Direct Injection of Paraffin into the Breast: Mammographic, Sonographic, and MRI Features of Early Complications

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1 Erguvan- Dogan and Yang Complicatio ns of Paraffin Injections for Breast Augmentatio n Women s Imaging Clinical Observations WOMEN S IMAGING Basak Erguvan-Dogan 1 Wei T. Yang Erguvan-Dogan B, Yang WT Keywords: breast, breast augmentation, breast MRI, breast sonography, mammography, paraffin injection DOI: /AJR Received January 12, 2005; accepted after revision February 9, Both authors: Department of Diagnostic Radiology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 135, Houston, TX Address correspondence to B. Erguvan-Dogan (basakerguvan@yahoo.com). AJR 2006; 186: X/06/ American Roentgen Ray Society Direct Injection of Paraffin into the Breast: Mammographic, Sonographic, and MRI Features of Early Complications OBJECTIVE. We present the mammographic, sonographic, and MRI features of the early complications of breast augmentation by direct injection of liquid paraffin. We also examined the imaging features in patients with paraffinoma, a later complication of these injections. CONCLUSION. Early complications of breast augmentation by direct injection of liquid paraffin differ in appearance from paraffinoma, which is a late complication of the same procedure. On mammography, early lesions appear as multiple circumscribed, noncalcified masses in the retroglandular and subpectoral regions. Sonography reveals multiple cystic masses within the breast parenchyma, retroglandular region, ipsilateral axilla, and pectoral muscle. MRI shows parenchymal and retroglandular fluid collections, which are hypointense on T1-weighted images and hyperintense on T2-weighted and fat-suppressed T2-weighted images, that do not enhance. iquid paraffin injection was used L as a form of breast augmentation throughout the world during the first half of the 20th century and continued to be widely used in the Far East until the 1970s. This form of breast augmentation has been largely abandoned because of the serious short- and long-term complications associated with the procedure but is still available in the Far East despite its disastrous outcomes. The method remains popular with backstreet practitioners because it is cheap, quick, and simple to perform; is relatively painless for the patient; and has an immediate, attractive cosmetic result. Most patients are initially asymptomatic after injection of liquid paraffin directly into the breast parenchyma. Gradually, however, a foreign-body reaction and fibrosis develop [1]. The latency period may vary from 2 years to several decades. Patients usually present with hard palpable masses, sometimes with sinus formation or ulceration. Paraffinomas are a late complication of this procedure, and their mammographic and sonographic appearances have been previously documented [2]. Mammographic findings include parenchymal distortion, streaky opacities, dystrophic parenchymal calcifications, flocculent ring calcifications that form around paraffin droplets, and multiple masses [2]. There may also be axillary lymphadenopathy. Although these findings may be confused with signs of inflammatory breast carcinoma, the distinguishing feature is that nipple retraction and peau d orange changes of the skin typically do not occur in patients who have received paraffin injections. As a result of fibrotic changes associated with extensive acoustic attenuation, particularly in the retroglandular region [2], sonography may be of limited value in diagnosis. Although fine-needle aspiration has been used, there are differing reports of its usefulness [3]. We recently encountered two young women who had breast lumpiness and palpable breast masses within 3 years of undergoing breast augmentation with liquid paraffin. This report contrasts the imaging findings of early complications of direct injection of liquid paraffin with those presenting later. Materials and Methods Sixteen women who had received direct paraffin injections underwent imaging evaluation with mammography, sonography, or MRI between 1997 and 2001 at an academic institution. The patients were between 30 and 82 years old (mean age, 59 years). Seven patients (44%) presented with hard breast masses, five (31%) with painful breast masses, two (12%) with bilateral breast pain and lumpiness, and one (6%) with a parasternal mass. One patient (6%) with a history of breast cancer was undergoing evaluation for recently developed 888 AJR:186, March 2006

