Diagnostic Assessment — Left Axilla - Subcutaneous Lipoma
Example 1 of 1 · fictitious patient (Veteran DK)
Diagnostic Assessment
Left Axilla - Subcutaneous Lipoma
BOP Code: 83 of 2024 (Subcutaneous Lipoma)
RH Code: 82 of 2024 (Subcutaneous Lipoma)
ADF History
Veteran DK, date of birth 19 October 1988, Australian Army, Combat Signaller, enlisted 07 July 2008, medically discharged 26 March 2020. Operational service: Afghanistan, 15 March 2012 to 30 October 2012 (warlike); Middle East Area of Operations (Iraq), 01 May 2017 to 20 November 2017 (warlike).
Occupational History
A combat signaller installs, operates and maintains radio, satellite and data communications for combat units, often attached to infantry and cavalry sub-units on patrol. Signallers carry radio sets, batteries and antennas weighing 10 to 20 kilograms in addition to body armour and personal equipment, and work in and on protected vehicles, climbing through hatches and over hulls.
The trade involves blunt trauma from vehicle movement, falls from vehicles and hatches, and blast exposure on operations, and the straps of radio harnesses and armour bear on the shoulders and axillae for long periods. Long operational tours, exposure to traumatic events and a culture of heavy drinking after deployment are recognised risks for alcohol misuse.
History
Veteran DK, a combat signaller in the Australian Army, sustained a blunt injury to the left axilla when he was thrown against a vehicle hatch rim in an improvised explosive device blast on warlike service in Afghanistan on 14 July 2012, and developed an encapsulated subcutaneous lipoma of the left axilla on 10 March 2015, together with benign symmetrical lipomatosis of the neck and shoulders in the setting of alcohol use disorder. The lipoma worsened, with marked enlargement and nerve compression, after its excision was delayed by his 2017 deployment to Iraq.
Timeline
- 14 Jul 2012 — On warlike service in Afghanistan, the protected mobility vehicle in which he was travelling as the signaller struck an improvised explosive device. He was standing in the rear hatch and was thrown against the hatch rim, which struck the left side of his chest wall and axilla. The regimental aid post recorded extensive bruising and a tender swelling in the left axilla. Ultrasound at the role 2 facility showed a 5 cm subcutaneous haematoma with no fracture or vascular injury. "blunt left axillary trauma, haematoma"
- 03 Jun 2013 — After return to Australia he reported nightmares, irritability and drinking ten to twelve standard drinks most nights. A psychiatrist diagnosed posttraumatic stress disorder related to the blast and alcohol use disorder of moderate severity, meeting six DSM-5 criteria including loss of control, craving, tolerance and continued use despite problems. He commenced psychological therapy, but drinking continued at a similar level through 2014 and 2015. "PTSD, alcohol use disorder moderate"
- 11 Feb 2015 — At his periodic health examination the skin and soft tissues of the axillae, neck and shoulders were examined and recorded as normal. Gamma-glutamyl transferase was 168 U/L and mean corpuscular volume 101 fL, consistent with ongoing heavy drinking. AUDIT score 24. "axillae normal, AUDIT 24"
- 16 Mar 2015 — He presented to the garrison health centre with a soft painless lump in the left axilla first noticed on 10 Mar 2015 when his armour harness rubbed it, at the site of the 2012 injury. He had also noticed fullness at the back of his neck and over both shoulders. Examination showed a 5 cm soft, mobile, well-defined mass in the left axilla and symmetrical diffuse fatty swellings over the posterior neck and both deltoid regions. "soft mobile left axillary lump"
- 08 Apr 2015 — Ultrasound and MRI showed a 5.4 cm encapsulated fatty mass in the subcutaneous tissue of the left axilla, consistent with a lipoma, and non-encapsulated symmetrical fat deposits in the posterior neck and shoulder regions. A general surgeon diagnosed a left axillary subcutaneous lipoma and benign symmetrical lipomatosis associated with alcohol use disorder, and placed him on the waiting list for excision of the axillary lipoma. "encapsulated lipoma, symmetrical lipomatosis"
- 05 Dec 2017 — After returning from warlike service in Iraq, where the excision could not be performed, he reported that the left axillary lump had grown, ached under his armour and harness, and caused tingling down the inner arm into the little finger. Ultrasound showed the lipoma had enlarged to 9.8 cm and was displacing the axillary neurovascular bundle. "lipoma 9.8 cm, arm paraesthesia"
- 12 Mar 2018 — The left axillary lipoma was excised under general anaesthetic. Histopathology confirmed a 10.2 cm encapsulated lipoma of mature adipose tissue with no atypia. The neck and shoulder lipomatosis was managed conservatively with alcohol treatment. He was left with a 12 cm scar, axillary tightness and numbness of the inner upper arm. "excision, encapsulated lipoma confirmed"
Symptoms
At onset the veteran had a soft, painless, mobile lump in the left axilla that was rubbed by his armour and radio harness, and diffuse fullness over the back of the neck and both shoulders.
