#❛ A CASE FOR MITOSIS┊ AESTHETIC.

[jcmicr]

Sub-Clavicular Hibernoma: A Rare Diagnosis of Lipomatous Tumor by Zaïd Boughaleb in Journal of Clinical and Medical Images, Case Reports  

Abstract

Lipomatous tumors are the most common soft tissue tumors, including a large variety of benign and malignant lesions. Hibernoma is a benign lipomatous tumor originating from the brown adipose tissue inherited from the fetus. The diagnosis is often incidental, since the large majority are asymptomatic or very slow growing. Differential diagnosis with other lipomatous tumors is often challenging. Hence the diagnostic work-up is large and must be multidisciplinary. Biopsy and large resection with sane margins are the standard of care. We describe a 48-year-old male patient with a history of a painless, mobile, slow growing right sub-clavicular mass apparently evolving for eleven years. This patient underwent ultrasound, mammography, MRI, CT Scan and ultrasound guided large core biopsy at different points in time. We describe this case of a well-documented hibernoma of the sub-clavicular region in line with the current literature.

Keywords: CT scan; hibernoma; lipomatous tumor; MRI; ultrasound.

Introduction

Lipomatous tumors including a large variety of benign and malignant lesions are the most common soft tissue tumors, their prevalence increasing with age [1]. Sometimes, overlapping imaging features can be misleading in diagnosis [2]. Since the distinction between benign and malignant lipomatous tumor is challenging, especially when based on clinical and superficial work-up, the differential diagnosis of lipomatous tumors includes hibernoma [3]. Hibernoma is a rare, heterogeneous, slow growing fatty tumor of good prognosis [1], arising from brown fat precursors, representing approximatively 1% of all tumors derived from lipomatous tissues [1]. Usually, no symptoms are associated except when the enlarging mass impinges on local tissues4. To date a few thousand cases worldwide have been described [1].

Case Presentation

A 48-year-old male patient was referred to our mammography unit with a history of a painless, mobile, slow growing right sub-clavicular mass apparently evolving for eleven years. No skin redness, fever or signs of nerve or vascular compression were related. Previous ultrasound examinations reported a fatty mass with a diagnosis of lipoma (well-differentiated fatty tumor without suspicious radiological signs of malignancy [3]). Mammography showed a radiolucent mass consistent with a lipomatous origin on a targeted modified medio-lateral oblique view [5]. Ultrasound revealed a hyperechoic, homogeneous mass compared to the subcutaneous fatty tissue, measuring 11,5 x 3,6 x 10 cm, with vascular hyperemia on color-doppler ultrasound (Figure 1). MRI examination was performed to assess the precise extent and possible invasion of the underlying tissues. MRI described a mass measuring 10 x 3,9 x 9 cm with hypersignal on T2 sequence (but slightly lower than the subcutaneous fat signal [3]), hyposignal on T1 sequence compared to muscle structure (but slightly higher than subcutaneous fat signal [3]), very low signal on a fat suppression sequence and moderate enhancement on the post-contrast T1 sequence. No invasion of the adjacent soft tissues, muscles or bones was described (Figure 2). A CT scan without contrast media injection recently performed for other reasons showed a pre-pectoral low attenuation mass without involvement of the underlying tissues. In our case, density of the lesion was slightly higher than subcutaneous fat [5]. Eventually, diagnostic large core needle biopsies under ultrasound control were performed yielding the histological diagnosis of adipocytes with a microvacuolar and eosinophilic cytoplasm without signs of mitosis or necrosis. The diagnosis of hibernoma was raised. For aesthetic reasons, this patient was referred to our oncologic plastic surgeon; preoperative laboratory testing reported no evidence of metabolic disorder or infectious component [6]. Surgery showed a mass alongside the pectoral fascia, without muscle or vessel invasion. Histology confirmed the diagnosis of hibernoma.

Figure 1: (A) Subclavicular swelling due to the clinical mass (black star). (B) Mediolateral modified oblique mammographic view showing a radiolucent mass (white star), nipple (with arrow). (C) Ultrasound: hyperechoic mass with peripheral vessels on color ultrasound (white star). (D) Axial non-enhanced CT scan showing the mass (white arrow).

Figure 2: (A) T2-weighted axial MRI image revealing a slightly hypointense mass compared to subcutaneous fatty tissue (black star). (B) Axial T1-weighted non-enhanced MRI image with fat suppression: hibernoma undistinguishable from adjacent fatty tissue. (C) Gross macroscopic specimen showing a lipomatous mass. (D) Axial T1-weighted MRI image with fat-suppression post Gadolinium injection demonstrating a slight enhancement of the mass (white arrow).

