Iraqi Postgraduate Medical Journal

BACKGROUND:
Wilms tumor is one of the most common nephrologic paediatric tumors, a retrospective study of 24 patients had wilms tumor were reviewed from clinical and epidemiological point in the oncology unit of Child Central Teaching Hospital for the period (June 1st 2004 to June 1st 2010).
OBJECTIVE:
To find out the main clinical features, diagnosis,treatment modalities and outcome of children with wilms tumor admitted to central teaching hospital.
PATIENTS AND METHODS:
Records of 24 cases were collected and analyzed as aretrospective study done in oncology unit in central teaching hospital over 6 year period from June 1st2004 to June 1st 2010
RESULTS:
Patients included 13 males and 11 females; the mean age at presentation for males was 3.7 years and 2.5years for females,male to female ratio was 1.18:1 .
Asymptomatic abdominal mass was the most common presenting feature in 24 patients (100%) followed by haematuria in 7patients (29.2%), hypertension in 3 patients (12.5%), congenital anomaly(which was hemihypertrophy of the Lt. side) in 1patient (4.2%) & other presenting features including: fever, weight loss, nausea, vomiting, abdominal pain in 15 patients (62.5%).
The tumor was left sided in 14 (58.3%) patients, right sided in 8 (33.4%) patients & bilateral in 2 patients (8.4%).
Stage III wilms tumor was the commonest histopathological type in 7 patients (29.2%).
The overall survival was (41.6%); the overall mortality rate was (16.7%); infection and sepsis were the main causes of death in 2 patient (8.3%).We had 4 patients died ,2 of them due to infection &sepsis , other 2 patients cause of death not reported.
CONCLUSION:
The study showed the clinicodemographic fates of patient with wilms tumor were similar to other studies but still infection &sepsis were common causes of death in advanced stages because of delayed referral in most cases.

BACKGROUND:
MiR-21 plays an important role in tumor formation and development , and it has been shown to be a key regulator of oncogenic processes and it may be a useful biomarker for breast cancer .
OBJECTIVE:
Estimation of miR-21 gene expression levels in both fresh tissues and serum of same breast cancer patients before and after operation by using stem-loop followed by Taq-Man Real Time PCR (RT-PCR) technique and correlate the miR-21 gene expression with stages of breast cancer and lymph node involvement.
MATERIAL AND METHODS:
Stem-loop RT-PCR was performed to identify the level of miR-21 gene expression in both fresh tissues and serum of same breast cancer patients before and after operation . The expression levels of miR-21 relative to mRNA of GAPDH were determined by using the livak method.
RESULTS:
Mean fold change of miR-21 was significantly higher in breast cancer than that of paracancerous tissues . Before operation ,the mean fold change of serum miR-21gene expression significantly statistical difference from healthy control ,the mean fold change of miR-21 in advance stage( III,IV) was significantly higher than that early stage (I,II) and mean fold change of miR‑21 in positive lymph node was higher than that of negative lymph node . After operation the mean fold change of serum miR-21gene expression was significantly higher than healthy control .A statistically significant difference was noted between advance stage with lymph node involvement and early stage with negative lymph node involvement .In contrast , the mean fold change of serum miR-21 was significantly lower from that before operation .
CONCLUSION:
Circulating miR-21 before and after operation can serve as a good biomarker for breast cancer detection and progression .