Before excision the lump enlarged, became aching and tender under load-carrying straps, and caused tingling and numbness down the inner arm into the ring and little fingers. Since excision he reports axillary scar tightness, reduced overhead reach, numbness of the inner upper arm and discomfort with straps and seat belts, and the neck and shoulder fat deposits persist.
Imaging
- 16 Jul 2012 — Ultrasound left axilla (role 2 facility): "5 cm subcutaneous haematoma in the left axilla. No vascular injury. No rib fracture."
- 08 Apr 2015 — Ultrasound and MRI left axilla, neck and shoulders: "5.4 x 4.0 x 2.8 cm encapsulated homogeneous fatty mass in the subcutaneous tissue of the left axilla with thin septa, consistent with lipoma. Symmetrical non-encapsulated subcutaneous fat deposits in the posterior neck and over both deltoids, consistent with benign symmetrical lipomatosis."
- 05 Dec 2017 — Ultrasound left axilla: "Encapsulated lipoma enlarged to 9.8 x 6.1 x 4.2 cm, displacing the axillary neurovascular bundle. No features of liposarcoma."
Onset Date
The most likely date of onset of this condition is 10 Mar 2015.
At that date the veteran was serving full time with a signal regiment in Australia, carrying radio harnesses and armour on exercises, and he was drinking heavily with a diagnosed alcohol use disorder that had developed after his warlike service in Afghanistan.
This date is appropriate because his periodic health examination of 11 Feb 2015 recorded normal skin and soft tissues of the axillae, neck and shoulders, and he first presented with the axillary lump on 16 Mar 2015, six days after he noticed it. It falls within continuous full-time service.
For the blunt trauma factor, the 3 years before onset run from 10 Mar 2012 to 10 Mar 2015, and the blunt injury to the left axilla on 14 Jul 2012 falls within that period, at the site where the encapsulated lipoma later formed. For the alcohol use disorder factor, the disorder was diagnosed on 03 Jun 2013 and was present on 10 Mar 2015, when the benign symmetrical lipomatosis was first noticed, with an AUDIT score of 24 and raised gamma-glutamyl transferase a month earlier.
For the worsening, the lipoma began on 10 Mar 2015 and was placed on the waiting list for excision on 08 Apr 2015, but excision was not performed before or during his deployment to Iraq from 01 May 2017 to 20 Nov 2017. The documented worsening on 05 Dec 2017 showed growth from 5.4 cm to 9.8 cm with compression of the axillary neurovascular bundle.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Subcutaneous Lipoma of the Left Axilla (ICD-10 D17.1), an encapsulated subcutaneous lipoma, occurring with benign symmetrical lipomatosis of the neck and shoulders, under the Statements of Principles concerning subcutaneous lipoma, Balance of Probabilities No. 83 of 2024 and Reasonable Hypothesis No. 82 of 2024.
A subcutaneous lipoma is a benign neoplasm of mature fat cells in the subcutaneous tissue, usually surrounded by a thin capsule. It presents as a soft, mobile, painless lump that grows slowly, and it can become painful or compress nearby nerves and vessels as it enlarges, particularly in confined areas such as the axilla. Blunt trauma is a recognised trigger for the formation of an encapsulated lipoma at the injured site, possibly through the release of growth factors from damaged fat. Benign symmetrical lipomatosis (Madelung disease) is a related disorder of multiple non-encapsulated symmetrical fat deposits in the neck and shoulders, strongly associated with alcohol use disorder.
The lipoma followed a blunt blast injury to the left axilla on warlike service in Afghanistan in 2012 and the alcohol use disorder that developed afterwards. It began on 10 March 2015, was confirmed on MRI on 08 April 2015, worsened in 2017 while excision was delayed and was confirmed on histopathology in March 2018.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
10 March 2015.
When did the veteran first present to a health / medical provider for this condition?
16 March 2015.
When was the condition confirmed / formally diagnosed?
08 April 2015.
When did the veteran first present to you (or your practice) for this condition?
14 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically on 16 March 2015 from a soft, mobile, well-defined mass in the left axilla, and confirmed by ultrasound and MRI on 08 April 2015, which showed a 5.4 cm encapsulated homogeneous fatty mass with thin septa in the subcutaneous tissue, and by a general surgeon. Histopathology of the excised mass on 12 March 2018 confirmed an encapsulated lipoma of mature adipose cells with no atypia. This meets the Statement of Principles definition of subcutaneous lipoma, and it is not breast lipoma, fat hyperplasia, liposarcoma or prolapse of adipose tissue.
MRI also showed symmetrical non-encapsulated fat deposits in the posterior neck and shoulders, and the surgeon diagnosed benign symmetrical lipomatosis. Ultrasound on 05 December 2017 confirmed the worsening, with growth to 9.8 cm and displacement of the axillary neurovascular bundle.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 10 March 2015, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2012, where the blunt axillary injury occurred and the traumatic exposure that led to his alcohol use disorder took place, and in Iraq in 2017, during which the lipoma worsened without treatment.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Subcutaneous Lipoma, No. 83 of 2024
Causative factors
Factor 9(1): having alcohol use disorder at the time of the clinical onset of benign symmetrical lipomatosis; — MET
- A psychiatrist diagnosed alcohol use disorder of moderate severity on 03 June 2013, with the veteran drinking ten to twelve standard drinks most nights in the setting of service-related posttraumatic stress disorder and the heavy-drinking culture of his unit. The disorder was present on 10 March 2015, when the benign symmetrical lipomatosis of the neck and shoulders was first noticed, with an AUDIT score of 24, a gamma-glutamyl transferase of 168 U/L and a macrocytosis a month earlier. MRI on 08 April 2015 confirmed the symmetrical lipomatosis.
