Reactive Nodular Fibrous Pseudotumor of the Omentum: A Rare Case Report and Literature Review

Reactive Nodular Fibrous Pseudotumor of the Omentum: A Rare Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Reactive Nodular Fibrous Pseudotumor of the Omentum: A Rare Case Report and Literature Review Xiujuan Sun, Chengyu Hu, Sisi Wang, Weihua Gong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6882209/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Reactive nodular fibrous pseudotumor (RNFP) is a rare, benign, reactive lesion of the gastrointestinal tract that can clinically and radiologically mimic malignant tumors. It has been associated with prior surgical intervention, trauma, or inflammation. We report a case of RNFP in a patient without any history of abdominal surgery or abdominal discomfort. Imaging findings included multiple, well-defined, solid omental masses that were isodense on CT and hypointense on both T1- and T2-weighted MRI, with progressive, mild contrast enhancement. Ultrasound and contrast-enhanced ultrasound revealed hypoechoic masses with limited contrast uptake. To our knowledge, this is the first reported case in which RNFP was comprehensively evaluated using CT, MRI, ultrasound, and contrast-enhanced ultrasound. Furthermore, it is the first case to specifically distinguish RNFP from Gardner fibroma. Reactive nodular fibrous pseudotumor Omentum imaging histopathology differential diagnosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Reactive nodular fibrous pseudotumor (RNFP) is an uncommon, benign lesion of postinflammatory origin characterized by fibroblastic/myofibroblastic proliferation embedded in dense collagenous stroma. First described in 2003, it has since been recognized as a distinct pathological entity. RNFP is often associated with previous abdominal surgery or inflammation and typically requires surgical resection for definitive diagnosis and treatment. Due to its rarity and nonspecific imaging features, it is frequently misdiagnosed preoperatively. Here, we present a case of RNFP occurring in a young adult male with no identifiable history of abdominal trauma or intervention. This case highlights the imaging and pathological features of RNFP and expands current knowledge by providing a comprehensive multimodal imaging assessment. A review of previously reported cases is included to aid clinicians and radiologists in the recognition and differentiation of this rare entity. Case report A previously healthy 31-year-old male with no history of abdominal surgery or pain accidentally palpated an abdominal mass for over one month and presented to another hospital. An abdominal CT scan revealed multiple masses in the abdomen. For further evaluation and management, the patient was referred to our hospital. On physical examination, a firm, mildly tender mass was palpated on the right side of the abdomen, with no other clinical symptoms noted. Laboratory test results were within normal limits. In our hospital, CT and MRI confirmed the presence of multiple solid omental nodules and masses in the abdomen, with the largest mass measuring approximately 12.1 × 4.6 × 9.7 cm. On non-contrast CT, the irregular masses appeared isodense, partially fused, and exhibited calcifications, with progressively mild enhancement on postcontrast imaging (Fig. 1 ). MRI demonstrated moderate hypointensity on T1-weighted images and significant hypointensity on T2-weighted images, with an enhancement pattern similar to that observed on CT (Fig. 2 ). Ultrasound (US) and contrast-enhanced ultrasound (CEUS) revealed hypoechoic masses with mild contrast media uptake (Fig. 3 ). Given these nonspecific radiological features, differential diagnoses included gastrointestinal stromal tumor (GIST) or Gardner fibroma. However, the patient had no personal or family history of Gardner's syndrome. Gastrointestinal tract endoscopy was subsequently performed and revealed no abnormalities. Surgical exploration revealed multiple well-circumscribed, firm, omental masses, the largest measuring approximately 12 cm (Fig. 4 a-b). Gross examination showed tan-white cut surfaces (Fig. 4 c). Immunohistochemistry revealed positivity for cytokeratin AE1/AE3, vimentin, Bcl-2, and Ki-67 (proliferation index 5%), and negativity for SMA, Desmin, CD34, and β-catenin (Fig. 4 d-f). Histologically, the lesions comprised spindle cell proliferation within a collagen-rich, hyalinized stroma, accompanied by lymphocytic infiltrates (Fig. 4 g-h). These features confirmed a diagnosis of RNFP. The patient remained recurrence-free