What is the best course of treatment for a patient with a history of breast implant surgery presenting with symptoms suggestive of siliconoma, such as chronic cough, pleuritic chest pain, or interstitial lung disease?

Management of Siliconoma

Patients with suspected siliconoma (systemic silicone granulomas from breast implant rupture) presenting with chronic cough, pleuritic chest pain, or interstitial lung disease require urgent surgical explantation of the ruptured implant with complete capsulectomy, as this is the only intervention that consistently resolves systemic symptoms and prevents further silicone migration. 1, 2

Diagnostic Confirmation

Initial Imaging Assessment

• Order MRI breast without contrast immediately as the gold-standard test to confirm implant rupture, with sensitivity of 87% and specificity of 89.9% for detecting both intracapsular and extracapsular rupture 3
• MRI will demonstrate the "linguini" or "wavy-line" sign for complete intracapsular rupture, or "inverted-loop," "keyhole," "teardrop," or "hang noose" signs for incomplete rupture 3
• Do not rely on clinical examination alone, as it is unreliable for detecting implant rupture 3

Systemic Evaluation for Siliconoma

• Obtain chest CT with contrast to evaluate for mediastinal lymphadenopathy, intrathoracic silicone deposits, and interstitial lung disease patterns 1, 2, 4
• Perform axillary ultrasound to assess for lymph nodes with characteristic "snowstorm" appearance indicating silicone deposition 3, 5
• Consider tissue biopsy (skin nodules or accessible lymph nodes) to confirm chronic granulomatous reaction with foreign-body giant cells if diagnosis is uncertain or malignancy must be excluded 1, 4

Metal Sensitization Testing

• In patients with confirmed interstitial lung disease, consider scanning electron microscopy (SEM) and X-ray fluorescence (XRF) analysis of biological samples to detect metals (silicon, nickel, zinc, tungsten, iron, aluminum, zirconium) from implant leakage 4
• MELISA testing can assess immune sensitization to 19 metals, particularly nickel, zinc, and tin, which may contribute to systemic inflammatory response 4

Definitive Treatment Algorithm

Urgent Surgical Intervention (Within 2-4 Weeks)

• Refer immediately to plastic surgery for bilateral implant explantation with total capsulectomy, as extracapsular rupture increases urgency for surgical intervention 6
• Complete removal prevents further silicone migration to lymph nodes and distant sites, though complete removal of all extracapsular silicone may not be technically possible 6
• In cases with intrathoracic siliconomas, coordinate with thoracic surgery for needle-localized removal of accessible thoracic silicone masses via video-assisted thoracoscopic surgery 2

Expected Outcomes Post-Explantation

• Cutaneous nodules typically disappear following implant removal 1
• Lymphadenopathy (mediastinal, axillary, internal mammary) decreases in size after explantation 1
• Systemic symptoms including chronic cough, pleuritic chest pain, and fatigue resolve dramatically after implant removal 2, 7
• Interstitial lung disease may stabilize or improve, though complete resolution is not guaranteed 4

Critical Pitfalls to Avoid

Diagnostic Errors

• Never dismiss chronic respiratory symptoms (cough, pleuritic pain) as unrelated to breast implants, even if implants are 15-20 years old 2, 7
• Do not assume saline implants are safe from causing systemic complications—siliconomas can occur even with saline-filled implants if the shell contains silicone elastomer 7
• Always exclude malignancy first in patients with breast cancer history presenting with lymphadenopathy, as silicone lymphadenopathy can mimic metastatic disease 1

Management Errors

• Do not attempt conservative management or observation once extracapsular rupture with systemic symptoms is confirmed—explantation is the only effective treatment 6, 1
• Do not order MRI with contrast for implant evaluation, as it adds no value for assessing implant integrity 3, 6
• Do not rely on ultrasound alone for diagnosis, as it has poor sensitivity (30%) and accuracy (72%) for intracapsular rupture 3, 6

Post-Operative Monitoring

Surveillance Protocol

• If patient chooses reimplantation, FDA recommends MRI or ultrasound every 2-3 years to monitor new implants 6
• Serial chest CT may be warranted in patients with documented intrathoracic siliconomas to monitor for resolution or progression 2
• Clinical follow-up at 3-6 months post-explantation to assess symptom resolution and lymph node regression 1