DOI:10.2214/AJR.05.0064
AJR 2006; 186:888-894
© American Roentgen Ray Society
Direct Injection of Paraffin into the Breast: Mammographic, Sonographic, and MRI Features of Early Complications
Basak Erguvan-Dogan1 and
Wei T. Yang1
1 Both authors: Department of Diagnostic Radiology, University of Texas M.D.
Anderson Cancer Center, 1515 Holcombe Blvd., Unit 135, Houston, TX
77030.
Received January 12, 2005;
accepted after revision February 9, 2005.
Address correspondence to B. Erguvan-Dogan
(basakerguvan{at}yahoo.com).
Abstract
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.
Keywords: breast • breast augmentation • breast MRI • breast sonography • mammography • paraffin injection
Introduction
Liquid paraffin injection was used 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
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.
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Fig. 1A —33-year-old woman with history of paraffin injection 1 year earlier
who presented with pain and lumpiness in both breasts. 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).
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Fig. 1B —33-year-old woman with history of paraffin injection 1 year earlier
who presented with pain and lumpiness in both breasts. 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.
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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 12.5-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 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 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].
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Fig. 2B —35-year-old woman with history of bilateral paraffin injections 3
years earlier presented with palpable abnormality in upper left breast.
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).
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Fig. 1C —33-year-old woman with history of paraffin injection 1 year earlier
who presented with pain and lumpiness in both breasts. 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.
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Fig. 1D —33-year-old woman with history of paraffin injection 1 year earlier
who presented with pain and lumpiness in both breasts. 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.
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Fig. 1E —33-year-old woman with history of paraffin injection 1 year earlier
who presented with pain and lumpiness in both breasts. 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.
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Fig. 2A —35-year-old woman with history of bilateral paraffin injections 3
years earlier presented with palpable abnormality in upper left breast. Left
mediolateral oblique mammogram reveals diffuse globular-shaped opacity in
central left breast (arrow) that is inseparable from underlying dense
breast parenchyma.
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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).
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Fig. 2C —35-year-old woman with history of bilateral paraffin injections 3
years earlier presented with palpable abnormality in upper left breast.
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.
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Fig. 2D —35-year-old woman with history of bilateral paraffin injections 3
years earlier presented with palpable abnormality in upper left breast.
T2-weighted fat-suppressed 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).
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MRI in one patient who had received liquid paraffin injections 30 years
earlier showed heterogeneous parenchymal and retroglandular 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.
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Fig. 3B —55-year-old woman with history of paraffin injection 30 years
earlier who presented with bilateral hard breast masses. 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.
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Fig. 3C —55-year-old woman with history of paraffin injection 30 years
earlier who presented with bilateral hard breast masses. 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.
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Fig. 3A —55-year-old woman with history of paraffin injection 30 years
earlier who presented with bilateral hard breast masses. Right mediolateral
oblique mammogram shows flocculent dystrophic ring calcifications and
retroglandular architectural distortion (arrows).
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Seven patients with painless hard masses and two with bilateral breast pain
did not require surgery and remained well. Three patients 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 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 intermediate- and 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
- Tinkler LF, Stock FE. Paraffinoma of the breast. Aust N
Z J Surg 1955; 25:142
-144[Medline]
- Yang WT, Suen M, Ho WS, Metreweli C. Paraffinomas of the breast:
mammographic, ultrasonographic and radiographic appearances with clinical and
histopathological correlation. Clin Radiol1996; 51:130
-133[CrossRef][Medline]
- Khong PL, Ho LWC, Chan JHM, Leong LLY. MR imaging of breast
paraffinomas. AJR 1999;173
: 929-932[Abstract/Free Full Text]
- 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
: 1259-1264[Medline]
- Harris KM, Ganott MA, Shestak KC, Losken HW, Tobon H. Silicone
implant rupture: detection with US. Radiology1993; 187:761
-768[Abstract/Free Full Text]
- 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
: 117-123[Medline]
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Abstract
Introduction