at over 4 years of follow-up. Discussion Since its initial description by Yantiss et al. in 2003, only 28 cases of RNFP have been reported in the English literature [ 1 ] , with additional cases documented in subsequent studies [ 2 – 17 ] . Our case represents the 29th reported instance of this lesion in the English literature. Among the 28 patients reviewed in the literature (Table 1), 17 were male (60.7%) and 11 were female (39.3%). Of these, 24 cases involved adults (85.7%), with the remaining cases including one in a 1-year-old boy [ 4 ] and three in teenagers [10,12,16] . The average age of patients was 47.6 years, and our case involved a 31-year-old male, further supporting the observation that adult males are more predisposed to this condition. Clinically, 12 patients (42.9%) presented with abdominal symptoms as the primary manifestation, among whom five experienced acute abdominal pain. Many authors have emphasized the importance of investigating patients' medical histories, particularly prior abdominal surgeries, as RNFP is believed to arise as an inflammatory response to antecedent abdominal trauma or surgical intervention. Indeed, 11 patients (39.3%) had a documented history of abdominal surgery. Additionally, significant abdominal medical histories were noted in eight cases (28.6%), including duodenal bulbar ulcer (1 case), perforated duodenal diverticulum (1 case), endometriosis (2 cases), chronic bowel obstruction complicated by an external fistula (1 case), ileus caused by a tumor of the ileum (1 case), and ingestion of a foreign body (2 cases). These findings suggest that past abdominal medical or surgical history plays a crucial role in the development of RNFP. However, our case is among the minority of RNFP cases that occur in patients without a prior abdominal operation or other identifiable inciting factors. Moreover, the patient in our case was asymptomatic, with no abdominal discomfort. Thus, similar to a small number of other reported cases, the precise etiology of RNFP in this instance remains unknown. RNFP typically originates from the subserosal surface of the bowel or within the adjacent mesentery and is frequently associated with local injury or inflammation [ 14 ] . The most commonly involved anatomic sites include the mesentery (10 cases), small bowel (8 cases), colon (7 cases), omentum (7 cases), appendix (3 cases), peritoneum (3 cases), gastric wall (2 cases), cecum (2 cases), ovary (2 cases), and duodenum, hepatic surface, hepatic hilum, gastrohepatic ligament, and peripancreas (1 case each). RNFP most often presents as a solitary mass (17 cases, 60.7%), although a minority of cases (11 cases, 39.3%) exhibit multiple masses. Notably, our patient presented with multiple abdominal masses localized exclusively to the omentum. Microscopically, RNFP is characterized by cellular proliferation of spindle cells within a hyalinized, dense collagenous background. Inflammatory cell infiltration, predominantly lymphocytes frequently arranged in lymphoid aggregates, is a consistent feature reported in most cases. Immunohistochemical analysis typically reveals positive staining for cytokeratins (AE1/AE3), vimentin, and smooth muscle actin (SMA) [4, 6]. In our case, spindle cells were positive for cytokeratins (AE1/AE3), vimentin, Bcl-2, and Ki67 but were negative for SMA. Among the 28 patients reviewed in the literature, only 7 patients (25%) underwent CT scans, and 3 patients (10.7%) underwent MRI scans. Radiological descriptions of RNFP are limited. The imaging features are as follows: Lesions appear isodense on non-contrast CT scans, sometimes with calcifications. On MRI, they show homogeneous hypointensity on T1-weighted images and marked hypointensity on T2-weighted images, with progressive mild enhancement. US and CEUS revealed hypoechoic masses with mild contrast media uptake. Our case represents the first reported instance in which comprehensive imaging evaluation was performed, including contrast-enhanced CT and MRI, US and CEUS. In our patient, the masses appeared isodense on non-contrast CT with calcifications, demonstrating progressive mild enhancement on postcontrast CT. MRI revealed moderate hypointensity on T1-weighted images and marked hypointensity on T2-weighted images. These imaging characteristics strongly suggest fibrotic tissue. The enhancement pattern observed on MRI was consistent with that seen on CT. The imaging findings in our patient align well with those previously described in the literature. Cases of RNFP originating in the omentum are exceptionally