Silicone prostheses comprise 82.4 percent of implants used in aesthetic and reconstructive breast surgery.1 Extremely safe,2 they have nevertheless been associated with rare adverse events such as sarcoidosis, although no causal relationship has been borne out by epidemiological studies. Here we describe a case of cutaneous sarcoidosis confined to the breasts following silicone implant placement.
A 49-year-old white woman with invasive mucinous carcinoma presented for bilateral mastectomies followed by staged reconstruction with tissue expanders. Postoperatively, she received adjuvant endocrine therapy but no radiation or chemotherapy. Her clinical course was complicated by left-sided wound infection requiring explantation and a subsequent unilateral pedicled latissimus dorsi myocutaneous flap. Bilateral silicone implants (Allergan) were placed without incident.
Eight months later, she returned with multiple hyperpigmented maculopapules involving both mastectomy skin flaps and the latissimus dorsi flap skin paddle (Fig. 1). Biopsy results showed noncaseating granulomas in the dermis without evidence of malignancy, polarizable materials, or microorganisms. No systemic involvement was noted, and pharmacologic treatment for cutaneous sarcoidosis of the breasts was started.
Thirteen months after implant placement, surveillance imaging showed evidence of hilar adenopathy. Biopsied mediastinal lymph nodes revealed poorly differentiated metastatic cancer and concurrent noncaseating granulomas. Additional studies also showed liver and spine metastases. After completion of chemotherapy, despite clinically stable sarcoidosis, the patient desired removal of her implants for fear of a link between silicone and sarcoidosis. Thirty-nine months after implant placement, she underwent bilateral explantation, capsulectomy, and takedown of the latissimus dorsi flap. Pathologic analysis revealed multifocal noncaseating granulomas throughout the capsules with no evidence of implant compromise. Gross lesions crossing the junction between the mastectomy skin flaps and the latissimus dorsi skin paddle also showed histologic correlates of noncaseating granulomas within the dermis spanning the incisional scar (Fig. 2).
A third of symptomatic sarcoidosis is isolated to the skin; disease involving the breasts occurs in less than 1 percent of cases.3 Silicone breast implants have a favorable safety profile.4 However, there have been rare cases implicating silicone implants in sarcoidosis. Silicone gel is associated with foreign-body granulomas that contain birefringent materials resembling silica. Biopsy specimens from our study did not contain polarizable foreign bodies, making this diagnosis unlikely.
A phenomenon known as autoimmune/inflammatory syndrome induced by adjuvants, or ASIA, may underlie the association between silicone implants and sarcoidosis, in which silicone serves as an immunologic adjuvant to enhance antigen-specific immune response and aid in antigen translocation to the regional lymph nodes. This leads to enhanced production and activation of both B and T cells.5
This case has several interesting features. First, the initial sarcoidosis was confined to the breasts, where the incidence of sarcoidosis is extremely low. Second, the presence of colocalized sarcoidosis and breast cancer metastases at the midthoracic level presented both imaging and management challenges. Third, granulomatous changes were noted to cross tissues with distinct blood supplies and traverse scar from the mastectomy flap to the latissimus dorsi paddle. This finding suggests not only development of new subdermal connections from mastectomy flap to skin paddle but also a permissive environment for sarcoid metastases.
Dr. Myckatyn receives grant funding and consultant fees from both Allergan and LifeCell, but these relationships are not relevant to the content of this article. The other authors have no financial relationships to disclose.
Hank H. Sun, B.A.
Neil S. Sachanandani, M.D.
Division of Plastic and Reconstructive Surgery
Brenda Jordan, M.D.
Department of Pathology and Immunology
Terence M. Myckatyn, M.D.
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Mo.
1. American Society of Plastic Surgeons. . 2011 Plastic surgery statistics report. Available at: http://www.plasticsurgery.org
, Accessed July 15, 2012
2. Muzaffar AR, Rohrich RJ. The silicone gel-filled breast implant controversy: An update. Plast Reconstr Surg. 2002;109:742–747; quiz 748
3. Dilaveri CA, Mac Bride MB, Sandhu NP, et al. Breast manifestations of systemic diseases. Intl J Women’s Health. 2012;4:35–43
4. Janowsky EC, Kupper LL, Hulka BS.. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342:781–790
5. Shoenfeld Y, Agmon-Levin N.. “ASIA”: Autoimmune/inflammatory syndrome induced by adjuvants. J Autoimmun. 2011;36:4–8
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