Background

Cervical lymphadenopathy can be caused by an array of different pathologies. These can be categorised into either benign (eg, systemic lupus erythematosus, Epstein-Barr virus, toxoplasmosis) or malignant (eg, lymphoma, metastatic disease).1 A comprehensive history and examination is essential in elucidating the most likely diagnoses. Additionally, in high-risk patients, it is crucial to undertake appropriate investigations to rule out more sinister pathology such as head and neck cancers.

Breast implants are frequently used in both aesthetic and reconstructive breast surgery. They are composed of silicone shells filled with saline or silicone gel.2 Numerous studies have examined the safety of such implants and demonstrated the potential for ruptures, malignancies and inflammatory reactions.3 4 Silicone-associated lymphadenopathy occurs following migration of silicone particles to regional lymph nodes. This can be a consequence of implant rupture, or when microscopic amounts of silicone gel leak from the outer shell (known as ‘gel bleed’). The majority of cases result in axillary or mediastinal lymphadenopathy. There are very few reported cases of silicone associated cervical lymphadenopathy.5 6

This case report both adds to the limited literature and emphasises the importance of considering silicone granulomas as a potential cause for cervical lymphadenopathy in patients with saline-based breast implants.

Case presentation

A 54-year-old woman presented to the outpatient ear, nose and throat neck lump clinic with a 2-week history of multiple bilateral neck lumps. These painless lumps had been progressively enlarging over a 2-week period. She had also been having episodes of night sweats but she felt these were related to her menopause. She had not noticed any other lumps around her body. She denied any weight loss and had no head and neck red flag symptoms or B-type symptoms. Additionally, she had no recent viral illness.

Thirteen years prior to presentation, she had bilateral breast augmentation with silicone-based implants. Three years following insertion, her silicone implants were recalled by the manufacturer and were replaced with saline-based implants. On removal, there was no evidence of implant rupture or leakage. She had no other relevant medical history. She was a non-smoker and consumed five units of alcohol per week.

On examination, she had multiple bilateral palpable lymph nodes in levels IV and Vb, more prominent on the left. A flexible nasoendoscopy and oral cavity examination were unremarkable. At this stage, the differential diagnosis included lymphoma, head and neck cancer, metastases and reactive lymphadenopathy secondary to infection.

Investigations

The patient subsequently underwent various blood tests including a Toxoplasma gondii and Cytomegalovirus screen. These were conducted since these two opportunistic infections often have mild clinical courses and are associated with generalised lymphadenopathy.7 Both these screens were negative for an acute infection.

The crucial investigation in this case was an ultrasonography guided biopsy of the lymph node. The ultrasonography (figure 1) demonstrated multiple mildly enlarged lymph nodes in levels IV and Vb bilaterally with the largest measuring up to 1.5 cm. There was a heterogeneous echogenic pattern with dispersion of the ultrasound beam causing posterior acoustic shadowing (snowstorm sign). A CT scan of the neck also confirmed the presence of bilateral small volume lymphadenopathy.

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Figure 1

Ultrasonography of affected lymph nodes demonstrating the snowstorm sign ultrasonography demonstrating multiple enlarged lymph nodes with a heterogeneous echogenic pattern and dispersion of the ultrasound beam causing posterior acoustic shadowing (snowstorm sign). Features indicative of a silicone granuloma.

The core biopsy (figure 2) revealed lymph node tissue with macrophages containing large vacuoles, scattered lymphocytes and multinucleate giant cells. These findings were typical of a silicone granuloma and the silicone had most likely dissolved from the vacuoles while preparing the specimen.

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Figure 2

Photomicrograph of the silicone granuloma (A) Photomicrograph (magnification ×30, H&E stain) demonstrating numerous empty vacuoles and multinucleate giant cells. The empty vacuoles previously contained silicone, which has been dissolved during preparation of the specimen. (B) Photomicrograph (magnification ×30) confirms the specimen is CD68 positive, a marker of macrophages.

Outcome and follow-up

Following discussion at the multidisciplinary team meeting (including the plastic surgery team), it was concluded that given saline-based implants are covered in a silicone shell, the lymphadenopathy was likely a consequence of gel bleeding. Subsequently, no further treatment was required. She currently remains well and has been reassured that this is not a malignant cause.