rare. Accurate differentiation of RNFP from other abdominal reactive processes is crucial, including nodular fasciitis, calcifying fibrous pseudotumor, sclerosing mesenteritis, intra-abdominal fibromatosis, and more aggressive neoplasms such as GIST, intra-abdominal inflammatory myofibroblastic tumors, and inflammatory fibrosarcoma [ 12 ] . In our case, the initial differential diagnosis included GIST and Gardner fibroma. GIST, the most common mesenchymal tumors of the gastrointestinal tract, typically demonstrate distinct CT characteristics: well-defined margins, large hypervascular enhancing masses with heterogeneous enhancement patterns due to necrotic and hemorrhagic components, and potential local invasion [ 18 ] . On MRI, the solid components of GIST typically appear hypointense on T1-weighted imaging, hypo- to iso-intense on T2-weighted imaging, and demonstrate moderate to marked contrast enhancement [ 19 ] . Histologically, GIST exhibit greater cellularity compared to RNFP and are immunohistochemically positive for DOG1, CD117, and CD34 [13, 20] . Gardner fibroma, characterized by hypocellular, densely collagenous tissue resembling normal fibrous tissue or scar, consistently expresses CD34 [ 21 ] . However, our patient showed no clinical evidence of Gardner's syndrome, with negative personal and family history, and unremarkable gastrointestinal endoscopy findings. Surgical resection remains the primary and effective treatment modality for RNFP. Among the 28 reviewed cases, complete resection was achieved in 25 patients (89.3%), while incomplete resection was performed in 3 cases (10.7%) due to extensive disease with multiple masses or nodules. Follow-up data were available for 17 patients (60.7%), with a follow-up duration ranging from 4 months to 7 years. Our case has maintained disease-free status during the 4-year follow-up period. The prognosis of RNFP is consistently favorable, with no reported cases of recurrence or distant metastasis following surgical intervention. Conclusion RNFP is a rare but benign fibrous lesion that should be considered in the differential diagnosis of omental or mesenteric masses, particularly in patients with a history of abdominal surgery or inflammation. Comprehensive imaging, including MRI and CEUS, can aid in preoperative assessment, although definitive diagnosis relies on histopathological evaluation. Awareness of this entity is crucial to avoid misdiagnosis and unnecessary aggressive treatment. Surgical resection remains curative, with an excellent prognosis. Declarations Author Contributions X. S. and C.H. wrote the main manuscript text and S. W. prepared figures. W. G.prepared conceptualization.All authors reviewed the manuscript. Acknowledgements None Funding This study was supported by Key research and development program of Zhejiang Province (Grant No. 2025C02054) Availability of data and materials All relevant data has been presented in the manuscript and further inquiry can be directed to the corresponding author. Ethical Approval and accordance The protocol was approved by the Human Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine in accordance with GCP and relevant laws and regulations. C onsent to publish Informed consent has been obtained from the participant and consent to participate and consent to release has been obtained C onsent to participate Not applicable. Consent for publication The patient gave written consent for publication. Competing interests The authors declare that they have no competing interests. References Yantiss RK, Nielsen GP, Lauwers GY, Rosenberg AE. Reactive Nodular Fibrous Pseudotumor of the Gastrointestinal Tract and Mesentery - A Clinicopathologic Study of Five Cases. Am J Surg Pathol (2003) 27(4):532–40. Chatelain D, Manaouil D, Levy P, Joly JP, Sevestre H, Regimbeau JM. Reactive Nodular Fibrous Pseudotumor of the Gastrointestinal Tract and Mesentery. Am J Surg Pathol (2004) 28(3):416. Zardawi IM, Catterall N, Cox SA. Reactive Nodular Fibrous Pseudotumor of the Gastrointestinal Tract and Mesentery. Am J Surg Pathol (2004) 28(2):276–7. Daum O, Vanecek T, Sima R, Curik R, ZamecnikM, Yamanaka S, et al. Reactive Nodular Fibrous Pseudotumors ofthe Gastrointestinal Tract: Report of 8 Cases. Int J Surg Pathol (2004) 12(4):365–74. Saglam EA, Usubutun A, Kart C, Ayhan A, Kucukali T. Reactive Nodular Fibrous Pseudotumor Involving the Pelvic and Abdominal Cavity: A Case Report and Review of Literature. Virchows Archiv (2005) 447(5):879–82. Gauchotte G, Bressenot A, Serradori T, Boissel P, Plenat F, Montagne K. Reactive Nodular