1. Case Report # [1] Submitted by:Michael Wright, MS4 Faculty reviewer:Sandra Oldham, M.D. Date accepted:27 August 2014 Radiological Category:Principal Modality (1): Principal Modality (2): Breast None CT

2. Case History The patient is a 35 year old transgender (male to female) with a history of nonishcemic cardiomyopathy, hypertension, hyperlipidemia, CKD, and HIV admitted for CHF exacerbation. CT images of the chest without contrast were obtained.

3. CT Without Contrast

5. Invasive Ductal Carcinoma Metastasis to the Breast Myofibroblastomas Foreign-Body Granulomas Gynecomastia Test Your Diagnosis

6. Multiple, round, well-circumscribed, subcutaneous, soft-tissue nodules seen within the breasts bilaterally. Malignant Lesions - IDC - Metastasis Benign Lesions - Gynecomastia - Myofibroblastomas - Granulomatous lesions Findings: Differentials: Findings and Differentials

7. Granulomas from free silicone injection. - Given the transgendered status correlated with the location, number, and appearance of the nodules, the diagnosis of granuloma formation from silicone injections can be made (foreign body granulomas). Discussion

8. Malignant lesions (IDC, Mets). The number of lesions make the diagnosis of a primary breast cancer unlikely, along with the benign appearance of the lesions. Lesions with undefined margins and speculation would be more worrisome for malignancy. The patient is also male, but given the transgender status, HRT could increase the chance of breast cancer (Less than 1% of breast cancer diagnoses will be in males. Metastasis to the breasts from other primary cancers is very rare, but can appear as a singular or multiple round well-circumscribed nodules Discussion

9. Myofibroblastomas and granulomas in the breast will appear as round, well- circumscribed nodules. Firboadenomas are common in adolescent women but exceptionally rare in men. Varying types calcifications can occur. Gynecomastia is a common normal finding that is seen in 55% of men at autopsy and the most common abnormality in the male breast. Usually presents with a prominent areola and a single, dense, central subareolar density. Margins can vary. Should be clinically correlated Discussion

10. Silicone injections were used during the 50s and 60s in the US for cosmetic augmentation, but the use of free silicone injections was banned in the 70s by the FDA due to health risks and complications. Even though the practice is outlawed many people still receive illicit silicone injections. It is a popular practice among the transgender community. Free silicone injections are still used in some Asian countries. Discussion

11. Imaging Appearance of Free Silicone in Other Modalities Ultrasound: variable appearance including - classic = highly echogenic pattern of scattered and reverberating echoes or "snowstorm" appearance. - lesion with acoustic shadowing - hypoechoic masses almost indistinguishable from cysts surrounded by echogenic noise Mammography: distortion of breast parenchyma with increase density of the breast MRI: low signal intensity on T1W with fat suppression, high signal intensity on T2W with water-suppression PET/CT: Possible uptake of 18F-FDG Granuloma formation from silicone injections can obscure the detection of breast cancer and other pathological problems. Silicone may also spread to other parts of the body. Discussion

12. Mammogram after Silicone Injections 57 year old female 42 year old female

13. 20 year old female “Snowstorm appearance” Ultrasound

14. 64 year old female Differentiating silicone granuloma and cancer MRI – T2

15. 48 year old male 18F-FDG Uptake in the Gluteal region PET/CT

16. Silicone Embolism Syndrome – Pulmonary embolism caused by free silicone. Symptoms and signs– Dyspnea, fever, tachycardia, cough, hemoptysis, chest pain, hypoxia, alveolar hemorrhage, petechiae (very similar to FES) ARDS, death The onset of symptoms are usually within 15 minutes to 2 days after injection, but may occur at anytime. Bilateral peripheral air-space disease can be seen on conventional images Diffuse, peripheral ground glass opacities, interlobular septal wall thickening, and alveolar and interstitial densities can be seen on CT. Discussion

17. Due to the benign appearance as round, well-circumscribed, soft tissue nodules, the sheer number of nodules present, the location in the breast and buttocks, and the patient’s transgendered status, the diagnosis of granuloma formation from free silicone injection can be made. Diagnosis

18. Silicone Embolism Syndrome: A Case Report, Review of the Literature, and Comparison With Fat Symbolism Syndrome. Schmid, Andreas MD; Tzur, Assaf MD; Leshko, Lidya MD; Krieger, Bruce MD. CHEST 2005 Illicit Cosmetic Silicone Injections Carry Lethal Consequences. Restrepo, Carlos MD. RSNA Press Release 2006 Spectrum of Imaging Findings in the Silicone-Injected Breast. Leibman, A Jill MD; Misra, Monica MD. Plastic and Reconstructive Surgery 2011 A Flase Postivie 18F-FDG PET/CT Scan Caused by Breast Silicone Injection. Chen, Chai-Jung MD; Lee, BI-Fang MD; Chiu, Nan-Tsing MD. Korean Journal of Radiology 2009 Silicone Pulmonary Embolism: Report of 10 Cases and Review of the Literature. Restrepo, Carlos MD et al. Journal of Computer Assisted Tomography 2009 Silicone Embolism Syndrome Clayton, Joshua MD. LearningRadiology.org Pathology of the Male Breast. Glassman, Leonard. Radiology Assistant by Radiological of the Netherlands. 2009 Radiological pitfall: Siliconoma in internal mammary lymph node mimics breast cancer recurrence. Steinke, Karen MD; Brook, Phillipa MD; Ramuz, Olivier MD. University of Washington Case Reports 2011 Silicone Mastopathy. Baratelli, Giorgio MD. Radiopedia.org Case Report References