Discussion

Huge progress has been made since the descriptions by Merkel in 1906 and Gery in 1914 [7, 8]. Brown fat is a particular form of fat found in the hibernating and non-hibernating animals [9]. Representing approximatively 1,6% of all benign lipomatous tumors, hibernomas are very slow growing tumors usually occurring between the age of 20 and 50 years [11, 12]. Average age at diagnosis is 38 years and various gender predominance have been described in the literature. Intraosseous hibernomas are found in older patient [13]. The most common location, as the majority of fat tumors, are neck, shoulder and periscapular regions which are areas with possible remaining brown fat tissue [14]. However, hibernomas can occur anywhere in the body [15]. The clinical manifestations are rare, but might occur as a painless soft tissue mass, with a locoregional irritation or neurovascular compression [16]. Conventional radiography demonstrates a radiolucent mass with no adjacent osseous abnormalities or mineralization [17]. Ultrasound describes a rather uniformly hyperechoic mass [5], with increased vascular flow [17] generally unspecific, like other soft tissue tumors. In our case, the diagnosis of a typical lipoma [5] was ruled out due to vascular hyperemia on color doppler ultrasound. On CT scan, hibernoma presents as a homogenous low-density mass of lipidic composition between the attenuation of subcutaneous fat and skeletal muscle [5]. Contrast enhanced CT scan usually shows variable degree of enhancement [16] and intra-tumoral septas [10]. Diagnosis of hibernoma cannot be excluded based on the lack of intra-tumoral vessels [10]. On MRI, the imaging modality of choice [3], hibernoma shows an hypoT1 and hyperT2 signal because of the fatty component alike our case but differs slightly from the fat signal. On a fat-suppressed sequence, attenuation is similar to fatty tissue. After Gadolinium contrast media injection, enhancement is variable but predominantly present and rather heterogeneous [5]; a common sign are large flow voids indicating fast flowing flood in intratumoral vessels. Internal septation, one of the features of hibernoma [3], was absent in our case. High level of FDG uptake has been described in brown adipose tissue [16], sometimes even higher than liposarcoma [10] but overlapping results [2] prevent clear distinction between both tumors. Four types of hibernomas have been described, based on a histological classification [15]: the typical variant, the most common one like our case, the “myxoid” variant, the “lipoma-like” variant and the “spindle-cell” variant. Differences in imaging characteristics among these different histological subtypes of hibernomas are due to the variable amounts of water and fat content. One study distinguished between “lipoma-like” and “non lipoma-like” hibernoma [18]. Non-lipomatous hibernomas are probably indistinguishable from other liposarcomas [17]. Differential diagnosis of hibernoma is very large and may include benign tumors (lipoma, angiolipoma, hemangioma, hemangiopericytoma, hemangioblastoma, xanthoma, granular cell tumor, adult rhabdomyoma, lipoblastoma…) [16, 19] and malignant tumors (liposarcoma, clear cell sarcoma,…) 5, 10, 16. Clinical and imaging features as previously described may guide the diagnosis, but the histological examination gives the final diagnostic. In the absence of treatment, hibernoma continues to grow and leads to functional or cosmetic consequences 2. Tumor regrowth has been reported with incomplete excision of hibernoma 19. The standard of care of hibernoma is surgical removal with clear margins. Surgical excision is advised to rule out a possible malignant lesion with hibernoma-like differentiation which could be missed by core needle biopsy 1. No risk factor has been described [1]. Multiple lesions in a single patient are possible 21. After resection, the tumor generally does not recur. Since no malignant transformation or metastatic (22) spread have been described in the current literature, hibernoma can be considered as a benign tumor 1 for patients is 20.

In conclusion, the diagnosis of fatty tumors, often challenging especially with rare tumors like hibernomas, should comprise ultrasound, MRI and large core needle biopsies. Since hibernomas are benign tumors with no tendency to recur or metastasize, surgical resection with clear margins is recommended 17.

Declarations

Funding

This work did not benefit from any financial support

Conflict of interest

All authors declare no conflict of interest.

Ethical approval statement

The study has been approved by the Ethical Committee of the institution (76/2021).

Patient consent statement

A written permission to publish has been obtained from the patient.

For more details : https://jcmimagescasereports.org/author-guidelines/ 

[boopypastaissalty]

Here sre some of my Sanders Sides theories. Long post btw so yee

Roman and Remus were originally one all-encompassing creativity, then they split and become the two different sides of creativity, or the "Creativitwins". Their names seem to follow a theme: Ancient Rome, specifically the legend surrounding the creation/beginning of Rome. I think that the original creativity's name was Romulus. Here's why: Remus killed Romulus over a land dispute and then started the city of Rome in his brother's name. Citizens of Rome are called Romans. Though it could be argued that Thomas's moral sense as a concept, not necessarily Patton, separated the two, thus "killing" the original creativity.

