Silicone Lymphadenopathy- An Unexpected Cause

8/10/2019 Silicone Lymphadenopathy- An Unexpected Cause

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Silicone lymphadenopathy: an unexpected cause

of neck lumps

E OMAKOBIA1, G PORTER1, S ARMSTRONG2, K DENTON3

Departments of 1

ENT, 2

Radiology, and 3

Histopathology, Southmead Hospital, Bristol, UK

AbstractObjective: To report a rare case of silicone lymphadenopathy solely affecting the left supraclavicular lymph nodes.

Case report: Our patient presented with a painless swelling in the left supraclavicular region. Notably, she had

previously undergone cosmetic breast augmentation using silicone-containing implants. Radiological imaging and

subsequent excisional biopsy of the swelling produced findings consistent with a silicone foreign body reaction

secondary to bilateral breast implant rupture.

Conclusion: Silicone lymphadenopathy following breast augmentation primarily affects the axillary nodes.

Supraclavicular lymph node involvement is unusual. To our knowledge, this is the first report in the English

language literature of silicone lymphadenopathy manifesting solely in the supraclavicular lymph nodes.

Although the need to exclude malignancy in such cases is of the utmost importance, silicone lymphadenopathy

should also be considered in the differential diagnosis. Fine needle aspiration cytology is a useful initial

investigation, which may be followed up by excisional biopsy and histological analysis for further confirmatory

diagnostic information.

Key words: Breast Implants; Mammoplasty; Silicone; Lymphadenopathy; Neck

IntroductionSilicone lymphadenopathy is defined as the presence ofsilicone in a lymph node, and is an uncommon compli-cation of using silicone prostheses for either joints or

plastic surgical procedures, specifically breast augmen-tation or reconstruction.1,2 Such cases pose a diagnosticchallenge as malignancy is often the initial consider-ation. In this report, we discuss a rare case of siliconelymphadenopathy occurring in the supraclavicularlymph nodes of a patient with a prior history of cos-metic augmentation mammoplasty with siliconeimplants. In such cases, fine needle aspiration cytology(FNAC) is a useful initial investigation and may be suf-ficient for diagnosis. If inconclusive, excisional biopsyof the affected lymph node for histological analysisshould also be performed.3

Case reportA 52-year-old woman presented to the ENT out-patientclinic with a two-month history of a non-tender lump inthe left supraclavicular region, having been referred byher general practitioner. There was no history of dys-

phagia, dysphonia or otalgia, and on questioning shereported no weight loss, poor appetite, feverishness ornight sweats. She had a 10 pack-year smoking

history. She reported having undergone bilateral

breast augmentation for cosmetic purposes 13 yearsearlier, and was currently being treated for hyperthyr-oidism, but there was no other past medical history ofnote.

Clinical examination confirmed a well circum-scribed, firm, non-tender, 2 cm lump in the left supra-clavicular fossa. No lymphadenopathy was notedelsewhere, and examination of the ears, nose andthroat was otherwise unremarkable.

An initial ultrasound scan of the neck revealedseveral areas of abnormal, increased echogenicity inthe left supraclavicular fossa (Figure 1). A 0.5 cm, ill-defined nodule in the thyroid isthmus was also noted,which was initially thought to be the primary site of

pathology. Fine needle aspiration of the thyroidlesion unfortunately yielded an insufficient specimenfor diagnosis; hence, further investigations were per-formed. The differential diagnoses considered at thisstage included primary head and neck malignancy,metastasis, lymphoma and reactive lymphadenopathysecondary to infection such as tuberculosis.

A subsequent magnetic resonance imaging scan ofthe neck demonstrated a cluster of abnormal left levelIV lymph nodes (Figure 2).

The patient was recalled for fine needle aspiration of

one of these lymph nodes. Cytological examination

Accepted for publication 29 March 2012 First published online 7 June 2012

The Journal of Laryngology & Otology (2012), 126,970973. CLINICAL RECORD JLO (1984) Limited, 2012

doi:10.1017/S0022215112001089


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showed a background of lymphocytes, numerousclusters of adipocytes, and a significant number of mul-tinucleate giant cells with ingested fatty material. Nofeatures of malignancy were seen (Figure 3).