Fibrous Pseudotumor: A First Report of Gastric Localization and Clinicopathologic Review. Gastroenterol Clin Et Biol (2009) 33(12):1076–81. Yin SS, Zhang LD, Cziffer-Paul A, Divino CM, Chin E. Reactive Nodular Fibrous Pseudotumor Presenting as a Small Bowel Obstruction. Am Surg (2011) 77(6):790–1. Virgilio E, Pucci E, Pilozzi E, Mongelli S, Cavallini M, Ferri M. Reactive Nodular Fibrous Pseudotumor of the Gastrointestinal Tract and Mesentery Giving Multiple Hepatic Deposits and Associated With Colon Cancer. Am Surgeon (2012) 78(5):E262–E4. Tam HM, Lee KF, To KF, Wong J, Lai PBS. Reactive Nodular Fibrous Pseudotumor After Laparoscopic Cholecystectomy. Surg Pract (2012) 16 (3):116–7. McAteer J, Huaco JC, Deutsch GH, Gow KW. Torsed Reactive Nodular Fibrous Pseudotumor in an Adolescent: Case Report and Review of the Literature. J Pediatr Surg (2012) 47(4):795–8. Salihi R, Moerman P, Timmerman D, Van Schoubroeck D, Op de Beeck K, Vergote I. Reactive Nodular Fibrous Pseudotumor: Case Report and Review of the Literature. Case Rep Obstet Gynecol (2014) 2014:421234. Yi X-J, Chen C-Q, Li Y, Ma J-P, Li Z-X, Cai S-R, et al. Rare Case of an Abdominal Mass: Reactive Nodular Fibrous Pseudotumor of the Stomach Encroaching on Multiple Abdominal Organs. World J Clin Cases (2014) 2 (4):111–9. YanF,MaYL, Sun JH,ZhuPC. ReactiveNodularFibrousPseudotumor Involving the Gastrointestinal Tract and Mesentery: A Case Report and Review of the Literature. Oncol Lett (2015) 9(3):1343–6. Ciftci B, Vardar E, Tasli F, Yakan S, Top E, Yildirim M. Reactive Nodular Fibrous Pseudotumor Presenting as a Huge Intra Abdominal Mass After Abdominal Surgery: A Case Report. Iranian J Pathol (2015) 10(2):149–54. Moodley J, Cutz JC, Schell M. Reactive Nodular Fibrous Pseudotumor Mimicking Metastatic Gastrointestinal Stromal Tumor to Perigastric Lymph Node: A Case Report and Review of the Literature. Int J Surg Pathol (2018) 26 (7):664–70. Girsowicz E, Cherkaoui Z, Pessaux P. Multiple Abdominal Calcified Reactive Nodular Fibrous Pseudotumor. J Visc Surg (2018) 155(6):511–2. Chen J, Zhang Y, Shi L, Qian Z, Cheng A and Fu L (2022) Reactive Nodular Fibrous Pseudotumor Mimicking Metastatic Tumor After Gastric Cancer Operation: A Case Report and Literature Review. Front. Oncol. 12:854997. Hong X , Choi H ,Loyer EM , Benjamin RS ,Trent JC , Charnsangavej C . Gastrointestinal stromal tumor: role of CT in diagnosis and in response evaluation and surveillance after treatment with imatinib. RadioGraphics 2006;26(2):481–95 . Yu MH , Lee JM , Baek JH ,Han JK , Choi BI . MRI features of gastrointestinal stromal tumors. Am J Roentgenol 2014;203(5):980–91 . Novelli M, Rossi S, Rodriguez‑Justo M, et al: DOG1 and CD117 are the antibodies of choice in the diagnosis of gastrointestinal stromal tumours. Histopathology 57: 259‑270, 2010. Jeffery A, Justin M, Differential Diagnostic Considerations of Desmoid-type Fibromatosis. Adv Anat Pathol 2015;22:260–266. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6882209","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":496706153,"identity":"0bf818d0-7980-4b39-b606-d5ac4ef0384a","order_by":0,"name":"Xiujuan Sun","email":"","orcid":"","institution":"The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Xiujuan","middleName":"","lastName":"Sun","suffix":""},{"id":496706154,"identity":"1cf384c9-d674-46ad-8390-10dddf817fa7","order_by":1,"name":"Chengyu Hu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chengyu","middleName":"","lastName":"Hu","suffix":""},{"id":496706155,"identity":"153231ff-1921-4478-8520-eb7c1921829f","order_by":2,"name":"Sisi Wang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sisi","middleName":"","lastName":"Wang","suffix":""},{"id":496706156,"identity":"9e4d25e1-1d74-4fcd-9af6-0b38f1c65d09","order_by":3,"name":"Weihua Gong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3RP4vCMBjH8ScUMkVdUwr1LUQCJ8LBvZUU34CTk/9AiMtxsw6+A4e+hIhgl6prtjsRnBSEgqMYvc5pR8F8l98z5DMFwOV6yZDMD08BfawqT7AoSwDnS9j/FhGWjOWB9Pphs7bILi0JYVULlHVsJF1OOFknvDU9x8yXwH0tvGBqIR86kgHB6yjWm1gYYg6BPWIjv3tDbg+S/ilDhsVEIxlUZC+Kd99oZIhgReQrjaQ//1GcacyBbmljlu7HgY34k+RIT9dByHarQ0a7n/Vq0l5mNpK3AqACPPr8TDQqBgADgJoCdCnz1uVyud6uO1omUMLsrwxbAAAAAElFTkSuQmCC","orcid":"","institution":"The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Weihua","middleName":"","lastName":"Gong","suffix":""}],"badges":[],"createdAt":"2025-06-12 16:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6882209/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6882209/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88772673,"identity":"de57e591-e25b-4a86-b44e-deab81ad7af4","added_by":"auto","created_at":"2025-08-11 09:54:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":937306,"visible":true,"origin":"","legend":"\u003cp\u003eCT image of RNFP. Theirregular masses were partially fused(white arrow), with calcifications(black arrow), and exhibitedprogressively mild enhancement onpostcontrast CT(a-b).