Pancreatitis, panniculitis and polyarthritis (PPP) syndrome

A young male presented with intermittent high-grade fever, asymmetric polyarthritis and erythematous, tender nodules over left shin for 2 months duration. He had a history of alcohol dependence with multiple episodes of acute pancreatitis. With polyarthritis progressing relentlessly, unresponsive to non-steroidal anti-inflammatory drugs and steroids, a provisional diagnosis of sarcoidosis was considered. Indeed, he was treated with azathioprine and rituximab with no effect. Biopsy of the skin nodule revealed subcutaneous fat necrosis, foam cells, deposition of eosinophilic amorphous material and calcification. Synovial fluid aspiration from the arthritic knee obtained purulent but surprisingly culture-negative material, rich in triglycerides. Abdominal CT confirmed chronic pancreatitis. Final diagnosis of pancreatitis, panniculitis and polyarthritis (PPP) syndrome was made. He underwent surgical pancreatic ductal drainage leading to complete remission of symptoms. PPP syndrome triad occurs due to leakage of pancreatic enzymes into systemic circulation and subsequent fat necrosis. Surgical drainage of pancreatic duct is often curative.

Epipericardial fat necrosis in chest CT and MRI: a case report of an unusual cause of chest pain associated with the initial diagnosis of undifferentiated connective tissue disease

BACKGROUND

Epipericardial fat necrosis (EFN) is a benign and self-limited condition of unknown cause with a good prognosis, usually affecting otherwise healthy patients. Clinically, it presents with severe acute left pleuritic chest pain, often leading the patient to the Emergency Room (ER).

CASE PRESENTATION

A 23-year-old male, smoker (5 pack-years), was evaluated in the ER due to left pleuritic chest pain, worsening with deep breathing and Valsalva maneuver. It was not associated with trauma and did not present other symptoms. The physical examination was unremarkable. The arterial blood gases while breathing room air and the laboratory tests, including D-dimers and high-sensitivity cardiac Troponin T, were normal. The chest radiograph, electrocardiogram, and transthoracic echocardiogram showed no abnormalities. A computed tomography (CT) pulmonary angiogram showed no signs of pulmonary embolism but depicted at the left cardiophrenic angle a focal 3 cm ovoid-shaped fat lesion with stranding and thin soft tissue margins, consistent with necrosis of the epicardial fat, which was confirmed by magnetic resonance (MRI) of the chest. The patient was medicated with ibuprofen and pantoprazole, with clinical improvement in four weeks. At a two-month follow-up, he was asymptomatic and presented radiologic resolution of the inflammatory changes of the epicardial fat of the left cardiophrenic angle on chest CT. Laboratory tests revealed positive antinuclear antibodies, positive anti-RNP antibody, and positive lupus anticoagulant. The patient complained of biphasic Raynaud's phenomenon initiated five years ago, and a diagnosis of undifferentiated connective tissue disease (UCTD) was made.

CONCLUSIONS

This case report highlights the diagnosis of EFN as a rare and frequently unknown clinical condition, which should be considered in the differential diagnosis of acute chest pain. It can mimic emergent conditions such as pulmonary embolism, acute coronary syndrome, or acute pericarditis. The diagnosis is confirmed by CT of the thorax or MRI. The treatment is supportive and usually includes non-steroidal anti-inflammatory drugs. The association of EFN with UCTD has not been previously described in the medical literature.

Subcutaneous and Intraosseous Fat Necrosis Associated with Chronic Pancreatitis

Background: Extra-abdominal manifestations of fat necrosis, like subcutaneous fat necrosis, polyarthritis, and polyserositis may appear with an occurrence rate of about 0.8%, wherein intraosseous fat necrosis is a more rare complication of pancreatitis, with few reports in English literature. Case report: A 34-year-old male with a 15-year-history of alcohol abuse was hospitalized several times in the last few years because of attacks of relapsed chronic pancreatitis. After the last attack, pancreatitis came in a stable state (“burned out”) with no symptoms and signs of the disease. The patient had been free of symptoms for 28 months since the last admission when he came with sub-febrile temperature, huge pain, swelling, and erythema in the area of the left lateral malleolar region with propagation in the foot. Blood biochemistry was normal. Conventional radiography showed multiple sites of osteolysis in the left calcaneus. Images on multislice computed tomography (MSCT) with 3D reconstruction revealed hypodense focuses that corresponded to osteonecrosis areas and bone marrow edema in the left calcaneus. Conclusions: The possibility of intraosseous fat necrosis should be considered in situations of unexplained polyarthritis or panniculitis, particularly in individuals with alcohol abuse or pancreatic disease.

