areas (arrowheads). (b) Sagittal short inversion time inversion recovery MR image shows the lesion (large arrow) with heterogeneous signal intensity and linear extension (small arrow) along the plantar aponeurosis (arrowheads). (c) Incision through the plantar surface of the foot reveals a firm, glistening nodule (arrows) of the medial plantar aponeurosis.
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Figure 12a. Abdominal desmoid tumor in a 38-year-old woman. (a) Axial T2-weighted image shows a large heterogeneous mass (arrow) that contains regions of intermediate to low signal intensity in the abdominal wall on the left side. (b) Sagittal gadolinium-enhanced T1-weighted image shows an enhanced tumor (arrow) that involves fascial layers of the left rectus abdominis muscle. (c) Photograph of the resected gross specimen demonstrates a well-circumscribed mass with a heterogeneous and fibrous "fish flesh" appearance.
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Figure 12b. Abdominal desmoid tumor in a 38-year-old woman. (a) Axial T2-weighted image shows a large heterogeneous mass (arrow) that contains regions of intermediate to low signal intensity in the abdominal wall on the left side. (b) Sagittal gadolinium-enhanced T1-weighted image shows an enhanced tumor (arrow) that involves fascial layers of the left rectus abdominis muscle. (c) Photograph of the resected gross specimen demonstrates a well-circumscribed mass with a heterogeneous and fibrous "fish flesh" appearance.
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Figure 12c. Abdominal desmoid tumor in a 38-year-old woman. (a) Axial T2-weighted image shows a large heterogeneous mass (arrow) that contains regions of intermediate to low signal intensity in the abdominal wall on the left side. (b) Sagittal gadolinium-enhanced T1-weighted image shows an enhanced tumor (arrow) that involves fascial layers of the left rectus abdominis muscle. (c) Photograph of the resected gross specimen demonstrates a well-circumscribed mass with a heterogeneous and fibrous "fish flesh" appearance.
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Figure 13a. Aggressive fibromatosis in an 18-year-old man. (a) Axial T2-weighted image shows the subcutaneous origin of a relatively cellular tumor (arrow) located posterior to the infraspinatus and deltoid muscles. (b) Sagittal gadolinium-enhanced fat-suppressed T1-weighted image, obtained within 1 year after lesion excision, shows an enhanced and infiltrative recurrent mass with spiculated margins (arrowheads) that extends posterior and inferior to the scapula. Note the deep intra- and intermuscular component (arrow) located between the supraspinatus and subscapularis muscles.
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Figure 13b. Aggressive fibromatosis in an 18-year-old man. (a) Axial T2-weighted image shows the subcutaneous origin of a relatively cellular tumor (arrow) located posterior to the infraspinatus and deltoid muscles. (b) Sagittal gadolinium-enhanced fat-suppressed T1-weighted image, obtained within 1 year after lesion excision, shows an enhanced and infiltrative recurrent mass with spiculated margins (arrowheads) that extends posterior and inferior to the scapula. Note the deep intra- and intermuscular component (arrow) located between the supraspinatus and subscapularis muscles.
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Figure 14a. Extraabdominal desmoid tumor in a 46-year-old man with a history of spinal fusion surgery. (a) Axial T2-weighted fast SE image shows a well-circumscribed mass (arrow), centered between the posterior layer of the thoracolumbar fascia and the multifidus muscle, that contains collagenous bands of low signal intensity that are most visible medially. (b) Sagittal T2-weighted fast SE image shows an infiltrative mass between muscle and fascia at the T12-L1 level that extends linearly along the fascia (arrowhead). (c) Photomicrograph (H-E stain) shows a poorly circumscribed proliferation of spindle cells and ectatic blood vessels. The lesion (*) has infiltrated adipose tissue (arrow) and skeletal muscle (M).
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Figure 14b. Extraabdominal desmoid tumor in a 46-year-old man with a history of spinal fusion surgery. (a) Axial T2-weighted fast SE image shows a well-circumscribed mass (arrow), centered between the posterior layer of the thoracolumbar fascia and the multifidus muscle, that contains collagenous bands of low signal intensity that are most visible medially. (b) Sagittal T2-weighted fast SE image shows an infiltrative mass between muscle and fascia at the T12-L1 level that extends linearly along the fascia (arrowhead). (c) Photomicrograph (H-E stain) shows a poorly circumscribed proliferation of spindle cells and ectatic blood vessels. The lesion (*) has infiltrated adipose tissue (arrow) and skeletal muscle (M).
