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Compiled by: Daniel B. Maloney, D.O.
History: 58-year-old female presents with a hard and swollen left breast. Previous silicone injections in the 1970s. Difficult to evaluate the breasts on mammography and sonography. Evaluate for malignancy.
Exam: Multisequence MRI of the breasts with and without contrast
Findings: Multiple scattered bilateral round foci demonstrating low signal intensity on T1 imaging and high signal intensity on T2 imaging are scattered throughout the breast parenchyma compatible with silicone injection granulomas (figures 1 and 2). The left breast is larger than the right breast and shows preferential skin thickening anteriorly. A curvilinear area of low signal intensity tissue in the anterior third of the left breast is seen on T2 imaging. This area shows rapid hyperenhancement (greater than 100%) on the first pass of the dynamic subtraction axial series (figure 3). This tissue extends to involve the nipple (figure 4). The last image (figure 5) demonstrates an abnormally appearing, hyperenhancing left axillary lymph node.
Images: Axial bilateral incoherent gradient echo 3D T1 appearing image (figure 1), axial T2 FSE image of the left breast (figure 2), bilateral axial first pass dynamic subtraction contrast enhanced images (figures 3, 4, and 5).
Figure 1
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Figure 2
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Figure 3
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Figure 4
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Figure 5
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Diagnosis: Presumed unilateral inflammatory carcinoma within the left breast with axillary metastases in a patient with bilateral silicone injection granulomas. (The patient is currently refusing any intervention, including biopsy.)
Discussion:
The patient has a history of silicone injections in the 1970’s. The patient developed a hard and swollen left breast, which made her seek medical attention. The patient’s mammograms showed dense breasts, multiple masses and nodules, and calcifications. The patient had a sonogram that revealed diffusely echogenic parenchyma, multiple nodules, and extensive acoustic shadowing. Breast MRI is the examination of choice in patients such as this, as it provides a window into the breast tissue on conventional MRI sequences and provides additional analysis with dynamic contrast enhancement.
Silicone injection granulomas typically demonstrate low signal intensity on T1 weighted images and high signal intensity on T2 weighted images. Cancer typically shows low signal intensity on both T1 and T2 weighted images. Abnormal contrast enhancement is clearly seen within the left breast parenchyma during the first minute on the dynamic contrast enhanced subtraction sequence. The key in this case is that the abnormal enhancement is not within the injection granulomas, but rather within the low signal intensity tissue that does not contain silicone material. Silicone granulomas can cause abnormal breast tissue enhancement, but this usually involves tissues associated in close proximity to the silicone. The patient also clinically presents with the typical inflammatory breast cancer symptoms and physical signs. The demonstration of abnormal enhancement extending from the breast parenchyma into the nipple is another reason why inflammatory carcinoma is a much more likely diagnosis than silicone granuloma related inflammation.
References:
Fischer, Uwe. Practical MR Mammography. Georg Thieme Verlag, Germany. 2004.
Bassett, Lawrence, et al. Diagnosis of Diseases of the Breast. Elsevier Inc., USA 2005.
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