\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6882209/v1/adac8405b383cf9ae1530d52.jpg"},{"id":88774683,"identity":"0c0f75d1-c143-4fee-b3fb-124b022e7f11","added_by":"auto","created_at":"2025-08-11 10:02:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1771810,"visible":true,"origin":"","legend":"\u003cp\u003eMRI image of RNFP. The irregular masses (white arrow) showed moderate hypointensity on axial T1-weighted MR images (a), and significant hypointensity on axial and coronal T2-weighted MR images (b-c). They exhibited progressively mild enhancement on postcontrast MRI (d).\u003c/p\u003e","description":"","filename":"Figure2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6882209/v1/f4fea1a3d6b8acc67dea8f29.jpg"},{"id":88772674,"identity":"ad7cbbfa-44d3-4820-bb93-78fd081488f4","added_by":"auto","created_at":"2025-08-11 09:54:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1062636,"visible":true,"origin":"","legend":"\u003cp\u003eUS and CEUS revealed hypoechoic masses with mild enhancement uptake of contrast media (white arrow).\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6882209/v1/06516dd10a4005fb93d17909.jpg"},{"id":88772685,"identity":"9440da60-fbcd-48be-ab4b-949ef912edd2","added_by":"auto","created_at":"2025-08-11 09:54:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":14758682,"visible":true,"origin":"","legend":"\u003cp\u003e(a-b) The lesions were irregular, well-circumscribed, firm, the largest one had a maximum diameter of about 12cm . (c) Serial sections of the mass were tan-white in color. (d) Immunohistochemistry results showed positive vimentin. (e) Immunohistochemistry results showed positive Ki67, proliferation index 5%. (f) Immunohistochemistry results showed negative SMA. (IHC ×100) (g-h)Histological examination of the H\u0026amp;E revealed that the tissue was composed of proliferative fibrous tissue with marked hyalinization, and focal chronic inflammatory cell infiltrates, predominantly consisting of lymphocytes (black arrow). (H\u0026amp;E, ×100, ×200)\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6882209/v1/10e01f05abdb9b4f75a91ac3.png"},{"id":91616730,"identity":"bbd0eafe-76de-4f19-861a-5cd7f5505892","added_by":"auto","created_at":"2025-09-18 10:40:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":21591860,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6882209/v1/91fb6af0-8a47-4e70-966d-5bc822126847.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reactive Nodular Fibrous Pseudotumor of the Omentum: A Rare Case Report and Literature Review","fulltext":[{"header":"Background","content":"\u003cp\u003eReactive nodular fibrous pseudotumor (RNFP) is an uncommon, benign lesion of postinflammatory origin characterized by fibroblastic/myofibroblastic proliferation embedded in dense collagenous stroma. First described in 2003, it has since been recognized as a distinct pathological entity. RNFP is often associated with previous abdominal surgery or inflammation and typically requires surgical resection for definitive diagnosis and treatment. Due to its rarity and nonspecific imaging features, it is frequently misdiagnosed preoperatively.\u003c/p\u003e\u003cp\u003eHere, we present a case of RNFP occurring in a young adult male with no identifiable history of abdominal trauma or intervention. This case highlights the imaging and pathological features of RNFP and expands current knowledge by providing a comprehensive multimodal imaging assessment. A review of previously reported cases is included to aid clinicians and radiologists in the recognition and differentiation of this rare entity.