British Journal of Radiology (2004) 77, 790-791
© 2004 British Institute of Radiology
doi: 10.1259/bjr/98330730
A leaking breast prosthesis presenting as an abdominal mass
M A Puckett, BM, MRCP, FRCR
D DeFriend, MBChB, FRCR
M P Williams, BM, BCh, MA, FRCR
and
C A Roobottom, MBChB(Hon), MRCP, FRCR
Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK
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Case report
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A 76-year-old woman was referred for CT examination, to investigate abdominal pain and a right sided abdominal mass. Contrast enhanced spiral CT of the abdomen and pelvis showed a mass and associated inflammatory changes within the subcutaneous tissues of the right iliac fossa extending up the right side of the abdomen and up into the chest. As these changes were demonstrated on the most superior image, the thorax was also examined. This demonstrated that the inflammatory change extended to the inferior aspect of an abnormally shaped right breast prosthesis. Further questioning of the patient revealed a history of bilateral mastectomy for suspected breast carcinoma and subsequent reconstruction. MRI of the breasts confirmed rupture of the right prosthesis, and a contained leak of the left, the appearances on CT and MRI demonstrated the bilateral "Linguini" sign of rupture.
Following the presumptive diagnosis of bilateral implant rupture, both implants were surgically removed and confirmed as ruptured. In addition the mass in the right iliac fossa and a right axillary lymph node were removed. Histology of the right groin lump showed "a florid foreign body giant cell reaction to lakes of non-bifringent material, presumably silicone gel (siliconoma)". The lymph node histologically proved to be a second siliconoma with no evidence of lymphoid tissue or malignancy.
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Figure 1. (a) Contrast enhanced CT of the chest demonstrating asymmetrically sized breast prosthesis, and bilateral "Linguini" sign. Contrast enhanced CT of (b) the upper and (c) lower abdomen demonstrating a right sided non-enhancing subcutaneous soft tissue mass (siliconoma) with localized inflammatory change.
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Discussion
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Silicone-gel-filled breast implants have been widely used for breast augmentation and reconstruction following mastectomy for many years [1, 2]. Rupture of the implants has been extensively documented in the world literature [1, 2] with less known about the aetiology and incidence of implant rupture [1]. This case demonstrates distant subcutaneous migration of silicone and a palpable inflammatory granulomatous reaction known as a "siliconoma", two complications that are more unusual and less well described [1, 3–7]. There are only two reports of silicone gel migrating through the subcutaneous tissues to the groin [5]. This may occur since silicone polymer is lipid soluble [7], which can aid in its migration. In addition there is some evidence of in vivo silicone biodegradation, in which alteration of the polymer structure results in a less viscous silicone thus enabling easier passage of the gel through the subcutaneous tissues [8].
Silicone gel prostheses have been shown in humans to produce a local microscopic granulomatous reaction. This mild foreign body response results in the localized formation of a collagenous capsule around the implant [9]. It is very unusual to have florid inflammatory changes in the tissues even in the presence of rupture or leakage [1, 9]. These exaggerated inflammatory changes can produce a granuloma (siliconoma), which are of a sufficient size to be palpable. This unusual inflammatory response can lead to the formation of sinuses, which have been shown to discharge the biochemically altered silicone [4]. More typically the inflammatory response is less vigorous and non-palpable even in the presence of rupture or leakage.
Several imaging modalities have been used to investigate leaking breast prostheses [1, 2]. In this case the initial suspicion of a leak was identified by CT, and indeed a study has demonstrated that detection of implant rupture rates by CT is comparable with MRI [10]. However, MRI remains the most accurate method for evaluating implant integrity with the added benefit of not exposing the patient to ionizing radiation.
In conclusion this case demonstrates an unusual presentation of a leaking breast prosthesis. The leak was initially suspected due to the subcutaneous mass and associated inflammatory changes on CT and the asymmetrical appearance of the breast prostheses. Both CT and MRI demonstrated the "linguini" sign of rupture, which represents the collapsed implant shell floating within silicone gel.
Received for publication March 20, 2003.
Revision received December 4, 2003.
Accepted for publication February 3, 2004.
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References
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