Polyacrylamide hydrogel breast augmentation

Case contributed by Yaïr Glick
Diagnosis certain

Presentation

Breast cancer on axillary lymph node biopsy. Had polyacrylamide hydrogel injection for breast augmentation almost 30 years earlier.

Patient Data

Age: 60 years
Gender: Female

PET-CT

Nuclear medicine

Brain: no pathological FDG uptake.

Neck: FDG uptake in multinodular goiter.

Chest: uptake in the breasts, most probably secondary to polyacrylamide hydrogel (PAAG) injection, with coarse calcifications and cystic changes. Low-intensity uptake in several left axillary lymph nodes up to 6 mm in small axis diameter. Nonspecific pulmonary nodules, e.g. 3 mm in RML. The lungs are actually clear. No mediastinal or hilar adenopathy. No pleural or pericardial effusion.

Abdomen-pelvis: focal uptake in 1.2 cm rectosigmoid junction soft tissue thickening . The liver is of normal size and texture, with several hypodense foci, e.g. 1.1 cm in segment 2.

Bones: FDG uptake in what appears as traumatic finding in posterior aspect of 10th right rib.

Summary: FDG uptake in breasts in context of post PAAG injection - difficult to discern malignancy from inflammatory process. Moderate intensity uptake in two left axillary lymph nodes.

Bilateral (only left breast shown here):
Soft tissue masses: bulky breast, numerous masses in the breast soft tissue.
Calcifications: clustered microcalcifications in the left breast, lower outer quadrant.
Fibroglandular tissue: normal.
Skin and areolar shadow: normal.
BIRADS: 5

US-guided biopsy

ultrasound

Breast full of partially calcified blobs.
At 4-5 o'clock, impression of tissue distortion. Trucut biopsy taken.

Post-chemo MRI

mri

Bilateral breast tissue is infiltrated extensively by PAA masses intermixed with fluid. In both breasts, some of the masses are surrounded by enhancement, possibly reactive; more prominent on left.
No enhancement in the area in the left breast where enhancement was seen on the previous MRI (not shown) that was diagnosed as a mass.
4-mm focus of vivid enhancement of unknown significance in the left breast, central inferior, middle third, and 5-mm peripheral enhancement focus; both more prominent than on previous MRI.

In summary:
Free silicone injected to both breasts.
Regression of malignancy in left breast and axilla.
Two enhancing foci in left breast not seen on previous examination, significance unknown.
If mastectomy not performed, MRI-guided biopsy for the latter findings is required.
BIRADS 6/BIRADS 4

Case Discussion

Pathological left axillary lymph node - intraductal carcinoma (IDC) on biopsy; ER highly positive (+3), PR negative, HER2 highly positive (+3).

The patient elected to have bilateral mastectomy.

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