Pathology of Pancreatic Panniculitis

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Dr Sampurna Roy MD 2022

Pancreatic panniculitis is a rare entity appearing in approximately 2-3 percent of all patients with pancreatic disease.

This is a rare cutaneous manifestation in patients with underlying pancreatic disease.

It is mostly associated with acute or chronic pancreatitis or, less commonly, pancreatic carcinoma, frequently of acinar cell type.

Less frequent associations include pseudocyst, vasculopancreatic fistulas and pancreas divisum.

Pancreatic panniculitis clinically present as painful or asymptomatic subcutaneous nodules or indurated plaques.

These are usually located on the thighs, buttocks, lower trunk or distal parts of the lower extremities.

Involvement of areas such as breasts, and abdomen are described.

There may also be polyserositis, arthritis, eosinophilia or rarely a leukemoid reaction.

Panniculitis has also been reported in association with an islet cell carcinoma.

Lesions probably result from the local action of blood-borne pancreatic lipase and trypsin, although other factors may also be involved.

Cases have been reported without pancreatic disease, but with circulating lipase or amylase of unknown origin.

Histopathology:

Histopathology Image of Pancreatic Panniculitis

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Sections of established lesions show a lobular panniculitis involving much of the fat of the affected lobule.

Sometimes, contiguous lobules show a different stage in the histological evolution of the process.

Early lesions show enzymatic fat necrosis, with the ghost-like outline of fat cells remaining.

It has been suggested on the basis of one case, that at an even earlier stage (there is a septal panniculitis).

Liquefaction with breakdown of fat cells will eventually occur.

At the margins of the necrotic fat there is a variable neutrophil infiltrate, usually mild, associated with nuclear dusting, fine basophilic calcium deposits and some hemorrhage.

The necrotic fat cells may also have a pale basophilic hue due to the deposition of calcium salt.

In older lesions there are giant cells, lipophages, lymphocytes, hemosiderin and other blood pigment, and eventual fibrosis.

There may be some extension of the inflammatory process into the underlying dermis.

The treatment of pancreatic panniculitis is directed at the underlying pancreatic disease.

Usually those cases associated with pancreatitis slowly undergo resolution once the inflammatory episode of the pancreas regresses.

When there is involvement of subcutaneous fat other than the lower extremities, persistent disease, frequent relapses, or ulceration, the possibility of an occult underlying carcinoma of the pancreas should be considered.