BACKGROUND:
CRC is one of the most common cancers in the world. K-ras is proto-oncogene with GTPase activity that is lost when the gene is mutated. Analysis of K-ras mutational status is very important for CRC treatment, being the most important predictors of resistance to targeted therapy.
OBJECTIVE:
This study aims to determine the frequency and spectrum of K-ras mutation among Iraqi patients with sporadic CRC.
PATIENTS, MATERIALS AND METHODS:
This study enrolled 35 cases with sporadic CRC; their clinicopathological parameters were analyzed. The FFPE blocks were used for DNA extraction; PCR amplification of K-ras gene and hybridization of allele-specific oligoprobes were performed. The assay covers 29 mutations in the K-ras gene (codons 12, 13, 59, 60, 61, 117 and 146).
RESULTS:
The majority of cases have left colonic tumours (57%), without LN involvement (57.1%), of non-mucinous adenocarcinoma histology (85.7%), grade II (82.9%) and stage III (37.1%) tumours. Fourteen mutations were detected in 13 (37%) patients with K-ras mutations; 10 (71.4%) mutations were in codon 12 while 4(28.6%) were in codon 13. The most frequent mutation was the G>T transversions [9 (64.4%)] and the most frequent mutation type was GGT>TGT (GLY>CYS) at codon 12.
CONCLUSION:
The incidence of K-ras mutations lies in the middle of the reported figures worldwide; the majority of mutations occurred at codon 12 followed by codon 13; predominantly of G>T transversion and Gly12Cys type that has a poorer prognosis.
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BACKGROUND:
A common problem facing the surgeon and the pathologist is evaluation of patient with apparently single thyroid nodule.
PATIENTS AND METHOD:
Over the period from August 1996 to September 1998 , (152 patients) with clinically solitary thyroid nodules were seen in the medical city , only 72 0f them proved to be single ,cold and cystic nodule and included in this study .
RESULT:
F.N.A.C was done for all patients (72),(57) patients of them were benign ,(6)patients were malignant or suspicious and(9) patients with indeterminate aspirit .pure spirit (ethanol injection into thyroid nodule was done in only 60 patients ) ,42 patients (70%) with benign nodule were successfully treated with aspiration and spirit injection , 24 patients (40%) of them had complete disappearance of nodule, 18 patients (30%)had more than 50% reduction in the size of the nodule ,in 18 patients no significant reduction .
CONCLUSION:
All patients with solitary thyroid nodule should undergo F.N.A.C. to role out malignancy. Cold benign cystic thyroid nodules were successfully treated in 70% of cases , only 3% recurrence was observed .complication requiring hospitalization were not reported .

BACKGROUND :
Pediatric vesical stones constitute 30% of all urinary tract stones in the developing countries. Management of pediatric urolithiasis has evolved from open surgery to minimally invasive techniques
OBJECTIVE :
To evaluate the efficacy and safety of using pneumatic lithotripsy in the treatment of vesical stone in pediatric age group.
PATIENTS AND METHODS:
Forty children (2 female and 38 male) with bladder calculi were evaluated in this prospective study and managed by transurethral pneumatic cystolithotripsy at the department of urology in Al-Ramadi Teaching Hospital during the period January 2010 through December2012. The age ranged between 2 years and 10 years with a mean age of 4.6 years. Bladder stone size ranged from 8mm to 17mm ,plain X-ray kidney, ureter and bladder (KUB) revealed that 28 patient's calculi were radiopaque and 12 patient's calculi were radiolucent , History and physical examination were performed. Laboratory investigations included complete blood count, blood urea, serum creatinine and urine analysis. Radiological examination included plain X-ray kidney, ureter and bladder (KUB) ,ultrasound and Excretory urogram (EU). transurethral pneumatic lithotripsy of bladder stone was done using semi rigid 9FR ureteroscope, after initial cystoscopy, Stone was fragmented with pneumatic lithoclast probe (3mm tip, storz). After completing the procedure 8-12 FR urethral Foley catheter was passed. Foley catheter was removed after 24-72 hours .
RESULT:
After one session of cystolithoclast, 92.5% (37) children became stone free. The mean operative time was 41.575 minutes with a range of (35-75 min).In this study the complications included significant hematuria in 5 patients (12.5%), urine retention in one patient (2.5%), and residual stone in 3 patients (7.5%) .
CONCLUSION:
Pneumatic lithotripsy using ureteroscope appears to be an effective and safe treatment method for bladder stone in children.
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BACKGROUND:
Extracorporeal shock wave lithotripsy (ESWL) has long been accepted as the least invasive and reliable method in the treatment of urolithiasis. The success rates have been very high in renal and upper ureteral stones .
OBJECTIVE:
Is early detection of bacteriuria and bacteriemia after extracorporeal shock wave lithotripsy (ESWL) of calcium and infection stones by measurement of plasma C-reactive protein (CRP) levels.
METHODS:
A total of 150 patients who had infection stones (n 54) and calcium stones (n 96) were included in the study. All patients had sterile urine before ESWL. The mean age was 41.6+_ 4.85 and male/female ratio was 2.12. Blood cultures were obtained within 1 hour post-ESWL period. Urine cultures were obtained 3 times just after and on the first and seventh day of ESWL.
RESULTS:
Post-ESWL evaluations showed 6 positive blood cultures with 4(5.32%) patients in infection stone and 2 (2.66%) patient in calcium stone groups, whereas urine cultures revealed 12 (16%) positive results in infection stones and 8(10..66%) in calcium stones. The patients who had positive cultures also had elevated plasma CRP levels when compared to the levels in patients with negative cultures (p 0.000).
CONCLUSION:
Bacteriuria and bacteriemia after ESWL have been well-identified entities and may be responsible from some of the post-ESWL complications. CRP can be useful for early detection of such complications.