2 Complications of Paraffin Injections for Breast Augmentation contralateral axillary lymphadenopathy. The time from the injection to the onset of symptoms ranged from 1 to 50 years. Two patients, who were 33 and 35 years old, constitute the focus of this report; they presented with symptoms of breast masses and lumpiness and had a history of paraffin injection less than 3 years earlier. All patients underwent mammography and sonography. In all patients, standard two-view mammography was performed on a Senographe DMR+ unit (GE Healthcare), with additional views obtained as necessary. Sonography was performed using a high-resolution unit with a 7.5- or MHz linear-array transducer on a 700 LOGIQ Expert/Pro series unit (GE Healthcare). Three patients underwent MRI of the breast. MRI of the breast was A Fig year-old woman with history of paraffin injection 1 year earlier who presented with pain and lumpiness in both breasts. A, Right mediolateral oblique mammogram reveals bandlike increased density (white arrows) in retromammary prepectoral space. Also note multiple obscured and circumscribed masses (black arrows) in breast parenchyma and prepectoral region that were better seen on anterior compression views (not shown). B, Right breast sonogram shows band of septated complicated fluid collection (arrows) in retromammary area and separate intramammary cystic collection (arrowhead). Pectoralis muscle is compressed and difficult to show. (Fig. 1 continues on next page) performed with a 1.5-T whole-body MR unit (Gyroscan ACS-NT, Philips Medical Systems). Breast MRI was performed in accordance with techniques described previously [4]. Contrast-enhanced sagittal T1-weighted spin-echo images with fat suppression were obtained after bolus IV injection of gadopentetate dimeglumine (Magnevist, Schering) at 0.2 mmol/kg of body weight. Results Mammographic findings of the two patients who had received paraffin injections within the previous 3 years included bandlike increased density in the retroglandular and prepectoral spaces (Figs. 1A and 1B) and multiple circumscribed, noncalcified, and obscured masses in the intramammary and prepectoral areas on mammography that were largely indistinguishable from breast parenchyma (Fig. 1A). This presentation was distinct from that of patients with paraffinomas who showed parenchymal distortion, streaky opacities throughout the glandular tissue, retro- or mid glandular dystrophic calcifications, ring calcifications, and indistinct masses mainly in the mid glandular area. Sonography in these two patients depicted dome-shaped retroglandular fluid (Figs. 1B and 2B) with occasional dissection of the retromammary fat (Fig. 2B). The fluid was characteristically septated and complicated with homogeneous internal echoes, but without a B AJR:186, March

3 Erguvan-Dogan and Yang C E Fig. 1 (continued) 33-year-old woman with history of paraffin injection 1 year earlier who presented with pain and lumpiness in both breasts. C, T1-weighted sagittal MR image (TR/TE, 450/15; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.4 mm) of right breast shows multiple hypointense loculated structures (arrows) in breast parenchyma and dome-shaped fluid (asterisk) in retroglandular region. D, T2-weighted sagittal fat-suppressed MR image (2,000/100; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.4 mm) of right breast shows multiple round intermediate- to high-signal-intensity fluid collections (arrows) in superficial breast parenchyma and subareolar region and hyperintense fluid (asterisk) in retroglandular area. E, Contrast-enhanced T1-weighted sagittal MR image of right breast with fat suppression (475/15; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.4 mm) shows no enhancement of intramammary and retroglandular fluid. D 890 AJR:186, March 2006

4 Complications of Paraffin Injections for Breast Augmentation A Fig year-old woman with history of bilateral paraffin injections 3 years earlier presented with palpable abnormality in upper left breast. A, Left mediolateral oblique mammogram reveals diffuse globular-shaped opacity in central left breast (arrow) that is inseparable from underlying dense breast parenchyma. B, Sagittal extended-field-of-view sonogram of left breast shows anechoic retroareolar fluid (straight arrows) with strand seen inferiorly (curved arrow), most likely representing dissected retroglandular fat better identified on MR images. Note breast parenchyma anteriorly (star) and compressed pectoralis posteriorly (asterisk). (Fig. 2 continues on next page) solid internal component, likely reflecting the high viscosity of liquid paraffin. No Doppler flow was shown within the fluid. Cystic masses were also present in the breast parenchyma (Fig. 1B), subcutaneous fat, and ipsilateral axilla and pectoralis muscle. Sonography of paraffinomas showed diffuse intraparenchymal or retroglandular shadowing obscuring further evaluation of glandular structures in chronic cases, which is consistent with the snowstorm appearance that has been described with siliconomas [5]. MRI in the two patients with a recent history of paraffin injection revealed retroglandular fluid collections. The fluid was hypointense on T1-weighted images (Figs. 1C and 2C) and hyperintense on T2-weighted images and fat-suppressed T2-weighted images (Figs. 1D and 2D). These fluid collections showed no enhancement after contrast administration (Fig. 1E). MRI in one patient who had received liquid paraffin injections 30 years earlier showed heterogeneous parenchymal and retroglandu- B AJR:186, March

5 Erguvan-Dogan and Yang Fig. 2 (continued) 35- year-old woman with history of bilateral paraffin injections 3 years earlier presented with palpable abnormality in upper left breast. C, T1-weighted sagittal image (TR/TE, 450/15; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.4 mm) of left breast shows hypointense fluid in retroglandular area. Note that dissected retroglandular fat (arrow) is seen as intersecting thin septum of high intensity within fluid. D, T2-weighted fatsuppressed sagittal image (2,000/100; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.4 mm) of left breast shows hyperintense retroglandular fluid with low-intensity septum (arrow). C D lar signal intensity that was intermediate on T1-weighted images (Fig. 3B) and intermediate to low on T2-weighted and fat-suppressed T2-weighted images. Marked hypointensity was detected throughout the fibroglandular structures on fat-suppressed images (Figs. 3B and 3C). The paraffin-related changes were not enhanced by gadopentetate dimeglumine. Seven patients with painless hard masses and two with bilateral breast pain did not require surgery and remained well. Three pa- Fig year-old woman with history of paraffin injection 30 years earlier who presented with bilateral hard breast masses. A, Right mediolateral oblique mammogram shows flocculent dystrophic ring calcifications and retroglandular architectural distortion (arrows). (Fig. 3 continues on next page) A 892 AJR:186, March 2006

