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Silicone Granulomatous Lymphadenopathy and Siliconomas of the Breast

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Silicone Granulomatous Lymphadenopathy and Siliconomas of the Breast Histology and Histol Histopathol (1997) 12: 1003-1011 001: 10.14670/HH-12.1003 Histopathology From Cell Biology to Tissue Engineering http://www.hh.um.es Silicone granulomatous lymphadenopathy and siliconomas of the breast R. Vaamonde1,2, J.M. Cabrera3, R.J. Vaamonde-Martrn1,2, I. Jimena1 and J. Marcos Martrn4 1Department of Morphological Sciences, Histology Section, College of Medicine, University of Cordoba, 2Department of Pathology, Red Cross Hospital, 3Department of Plastic Surgery, Red Cross Hospital, Cordoba, and 4Department of Analytical Chemistry, University of Cordoba, Cordoba, Spain Summary. In the present study, two histologically­ following implant removal. Immunogenic capacity was distinct cases of granulomatous lymphadenitis induced refuted by Smith (1995) in comparisons with standard by dimethylpolysiloxane (silicone polymer) implants antigens. Nairn et al. (1995), while accepting in principle were studied. Four and six years after implant, and the "stability" of silicone, concluded that silicone following surgery for breast cancer, painful homolateral constituted a powerful humoral adjuvant potentially axillary adenopathies were observed and biopsied. In stimulating the formation of autoantibodies to both cases, histological examination led to a diagnosis of thyroglobulin and collagen. Nevertheless, the immune "silicone-induced granulomatous adenitis" requiring response produced neither thyroiditis nor arthritis. removal of implants. Foreign-body granulomas Numerous studies report wide-ranging local (breast) (siliconomas) were observed in surrounding tissue with and remote clinical symptoms in patients with silicone no apparent rupture of implant capsules; however, visible implants (Arion, 1995; Logothetis, 1995; Vasey, 1995b). retraction, hardening and scattered calcifications were These symptoms become less marked or completely noted. The presence of silica was revealed by disappear following implant removal. A growing number incineration of a number of biopsied lymph nodes, a of women are dissatisfied with their breast implants and technique not hitherto used in the study of this an International Association has already been set up for pathology. A review is offered of the literature available. those women suffering from implant-related disorders and several questions have been discussed already in the Key words: Silicone, Siliconoma, Granulomatous Tribunals (Marshall, 1996). The most frequently reported lymphadenitis, Mammoplasty, Silica symptoms are: frequent fatigue, (82%); joint and muscle pain (62%); neuritis, lymphadenitis, rheumatism (Vasey et aI., 1995a); cutaneous lesions, chest or axillary pain Introduction (Sichere et aI., 1995); dyspnoea (Celli et aI., 1978); and endocarditis (Travis et ai., 1986). Many of these Over the last 30 years (Duffy and Woods, 1994; symptoms are accompanied by impairment of the Friedman, 1994), almost 2 million American women immune system (Espinoza, 1995; Schiller et aI., 1995), have received silicone implants (Emery et aI., 1994), the connective tissue disorders (Valesini et ai., 1995; most common types being the implant developed by Hochberg et aI., 1996; Hochberg and Perlmutter, 1996) Ben-Hur et al. (1967) and subsequent modifications by and modified biochemical parameter (Field and Bridges, Rudolph et al. (1978) and Truong et al. (1988). Although 1996). The most frequent local symptoms are: capsular implant material was initially defined as "non hardening and contraction (Friedman, 1994; Thuesen et biodegradable" (Demergian, 1963) and harmless, its use aI., 1995); and pericapsular granulomatous reactions has become the subject of considerable and ongoing (Sanger et aI., 1995). Rosenberg (1996) studied 131 controversy. Brautbar et al. (1995) have demonstrated women diagnosed as having a neurological problem "in vitro" that silicone is both degradable and immuno­ related to silicone breast implants. Most patients (66%) genic; silicone leaks from the implant were reported to had normal neurological examinations. No pattern of migrate throughout the lymph and reticuloendothelial laboratoy abnormalities was seen. Their conclusion: "is systems, (Kikuchi's syndrome, Sever et ai., 1996), no evidence that silicone breast implants are causally leading to possible autoimmunization and immune related to the development of any neurological disease". system disorders reversible in 50% to 70% of cases Contrarily, Shoaib and Patten (1996) described a new syndrome that appears as a systemic inflammatory Offprint requests to: Prof. R. Vaamonde, Department of Morphological autoinmune disease within the central nervous system Sciences, Histology Section, College of Medicine, University