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Figure 14c. Extraabdominal desmoid tumor in a 46-year-old man with a history of spinal fusion surgery. (a) Axial T2-weighted fast SE image shows a well-circumscribed mass (arrow), centered between the posterior layer of the thoracolumbar fascia and the multifidus muscle, that contains collagenous bands of low signal intensity that are most visible medially. (b) Sagittal T2-weighted fast SE image shows an infiltrative mass between muscle and fascia at the T12-L1 level that extends linearly along the fascia (arrowhead). (c) Photomicrograph (H-E stain) shows a poorly circumscribed proliferation of spindle cells and ectatic blood vessels. The lesion (*) has infiltrated adipose tissue (arrow) and skeletal muscle (M).
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Figure 15a. Extraabdominal desmoid tumor in the neck of a 26-year-old woman. (a) Axial T2-weighted fat-suppressed fast SE image shows a predominantly intermuscular mass with prominent low-signal-intensity fibrous bands (arrow) surrounded by cellular regions of higher signal intensity. (b) Sagittal gadolinium-enhanced T1-weighted image shows longitudinal extension of the enhanced tumor (arrows) along the fascia, and nonenhanced fibrous bands (arrowheads). (c) Gross specimen photograph demonstrates the infiltrative border (arrow) of the fibroblastic tumor, with multiple fibrous bands (arrowheads). (d) Photomicrograph (H-E stain) at intermediate power shows bland myofibroblasts parallel to elongated vessels, and keloidal collagen (pink).
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Figure 15b. Extraabdominal desmoid tumor in the neck of a 26-year-old woman. (a) Axial T2-weighted fat-suppressed fast SE image shows a predominantly intermuscular mass with prominent low-signal-intensity fibrous bands (arrow) surrounded by cellular regions of higher signal intensity. (b) Sagittal gadolinium-enhanced T1-weighted image shows longitudinal extension of the enhanced tumor (arrows) along the fascia, and nonenhanced fibrous bands (arrowheads). (c) Gross specimen photograph demonstrates the infiltrative border (arrow) of the fibroblastic tumor, with multiple fibrous bands (arrowheads). (d) Photomicrograph (H-E stain) at intermediate power shows bland myofibroblasts parallel to elongated vessels, and keloidal collagen (pink).
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Figure 15c. Extraabdominal desmoid tumor in the neck of a 26-year-old woman. (a) Axial T2-weighted fat-suppressed fast SE image shows a predominantly intermuscular mass with prominent low-signal-intensity fibrous bands (arrow) surrounded by cellular regions of higher signal intensity. (b) Sagittal gadolinium-enhanced T1-weighted image shows longitudinal extension of the enhanced tumor (arrows) along the fascia, and nonenhanced fibrous bands (arrowheads). (c) Gross specimen photograph demonstrates the infiltrative border (arrow) of the fibroblastic tumor, with multiple fibrous bands (arrowheads). (d) Photomicrograph (H-E stain) at intermediate power shows bland myofibroblasts parallel to elongated vessels, and keloidal collagen (pink).
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Figure 15d. Extraabdominal desmoid tumor in the neck of a 26-year-old woman. (a) Axial T2-weighted fat-suppressed fast SE image shows a predominantly intermuscular mass with prominent low-signal-intensity fibrous bands (arrow) surrounded by cellular regions of higher signal intensity. (b) Sagittal gadolinium-enhanced T1-weighted image shows longitudinal extension of the enhanced tumor (arrows) along the fascia, and nonenhanced fibrous bands (arrowheads). (c) Gross specimen photograph demonstrates the infiltrative border (arrow) of the fibroblastic tumor, with multiple fibrous bands (arrowheads). (d) Photomicrograph (H-E stain) at intermediate power shows bland myofibroblasts parallel to elongated vessels, and keloidal collagen (pink).
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