Patton may have suffered from anxiety and could have created Virgil as a way to relieve some of his stress, therefore making him Virgil's "dad" in a sense, in Patton's mind warranting him calling Virgil "kiddo" all the time.

We all know that Patton is allergic to cats, but what about the others? What are their weaknesses? My speculations are that Virgil is iron deficient, as he doesn't like to rise up because it makes him dizzy, he is also described by Roman to be the "fairest of them all" and then admitting it was a pale joke in Virgil's expense. Roman is lactose intolerant, as when Patton is feeding him cream of broccoli soup, Logan says that it will "upset Princey's stomach". Logan is OCD: Always planning and organizing things. He gets upset when things don't go exactly as he plans it. He also feels the need to always be right and to make sure everyone else is kept in line. Also: Patton seems to suffer from depression. Oftentimes depressed people crack jokes and give people the general idea that they are happy. They also try to make other people happy. Patton also sometimes gets into these sad funks and even says "I had this problem where I'd hide my less than awesome feelings, so when I would feel like sobbing I'd just smile and crack jokes. I thought that was coping, only joking, never showing sadness, hoping it would just go away".

The thumbnail for "Putting Others First - Selfishness v. Selflessness Redux" has a character selection screen telling the viewer to "select a side", but one thing I noticed is that there is a blank box, indicating a locked character or a character who hasn't been revealed yet. Another thing I noticed is that the sides have a rainbow theme going on. Thomas even says that he is "full rainbow all the time" as an allusion to his sexuality, and possibly even the sides in general. Roman is red, there is no known orange side, Janus is yellow, Remus is green, Patton is light blue, Logan is indigo, and Virgil is violet/purple. Red is the color of physical strength, power, confidence, and passion, which suits Roman's personality. Yellow can be happiness and joy, but also directly means cowardice and deceit, which is self explanatory. Green is a color of healing, life, and vitality, but the flip side being greed, jealousy, pessimism, and superficially. Blue is the color of trust, loyalty, faith, wisdom, truth, patience, and understanding, which sums Patton up pretty well. Indigo resembles wisdom, integrity, fairness, impartiality, and justice, which is all right up Logan's alley. Violet is the color of ambition, dignity, devotion, pride, mystery, independence, magic, being cynical, and mourning, which all makes sense in Virgil's case. Now to orange, which resembles joy, sunshine, risk taking, adventure, enthusiasm, creativity, attraction, success, rudeness, frivolity, and untrustworthiness, which is a balance of traits that both Roman and Remus have and directly resembles creativity, so orange could be a fusion of Roman and Remus, the original creativity before they split. Another possibility for the next side is someone who resembles ethos, as we have pathos and logos (Patton and Logan).

All the sides have an ancient Rome theme going on. Roman and Remus, after the legend surrounding the beginning of Rome. Virgil, after the Roman poet Publius Vergilius Maro, who is often called Virgil. Janus (formerly known as Deceit) after the Roman god of the same name (Janus is the god of new beginnings and transitions, often depicted with two faces facing in opposite directions, one for the past and one for the future). All of the sides except for Patton and Logan, whose names are derived from pathos and logos, an ancient Greek concept proposed by Aristotle. And have you noticed that they mirror each other in almost every way, suggesting that, much like Roman and Remus, they are brothers, possibly even twins?

Dukes tend to not be a part of the royal family, but if so they are princes who have gotten married. Does this mean that Remus is married?!?!? If so to whoooo?

Welcome to me overthinking things again! What if Roman has control over the other sides? Like he's creativity and the sides are figments of Thomas' imagination, so like what if one day he was just done with Logan's nonstop fact train he just (this is extreme) went: "Fuck you, Logan, you're dead now" and Logan straight up dies? Like where would his power end if he could do that? Overthinking things can be scary kids, let me do it for you.

If you overthink it: Patton basically just was like "Nah" in POF SvSR. So he said in SvS that going to the wedding would make Thomas feel good, something that he basically controls because he is Thomas' moral sense and at the center of most of his feelings. Basically Thomas went to the wedding and Patton was like: "This is nice and all and you did the right thing, but uhmmm about those happy feelings. No." And then got all sorts of frustrated about being wrong. So yee. I am just doing the overthinking things thing again.

What if creativity split solely as a big "Fuck you, Logan"? Like I just imagine: C: "Hey Logan, I'm performing mitosis"

L: "Yes, your cells- *he looks up* Whaaaaa?"