6 Complications of Paraffin Injections for Breast Augmentation B Fig. 3 (continued) 55-year-old woman with history of paraffin injection 30 years earlier who presented with bilateral hard breast masses. B, T2-weighted fat-suppressed sagittal image (TR/TE, 2,000/100; field of view, 30.0 cm; slice thickness, 4.0 mm; interslice gap, 0.5 mm) of right breast shows subglandular region (arrows) to be low intensity relative to breast parenchyma and fat. C, T1-weighted contrast-enhanced fat-suppressed image (475/15; slice thickness, 4.0 mm; interslice gap, 0.4 mm; field of view, 35 cm) of right breast shows profound suppression and signal void due to calcifications associated with fibrosis and plaquelike changes in retroglandular region (arrows). T1-weighted nonenhanced sagittal image (not shown) of right breast showed round hypo- to isointense structures in retromammary region. tients with hard painful masses had local excision, and two with painful masses, one associated with ulceration and a discharging sinus, underwent bilateral mastectomies. One patient who had undergone bilateral mastectomies for paraffinomas presented with recurrent ulcerating chest wall masses and underwent wide local excision with reconstruction. One patient who had a coexisting contralateral axillary metastasis from a previously treated breast cancer underwent mastectomy and axillary dissection after systemic chemotherapy. The breast specimen did not reveal malignancy. Discussion The mammographic, sonographic, and MRI characteristics of recent liquid paraffin injections into the breast probably reflect a more liquid state of the paraffin in vivo and differ from the imaging features of paraffinomas, which are a late complication of paraffin injection. To our knowledge, these characteristics of recent liquid paraffin injection into the breast have not been previously described in the literature. Mammography shows multiple circumscribed and obscured masses in the breast parenchyma in patients with recent paraffin injections and architectural distortion and dystrophic calcifications in patients with paraffinomas. Sonography is particularly useful in revealing stray fluid collections in the breast and in the retroglandular space. This contrasts with its limited usefulness in investigating the breast in women with paraffinomas, which exhibit marked posterior acoustic shadowing in the retroglandular region. Distinct MRI features of paraffinomas have been reported [3, 6]. Khong et al. [3] hypothesized that paraffinomas have two components: a plaquelike fibrous component that shows intermediate intensity on T1- and hypointensity C AJR:186, March

7 Erguvan-Dogan and Yang on T2-weighted images and a liquid paraffin component that shows hypointensity on both T1- and T2-weighted images. Wang et al. [6] noted paraffinomas appearing as intermediateand low-intensity structures on T1- and T2- weighted images, respectively. In both patients in our series who underwent MRI within 3 years of paraffin injection, paraffin-related changes were hypointense on T1-weighted images, hyperintense on T2-weighted images, and hyperintense on fat-suppressed T2- weighted images. This difference may be explained by the fact that in all the patients in the series of Khong et al. the latency period was more than 20 years, which allowed the paraffin to turn to a semisolid state. The latency period was less than 3 years in the two patients who are the focus of this report. In our patients, the paraffin was likely still in a liquid state; therefore, most of the proton molecules within the paraffin were less restricted. This theory is also supported by the fact that the single patient in our series who had undergone breast augmentation 30 years earlier showed signal intensity characteristics consistent with fibrosis. The radiologic findings in patients who have received recent intramammary paraffin injections may be confused with those resulting from retroglandular implants or fibrocystic changes. Being aware of this rare form of breast augmentation and obtaining a pertinent patient history will help clinicians establish the correct diagnosis. References 1. Tinkler LF, Stock FE. Paraffinoma of the breast. Aust N Z J Surg 1955; 25: Yang WT, Suen M, Ho WS, Metreweli C. Paraffinomas of the breast: mammographic, ultrasonographic and radiographic appearances with clinical and histopathological correlation. Clin Radiol 1996; 51: Khong PL, Ho LWC, Chan JHM, Leong LLY. MR imaging of breast paraffinomas. AJR 1999; 173: Cheung G, Tse S, Lai D, Yeung H. Relationship between lesion size and signal enhancement on subtraction fat-suppressed MR imaging of the breast. Magn Reson Imaging 2004; 22: Harris KM, Ganott MA, Shestak KC, Losken HW, Tobon H. Silicone implant rupture: detection with US. Radiology 1993; 187: Wang J, Shih TT, Li YW, Chang KJ, Huang HY. Magnetic resonance imaging characteristics of paraffinomas and siliconomas after mammoplasty. J Formos Med Assoc 2002; 101: AJR:186, March 2006