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA previously healthy 31-year-old male with no history of abdominal surgery or pain accidentally palpated an abdominal mass for over one month and presented to another hospital. An abdominal CT scan revealed multiple masses in the abdomen. For further evaluation and management, the patient was referred to our hospital. On physical examination, a firm, mildly tender mass was palpated on the right side of the abdomen, with no other clinical symptoms noted. Laboratory test results were within normal limits. In our hospital, CT and MRI confirmed the presence of multiple solid omental nodules and masses in the abdomen, with the largest mass measuring approximately 12.1 \u0026times; 4.6 \u0026times; 9.7 cm. On non-contrast CT, the irregular masses appeared isodense, partially fused, and exhibited calcifications, with progressively mild enhancement on postcontrast imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). MRI demonstrated moderate hypointensity on T1-weighted images and significant hypointensity on T2-weighted images, with an enhancement pattern similar to that observed on CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Ultrasound (US) and contrast-enhanced ultrasound (CEUS) revealed hypoechoic masses with mild contrast media uptake (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Given these nonspecific radiological features, differential diagnoses included gastrointestinal stromal tumor (GIST) or Gardner fibroma. However, the patient had no personal or family history of Gardner's syndrome. Gastrointestinal tract endoscopy was subsequently performed and revealed no abnormalities.\u003c/p\u003e\u003cp\u003eSurgical exploration revealed multiple well-circumscribed, firm, omental masses, the largest measuring approximately 12 cm (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea-b). Gross examination showed tan-white cut surfaces (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ec). Immunohistochemistry revealed positivity for cytokeratin AE1/AE3, vimentin, Bcl-2, and Ki-67 (proliferation index 5%), and negativity for SMA, Desmin, CD34, and β-catenin (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ed-f). Histologically, the lesions comprised spindle cell proliferation within a collagen-rich, hyalinized stroma, accompanied by lymphocytic infiltrates (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eg-h). These features confirmed a diagnosis of RNFP. The patient remained recurrence-free at over 4 years of follow-up.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSince its initial description by Yantiss et al. in 2003, only 28 cases of RNFP have been reported in the English literature \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, with additional cases documented in subsequent studies\u003csup\u003e[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Our case represents the 29th reported instance of this lesion in the English literature. Among the 28 patients reviewed in the literature (Table\u0026nbsp;1), 17 were male (60.7%) and 11 were female (39.3%). Of these, 24 cases involved adults (85.7%), with the remaining cases including one in a 1-year-old boy\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e and three in teenagers\u003csup\u003e[10,12,16]\u003c/sup\u003e. The average age of patients was 47.6 years, and our case involved a 31-year-old male, further supporting the observation that adult males are more predisposed to this condition. Clinically, 12 patients (42.9%) presented with abdominal symptoms as the primary manifestation, among whom five experienced acute abdominal pain. Many authors have emphasized the importance of investigating patients' medical histories, particularly prior abdominal surgeries, as RNFP is believed to arise as an inflammatory response to antecedent abdominal trauma or surgical intervention. Indeed, 11 patients (39.3%) had a documented history of abdominal surgery. Additionally, significant abdominal medical histories were noted in eight cases (28.6%), including duodenal bulbar ulcer (1 case), perforated duodenal diverticulum (1 case), endometriosis (2 cases), chronic bowel obstruction complicated by an external fistula (1 case), ileus caused by a tumor of the ileum (1 case), and ingestion of a foreign body (2 cases). These findings suggest that past abdominal medical or surgical history plays a crucial role in the development of RNFP. However, our case is among the minority of RNFP cases that occur in patients without a prior abdominal operation or other identifiable inciting factors. Moreover, the patient in our case was asymptomatic, with no abdominal discomfort. Thus, similar to a small number of other reported cases, the precise etiology of RNFP in this instance remains unknown.