Silicone Thorax Due to a Ruptured Breast Implant

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Subj: CHEST: Silicone Thorax Due to a Ruptured Breast Implant

Date: 5/12/2005 12:35:32 PM Eastern Standard Time

From: ilena03@...

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Silicone Thorax Due to a

Ruptured Breast Implant*

L. Levine, MD; C. , MD, JD;

Joiner Cartwright, Jr., PhD; and Philip T. Cagle, MD

A woman with a history of bilateral mastectomy and

silicone implants for fibrocystic disease and a history

of atrial septal defect repair presented with pleural

nodules on a chest radiograph. A thorascopic biopsy

performed for possible mesothelioma demonstrated

chronic inflammation and focal pleural fibrosis due

to a foreign-body reaction secondary to silicone. This

was confirmed using scanning electron microscopy

and energy-dispersive radiograph elemental analysis.

As the population ages, the increasing frequency

of ruptured silicone implants and the need for heart

surgery may result in a corresponding increase in the

risk for fibrothorax secondary to inadvertent silicone

introduction during surgery.

(CHEST 2005; 127:1854–1857)

Key words: cardiac surgery; fibrothorax; silicone breast implants;

silicone thorax

Abbreviations: EDXEA energy dispersive X-ray elemental

analysis; EM scanning electron microscopy

More than 1.5 million women in the United States have

silicone breast implants.1 Due to safety concerns, in

1992 the US Food and Drug Administration restricted the

use of silicone breast implants, and the Institute of

Medicine issued a report1 on the safety of silicone breast

implants, citing local and perioperative complications as

the principal safety issues, noting that risks mount over the

lifetime of an implant. Based on the Institute of Medicine

conclusion that there was no support for a novel syndrome

associated with silicone breast implants, nor increased risk

for cancer, connective tissue diseases, neurologic diseases,

or other systemic complaints,1 the Food and Drug Administration

is considering reinstitution of silicone breast

implants for augmentation mammoplasty.

The literature on existing silicone implants indicates as

many as one third of symptomatic patients have ruptured

gel implants at the time of explantation.2 More than

465,000 women undergo chest surgery in the United

States each year,3 with the potential for silicone from

ruptured implants to be introduced into the pleural space

at the time of surgery either through the surgery itself or

chest tube placement. We present a case of fibrothorax

due to introduction of silicone from ruptured implants at

the time of atrial septal defect repair.

Case Reports

A 61-year-old woman presented for evaluation of a hard right

inframammary mass. She noted the onset of the mass approximately

1 year earlier, 1 year after cardiac surgery for closure of an

atrial septal defect. The patient complained of discomfort around

the mass and a vague sense of discomfort in the right hemithorax

with respiration. She had no systemic complaints. Her history was

significant for deep venous thrombosis, nephrolithiasis, and a

distant history of pneumonia. Significant surgical history included

bilateral mastectomies for severe fibrocystic disease with submuscular

silicone gel implants for breast reconstruction, and hysterectomy.

She never smoked and had no known exposure to

asbestos. Physical examination demonstrated a hard, 3-cm mobile

mass over the tenth rib in the midclavicular line, but was

otherwise unremarkable. A chest radiograph revealed right pleural

based masses, confirmed on chest CT. These were suspicious

for mesothelioma or metastatic disease, and the patient underwent

thorascopic biopsy.

Routine glass-mounted histologic sections stained with hematoxylin-

eosin were examined and photographed by light microscopy.

They were reprocessed for scanning electron microscopy

(EM) and energy-dispersive radiograph elemental analysis

(EDXEA) by the method of Pickett et al.4 The tissue sections

were transferred to graphite specimen mounts, coated with

carbon, and examined in an electron microscope (100-C TEMSCAN;

JEOL USA; Peabody, MA). Areas of interest studied by

light microscopy were located and analyzed using a Tracor TN

5500 microprobe (Tracor-Northern; Madison, WI).

Results

By light microscopy, hematoxylin-eosin–stained sections

of the formalin-fixed, paraffin-embedded tissue

showed lung parenchyma and overlying pleura, fibrous

adhesions, and fibroadipose tissue. Within the pleura and

fibroadipose tissue were numerous vacuoles of various

sizes, occasionally surrounded by foreign-body giant cells.

Translucent, refractile material was observed in many of

the vacuoles (Fig 1).