R&R: "Cha cha real smooth, Logan"

And thus the twins were "born"

Logan thinks feelings are bad and claims to not have feelings, even though he clearly does (cough, cough, Crofters the Musical? Getting angry in some episodes? Logan, you're a bad liar, bud). So he bottles up most of his feelings, for all practical purposes making him a ticking time bomb. Something's probably going to happen and he won't be able to hold it all in and he'll have an emotional breakdown of sorts. Another thing is he will not duck out. He knows he's too important to Thomas' mental wellbeing for that. He is also getting progressively more angry as the others listen to him less, so he's probably going to overwork himself trying to get everyone to listen to the point where he physically can't be there for Thomas. Cuz like I suspect Logan leaving would have the same effect as Thomas having a massive stroke: The right side of his body wouldn't work, he wouldn't be able to talk/communicate, and his reasoning skills would be gone.

Janus just loves philosophy. Every episode in the main timeline, he makes references to famous philosophers to get his point across.

Patton is always the first of the light sides to accept the dark sides. First with Virgil and then with Janus. He may be taking them in as his troubled but lovable children who he will defend under almost any circumstance.

Virgil's name is not Virgil. People think his full name is Virgilius, though Thomas and Joan have previously stated that it isn’t. Bc of that, some people have theorized that Virgil was lying about his name, or that when he moved to the “light sides” he changed/used a different name, and maybe they’re going to reveal that sometime. Like the scene with Remus and Vee where Re goes, “I would never hide anything from you” looks pointedly at Virgil, and you assume it’s bc he took forever to tell Thomas, but what if it’s bc he was lying about his name from the moment he told Thomas??? And also the moment when Janus says "It takes a liar to know a liar" and Virgil says "Don't" and the response was "What? I'm only talking about your name" I think his name could be Acanthus

Ya know, Patton probably has an indirect role in how the other sides look. Not like "But you're anxiety, you wear the hoodie" but closer to Thomas beliefs of stuff like lying is bad and the fact that Janus often plays devils advocate, so he has a snake face

Random thoughts:

Virgil has the most ace/demi aesthetic and I love that

SvS: Multi part episode, "bad/evil/dark" side gets accepted, the FEELS, angst. Hmmm…

The twins getting along and just like sitting at a table causing minor chaos.

Patton randomly hugs everyone. He just does.

Janus and Patton: animal bros

[designmeblogss]

Unusual Article Uncovers the Deceptive Practices of Create Links in Bio

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The bulk of the animals dwelling in the desert biome are nocturnal. Naturally there are larger animals in the desert biome since they can feed on the smaller ones. Many desert biomes can go many years at one time with no rainfall in any respect.

Without photosynthesis and respiration, living things wouldn't be able to find energy that's required to survive. So it's useful if you own a computer accessible. Most cells in the body are made by mitosis.

[designcompanys-blog]

Unusual Article Uncovers the Deceptive Practices of Create Links in Bio

This sort of bio is clearly supposed to be temporary. Once you own a bio you're comfortable with, don't forget that it isn't set in stone links in bio. A specialist bio is just a story-based variant of the info you would typically include in a resume.

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On-line readers have a tendency to skim content, so ensure it is simple for them to read it. You're writing an audio business document. In that sense, it's a clickable Instagram link, but more to the point, it is but one of the most seamless shopping experiences for users, and a tremendous way for companies to integrate Stories with their merchandise and make it simpler for their audience to purchase.

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The bulk of the animals dwelling in the desert biome are nocturnal. Naturally there are larger animals in the desert biome since they can feed on the smaller ones. Many desert biomes can go many years at one time with no rainfall in any respect.

Without photosynthesis and respiration, living things wouldn't be able to find energy that's required to survive. So it's useful if you own a computer accessible. Most cells in the body are made by mitosis.

[caffeine-creativity]

Studyblr Tag

I originally found this tag from @organizedminimalist and wanted to share because my studyblr is relatively new! Make sure you use the #studyblr tag if you decide to do it also, which I hope you do.

GENERAL

What country are you currently studying in? Pennsylvania, USA.

What’s your major or specialization? Neuroscience as my major and creative writing as my minor

What year are you in? 1st year of undergrad

What courses are you taking? This semester I’m in creative writing, psych/neuro introduction, German language, and international politics, but next semester I’ll be taking biology, the nature of hope (psych-based), modernism and modernity in literature, and archeoastronomy.

Favorite course? My favorite course is actually from my dual enrollment in high school at a different university; I took an anthro class on Women and Religion. It was superb and the prof was very intelligent/ laid back.