Subcutaneous Fat Necrosis of the Newborn

A boy weighing 4500 g was born at 41 weeks' gestation by Cesarean section due to fetal distress. The pregnancy was complicated by gestational diabetes. He had an Apgar score of 5 and 6 after 5 and 10 minutes, respectively. At birth, the newborn manifested respiratory distress, which needed assisted ventilation for 48 hours. He developed a convulsive attack, diagnosed as a grade 2 hypoxic-ischemic encephalopathy, which was controlled by phenobarbital. Four days later, dermatologic examination revealed subcutaneous and firm nodules, ranging from 1 to 4 cm in diameter, on the cheeks, neck, arms, legs, and back (Figure 1). Some nodules became fluctuant as abscesses. Fine-needle aspiration cytology performed on a nodule revealed a dirty background with necrotic fat-containing characteristic, radially- oriented, refractile, needle-shaped crystals (Figure 2), which was diagnosed as subcutaneous fat necrosis. The diagnosis of subcutaneous fat necrosis of the newborn was made. Laboratory studies revealed hypocalcemia at 1.65 mmol/L, hypomagnesemia at 0.48 mmol/L, and hypokalemia at 3 mmol/L. The infant received calcium, magnesium, vitamin D, and potassium supplementation. On day 18, the serum calcium increased to 3.3 mmol/L. It was associated with hypertriglyceridemia at 2.6 mmol/L. Bilateral nephrocalcinosis was detected on renal ultrasound. So, hyperhydration, diuretics, and withdrawal of vitamin D were indicated. The patient was given betamethasone 0.125 mg/kg/day for 3 weeks. After a two months course, there had been complete healing of the fat necrosis (Figure 3), normalization of the calcium and triglyceride levels, and a normal growth pattern.

Epipericardial Fat Pad Necrosis-A Rare Cause of Chest Pain in an Adolescent

ABSTRACT

Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain reported in approximately 40 cases. This diagnosis mimics a myocardial infarction, pulmonary embolism, or pericarditis; however, the cardiac enzymes and electrocardiogram are usually normal. We present the first reported case of epipericardial fat necrosis in an adolescent.

Breast density in dedicated breast computed tomography: Proposal of a classification system and interreader reliability

The aim of this study was to develop a new breast density classification system for dedicated breast computed tomography (BCT) based on lesion detectability analogous to the ACR BI-RADS breast density scale for mammography, and to evaluate its interrater reliability.In this retrospective study, 1454 BCT examinations without contrast media were screened for suitability. Excluding datasets without additional ultrasound and exams without any detected lesions resulted in 114 BCT examinations. Based on lesion detectability, an atlas-based BCT density (BCTD) classification system of breast parenchyma was defined using 4 categories. Interrater reliability was examined in 40 BCT datasets between 3 experienced radiologists.Among the included lesions were 63 cysts (55%), 18 fibroadenomas (16%), 7 lesions of fatty necrosis (6%), and 6 breast cancers (5%) with a median diameter of 11 mm. X-ray absorption was identical between lesions and breast tissue; therefore, the lack of fatty septae was identified as the most important criteria for the presence of lesions in glandular tissue. Applying a lesion diameter of 10 mm as desired cut-off for the recommendation of an additional ultrasound, an atlas of 4 BCTD categories was defined resulting in a distribution of 17.5% for density A, 39.5% (B), 31.6% (C), and 11.4% (D) with an intraclass correlation coefficient (ICC) among 3 readers of 0.85 to 0.87.We propose a dedicated atlas-based BCTD classification system, which is calibrated to lesion detectability. The new classification system exhibits a high interrater reliability and may be used for the decision whether additional ultrasound is recommended.