By EM, the refractile material within the vacuoles

appeared fluid and noncrystalline (Fig 2, top). EDXEA of

the material in the vacuoles showed the mineral content to

be exclusively silicon (Fig 3). Dot mapping indicated that

silicon distribution corresponded to the material seen in

the light vacuoles by light microscopy (Fig 2, bottom).

Subsequently, the patient had both gel implants removed

with free rupture of silicone noted at the time of surgery. The

submammary mass was removed and found to be due to

extruded silicone. The pleural masses have remained stable,

although the patient notes pleuritic discomfort with painful

respiration. Pulmonary function remains normal as documented

by serial pulmonary function testing.

Discussion

The frequency of rupture of gel implants is unknown.

Brown et al5 found that 77% of women with silicone breast

implants, without regard to complaints or symptoms, had at

least one breast implant rupture; median implant age at the

time of rupture was 10.8 years. Extruded silicone causes

localized and distant areas of inflammation in the breast and

surrounding tissues, including axillary lymph nodes, leading

to the formation of pseudotumors.6–7 Diagnosis of ruptured

implants is difficult and is performed with physical examination,

mammography, ultrasound, CT, and MRI. None of

these techniques can detect all ruptures; CT and MRI detect

approximately 80% and 90%, respectively.8,9 Proof that a

lesion is due to silicone requires further testing. We used a

combination of EM and EDXEA to prove that silicon was

contained in the pleural nodules. EDXEA has been used

infrequently in medicine to determine elemental content of

foreign material within tissue.

To our knowledge, this is the first reported case of

fibrothorax due to the introduction of silicone from ruptured

breast implants at the time of cardiac surgery. Though this

patient’s pulmonary function remains intact, fibrothorax can

cause disabling dyspnea, and a severe restrictive defect or

trapped lung, and may possibly require pleural decortication.

We suspect the introduction of silicone into the pleural space

in this case was associated with chest tube placement related

to cardiac surgery. One case of pleural effusion was reported

with a similar etiology,10 and an acute empyema and pleural

rind has been reported after chest tube insertion through an

intact gel implant.11

Conclusion

With 1.5 million women undergoing augmentation

mammoplasties and 465,000 chest surgeries performed

annually,3 the likelihood is great that this complication will

develop with increasing frequency as the population of

women with implants ages and subsequently undergoes

cardiac surgery. While the long-term risk for progression of

the disease in this patient is unclear, the implication for the

general population is that extreme care must be taken at the

time of thoracic surgery or chest tube insertion to avoid

introducing silicone into the pleural space when operating on

women with silicone gel implants. If silicone breast implants

are reintroduced into the market for general augmentation,

the risk of silicone thorax will be extended for decades.

References

1 Bondurant S, Ernster V, Herdman R, ed. Safety of silicone

breast implants. Committee on the Safety of Silicone Breast

Implants, Division of Health Promotion and Disease Prevention,

Institute of Medicine. Washington, DC: National Academy

Press, 2000

2 de Camara DL, Sheridan JM, Kammer BA. Rupture and

aging of silicone gel breast implants. Plast Reconstr Surg

1993; 91:828–836

3 Hall MJ, Owings MF. 2001 National Hospital Discharge

Survey. Advance Data Vital Heal Stat. No. 332. Hyattsville,

MD: National Center for Health Statistics, 2003; DHHS

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4 Pickett JP, Ingram P, Shelburn JD. Identification of inorganic

particulates in a single histologic section using both light

microscopy and X-ray microprobe analysis. J Histotechnol

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5 Brown SL, Middleton MS, Berg WA, et al. Prevalence of

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7 Persellin S, Vogler JB, Brazis PW, et al. Detection of

migratory silicone pseudotumor with use of magnetic resonance

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8 Everson LI, Parantainen H, Detlie T, et al. Diagnosis of

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9 Herborn CU, Marincek B, Erfmann D, et al. Breast augmentation

and reconstructive surgery: MR imaging of implant

rupture and malignancy. Eur Radiol 2002; 12:2198–2206

10 Taupmann RE, Adler S. Silicone pleural effusion due to

iatrogenic breast implant rupture. South Med J 1993; 86:570–

571

11 Rice DC, Agasthian T, Clay RP, et al. Silicone thorax: a

complication of tube thoracostomy in the presence of mammary

implants. Ann Thorac Surg 1995; 60:1417–1419