Mediastinal Silicone Lymphadenopathy Secondary to a Ruptured Breast Implant

Abstract

A n 80-year-old woman presented with complaints of a cough associated with increasing fatigue and weight loss. Her past medical history was significant for Stage I (T1 N0 M0) breast cancer for which she underwent a left modified radical mastectomy followed by immediate reconstruction with a Siltex Becker dual-lumen implant, 15 years previously. Physical examination was essentially negative. There was no evidence of splenomegaly or cervical, supraclavicular, axillary, or inguinal lymphadenopathy. Laboratory evaluation was negative for pulmonary pathology, sarcoidosis, fungal infection, or hematologic dyscrasia. Chest X-ray was unremarkable, but CT scan of the chest demonstrated mediastinal lymphadenopathy that was a new finding when compared to a CT scan obtained 9 years previously. The new chest CT scan also revealed irregularity of the left breast implant capsule with extra capsular fluid, suggesting implant rupture (Fig. 1). The patient underwent mediastinoscopy with excisional biopsy of the enlarged lymph nodes. Auramine-rhodamine and Gomori's methenamine silver (GMS) special stains and cultures were negative for aerobic and anaerobic bacteria, Mycobacteria, Legionella, Actinomyces, and fungi. Light microscopy of hematoxylin-eosin fixed tissue demonstrated diffuse involvement by a multinucleated giant cell foreign-body reaction in all specimens. Inclusions were seen that were consistent with silicone (Fig. 2). All samples were negative for neoplasm. Refractile material within vacuoles was seen by TEM and EDX confirming the presence of silicon (Fig. 3).Silicone (polymers of dimethysiloxane) has become one of the most popular utilized materials for the manufacture of prostheses because it is non-biodegradable and biologically stable, even though it behaves as a foreign body and stimulates a cell-mediated immune response. Silicone migration through regional lymphatic channels is a rare and unique complication that has been reported to be associated with silicone Figure 1. Selected axial images from computed tomography of the chest demonstrate moderate lymphadenopathy throughout the mediastinum. Irregularity of left breast implant capsule with extra capsular fluid is suggestive of implant rupture.

Breast-implant Related Silicone Lymphadenopathy: Asteroid Bodies do not Always Equal Sarcoidosis!

“…In rare cases, mediastinal lymph nodes are involved by silicone lymphadenopathy, presenting a particular challenging differential diagnosis with sarcoidosis. 6 This brief pictorial essay also emphasizes the importance of clinical-pathological correlation before establishing a diagnosis. Information about the patient having (or having had) silicone breast prostheses is often lacking on the pathology request form.…”

“…This phenomenon is designated as silicone lymphadenopathy. 5,6 Silicone is histologically visible as amorphous, refractile, non-birefringent extracellular droplets, as well as intracellular amorphous granular inclusions. 3 Here, we discuss a series of twelve women with breast implant-related asteroid bodies in their lymph nodes and/or breast tissue, illustrating that the presence of asteroid bodies in a lymph node does not necessarily indicate a diagnosis of sarcoidosis.…”

The Spectrum of Non-neoplastic Changes Associated With Breast Implants

“…Mediastinal and cervical LAD may also occur. 96,97 Imaging Imaging studies including US, MRI, CT, and PET-CT scan can be used to detect enlarged lymph nodes and to track and monitor disease. 92,98 US is more sensitive than MRI for detecting silicone LAD.…”

“…More substantial amounts of silicone appear with implant rupture and appear as large empty spaces in the lymph node, frequently associated with sinus histiocytosis, as well as a foreign body giant cell reaction; asteroid bodies can be observed in histiocytes. 93,97,100 "Bleeding" of silicone appears as small vacuoles in histiocytes (Fig. 9D).…”

“…The diagnosis is usually clinical, and patients may experience a palpable lump in the axilla, breast, or around the implant. Mediastinal and cervical LAD may also occur 96,97 …”