Since no definitive cytological diagnosis could bemade, the patient was scheduled for direct endoscopyof the upper aerodigestive tract and excisional biopsyof the enlarged left supraclavicular lymph node. Onmacroscopic inspection, the specimen was solid andgrey-white in colour. Endoscopy of the pharynx,

larynx and upper oesophagus was unremarkable.Histological analysis identified a lymph node whichhad largely been replaced by foreign materialmasses, with a pronounced foreign body response(Figure 4). No evidence of malignancy was seen. Itwas concluded that the appearances were in keepingwith a foreign body response to silicone from aleaking breast implant. Tissue culture yielded no

growth and no acid-alcohol-fast bacilli were seen ondirect staining, making a diagnosis of tuberculosisunlikely.

Subsequent computed tomography (CT) scanning ofthe neck, thorax, abdomen and pelvis revealed no lungor mediastinal lesions. Apart from small nodes in the

porta hepatis, which were deemed to be within normallimits, no other areas of lymphadenopathy were seen.Hence, a diagnosis of lymphoma was very unlikely.The CT images were later reviewed by a breast radiol-

ogist who noted irregularity of the capsule of bothbreast implants, consistent with bilateral rupture (this istermed the linguine sign) (Figure 5).

The patient was reassured that malignancy had notbeen detected. She was referred back to the plasticsurgeon who had performed the original breast aug-mentation, with a view to further assessment ofleakage or rupture of the silicone breast prostheses.

FIG. 1

Ultrasound scan of the neck showing abnormally increased echo-genicity in the left supraclavicular fossa. In retrospect, this is theclassically described snowstorm appearance of silicone in lymph

nodes.

FIG. 2

Coronal magnetic resonance imaging scan of the neck demonstrat-ing a cluster of abnormal left level IV lymph nodes.

FIG. 3

Photomicrograph of fine needle aspiration cytology specimen fromthe abnormal left level IV lymph nodes, showing multinucleategiant cells together with macrophages containing clear material.

(May Grunwald Giemsa stain; 400)

FIG. 4

Photomicrograph of left enlarged supraclavicular lymph node fol-lowing excisional biopsy, showing that normal lymph node contentshave been displaced by multinucleate giant cells and clear globular

areas (where the silicone is located). (H&E; 200)

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DiscussionSilicone lymphadenopathy, involving a foreign bodyreaction to silicone, is a well documented complicationof breast augmentation using silicone-containingmaterials.1,4

It has been postulated that silicone can migratethrough tissues via two distinct mechanisms: firstly,through rupture or erosion of a silicone-containingsurface; or secondly, through continued leakagethrough an intact surface.5,6 When silicone tissuemigration occurs via either of these mechanisms, fibro-sis and foreign body granulomatous reactions canoccur.7 Silicone particles may be transported toregional lymph nodes via macrophages in the reti-culo-endothelial system.3 The resulting foreign bodyreaction may produce local swelling of the involvedlymph node, such as the left supraclavicular lymphnodes in the case reported.

Silicone lymphadenopathy following breast

augmentation primarily affects the axillary nodes,5,8

but there have been reported cases involving intramam-mary,4 internal mammary9 and supraclavicular lymphnodes.10 The current case is particularly unusual inthat, to our knowledge, it is the first reported case ofsilicone lymphadenopathy manifesting solely in asupraclavicular lymph node in a patient with no priorhistory of breast cancer. Shipchandleret al. describeda similar case of supraclavicular lymphadenopathydue to silicone breast implants in 2007; however, this

patient later developed bilateral axillary siliconelymphadenopathy.

Silicone lymphadenopathy poses important clinical

considerations in the approach to the patient with alump in the neck or axilla and a prior history of siliconeaugmentation mammoplasty. Although the cliniciansinitial priority should be to exclude malignancy, it is

important to note whether there is any prior history ofbreast augmentation using silicone-containingmaterials. If not considered in the initial differentialdiagnosis, silicone foreign body reaction is a difficultdiagnosis to arrive at. Furthermore, in patients whohave had breast cancer treated with mastectomy fol-

lowed by reconstructive mammoplasty using siliconegel implants, the possibility of metastatic breastcancer should obviously be high in the differentialdiagnosis; however, silicone lymphadenopathy shouldnot be disregarded. For the majority of individualswho have had silicone augmentation mammoplasty

purely for cosmetic purposes, silicone lymphadenopa-thy should be considered, in addition to a possiblenew diagnosis of malignancy.