What languages do you know? Which do you want to learn? My first language is English but I’m also proficient in German, and in the future I want to learn Morse code and French! I started studying German in seventh grade, so about 12 years old??

What language do you study in? Which language do you think in? I study in English (except for my German homework😜 ) and usually I’ll think something first in English and then my brain tries to articulate the same thing in German. Weird, right?! Sometimes I also try to think of a German synonym for an English word if I’m writing a paper.

Career aspiration? My goal is to either go to Med school for psychiatry or get my PhD and become a professor. I love being able to mentor people and help them reach their fullest potential! Conducting research is also super fulfilling to me.

If you couldn’t be #8, what would you be? I would want to be a poet, pastry chef, museum exhibit designer, or public figure.

Moment when you knew what you wanted to do? I don’t think there was a definitive moment when I decided… it was more of a process or system in which I weeded out what I like and don’t like. And I’m still going through that process!

STUDY ENVIRONMENT

Where is your favorite place to study? It depends on what I’m doing and what mood I’m in but usually a quiet place that’s good for people watching. So perhaps a library or cafe :)

When is your favorite time to study? The morning!

Clean desk or organized mess? Best intentions are tidy though sometimes I fall short

Music or no music? For studying I sometimes listen to piano/violin classical or swing jazz but usually nothing with lyrics; it gets distracting and I can’t focus!

Name top 3 worst distractions: Adding stuff to a to-do list, TUMBLR, and online shopping (Bonus: non-pressing or fun assignments)

Exam time, dress up or down? Usually dress up but it has to be comfortable and include socks so my feet stay warm lol

Exam time, hair up or hair down? Hair up for dayzzzz

Favorite outfit for studying: Leggings and a sweater plus cozy socks

Favorite study scent: Not sure if this counts, but my fave perfume, which is Light Blue. It makes me feel confident to take on my work!

STUDY TOOLS

Name 5 things you would consider your ‘study essentials.’ Water, laptop, notebook(s), class notes, and a quiet environment

Hard copy books or pdf online? Both work:)

Favorite study snack/drink: latte or water + goldfish crackers or Chex mix

Fave pen and pencil? InkJoy gel pens, pilot pens, and Ticonderoga pencils

Name 5 apps/tools that help you be productive. Inspiration graphic organizing software, Noodletools, google drive, onelook thesaurus, earbuds.

How many pens/pencils/markers are in your pencil case? Too many to count

Backpack or purse? Backpack for practicality although leather satchels just look so aesthetic and collegiate lol

How many notebooks do you have? Again, too many to count although probably 6 or 7 in current use.

STUDY HABITS

How do you motivate yourself when you’re not motivated? Talk to a close friend, look at other studyblrs for tips, assemble my study outfit, snacks, and tools and dive in!

Pump up routine before an exam? Usually I have to pump myself DOWN haha because I’m jittery. I’ll take deep breaths and think about how everything in my life will be the exact same after it’s over and that in the long run, it probably won’t matter.

Crammer or pacer? Pacer!

Type of learner? Kinesthetic, visual, and writing

How do you plan? With my at-a-glance weekly/monthly planner and occasionally google calendar.

Preferred note-taking method: by hand for sure. I can make all sorts of graphs and notes during class that take too long to generate online

Do you make to do lists? Every day, but sometimes I need to take a break because I get too overwhelmed with them.

Do you stick to your to do lists? Mostlyyyyy:)

Group study or independent study? 99% of time time—independent but once I have most of the material down I’ll review with others who also want to do well.

Average number of hours of sleep during exam time? 7?

Ever pulled an all nighter? Nope!

STUDY MENTALITY

What of you do to recover from getting a grade lower than expected? I always remind myself that it’s the collective that matters, not each individual test. Then I usually mope for a bit and then go get help from my teacher/professor.

One advice you’d give to others? Don’t try to study all the time! Have other important projects that you invest yourself into, such as volunteering or creating an online presence.

What are you most proud of right now? In high school I won a national award for a research project that is very near and dear to my heart. Other than that, I’m currently working on a chapbook so that makes me proud!

Favorite quote to keep you going? “It’s all temporary.”

Favorite way to destress? Exercise, Tumblr, youtube, talking to close friends, creating something.

OTHER

Favorite five studyblrs? Studyquill, TeaCoffeeBooks, Students and Lattes, My Little Study Spo, and Force of Nature

How often do you check Tumblr? Probably 3x per day?

Hobbies when you’re not studying? Writing poetry, making videos, running, reading

Favorite compulsory-reading book? Theories of Vision from Al-Kindi to Kepler by David C. Lindberg

First nerdy joke that pops into your head? What did the cell say to his sister when she stepped on his foot? Mitosis!