The Pancreatitis, Panniculitis, and Polyarthritis (PPP) Syndrome: Subcutaneous Nodular Fat Necrosis, a Cutaneous Marker of Pancreatic Neoplasia

The pancreatitis, panniculitis, polyarthritis (PPP) syndrome is a rare skin, joint, and pancreatic disorder, also known as subcutaneous nodular fat necrosis. It results from obstruction of pancreatic ducts with direct secretion of pancreatic enzymes into the bloodstream, causing extra pancreatic fat necrosis with subcutaneous tissue and joint inflammation. It is usually a cutaneous sign of pancreatic cancer or pancreatitis. To our knowledge, this is the first case associated with a pancreatic pseudotumor. We describe a 59-year-old man initially presenting with numerous painful erythematous subcutaneous nodules due to a fibrous pancreatic pseudotumor and its extreme dermatologic disease, resulting in necrosis of the shin and foot so severe that an amputation of the lower leg above the knee was required, a complication not previously described, to our knowledge. We emphasize that PPP syndrome is a cutaneous marker of internal malignancy, most often of pancreatic cancer or pancreatitis, but in this case of a rare pancreatic pseudotumor.

Diagnosis of Epipericardial Fat Necrosis on multimodality imaging in a pediatric patient: a case report and review of the literature

This is a case report of a 13-year-old male, presented to the Emergency Department complaining of a sudden onset left-sided pleuritic chest pain for 1 day. He was found to have a mass in the left Epipericardial fat with fat stranding and pleural effusion supporting the diagnosis of Epipericardial Fat Necrosis. The findings were established by Computed tomography and Ultrasound, and the final diagnosis was confirmed by Magnetic resonance imaging. Subsequently, the patient was discharged on analgesia; reassessment one-month later showed clinical improvement with no symptom recurrence. Repeated Ultrasound demonstrated a marked decrease in size and echogenicity of the mass. In this paper we review the clinical and radiological manifestations of Epipericardial fat necrosis and the different management approaches taken over the years.

A Peculiar Form of Breast Fat Necrosis Simulating Hyaline Ring Granuloma (So-called Pulse Granuloma): A Rare Complication of Hyperparathyroidism

Pulse granuloma is a rare, foreign body inflammatory reaction that occurs mainly in the oral cavity. It is exceedingly rare elsewhere, with only isolated cases described in the literature. We report the case of a 79-year-old woman with a history of normocalcemic hyperparathyroidism who presented to our hospital with a painful 4-cm lump in the upper quadrants-upper outer quadrant of her left breast. The clinical and radiological (BIRADS-5) findings were indicative of a malignant lesion. However, core needle biopsy revealed features simulating hyaline ring granuloma (pulse granuloma-like). A definitive diagnosis of lipomembranous fat necrosis was made by identifying its characteristic histomorphology. Histopathological study is essential to establish an exact diagnosis since clinical and imaging features may mimic breast carcinoma. To our knowledge, this is the first reported case of a hyaline ring granuloma-like in the breast, which may represent a peculiar form of degenerative change of lipomembranous fat necrosis.

[A skin lesion with ghost cells]

An 83-year-old woman presented with painful erythematous nodules on her feet and legs. Recently, she had been admitted several times because of pancreatitis of unknown cause. A biopsy showed fat cell necrosis with ghost cells and the diagnosis of pancreatic panniculitis was made.

Digital breast tomosynthesis findings after surgical lipomodeling in a breast cancer survivor

Autologous fat grafting or lipomodeling is a newly-adopted technique that is gaining increasing popularity in the treatment of contour deformities following breast conservation therapy. Here, we describe the case of a 47-year-old woman with a prior history of breast cancer treated with a lumpectomy and radiation therapy. She underwent lipomodeling not only of her treated breast but also of the contralateral breast. She presented for her annual mammogram which was performed with digital breast tomosynthesis. On imaging, a space-occupying lesion of mixed density was seen, expanding the lumpectomy site. There was also subtle distortion in the contralateral, non-treated breast. This case aims to highlight the mammographic and tomosynthesis findings seen following lipomodeling that may present diagnostic challenges in this patient population.

Cosmetic fat augmentation following breast reconstruction: sonographic appearance with cytopathologic correlation

This series presents the history and imaging of patients who had cosmetic fat augmentation following mastectomy and reconstruction. The cases provide the useful reminder that a complete surgical history is essential when assessing the imaging of a post-operative breast patient and that speaking directly with patients can be a critical step in putting together a complete clinical picture and adding value to their care.