BACKGROUND:
Serum ferritin is the standard measurement for the body iron stores, and is the most reliable marker for iron status. During pregnancy, there is a gradual decline in serum ferritin level. However, elevated maternal serum ferritin was notified in women with gestational diabetes mellitus (GDM).
OBJECTIVE:
To investigate the association between maternal serum ferritin level and gestational diabetes.
METHODS:
A prospective case control study of 50 women with singleton pregnancy that had gestational diabetes compared to 50 healthy pregnant women. The study was performed in Baghdad teaching hospital for one year period from June 2010 through June 2011. Serum iron, total iron binding capacity, and serum ferritin level were assayed. Mean serum ferritin was elevated (95.6027±99 ng/ml) in women with gestational diabetes, compared to that in the control group (31.7213±42ng/ml).
RESULTS:
There was a statistically significant elevation of serum ferritin in women with gestational diabetes. CONCLUSION:
We concluded that there is a positive association between the elevated serum ferritin and gestational diabetes.

BACKGROUND:
Brain hemorrhage is defined as the extravasation of blood from the vascular bed into the intracranial space, resulting in clinical dysfunction of nervous system. Intracerebral hemorrhage is a heterogeneous disease with deep and lobar subtypes. The amount of serum lipid may also affect the integrity of blood vessel wall and abnormal lipid profile may consider as a risk factor for intracerebral hemorrhage.
OBJECTIVE:
The present study was designed to evaluate the relationship between serum lipids and the site of intracerebral hemorrhage.
METHOD:
A cross-sectional study for 100 patients (50 with deep seated, 50 with lobar intracerebral hemorrhage) from Al-Kadhymia teaching hospital and Bagdad Teaching Hospital between August 2012 and June 2014. Case subjects included those patients from 20 to 89 years of age experiencing ICH within first 48 hours of presentation. Total cholesterol (TC), High-density lipoprotein (HDL) cholesterol, Low-density lipoprotein (LDL) cholesterol and Triglycerides (TG) serum level, was compared in deep seated and lobar intracerebral hemorrhage.
RESULTS:
There was significant relationship between high HDL level in deep seated compared to lobar hemorrhage, while there was no statistical significant relationship between the site of hemorrhage by TC, LDL and TG level
CONCLUSION:
High HDL level is a risk factor for deep seated rather for lobar intracerebral hemorrhage.TC, TG, LDL have no effect on the site of hemorrhage.

BACKGROUND:
Cerebral palsy (CP) is the result of non-progressive damage to the developing brain and consists of a number of clinical neurological syndromes of heterogeneous etiology. Epilepsy is known to have a higher association with cerebral palsy; 15–60% of children with cerebral palsy have been reported to have epilepsy.
OBJECTIVE:
This study was performed to determine and assess the characteristics of cerebral palsy and explore the relationship between type of cerebral palsy and patterns of epileptic seizures and to determine the associated factors, nature and prognosis of epilepsy in children with cerebral palsy.
PATIENTS AND METHODS:
Design:A prospective, hospital-based, case-control study.
Setting: RaparinPediatric Teaching Hospital, Rizgary Teaching Hospital-Neurology Department and Helina Handicap Care Centre during the period of January 2013- July 2015, Erbil, KRG, Iraq.
PATIENTS:
One hundred and twelve children had CP and seizures were studied (group1). Two control groups included 70 children had CP without seizures (group2), and 50 children had seizures without CP (group3).
The following data were ascertained: Type of CP, pattern of seizures, age, gender, age at onset of seizures, mode of delivery, history of hypoxic ischemic encephalopathy in the neonatal period, neonatal seizures, history of status epilepticus, family history of seizures, developmental delay, EEG data, image findings, use of anti-epileptic drugs, seizures control and seizures outcome. Children with febrile convulsion were excluded from this study.
RESULTS:
Spastic tetraplegia wasthe most common type of CP (29.46%, 35.71%) in group 1 and 2 respectively.Generalized tonic, clonic or tonic clonic seizures were the most common types of seizures in both groups. Unlike those who had epilepsy without CP,themajority; 57(50.89%) of patients who had epilepsy and CPdeveloped seizures in the first year of life. Twenty eight percent of caseswith epilepsy and cerebral palsy, and 88% of cases with epilepsies alone showed good seizure control by antiepileptic therapy. Children who had epilepsy and CPhad a higher frequency of; neonatal seizures44 (39.28%), developmental delay98 (87.5), abnormal brain CT scan 91(81.25%) and family history of seizures47 (41.69%). Large number of patients who had epilepsy and CP 81(72.32%) needed poly therapy while majority ofthose who had epilepsy without CP needed single therapy 60(90%).
CONCLUSION:
Cerebral palsy is associated with a higher incidence of seizure disorders, whichin a majority has its onset in the first year life.Brain imaging showed abnormal pathology in most affected children and needed poly therapy and even difficult to control.

