Silicone-induced granuloma of breast implant capsule (SIGBIC): similarities and differences with anaplastic large cell lymphoma (ALCL) and their differential diagnosis

Abstract

Primary breast lymphoma is a rare disease and accounts for 0.5% of cases of breast cancer. Most primary breast lymphomas develop from B cells, and the involvement of T cells is rare. Anaplastic large cell lymphoma (ALCL) is a recently discovered T-cell lymphoma associated with breast implants. Only a few cases have been reported to date. It is believed that the incidence of ALCL is increasing because of the increasing number of breast implants. The clinical presentation is variable and can manifest as a palpable mass in the breast or armpit, breast pain, or capsular contracture. Because of the rarity of the disease and the lack of knowledge to date, clinical diagnosis is often delayed, with consequent delays in treatment. The cause and pathogenesis have not been fully elucidated, and there are no evidence-based guidelines for diagnosis, treatment, or follow-up of this disease. We present a review of cases of patients with silicone breast implants, including ALCL, a rare type of breast cancer that is still under study, and silicone-induced granuloma of breast implant capsule and its differential diagnosis, and discuss if a silicone-induced granuloma of breast implant capsule could be the precursor of the disease.

Keywords: breast cancer; granuloma; implant; lymphoma.

Figure 1

A 57-year-old patient with asymmetric enlargement of the right breast and clinical signs of capsular contracture. Notes: MRI images in (A) STIR, (B) SP1R, (C) after the injection of contrast agent, and (D) with subtraction show the heterogeneous tissue in the space between the fibrous capsule and the breast implant associated with fluid fill. These findings are compatible with ALCL. Specimen of core needle biopsy of the lesion shows a proliferation of monoclonal T lymphocytes (E). The immunohistochemistry is positive for CD30⁺ (F). The diagnosis was confirmed as ALCL. Magnification ×500. Abbreviations: MRI, magnetic resonance imaging; ST1R, short-TI inversion recovery; SPIR, spectral presaturation with inversion recovery; ALCL, anaplastic large cell lymphoma.

Figure 2

A 53-year-old patient at the breast screening program. Notes: Sequence of mammography shows a mass developing at the fibrous capsule of the implant in the year of 2015 and subcapsular mass that increase in size in 2016, when compared to 2015 mammogram (arrows). It was given BI-RADS category 4, but she and her physician opted to follow up the lesion. One year later the mass grows up and was given a BI-RADS category 4 again. Abbreviation: BI-RADS, breast imaging reporting and data system.

Figure 3

The same 53-year-old patient noted in the earlier figure underwent ultrasound scan that shows (A) a hard mass at the elastography, (B) with high vascularity at the color Doppler scan, and (C) when processing a CAD software of the lesion, the result shows a mass composed essentially of hard tissue, 98.14% of hard tissue. Abbreviation: CAD, computer-assisted diagnosis.

Figure 4

MRI of the same 53-year-old patient noted in the earlier figures. Notes: A fibrous mass at the same regions of the earlier figures was observed. The characteristics of the signals show a fibrous lesion, with low signal at all sequences and enhancement after the contrast injection. Arrows indicate subcapsular mass with contrast enhancement. There is no signal of implant rupture. Abbreviations: PD, proton density; ST1R, short T1 inversion recovery; MRI, MRI, magnetic resonance imaging.

Figure 5

Specimen of core needle biopsy of the lesion shows a rigid lesion. Notes: The microscopic analysis shows (A) epithelioid granulomatous process with giant cells induced by silicone (B–E). CD68 immunohistochemistry positivity, denoting histiocytic nature of cells. The diagnosis was confirmed as SIGBIC. Magnification for (B) ×40; (C) ×500; (D) ×100; (E) ×500. Abbreviation: SIGBIC, silicone-induced granuloma of breast implant capsule.

Figure 6

Schematic representation of the location of ALCL and SIGBIC. Abbreviations: ALCL, anaplastic large cell lymphoma; SIGBIC, silicone-induced granuloma of breast implant capsule.

Figure 7

A 43-year-old patient with thickening and discomfort in the left breast. Notes: (A) Sagittal PD images of the left breast and (B) axial images after injection of the contrast agent show the increase in the anteroposterior diameter of the left breast implant, with thickening of the fibrous capsule and enhanced contrast compared with the right side. Abbreviation: PD, proton density.

Figure 8

A 48-year-old patient with pain and enlargement on the right breast. Notes: The MRI shows an intracapsular fluid fill around the implant with heterogeneous, signal compatible with hematoma. There is no mass enhancement after the contrast media injection. Arrows indicate limit between prosthesis and hematoma. Abbreviations: PD, proton density; ST1R, Short T1 inversion recovery; Sil, silicone; MRI, magnetic resonance imaging.

Figure 9

A 35-year-old patient with signs of fluid collection in the right breast 7 years after implantation. Notes: The image was acquired in January 2016 and shows (A) the diffuse thickening of the fibrous capsule, with contrast enhancement in the adjacent fibrous glandular tissue. The patient was subjected to percutaneous biopsy and was diagnosed with mastitis. Antibiotic treatment was performed and resulted in clinical improvement. An MRI image shows (B) the control of the disease at 6 months and improvement of the image status. Abbreviation: MRI, magnetic resonance imaging.