Encapsulated fat necrosis mimicking subcutaneous liposarcoma: radiologic findings on MR, PET-CT, and US imaging

We present a case of a subcutaneous encapsulated fat necrosis of the upper extremity that mimicked subcutaneous liposarcoma because of heterogeneous signal intensity, its relatively large size, and pronounced enhancement on magnetic resonance imaging (MRI). For this case, we present the radiologic findings including MRI, positron emission tomography-computed tomography (PET-CT), ultrasonography, and radiography. We emphasize the imaging features of this lesion, which has a fibrous capsule and briefly discuss its nomenclature and pathophysiology.

Sonography of fat necrosis of the breast: correlation with mammography and MR imaging

Fat necrosis (FN) of the breast is a benign nonsuppurative inflammatory process of the adipose tissue. The radiologic appearance ranges from benign to suspicious for malignancy; therefore, it is very important to know the distinguishing radiologic features of FN on different modalities. Mammography is more helpful in identifying FN than ultrasonography in most of the cases, and MRI may also be used to rule out malignancy as an adjunct to mammography and sonography. Even when modern diagnostic modalities are used, biopsy may still be unavoidable for some cases. In conclusion, an accurate history and familiarity with the radiologic findings are crucial to recognizing FN and avoiding unnecessary interventions.

Imaging of fat-containing lesions of the breast: a pictorial essay

Fat-containing breast lesions constitute a heterogeneous group of predominantly benign tumors and non-neoplastic conditions. The role of imaging is to distinguish leave-me-alone lesions from rarely occurring malignant fat-containing tumors that require histologic analysis. Correlating mammographic findings with appearance at ultrasonography often helps in identifying lesions that do not require further work-up. MRI can be valuable to confirm the presence of fat and characterize lesions indeterminate on conventional imaging. The purpose of this multimodality imaging review is to exemplify the radiologic appearances of common and uncommon fat-containing breast lesions to facilitate accurate diagnosis, avoid unnecessary interventions, and ensure appropriate management.

Fat necrosis of transverse colon and necrotizing pancreatitis in a patient with acute lymphoblastic leukemia (ALL): cause of massive ascites and high fever

We report a nine-year-old boy with acute lymphoblastic leukemia L3 (ALL-L3) and necrotizing pancreatitis in which necrosis was not limited to the pancreas. As our patient had a defective inflammatory process as a result of underlying malignant disease and neutropenia, the peripancreatic collection could not be limited and no pseudocyst was formed. In our patient, the unlimited inflammatory process and pancreatic secretions infiltrated the transverse mesocolon and transverse colon, leading to fat necrosis of the transverse colon, causing massive ascites and high fever. As there was no response to medical treatment, the success was achieved only by surgical resection. The infiltration of surrounding tissue and nearby organs by inflammation and fat necrosis in necrotizing pancreatitis has not been reported previously in a pediatric patient.

[A man with acute pain of the left side of the chest]

A 42-year-old man came to the emergency department because of acute pain on the left side of the chest. Physical examination, ECG and blood tests revealed no abnormalities. With a CT scan of the thorax we made the diagnosis: 'pericardial fat necrosis'. This is a very rare, self-limiting disease.

Nephrocalcinosis as a complication of subcutaneous fat necrosis of the newborn

Subcutaneous fat necrosis of the newborn is an uncommon disorder affecting the adipose tissue of term infants. It is usually known as a transient, benign and self-limited disease, characterized by painful skin lesions beginning within the first week of life. The prognosis of the disease is generally good, but it may be complicated by potentially life-threatening metabolic alterations, including hypercalcemia, thrombocytopenia, hypoglycemia, and hypertriglyceridemia. Hypercalcemia is the most serious complication of subcutaneous fat necrosis because of its effects on the renal and cardiovascular systems. We thereby present a case of subcutaneous fat necrosis with all these metabolic alterations, which was also complicated by nephrocalcinosis as a non-transient and serious complication.

