An Interesting Presentation of Ischemic Septal Panniculitis of the Breast

Abstract

A 68 year-old woman, with end-stage renal disease requiring hemodialysis, presented with a gradually enlarging mass in her left breast. Physical examination demonstrated a palpable 4-5 cm mass in the upper mid left breast above the nipple with some overlying skin discoloration. The patient had fallen with injury to her leg a few months prior, but could not recall any injury to her breast. Initial biopsy by palpation showed fat necrosis and inflammation. However, the mass became increasingly painful and the overlying skin developed a black eschar. Diagnostic mammogram demonstrated diffuse wire-like vascular calcifications (Fig. 1). A cardiac pacemaker and hemodialysis catheter were also noted. Tomosynthesis images aided visualization of innumerable tiny calcified vessels corresponding to neovascularization which could be mistaken for Cooper's ligaments on 2D images (Fig. 2). A left partial mastectomy was performed. The excised breast tissue was comprised of areas of septal panniculitis and overlying epidermal necrosis with intimal vascular calcifications associated with chronic dialysis and neovascularization (Fig. 3). Following surgery, the patient reported immediate relief of the disabling pain.Panniculitis is essentially inflammation of subcutaneous fat. Clinically, it presents as tender or painless nodules. The etiology is diverse. Subcutaneous fat is comprised of fat cells which are arranged in lobules surrounded by fibrous septa. The fibrous septa contain Figure 2. Tomosynthesis CC (b) and MLO (e) images with reconstructed 2D CC (c) and MLO (f) views aids visualization of innumerable tiny calcified vessels corresponding to neovascularization, which could be mistaken for Cooper's ligaments on traditional 2D CC (a) and MLO (d) mammogram.Figure 1. CC (a) and MLO (b) mammographic views of both breasts demonstrating diffuse vascular calcifications.