Foreign body granuloma formation 41 years after a breast implant

Clinical History

An 82-year-old woman arrived at our hospital with bilateral breast swelling that over time has increased in volume and her breasts had become hard.

Imaging Findings

An 82-year-old woman came with bilateral breast swelling. She denied having any trauma or inflammatory diseases; she underwent breast augmentation on both sides 41 years before with prosthesis. They were still in place and she had never done any checks on them until this day.
Physical examination confirmed the presence of three nodules, two on the outer side of the right breast and one on the left side along the extension of axillary.
US investigation showed in correspondence with the palpable lesions, irregular and poorly defined contours of the prosthesis profiles with the typical, posterior, snowstorm appearance with an hypoechoic area which appeared superficial to the implant. Magnetic resonance imaging, expecially with T2-weighted inversion recovery water suppressed scan,better revealed the extracapsular rupture of both silicone prosthesis and the anatomical locations of silicone-gel migration along the axillae and in the left nipple.

Discussion

Silicone has become one of the most commonly used biomaterials in modern medicine, so there is a greater number of cases of disease related to silicone.
Although breast implant rupture is a known complication of surgery for breast implants, little is known about the frequency which is often higher than the real one because in the literature most studies have been performed on symptomatic women awaiting surgery. The risk of rupture and/or leakage increases with increasing age of the implant, the site of implantation, the presence of local tissue contracture, closed capsulotomy, mammography or trauma and it is approximately 26% after 12 years after surgery and 55% after 16.4 years [1].
Silicone is a non-biodegradable material that causes a relatively small amount of local inflammation in most people because of its low immunogenicity. However, although it was initially regarded as a biologically inert substance, we have seen in the literature that there may be some complications, including local and systemic inflammatory granulomatous reactions or various connective tissue and autoimmune diseases. Once the silicon particles have violated the borders of their prosthesis they can migrate through tissue and they can pass through any local fibrotic reaction, and may be carried to regional lymph nodes by macrophages of the reticuloendothelial system. The resulting reactions may resemble granulomatous lymphadenopathy, and when located in the axilla, ipsilateral breast cancers should be excluded [2-3].
Magnetic resonance imaging of the breast is widely accepted to be the imaging study of choice, compared to mammography or ultrasound, in locating free silicone and evaluating an implant rupture, with a sensitivity of approximately 94% and specificity of 97%.The most commonly used MR sequences include T2-weighted and STIR, which are often used in conjunction with chemical water suppression, and chemical shift imaging. Magnetic resonance has also the ability to image the entire implant without the use of ionizing radiation but unfortunately some women are unable to have a MR because of pacemakers, claustrophobia or other controindications. Therefore, mammography, ultrasonography and CT will have roles in the diagnosis of silicone breast implant ruptures also because US, in most cases, is the exam conducted in the first istance. The major disadvantage of US is that its accuracy depends on the capability of the operator to recognize the abnormality [3].

Differential Diagnosis List

Final Diagnosis

Extracapsular rupture of bilateral breast implants

URL:	https://www.eurorad.org/case/9303
DOI:	10.1594/EURORAD/CASE.9303
ISSN:	1563-4086