Diagnostic ultrasonography in cattle with abdominal fat necrosis

This study describes the ultrasonographic findings in 14 cows with abdominal fat necrosis. Ultrasonography of the abdomen revealed the presence of heterogeneous hyperechoic masses and hyperechoic omentum with localized masses floating in a hypoechoic peritoneal fluid. A hyperechogenic rim was imaged around both kidneys. The intestines were coated with hyperechoic capsules and the intestinal lumens were constricted. Ultrasonographic examination of the pancreatic parenchyma showed an overall increased echogenicity which was homogenously distributed in 3 cases. A diagnosis of abdominal fat necrosis was made with ultrasound-guided biopsy of the echogenic masses, and thereafter at postmortem examination. Results from this study demonstrate the efficacy of ultrasonography as an imaging modality for antemortem diagnosis of abdominal lipomatosis in cattle. To the authors' knowledge, this study is the first that illustrates ultrasonographic findings in cattle affected with abdominal lipomatosis.

Infarction of lesser omental fat mimicking an exophytic pancreatic tumor by sonography

We report a case of infarction of lesser omental fat in a 30-year-old woman who presented with epigastric pain. Sonography revealed a painful echogenic mass in the epigastrium that could not be separated from the adjacent hyperechoic pancreas and mimicked an exophytic pancreatic tumor. On CT, the mass was identified as an inflammatory lipomatous mass in the lesser sac, leading to the diagnosis of infarction of lesser omental fat. The patient was successfully treated conservatively.

Nontraumatic giant fat necrosis of the breast presenting as a rapidly growing tumor

Nontraumatic rapid growing giant fat necrosis of the breast mimicking breast tumors is a rare clinical manifestation. The imaging features of the fat necrosis which range from benign to malign findings may be better explained with associated aetiology. The present paper reports a 54-year old woman with a rapid growing, fibrous, and hard giant mass originating in the subareolar region of the left breast. Mammography and magnetic resonance imaging demonstrated a heterogeneous, well circumscribed mass in 12 × 12 cm size in the left breast. The lesion was suspected as a malignant tumor and underwent core biopsy. The histopathology examination of the biopsy revealed mononuclear cells, foamy, vacuolated, and bubbly cells containing fat. Excision biopsy of the mass was performed and the final pathological diagnosis was confirmed as fat necrosis. The wide clinical and radiologic manifestations of fat necrosis are still difficult to diagnose even with the new diagnostic modalities and a great proportion of these lesions need a biopsy to diagnose.

[Epipericardial fat necrosis - Case report]

Epipericardial fat necrosis is an uncommon benign entity of unknown cause, with only 20 cases reported in the English-language literature. It should be remembered as a possible diagnosis in a person who presents with acute pleuritic chest pain and paracardiac density or pleural effusion on chest radiography (X-ray). The computed tomography (CT) or surgical approach allows the final diagnosis and characterization. The authors describe a case of a 48-year-old woman, admitted to our department because of complaints of fatigue, cough and sudden pleuritic pain on thoracic left side. The chest X-ray showed mild/moderate left pleural effusion and CT scan revealed local slight thickening of pericardium and epipericardial fat, surrounded by thick rim of higher density in the left cardiophrenic space. This made the diagnosis of epipericardial fat necrosis. During hospitalization the patient remained stable and was discharged home with symptomatic relieve therapy. Because of benign, self-limited nature of this entity, only conservative treatment is indicated.

Pericardial fat necrosis: a review and update

A previously healthy middle-aged person presents with excruciating left-sided chest pain of 6 hours' duration. The pain has come on abruptly, without warning, and is located in the lower part of the chest anteriorly. It radiates to the neck and left shoulder and worsens on deep inspiration. The patient appears seriously ill, with tachypnea, tachycardia, and diaphoresis. Otherwise, the physical examination is unremarkable. The electrocardiogram shows sinus tachycardia. Results of conventional blood studies and the chest radiograph are within normal limits. Three days later, a follow-up chest radiograph shows a 3.5 x 4-cm mass adjacent to the left side of the heart near the diaphragm.

Torsion of an appendix epiploica present at the vermiform appendix: a rare cause of acute abdomen

An extremely rare case of torsion of an appendix epiploica attached to the vermiform appendix is reported in a 57-year-old male who presented with acute abdominal pain and tender right inguinal fossa. An infarcted appendix epiploica was seen attached near the tip of an otherwise unremarkable vermiform appendix through a narrow stalk. The histological examination revealed lobulated fibrofatty tissue showing congestion, acute inflammation and fat necrosis. The appendix was otherwise unremarkable.

