for Treating Granulomas Produced by Silicones Injected to Modify Body Contour

Systemic manifestations

Local manifestations

Myalgia, myositis, muscle weakness

Inflammatory nodules

Arthralgias and/or arthritis

Cutaneous hyperpigmentation, edema and angioedema

Pyrexia, dry mouth, chronic fatigue

Cutaneous induration, pseudo abscesses

Sleep disorders, cognitive disorders

Axillary lymphadenopathy

Palmar erythema, livedo reticularis

Panniculitis, morphea, and sarcoidosis

Neurological manifestations

Necrosis, ulcers

Pulmonary manifestations, pulmonary hypertension, dyspnea

Systemic lupus erythematosus (SLE)

Vasculitis

Sjogren’s syndrome

Scleroderma

Eosinophilic fasciitis

Autoimmune syndrome induced by adjuvants (ASIA)

Still’s disease

It should be noted that eliminating the triggering agent improves symptoms. Recently, Shoenfeld and Agmon-Levin coined the term adjuvant-induced autoimmune/autoinflammatory syndrome (ASIA) to define a set of conditions that result from a body’s innate immune response to adjuvants (aluminum, silicone, bacterial antigens, etc.) (see Chaps. 6 and 8) [6].

Silicone has an adjuvant effect and can act as a pathogen-associated molecular pattern, resulting in the activation of pattern-recognition receptors and the release of proinflammatory cytokines, like TNF-α, IL-1β, IL-6, IFN-γ, and IFN-α [7–9]. Of these, the last is responsible for inducing the maturation of monocytes in dendritic cells, increasing the release of co-stimulatory molecules, and triggering the expression of the major histocompatibility complex which, aided by IL-6, favors the secretion of antibodies [10, 11]. In addition to activating the immune system, silicone can cause systemic effects via the degradation of its fragments. In patients with severe immune reactions, there is an increased concentration of immunoglobulin G in surrounding tissues and high levels of anti-silicone antibodies.

Diagnostic Imaging

Although it is critical to detect breast cancer as early as possible to enhance survival, the presence of injected silicone makes it difficult to interpret diagnostic images for mammary pathology. Currently, magnetic resonance imaging (MRI), breast ultrasound, and mammography continue to be the frontline tools for accurate diagnosis. The following table shows the requirements, advantages, and limitations of each study in patients with a history of liquid silicone injection (Table 9.2).

Table 9.2

Diagnostic utility of imaging studies

Mammography	Breast ultrasound	MRI
Requirements: Perform bilateral examinations, in craniocaudal and mediolateral oblique positions. Include the axillae	Requirements: The examination should extend beyond the limits of the breast and include the chest wall and axilla	Requirements: The examination should be performed with the patient in a prone position. Administer gadolinium IV. Use high magnetic field equipment (1,5 or 3 T) and specific coils. This allows one to explore both breasts with extension into the chest wall and axilla
Strengths: Greater sensitivity to detect liquid silicone in breast parenchyma (in all mammary planes, from subdermal to posterior). It also shows infiltrates in the pectoral muscle and axillae. It is possible to observe compromise in the lymphatic tissue (expressed as dense, linear and parallel lines, shaped like multi-lobed lobed nodules)	Strengths: The ultrasound image usually has the appearance of a “snowfall” (intense and homogenously hyperechoic nodules, with a delimited and rounded anterior contour), which generates a shadow that obscures the posterior border [12]. Some silicone collections initially present as complex cysts. It is also possible to observe isoechogenic solid nodules and fibrosis	Strengths: This technique offers morphological information and data related to breast parenchymal physiology (perfusion and enhancement kinetics). It does not use ionizing radiation. Injected silicone may manifest as nodular images or as silicone-signaling images that infiltrate the fibroglandular tissue and may migrate to the adjacent axilla and other soft tissues [12]. Additional benefits: Determines the location of silicone and its eventual migration. It allows for visualization of pathologies that cannot be observed by conventional studies. It has a very high negative predictive value for invasive carcinoma, in the absence of enhancement [12]
Limitations: 1. The high density of siliconomas and diffuse infiltration of breast tissue make it difficult to interpret suspicious images (microcalcifications or non-visible nodules), which prevents the diagnosis of small cancerous lesions 2. It is impossible to evaluate the full extent of the siliconoma, since only that sector of the body included in the field of study can be observed, leaving out the intermammary groove, abdomen, and thoracic wall [12]	Limitations: Ultrasound is not useful to detect lesions suspected of being neoplastic	Limitations: It has high sensitivity to detect lesions, but only moderate specificity for detecting breast cancer [12]

Mammography

Breast ultrasound

MRI

Requirements:

Perform bilateral examinations, in craniocaudal and mediolateral oblique positions. Include the axillae

Requirements:

The examination should extend beyond the limits of the breast and include the chest wall and axilla

Requirements:

The examination should be performed with the patient in a prone position. Administer gadolinium IV. Use high magnetic field equipment (1,5 or 3 T) and specific coils. This allows one to explore both breasts with extension into the chest wall and axilla

Strengths:

Greater sensitivity to detect liquid silicone in breast parenchyma (in all mammary planes, from subdermal to posterior). It also shows infiltrates in the pectoral muscle and axillae. It is possible to observe compromise in the lymphatic tissue (expressed as dense, linear and parallel lines, shaped like multi-lobed lobed nodules)

Strengths:

The ultrasound image usually has the appearance of a “snowfall” (intense and homogenously hyperechoic nodules, with a delimited and rounded anterior contour), which generates a shadow that obscures the posterior border [12].

Some silicone collections initially present as complex cysts. It is also possible to observe isoechogenic solid nodules and fibrosis

Strengths:

This technique offers morphological information and data related to breast parenchymal physiology (perfusion and enhancement kinetics). It does not use ionizing radiation. Injected silicone may manifest as nodular images or as silicone-signaling images that infiltrate the fibroglandular tissue and may migrate to the adjacent axilla and other soft tissues [12].

Additional benefits:

Determines the location of silicone and its eventual migration. It allows for visualization of pathologies that cannot be observed by conventional studies. It has a very high negative predictive value for invasive carcinoma, in the absence of enhancement [12]

Limitations:

1. The high density of siliconomas and diffuse infiltration of breast tissue make it difficult to interpret suspicious images (microcalcifications or non-visible nodules), which prevents the diagnosis of small cancerous lesions

2. It is impossible to evaluate the full extent of the siliconoma, since only that sector of the body included in the field of study can be observed, leaving out the intermammary groove, abdomen, and thoracic wall [12]

Limitations:

Ultrasound is not useful to detect lesions suspected of being neoplastic

Limitations:

It has high sensitivity to detect lesions, but only moderate specificity for detecting breast cancer [12]

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