502 • ganau et al.
Silicone Lymphadenopathy: An Unusual Cause of Internal Mammary Lymph Node Enlargement Sergi Ganau, MD,* Lidia Tortajada, MD,* Xavier Rodrı´guez, MD, Guadalupe Gonza´lez, MD,à and Melcior Sentı´s, MD* *Women’s Imaging, Department of Radiology, UDIAT-CD, Corporacio´ Sanita`ria Parc Taulı´, Institut Universitari PT-UAB, Sabadell and Departments of Surgery and àPathology, Hospital Mu´tua de Terrassa, Terrassa, Barcelona, Spain
A
61-year-old woman was treated for a ductal invasive carcinoma in the right breast (mastectomy, axillary dissection and chemotherapy in 1990, and breast reconstruction with submuscular Becker silicone outside ⁄ saline inside double lumen prosthesis in 1994). In 2002, she presented with a progressive shrinkage of the right breast volume since 2000, after a traffic accident. A rupture of the implant was suggested. For this reason, a magnetic resonance imaging examination with specific prosthesis sequences and contrast-enhanced dynamic study was performed, showing both intracapsular rupture (linguini sign) and silicone bleeds outside the implant capsule (Fig. 1a,b). Although contrast-enhanced magnetic resonance study showed no appreciable enhancement, there was an evidence of a right internal mammary node measuring 1 cm (Fig. 1c). The significance of the node was uncertain, but on clinical considerations (possible regional spread of breast cancer), this lymph node was excised at the same time as the breast implant removal. Pathologic examination identified an histiocytic infiltrate with multinucleated giant cells, vacuoles, and refractive material consistent with silicone lymphadenopathy (Fig. 2). Magnetic resonance imaging was repeated 12 months after the initial study and showed no implant complications (a single lumen entirely gelfilled prosthesis reimplantation) or contrast enhancement. However, a new right internal mammary node measuring 0.8 cm was demonstrated (Fig. 3). Because of the similarity of its appearance to that seen before, the node was not removed. On follow-up 12 months
Address correspondence and reprint requests to: Sergi Ganau, Women’s Imaging, UDIAT – CD, Parc Tauli s ⁄ n Sabadell, Barcelona 08208, Spain, or e-mail:
[email protected],
[email protected]. ª 2008 Wiley Periodicals, Inc., 1075-122X/08 The Breast Journal, Volume 14 Number 5, 2008 502–503
(a)
(b)
(c)
Figure 1. (a, b) Axial magnetic resonance (MR) mammography shows a silicone ouside ⁄ saline inside double lumen prosthesis with linguini sign (wide arrow) and extracapsular silicone gel leakage (thin arrow). (c) Coronal subtracted MR mammography shows a contrast-enhancing enlarged right internal mammary node (arrow).
Silicone Lymphadenopathy • 503
Figure 2. Lymph node with multinucleated giant cells, vacuoles, and refractive material consistent with silicone (hematoxylin-eosin stain).
Figure 3. Coronal magnetic resonance mammography shows an intact single lumen silicone implant and a right internal mammary node with the same signal intensity as the silicone (arrow).
Figure 4. Axial magnetic resonance mammography shows an intact single lumen silicone implant and a right internal mammary node with the same signal intensity as the silicone (arrow).
later, the patient was cancer-free and specific sequences for implants showed two nodes in the right internal mammary chain, smaller than 1 cm in diameter, with hyperintense signal with the same behavior as the silicone in the implants, corresponding to silicone lymphadenopathies (Fig. 4). Migration of silicone gel to axillary, supraclavicular, and intramammary lymph nodes is a known but rare complication of breast with silicone gel implants. Enlarged internal mammary lymph nodes should be dealt with cautiously in patients with previous history of prosthetic breast reconstruction. Selective silicone sequences are useful for differentiating lymph node cancer involvement from reactive lymphadenopathy because of silicone leakage.