Perforation of a retrocaecal appendix presenting clinically as a right lumbar abscess

Presentations of acute appendicitis represent an ongoing challenge to surgeons. This case of retrocaecal perforated appendicitis presented clinically as a right lumbar abscess, with the concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. This case emphasises the importance of an abdominal CT scan in any patient presenting with unusual sepsis near the abdomen.

Occasional finding of mesenteric lipodystrophy during laparoscopy: A difficult diagnosis

Mesenteric lipodystrophy is a rare pathological condition affecting the mesentery. Its initial presentation is typically asymptomatic. Pathological characteristics are unspecific, and generally attributed to inflammation, unless the diagnosis is suspected. Laparoscopy done for other reasons has been, as in this case, unsuccessful in providing evidence for the correct diagnosis, thus requiring laparotomy due to lack of diagnostic tissue. After 6 mo no further medical therapy is required, as the patient remains asymptomatic. Discussion of this case and a brief review of the literature are presented in the following paragraphs.

Subcutaneous fat necrosis of the newborn

Subcutaneous fat necrosis of the newborn (SCFN) is an uncommon disorder in full term infants who have a perinatal condition. The authors reported seven cases of subcutaneous fat necrosis of the newborn at Queen Sirikit National Institute of Child Health from 2002 to 2005. All cases were term babies with four male cases, and three female cases. Five cases (70%) had perinatal asphyxia. The mean age of onset was 14 days (range 3-42 days). The locations of SCFN were back (3 cases), shoulder (2cases), arm (2 cases), buttock (1 case), and neck (1 case). Skin biopsy was performed in three cases and was compatible with subcutaneous fat necrosis. The treatment was supportive with close monitoring of serum calcium. Hypercalcemia was seen in five cases (70%) and three cases were treated with oral prednisolone. Cutaneous lesions of all cases resolved without sequelae. In conclusion, infants with subcutaneous fat necrosis should have serial serum calcium determinations and should be observed closely for signs and symptoms of hypercalcemia such as irritability, anorexia, constipation, and failure to thrive.

Perforated retrocaecal appendix presenting as right lumbar abscess

BACKGROUND

Acute appendicitis is common in older patients, however, the presentation may differ from the younger population and it is often complicated by coexistent disease and delays in presentation.

AIMS

This case report describes an unusual presentation of acute appendicitis in an elderly patient and also demonstrates a unique anatomical pathway of disease extension. In addition, this case report highlights the advantages of CT in preoperative evaluation and subsequent management of these protean presentations of acute appendicitis.

METHODS

This report describes a case of an asymptomatic retrocaecal perforated appendicitis which presented clinically as a right lumbar abscess with surrounding cellulitis, and was further complicated by a concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male.

CONCLUSION

Elderly or immunocompromised patients presenting with cellulitis or a cutaneous abscess of the abdominal wall or lumbar region may benefit from an abdominal CT to demonstrate an intraperitoneal source of sepsis.

Mediastinal necrosis in acute pancreatitis - case report

Ascites, pseudocyst, necrosis of the retroperitoneal fat tissue and pancreatopleural fistula with left sided pleural effusion may complicate pancreatitis. However, steatonecrosis of the mediastinum and right side pleural effusion are rather rare complications of pancreatitis. We present a case of a patient with alcohol induced pancreatitis. Chest x-ray showed right sided pleural effusion. Although high levels of amylase in pleural fluid made the diagnosis of pancreatopleural fistula most likely, necrosis of the mediastinal fat tissue with right side pleural effusion was found postmortem.

Fat necrosis simulating recurrent neoplasia following external beam radiotherapy in a dog

A 4.5-year-old neutered male dog was diagnosed with incompletely excised well-differentiated lymphangiosarcoma in the right inguinal subcutaneous region. The mass had metastasized to the right hypogastric and medial iliac lymph nodes. Surgery followed by definitive radiation therapy was administered to the primary site and the sites of metastasis. The dog had a complete response to radiotherapy, and minimal acute side effects. Doxorubicin was administered after radiotherapy. Approximately 4 months following radiation therapy, the dog developed a mass, presumed recurrent tumor, in the original site. In a biopsy only steatitis and fibrosis were found. The mass continued to grow and conservative surgical excision was elected. Histopathologically the diagnosis was fat necrosis and steatitis, with a microscopic focus of lymphangiosarcoma. Fat necrosis is an uncommon sequelum to breast irradiation in people and also appears to be rare in animals. Fat necrosis should be considered as a differential diagnosis when recurrent tumor is suspected in a previously irradiated subcutaneous site in a dog.