Worsening factors
Factor 9(2): inability to obtain appropriate clinical management for subcutaneous lipoma before clinical worsening. — MET
- The veteran was placed on the surgical waiting list for excision of the axillary lipoma on 08 April 2015, but the operation was deferred repeatedly over 32 months because of field exercises, a lack of theatre time at the garrison hospital and his deployment to Iraq from 01 May 2017 to 20 November 2017, where excision was not available. By 05 December 2017 the lipoma had grown from 5.4 cm to 9.8 cm and was compressing the axillary neurovascular bundle. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
Reasonable Hypothesis — Statement of Principles concerning Subcutaneous Lipoma, No. 82 of 2024
Causative factors
Factor 9(1): having alcohol use disorder at the time of the clinical onset of benign symmetrical lipomatosis; — MET
- The alcohol use disorder developed after the veteran's warlike service in Afghanistan in 2012, as a way of coping with the posttraumatic stress disorder that followed the improvised explosive device blast of 14 July 2012, and was diagnosed on 03 June 2013. It was present, with an AUDIT score of 24, at the onset of the benign symmetrical lipomatosis on 10 March 2015.
Factor 9(2): having blunt trauma to the affected site within the 3 years the before the clinical onset of encapsulated lipoma; — MET
- On 14 July 2012, on warlike service in Afghanistan, the veteran was thrown against the rim of a vehicle hatch in an improvised explosive device blast, striking the left axilla. Bruising and a tender swelling were recorded at the regimental aid post and ultrasound on 16 July 2012 showed a 5 cm subcutaneous haematoma at the site. The encapsulated lipoma formed at the same site, with onset on 10 March 2015, within the 3 years before onset, from 10 March 2012 to 10 March 2015.
Worsening factors
Factor 9(3): inability to obtain appropriate clinical management for subcutaneous lipoma before clinical worsening. — MET
- Excision of the lipoma, on the waiting list since 08 April 2015, was not available during the veteran's warlike service in Iraq from 01 May 2017 to 20 November 2017, where the lipoma enlarged under his armour and radio harness and began to compress the axillary nerves. The worsening was documented on 05 December 2017, two weeks after his return.
The % contribution of the causes is 100% and significant.
Sequelae
The left axillary lipoma is a sequela of the blunt injury to the left axilla sustained in an improvised explosive device blast on warlike service in Afghanistan, and the associated benign symmetrical lipomatosis is a sequela of his accepted alcohol use disorder and posttraumatic stress disorder arising from that service. The enlarged lipoma caused compression of the axillary nerves, and its excision has left scar tightness, reduced overhead reach and numbness of the inner upper arm.
Unintended Consequence
Met. The numbness of the inner upper arm and the axillary scar contracture are unintended consequences of the excision of 12 March 2018, performed as Defence-funded treatment while the veteran was serving, and their extent reflects the larger operation required after the lipoma grew while excision was delayed (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. The veteran was placed on the waiting list for excision of the left axillary lipoma on 08 April 2015, but the operation was deferred for almost three years because of field commitments, limited theatre time at the garrison hospital and his deployment on warlike service to Iraq from May to November 2017, where no elective surgery was available. During that time the lipoma nearly doubled in size, from 5.4 cm to 9.8 cm, and began to compress the axillary neurovascular bundle, causing ulnar-distribution paraesthesia, and a larger excision with nerve-related complications was required. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a prolonged delay in recommended surgery caused by service circumstances outside the veteran's control amounts to an inability to obtain appropriate clinical management before the clinical worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Jul 2012, Regimental aid post record, Medical Officer, Afghanistan
- 16 Jul 2012, Ultrasound left axilla, Role 2 facility, Afghanistan
- 03 Jun 2013, Psychiatric assessment, Consultant psychiatrist
- 11 Feb 2015, Periodic health examination and pathology, Medical Officer, Garrison health centre
- 16 Mar 2015, Outpatient health record, Medical Officer, Garrison health centre
- 08 Apr 2015, Ultrasound and MRI report, Radiologist
- 08 Apr 2015, Surgical consultation, General surgeon
- 05 Dec 2017, Ultrasound left axilla and surgical review, General surgeon
- 12 Mar 2018, Operation report and histopathology, General surgeon
- Statement of Principles concerning Subcutaneous Lipoma (Balance of Probabilities) No. 83 of 2024, Repatriation Medical Authority
- Statement of Principles concerning Subcutaneous Lipoma (Reasonable Hypothesis) No. 82 of 2024, Repatriation Medical Authority
