AJR 2001; 177:1489
© American Roentgen Ray Society
Florid Dystrophic Calcification Associated with Fatty Degeneration of Muscle Component in the TRAM Flap
Lai Man Pang,
Edmund Chan and
Wei Tse Yang
Prince of Wales Hospital, Chinese University of Hong Kong Shatin, New
Territories Hong Kong
We report an unusual pattern of florid dystrophic calcification occurring
in the muscle component of a pedicled transverse rectus abdominis myocutaneous
(TRAM) flap, which we believe represents fatty degeneration and muscle
atrophy. A slim, nonsmoking 39-year-old woman presented with a progressively
increasing firmness over the right breast. Four years earlier, she had
undergone a right mastectomy for breast cancer and an immediate pedicled TRAM
flap reconstruction. The patient did not receive postoperative adjuvant
therapy. Physical examination revealed induration over the superior aspect of
the reconstructed breast but no palpable mass or overlying skin change.
Mammography revealed flocculent calcification deep in the myocutaneous flap
anterior to the chest wall with surrounding radiolucency representing fat
(Fig. 5A). Axial CT of the thorax showed fatty replacement of the muscle
component of the flap with a thick rim of curvilinear calcification (Fig. 5B).
MR imaging revealed muscle atrophy of the right TRAM flap, with internal high
signal intensity on T1- and T2-weighted images (Fig. 5C) that was suppressed
on T1-weighted fat suppressed images (Fig. 5D). These imaging findings were
consistent with fatty degeneration in the atrophied muscle component of the
TRAM flap. The patient is being seen at follow-up and remains well.
Fat necrosis is a benign condition that may mimic breast malignancy
clinically and radiographically. It can occur after blunt trauma, cyst
aspiration, biopsy, lumpectomy, radiation therapy, reduction mammoplasty,
breast reconstruction with TRAM flap, implant removal, and anticoagulant
therapy. Fat necrosis in TRAM flaps is more common in obese patients, smokers,
and patients with a pedicled flap
[1]. A palpable mass,
irregularity, or increased tenderness suggests fat necrosis or recurrent
malignancy. Mammography after TRAM flap reconstruction may reveal
calcifications that may be clustered, dermal, or related to a hematoma, as
well as areas of increased or decreased density without calcification that are
related to fat necrosis and post-surgical changes
[2]. Mammograms revealing
recurrent carcinoma in the TRAM flap reconstruction have been described as
showing a mass, pleomorphic microcalcifications, or a mass with calcifications
[3]. To our knowledge, such
extensive benign flocculent calcification associated with fatty degeneration
and atrophy of the rectus muscle in a patient with a TRAM flap has not
previously been described and is reminiscent of calcifications associated with
paraffinomas arising after direct injection of paraffin for breast augmention
[4].
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