Early mammographic and sonographic findings after intraoperative radiotherapy (IORT) as a boost in patients with breast cancer

The aim of this study was to evaluate mammographic and sonographic changes at the surgical site within the first 2 years after IORT as a boost followed by whole-breast radiotherapy (WBRT), compared with a control group treated with WBRT alone. All patients had breast-conserving surgery for early-stage breast cancer. Group A: n = 27, IORT (20 Gy) followed by WBRT (46 Gy). Group B (control group): n = 27, WBRT alone (56-66 Gy). Mammography: fat necrosis in 14 group A versus four group B patients (P < 0.001); parenchymal scarring classified as unorganized at the last follow-up in 16 vs seven cases, respectively (P = 0.03). Ultrasound: overall number of patients with circumscribed findings 27 vs 18 (P < 0.001); particular hematomas/seromas in 26 vs 13 patients (P < 0.001). Synopsis of mammography and ultrasound: overall postoperative changes were significantly higher classified in group A (P = 0.01), but not judged to have a significantly higher impact on interpretation. Additional diagnostic procedures, due to unclear findings at the surgical site, were performed on four patients of both groups. Within the first 2 years after IORT as a boost, therapy-induced changes at the original tumor site are significantly more pronounced compared with a control group. There is no evidence that the interpretation of findings is complicated after IORT.

Subcutaneous fat necrosis in a newborn following icebag application for treatment of supraventricular tachycardia

Cases of subcutaneous fat necrosis of the newborn (SCFN) and neonatal cold panniculitis have been reported most often secondary to perinatal distress or hypothermia. We present a case of a newborn infant who developed erythematous, indurated plaques on both cheeks and right shoulder following ice pack application for supraventricular tachycardia. The distinction between SCFN and cold panniculitis is important as SCFN may have complications such as hypercalcemia, whereas cold panniculitis is not associated with such sequelae. Clinicians should be aware of the diagnostic similarities and differences between these two conditions because of differences in potential serious sequelae.

Fat necrosis of the breast—A review

Fat necrosis of the breast is a benign condition that most frequently affects peri-menopausal women. It can mimic breast cancer clinically or radiologically. In other cases it can obscure malignant lesions. The core of this review is derived from a MEDLINE database literature search from 1966-2004. Further references were from lateral search. In this paper, we review the pathogenesis and pathology clinical and radiological features of fat necrosis of the breast. The implication of fat necrosis in the management of patients with breast lump is also discussed. Fat necrosis of breast is a complex process. Therefore, a systematic review of this condition will enable surgeons, radiologists and oncologists working in the field of breast disease to understand it better and improve its management.

Subcutaneous fat necrosis presenting as a large mass

Subcutaneous fat necrosis, though a rare phenomenon, can occur in patients of all ages. In newborns, it is an uncommon, self-limited panniculitis of traumatic origin, while in adults it is most commonly encountered among women presenting to breast clinics following a trivial or unnoticed injury sustained long ago. An acute presentation of fat necrosis as a large mass, however, is quite unusual and that may confuse the observer. History of trauma gives a clue to the diagnosis. We report an interesting case of traumatic subcutaneous fat necrosis because of massage therapy in a 66-year-old lady.

Subcutaneous fat necrosis associated with severe hypocalcaemia in a neonate

Subcutaneous fat necrosis (SFN) of the newborn is an uncommon disorder of the adipose tissue, mostly affecting full-term or post-term newborns who experience perinatal distress. The lesions of SFN typically occur during the first six weeks of life; they are usually self-limited and no specific therapy is required. The disorder may be rarely complicated with hypercalcaemia. We present the case of a neonate with perinatal asphyxia who manifested SFN followed by hypocalcaemia instead of hypercalcaemia and a biochemical profile of pseudohypoparathyroidism four weeks after the eruption of skin lesions. The infant was treated with alfacalcidiol. Blood biochemistry was normalized within one week and serum parathyroid hormone levels declined to normal over the next two months. It is suggested that perinatal asphyxia was the common etiopathogenetic factor for the development of both SFN and pseudohypoparathyroidism.