Once a silicone foreign body reaction is suspected,FNAC of the affected lymph node has been shown to

be a cost-effective and accurate initial investigation to

aid diagnosis.3,11

In such cases, FNAC shows aforeign body reactive, lymphoid background withnumerous giant cells, as in the case described. Ifthere is clinical suspicion of silicone lymphadenopathy,FNAC alone may be sufficient for a definitive diagno-sis. However, if FNAC is inconclusive, or if other,more sinister diagnoses are suspected, a conservativeexcisional lymph node biopsy is advisable to providea histological diagnosis and to exclude concomitantmalignancy.3

Silicone lymphadenopathy is a rarecomplication of procedures involving silicone

Axillary lymph nodes are the most commonly

affected after silicone mammoplasty

Supraclavicular lymph nodes are very rarely

involved

Malignancy is the most important differential

diagnosis

Diagnosis is by fine needle aspiration

cytology, plus excisional biopsy histology if

needed

Plastic or breast surgeons should assessimplant leakage or rupture before

considering removal

Here, we describe a rare case of supraclavicular lym-phadenopathy secondary to silicone foreign body reac-tion. In patients with a prior history of siliconeaugmentation mammoplasty, silicone lymphadenopa-thy should be considered in the differential diagnosisof supraclavicular neck lumps. However, the initial pri-ority in such cases should be to exclude malignancy.

Fine needle aspiration cytology may be sufficient fordiagnosis, but in the absence of conclusive findingsexcisional biopsy should also be performed to

provide a histological diagnosis.

FIG. 5

Axial, arterial phase, soft tissue window, computed tomographyscan of the thorax, demonstrating irregularity of the capsule of

both breast implants (the linguine sign) consistent with bilateralrupture.

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ConclusionSilicone lymphadenopathy is a rare but recognisedcomplication of procedures involving the use of sili-cone. In the case of silicone augmentation mammo-

plasty, the axillary lymph nodes are the mostcommonly affected site; very rarely, the supraclavicular

lymph nodes may be involved. In such cases, malig-nancy is the most important differential diagnosis, butsilicone lymphadenopathy should also be considered.Although fine needle aspiration cytology alone may

be sufficient for definitive diagnosis, in doubtfulcases lymph node excisional biopsy should also be per-formed for histological analysis. Affected patientsshould be referred to a plastic or breast surgeon forassessment of implant leakage or rupture beforeremoval is considered.

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2 Christie AJ, Weinberger KA, Dietnich M. Silicone lymphadeno-pathy and synovitis: complications of silicone elastomer fingerjoint prostheses.JAMA 1977;237:14634

3 Tabatowski K, Elson CE, Johnston WW. Silicone lymphadeno-pathy in a patient with mammary prosthesis. Fine needle aspira-tion cytology, histology and analytical electron microscopy.

Acta Cytol1990;34:10144 Rivero MA, Schwartz DS, Mies C. Silicone lymphadenopathy

involving intramammary lymph nodes: a new complication of

silicone mammoplasty. AJR Am J Roentgenol 1994;162:108990

5 Adams ST, Cox J, Rao GS. Axillary silicone lymphadenopathypresenting with a lump and altered sensation in the breast: a casereport.J Med Case Reports 2009;3:6442

6 Hausner RJ, Schoen FJ, Mendez-Fernandez MA, Henly WS,Geis RC. Migration of silicone gel to axillary lymph nodesafter prosthetic mammoplasty. Arch Pathol Lab Med 1981;

105:37127 Van Diest PJ, Beekman WH, Hage JJ. Pathology of silicone

leakage from breast implants.J Clin Pathol1998;51:49378 Kulber DA, MacKenzie D, Steiner JH, Glassman H, Hopp D,

Hiatt JR et al. Monitoring the axilla in patients with siliconegel implants. Ann Plast Surg1995;35:5804

9 Kao CC, Rand RP, Holt CA, Pierce RH, Timmons JH, WoodDE. Internal mammary silicone lymphadenopathy mimickingrecurrent breast cancer. Plast Reconstr Surg1997;99:2259

10 Shipchandler TZ, Lorenz RR, McMahon J, Tubbs R.Supraclavicular lymphadenopathy due to silicone breastimplants. Arch Otolaryngol Head Neck Surg2007;133:8302

11 Santos-Briz A Jr, Lopez-Rios F, Santos-Briz A, De Agustin PP.Granulomatous reaction to silicone in axillary lymph nodes acase report with cytologic findings. Acta Cytol1999;43:11635

Address for correspondence:Dr Eugene Omakobia,ENT Clinical Fellow,ENT Department,Southmead Hospital,Bristol BS10 5NB, UK

Fax: +44 (0)117 323 5850E-mail: [email protected]

Dr E Omakobia takes responsibility for the integrityof the content of the paperCompeting interests: None declared

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Silicone Lymphadenopathy- An Unexpected Cause