of (multiple sclerosis-like syndrome), in twenty-six women. C6rdoba, Avda. Menendez Pidal sIn. 14004 C6rdoba, Spain The median latency period betwen breast implants of 1004 Silicone and pathology silicone and onset of symptoms was 5.71 years. implants. There has been greater controversy as regards There is much debate concerning the precise effects on the immune system (Vojdani et aI., 1992; pathogenic mechanisms involved and the actual Koeger et aI., 1993, 1994; Campbell et aI. , 1994; existence of a causal relationship between clinical Edelman et aI., 1994a,b; Cohen, 1995; Cuellar et aI., symptoms and the presence of silicone in surrounding 1995; Mena et aI., 1995; Peters, 1995; Teuber et aI., tissue. In order to put this problem into context, the 1995), the appearance of local inflammatory reactions following points should be considered: (Karlsson et aI. , 1992), or inflammation of connective tissue in general (Cuellar and Espinoza, 1994; Rowley et 1) Silicone diffusion aI., 1994; Martin, 1995; Sanchez-Guerrero et aI., 1995). Doi and Refojo (1995) found small droplets ingested For years, scientists have warned of the possible by mononuclear cells in the vitreus cavity or preretina at "leakage" of silicone into tissue surrounding silicone 4.6 months in silicone-fluorosilicone copolymer oil implants (O' Hanlon et aI., 1996), and even to more injected in rabbit phakic eyes. Knorr et al. (1996) did remote sites: (Symmers, 1968; Capozzi et aI., 1978; histological examinations on 36 enucleated globes after Wintsch et aI., 1978; Hausner et aI. , 1978; Mason and silicone oil injection. They observed histological Apisarnthanarax, 1981; Rich et aI., 1982; Argenta et aI. , changes in all layers of the eyes and vacuoles both free 1983; Frey et aI., 1992; Jansen et aI., 1993; DeCamara et and incorporated by macrophages in all layers of the aI., 1993; Laxenaire et aI., 1994; Duffy and Woods, retina, optic nerve, choroid, ciliary body, iris, chamber 1994; Brautbar et aI. , 1995; Freundlich et aI., 1996; angel and corneal. Shanklin et aI., 1996). The possibility of injury-induced Biological causes should not be ruled out (Vojdani et (Malata et aI., 1994) or iatrogenic (DeCamara et aI. , aI., 1992; Brautbar et aI., 1995; Gedalia et aI., 1995; 1993; Teuber et al. , 1995) ruptures should not be ruled Smith, 1995; Bar-Meir et al., 1995). Vojdani et al. (1992) out. Teuber et al. (1995) reported deterioration of all have reported inhibition of mitogenic T-cell response, silicone capsules 10 or more years after implant. reduced lymphocyte capacity to eliminate tumoral target Several authors have discussed possible silicone cells, an increase in antinuclear, antithyroid, anti-smooth migration: Greene et al. (1995) used microanalysis to muscle, antimyelin and antihistone immunocomplexes. identify silicone in histiocytes and extracapsular Cuellar et ai. (1995) discovered 20 serum auto­ connective tissue in 12 women with implants. Silica was antibodies in 116 women with silicone implants. They discovered in synovial fluid in four women (a condition concluded that the implant had an "adjuvant" effect on also reported by Vasey et aI., 1995a), and also in the skin immune response in 20% of these women. "The silicone of one woman (scleroderma). Teuber et al. (1995), using serves as adjuvant and therefore might have an effect on X-ray and MRI techniques, discovered traces of silicone­ immune tolerance ... suggesting an atypical autoimmune type material in surrounding soft tissue, and warned of disease" (Lewy and Ezrailson, 1996). ANA levels its destructive effect on tissue, especially in the case of increased by between 30% and 57.8% depending on the ruptured implants. Emery et al. (1994), in an electron­ antigen used. 55% of 500 women with silicone implants microscopic and infra-red spectroscopic study of 103 have autoantibodies (ANA performed using Hep-2 cells) ruptured and 80 healthy capsules, observed giant compared to age-matched asymptomatic women foreign-body multinuclear cell inflammatory reactions in (Bridges et al. 1996). Similar findings are published by all cases, with no basement membrane interposition Claman and Robertson (1996). Rowley et al. (1994), between cellular elements and implant capsules. These employed the ELISA method to demonstrate a results led Grant and Edelman (1994) to warn against significant increase in antibodies to collagen type 1 and breastfeeding for women with implants. The letter of compared these results with reactions to collagen type II Eptstein (1996) serves in order to confirm this idea. which is more common in rheumatoid arthritis. T and B Gedalia et al. (1995) also reported rashes and lupus in lymphocytes were identified by Sanger et al. (1995). the newly born child of a mother with a silicone implant. However, consistent increases in immunoglobulins, C3 Malata et al. (1994) studied
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