BACKGROUND:
Combat Gunshot Head Injury is an increasingly important issue with all its drawbacks on the health care system .
OBJECTIVE:
This study presents an evaluation of traumatic brain injury caused by gunshots and discusses possible predictive factors for the outcome of surgical intervention.
PATIENTS AND METHOD:
A prospective study performed at Al Shaheed Mohammed Al Majed hospital, Samarra, Saladin, Iraq consisted of 60 patients who underwent surgery for penetrating TBI over a 1 year period (2015 – 2016). All injuries were caused by gunshot.
RESULTS:
Mean patients’ age was 31.5 years. The Glasgow Coma Scale (GCS) score on admission was > 8 in 43 patients (71.7%) and ≤ 8 in 17 patients (28.3%). Commonest site of brain injury is the frontal lobe (28%). Ballistic trajectory through brain affects the post operative outcome with good outcome (50%) in the anteroposterior bullet trajectory plane. 5 patients (8.3%) died despite surgical management.
CONCLUSION:
Admission GCS score, bullet trajectory and ventricular involvement are the most powerful prognostic indicator with a score of more than 8, no ventricular hemorrhage, anteroposterior trajectory of bullet and lesions limited to a single lobe of the brain, have improved surgical outcomes. Early and less invasive surgery in conjunction with short transportation time to the hospital could decrease mortality rates.
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BACKGROUND:
Sperm motility is essential in fertilization because non active or mal active sperms never reach the ovum, but the progress in the assisted reproductive techniques makes it easy for doctors to select viable sperm to be used in intracytoplasmic sperm injection thus the differentiation between viable and non-viable sperms is very important especially in sever asthenospermic samples.
OBJECTIVE:
To evaluate low level Helium Neon laser irradiation of the whole seminal sample as a method to activate mal or non-active sperms and to study and follow up the late effect of laser irradiation on the seminal samples.
MATERIALS AND METHODS:
100 samples were included in this study from patients attending seminal fluid examination lab. After digital seminal fluid examination, samples were divided in 2 parts, the first was incubated for 120min at 37C and the other was irradiated with 623.8 wave length Helium Neon laser and an output power of 2mW at 1cm distance for 10min and then examined digitally after irradiation then incubated with the first part to 120min also to be examined again with the first part.
RESULTS:
It was found that there is a significant increase in the progressive motile sperm percentage in the laser irradiated samples from about 33.6% to 41.6% (p<0.005) and also decrease in the percentage of the immotile sperms from about 44.1% to 34.4% (p<0.001). While after 120min incubation, active sperms percentage in the irradiated sample was about 43% which is higher than the non-treated part (31.6%; p<0.01) that showed also higher percentage of immotile sperms (52.8%) against (39.9%) in the treated part.
CONCLUSION:
Helium Neon laser irradiation to the whole seminal sample increase the sperms activity and decrease the percentage of immotile sperms which mean that it stimulates viable but immotile sperm to move. And also, sperms in laser irradiated samples preserved their increased activity for more than 2hours after laser irradiation.