\u003c/p\u003e\u003cp\u003eRNFP typically originates from the subserosal surface of the bowel or within the adjacent mesentery and is frequently associated with local injury or inflammation \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The most commonly involved anatomic sites include the mesentery (10 cases), small bowel (8 cases), colon (7 cases), omentum (7 cases), appendix (3 cases), peritoneum (3 cases), gastric wall (2 cases), cecum (2 cases), ovary (2 cases), and duodenum, hepatic surface, hepatic hilum, gastrohepatic ligament, and peripancreas (1 case each). RNFP most often presents as a solitary mass (17 cases, 60.7%), although a minority of cases (11 cases, 39.3%) exhibit multiple masses. Notably, our patient presented with multiple abdominal masses localized exclusively to the omentum.\u003c/p\u003e\u003cp\u003eMicroscopically, RNFP is characterized by cellular proliferation of spindle cells within a hyalinized, dense collagenous background. Inflammatory cell infiltration, predominantly lymphocytes frequently arranged in lymphoid aggregates, is a consistent feature reported in most cases. Immunohistochemical analysis typically reveals positive staining for cytokeratins (AE1/AE3), vimentin, and smooth muscle actin (SMA) [4, 6]. In our case, spindle cells were positive for cytokeratins (AE1/AE3), vimentin, Bcl-2, and Ki67 but were negative for SMA.\u003c/p\u003e\u003cp\u003eAmong the 28 patients reviewed in the literature, only 7 patients (25%) underwent CT scans, and 3 patients (10.7%) underwent MRI scans. Radiological descriptions of RNFP are limited. The imaging features are as follows: Lesions appear isodense on non-contrast CT scans, sometimes with calcifications. On MRI, they show homogeneous hypointensity on T1-weighted images and marked hypointensity on T2-weighted images, with progressive mild enhancement. US and CEUS revealed hypoechoic masses with mild contrast media uptake. Our case represents the first reported instance in which comprehensive imaging evaluation was performed, including contrast-enhanced CT and MRI, US and CEUS. In our patient, the masses appeared isodense on non-contrast CT with calcifications, demonstrating progressive mild enhancement on postcontrast CT. MRI revealed moderate hypointensity on T1-weighted images and marked hypointensity on T2-weighted images. These imaging characteristics strongly suggest fibrotic tissue. The enhancement pattern observed on MRI was consistent with that seen on CT. The imaging findings in our patient align well with those previously described in the literature.\u003c/p\u003e\u003cp\u003eCases of RNFP originating in the omentum are exceptionally rare. Accurate differentiation of RNFP from other abdominal reactive processes is crucial, including nodular fasciitis, calcifying fibrous pseudotumor, sclerosing mesenteritis, intra-abdominal fibromatosis, and more aggressive neoplasms such as GIST, intra-abdominal inflammatory myofibroblastic tumors, and inflammatory fibrosarcoma \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. In our case, the initial differential diagnosis included GIST and Gardner fibroma. GIST, the most common mesenchymal tumors of the gastrointestinal tract, typically demonstrate distinct CT characteristics: well-defined margins, large hypervascular enhancing masses with heterogeneous enhancement patterns due to necrotic and hemorrhagic components, and potential local invasion \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. On MRI, the solid components of GIST typically appear hypointense on T1-weighted imaging, hypo- to iso-intense on T2-weighted imaging, and demonstrate moderate to marked contrast enhancement \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Histologically, GIST exhibit greater cellularity compared to RNFP and are immunohistochemically positive for DOG1, CD117, and CD34 \u003csup\u003e[13, 20]\u003c/sup\u003e. Gardner fibroma, characterized by hypocellular, densely collagenous tissue resembling normal fibrous tissue or scar, consistently expresses CD34 \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. However, our patient showed no clinical evidence of Gardner's syndrome, with negative personal and family history, and unremarkable gastrointestinal endoscopy findings.\u003c/p\u003e\u003cp\u003eSurgical resection remains the primary and effective treatment modality for RNFP. Among the 28 reviewed cases, complete resection was achieved in 25 patients (89.3%), while incomplete resection was performed in 3 cases (10.7%) due to extensive disease with multiple masses or nodules. Follow-up data were available for 17 patients (60.7%), with a follow-up duration ranging from 4 months to 7 years. Our case has maintained disease-free status during the 4-year follow-up period. The prognosis of RNFP is consistently favorable, with no reported cases of recurrence or distant metastasis following surgical intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRNFP is a rare but benign fibrous lesion that should be considered in the differential diagnosis of omental or mesenteric masses, particularly in patients with a history of abdominal surgery or inflammation. Comprehensive imaging, including MRI and CEUS, can aid in preoperative assessment, although definitive diagnosis relies on histopathological evaluation. Awareness of this entity is crucial to avoid misdiagnosis and unnecessary aggressive treatment. Surgical resection remains curative, with an excellent prognosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eX. S. and C.H. wrote the main manuscript text and S. W. prepared figures. \u0026nbsp;W. G.prepared conceptualization.All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Key research and development program of Zhejiang Province (Grant No. 2025C02054)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data has been presented in the manuscript and further inquiry can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and accordance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the Human Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine in accordance with GCP and relevant laws and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eonsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent has been obtained from the participant and consent to participate and consent to release has been obtained\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eonsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient gave written consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYantiss RK, Nielsen GP, Lauwers GY, Rosenberg AE. 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J Visc Surg (2018) 155(6):511\u0026ndash;2. \u003c/li\u003e\n\u003cli\u003eChen J, Zhang Y, Shi L, Qian Z, Cheng A and Fu L (2022) Reactive Nodular Fibrous Pseudotumor Mimicking Metastatic Tumor After Gastric Cancer Operation: A Case Report and Literature Review. Front. Oncol. 12:854997.\u003c/li\u003e\n\u003cli\u003eHong X , Choi H ,Loyer EM , Benjamin RS ,Trent JC , Charnsangavej C . Gastrointestinal stromal tumor: role of CT in diagnosis and in response evaluation and surveillance after treatment with imatinib. RadioGraphics 2006;26(2):481\u0026ndash;95 .\u003c/li\u003e\n\u003cli\u003eYu MH , Lee JM , Baek JH ,Han JK , Choi BI . MRI features of gastrointestinal stromal tumors. Am J Roentgenol 2014;203(5):980\u0026ndash;91 .\u003c/li\u003e\n\u003cli\u003eNovelli M, Rossi S, Rodriguez‑Justo M, et al: DOG1 and CD117 are the antibodies of choice in the diagnosis of gastrointestinal stromal tumours. Histopathology 57: 259‑270, 2010.\u003c/li\u003e\n\u003cli\u003eJeffery A, Justin M, Differential Diagnostic Considerations of Desmoid-type Fibromatosis. Adv Anat Pathol 2015;22:260\u0026ndash;266.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Reactive nodular fibrous pseudotumor, Omentum, imaging, histopathology, differential diagnosis","lastPublishedDoi":"10.21203/rs.3.rs-6882209/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6882209/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eReactive nodular fibrous pseudotumor (RNFP) is a rare, benign, reactive lesion of the gastrointestinal tract that can clinically and radiologically mimic malignant tumors. It has been associated with prior surgical intervention, trauma, or inflammation. We report a case of RNFP in a patient without any history of abdominal surgery or abdominal discomfort. Imaging findings included multiple, well-defined, solid omental masses that were isodense on CT and hypointense on both T1- and T2-weighted MRI, with progressive, mild contrast enhancement. Ultrasound and contrast-enhanced ultrasound revealed hypoechoic masses with limited contrast uptake. To our knowledge, this is the first reported case in which RNFP was comprehensively evaluated using CT, MRI, ultrasound, and contrast-enhanced ultrasound. Furthermore, it is the first case to specifically distinguish RNFP from Gardner fibroma.\u003c/p\u003e","manuscriptTitle":"Reactive Nodular Fibrous Pseudotumor of the Omentum: A Rare Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 09:54:40","doi":"10.21203/rs.3.rs-6882209/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66a367ee-628f-4eb6-8784-43a7a390eb44","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T10:39:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 09:54:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6882209","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6882209","identity":"rs-6882209","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}