BACKGROUND:
Thymectomy is a good option for the treatment of patients with myasthenia gravis (MG).
OBJECTIVE:
To show the effect of thymectomy as treatment for patients with myasthenia gravis.
PATIENT AND METHODS:
A retrospective study of 75 patients admitted to AL-Hariri martyr hospital from January 2010 to December 2014. They were reviewed using special form included patients' (age, sex, hospitalization period, CT-findings, preoperative medication, respiratory care unit (RCU) admissions, plasmapheresis sessions, number of drains in operation, complications post operatively, type of surgery, histopathological findings) with their symptoms being staged according to Osserman classification. All patients managed with trans-sternal thymectomy and extensive tissue removal of the thymus and fatty tissue around it.
RESULTS:
From 75 patients, 33% achieved complete remission, 27% had partial improvement, 32% with no changes and 8% got worse. 45 patients (60%) are between 20ys and 40ys with female predominance and good responses to surgery. 30 patients (40%) are above 40 with less improvement after thymectomy. Patients with severe symptoms (32 patients) appear to improve. This is also true in patients underwent thymectomy and the histopathological findings of thymic follicular hyperplasia (35 patients).
CONCLUSION:
Trans-sternal thymectomy is a safe treating method for patients with myasthenia gravis. Age, sex of the patients and presence or absences of thymoma are significant predictors. Patients with severe symptoms and those with a biopsy of thymic follicular hyperplasia improve remarkably.

BACKGROUND: Osteochndritis Dissecans is relatively rare disorder commonly affect adolescent males, non weight bearing area of the medial femoral condyle is the most common site. OCD is a radiological diagnosis with MRI sensitivity about (97%). Non operative treatment indicated in juvenile form and stable type. Operative intervention indicated in adult form and unstable lesions.
OBJECTIVE: To the postoperative clinical knee functional outcome between arthroscopic screw fixation and arthroscopic subchondral bone drilling in OCD. PATIENTS AND METHODS: A retrospective comparative non randomized study was performed on 10 patient (8 males and 2 females) with adult form of OCD. The patients were divided into 2 groups( A and B), each group consisting of 4 males and 1 female. All patients in group( A) underwent arthroscopic screw fixation, and all patients in group (B) underwent arthroscopic subchondral bone drilling. After 3, 6 and 12 months follow up, the 2 groups were compared preoperative and postoperative according to Lasholm Score changes. RESULTS: In both groups ( A and B), the difference in improvement of the clinical knee outcome postoperatively better than preoperatively according to Lasholm Score( P value less than 0.001) which was statistically significant, and the difference in improvement in group (A) better than in group (B) postoperatively, P value < 0.001 which was statistically significant. CONCLUSION: Arthroscopic screw fixation in OCD has statistically better clinical knee functional outcome than arthroscopic subchondral bone drilling, and it is recommended to do arthroscopic screw fixation if possible. .

BACKGROUND:
Juvenile idiopathic arthritis (JIA) is an immune mediated chronic disease. In its most severe clinical form, JIA may show localized and/or systemic and oral complications. This may result in variable growth and developmental anomalies. As a result, it is not uncommon for JIA patients to present with skeletal Class II and open bite malocclusions.
OBJECTIVE:
This study was conducted to assess temporomandibular joint (TMJ) among patients with JIA.
MATERIALS AND METHODS:
A cross sectional study was conducted among JIA patients attending Baghdad Teaching Hospital from November 2014 to April 2015. All patients underwent a clinical evaluation of their TMJ condition. TMJ disorder was assessed by using Helkimo’s index (1974a), and distribution of TMJ disorders was assessed according to the age, gender, duration of illness and types of medication.
RESULTS:
The mean age of JIA patients was 17.59±9.63 years old and mean Illness duration of 8.45± 9.29 years. High percentage of patients (93.8%) presented with clinical dysfunction of TMJ (CDI). 22 patients with JIA (27.16%) presented with severe clinical dysfunction, 19 patients with JIA (23.46%) presented with moderate clinical dysfunction and 35 patients (43.21%) presented with mild clinical dysfunction of TMJ. No significant difference in mean value of CDI according to age and duration of illness. Females were affected by clinical dysfunctional index of TMJ more than males, but statistically non- significant. The highest mean value of CDI was among patients treated with prednisolone, while patients treated with combination of drugs were the least affected.
CONCLUSION:
This study confirms that patients with JIA have a high incidence of TMJ dysfunction. The systemic effect of disease may impact on development of TMJ and facial growth. Close supervision is required to JIA patients for orthodontic intervention need, regular dental care, and TMJ evaluation.

BACKGROUND:
Anal dilatation is streaching of the anal incision gently with special dilators as a part of follow up after posterior sagittal anorectoplasty (PSARP) and pull through operations in peadiatric patients . Sevoflurane has many of the features of an ideal volatile anaesthetic agent with rapid induction which make it particularly useful in children . Propofol is the most desirable intravenous agent in outpatient anaesthesia because of rapid induction and recovery.
OBJECTIVE:
Is to compare propofol with sevoflurane as a single anaesthetic agent for anal dilatation in peadiatric patients that produce more rapid turn over of cases.
Patients and methods: 50 peadiatric patients who had anal dilatation with Hegar dilators allocated into 2 groups according to the anaesthetic agent used sevoflurane (S) or propofol(P) . The variables measured are the induction time(T1) and the time needed to achieve good relaxation(T2).
RESULTS:
T1 was shorter in group P(mean 60 sec)than group S(mean 86 sec)p value0,000(highly significant),T2also shorter in group P(mean 99.5 sec)than group S(mean 121.3 sec)p value0.012(significant) so both variables measured were shorter in case of using propofol with statistical significancy.
CONCLUSION:
Propofol produces more rapid turn over of short cases than sevoflurane and with no risk of malignant hyperthermia.
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BACKGROUND:
Stigma and discrimination towards people suffering from mental illness is still unfortunately common in our community and this can negatively affects the attitudes of medical students. Medical curricula in different medical schools were found to have less effect than expected on these attitudes.
OBJECTIVE:
To compare the stigma and attitudes between fourth and sixth year medical students (before and after their psychiatry placement) at the College of Medicine, University of Baghdad, towards mentally ill people.
SUBJECTS & METHODS:
A case control study with random samples were taken from the fourth and sixth year students. The community attitudes towards mental illness questionnaire was used to rate attitudes and stigma amongst both groups of students. Independent sample's t test was used to compare between both groups. P value ≤ 0.05 was considered significant.
RESULTS:
A total of 106 students from fourth year and 107 students from the sixth year had participated in this study, male to female ratio was 0.3:1 and 0.9:1 respectively. Mean age was 21.5±0.8 for the fourth year and 23.7±0.7 for the sixth year. Majority of students were from Baghdad city (92.45% of 4th year and 89.72% of 6th year) .Crowding index was almost similar between both groups. Stigma was not significantly different between fourth and sixth year students (p =0.1). Authoritarianism was significantly higher among sixth year students (p=0.02), while other subscales (benevolence, social restrictiveness, and community mental health ideology) were not significantly different (P value was 0.6, 0.08, and 0.2 respectively). Crowding index had no effect on stigma and other community attitudes towards mentally ill (CAMI) subscales.
CONCLUSION:
Stigma and attitudes towards mentally ill people were the same in fourth and sixth years' students. It seems that psychiatry curriculum did not help in changing attitudes of students towards mentally ill people.
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Breast Cancer is the most common malignancy associated with Cutenous metastasis. Cancer en Cuirasse is the term used to describe a rare dramatic and extensive clinical presentation of Cutenous Metastasis from Breast Carcinoma that is very rarely manifest as the primary presentation of the underlying cancer. In the present paper, we report a rare condition of Cancer en Cuirasse in a 43-year-old lady who is totally unaware of her underlying pathology. The case story and diagnosis are presented and discussed along with recent management options and appropriate literature reference.
KEYWORDS: breast carcinoma,cutenous metastasis , advanced breast carcinoma, cancer en cuirasse
INTRODUCTION:
Cutaneous Metastasis (CM) is a phenomenon that can associate internal organ malignancies and it is often a sign of advanced tumor stage (1).
Breast cancer (BC) is not only the most common malignancy in women, but it is also the most common cancer that is associated with CM and account for about 70% of the sources followed by the colonic cancer, malignant melanoma and ovarian/cervical cancers in this order (1). About 25% of women with breast BC will develop a sort of CM in the life time of the disease (2, 3).
Cancer en Cuirasse (CEC) is the term used to describe a rare dramatic and extensive clinical presentation of CM from BC (4). Lymphatics invaded by cancer cells become obstructed resulting in extensive thickening, oedema and fibrosis of the dermis and subdermis of the chest wall (5). It is usually seen as a local recurrence after mastectomy for BC but may rarely be seen as the presenting feature of an underlying BC (4, 5).