Case Number : Case 2851- 10 June 2021 Posted By: Saleem Taibjee

granulomatous panniculitis 

do the routine stains to rule out bugs

consider silicone granulomatous inflammation

? Early stage of nodular vasculitis which has not ulcerated yet, after exclusion on infections.

Silicon granuloma which can occur at distant sites due to ruptured breast implants,

Not sure about silicon-related lesion...It seems a subcutaneous granulomatous reaction. The granulomas aren’t sarcoids-like, but they are all similar each other. Favor a sarcoidosis. 

Silicone from older implants is known to spread through lymphatics and blood vessels after dehiscence. Since all the giant cells are of foreign body type, with these circular uniform empty spaces, I favour silicone granulomas.

Interesting comments! Originally I was considering erythema induratum/nodular vasculitis on the basis of clinically panniculitic lesions, with a predominantly lobular granulomatous inflammation. I was trying to highlight possible chronic vasculitic changes (re-organising vessels) in the last 2 images.

I am interested about the suggestion of silicone granuloma. I had thought/assumed that the cystic spaces are degenerative adipocytes (many with eccentric nuclei) within fat lobules (with associated granulomatous inflammation). However, I have now also taken additional snapshots of septal areas where there appear to be clefted acellular spaces i.e. it seems that the spaces cannot be attributed to adipocytes only.

It would be curious to develop silicone granulomas many years after the breast cancer surgery/implants though.

I have sent some images to Luis Requena.

He comments, "I see sarcoidal granulomas involving the fat lobules. I don't see any implanted material in this biopsy. So, subcutaneous sarcoidosis would be my first possibility."

This also leads on to a discussion about the nature of the multinucleated giant cells in sarcoidosis. I suppose these can be predominantly foreign body type as well as Langhans, as in this case? But as we know, we can get sarcoidal reactions to foreign material (e.g. tattoos, etc). I suppose the patient will need investigation to exclude underlying sarcoidosis.

It is certainly an intriguing case. I'll let you know if anything further transpires.

BW 

Saleem

There are round empty spaces surrounded by granulomas, even in mid reticular dermis, it would be unusual for so many discrete foci of fat lobules situated in mid dermis. That's why was not sure if the round empty spaces represent adipocytes or some other type of vacuoles. Apart from silicon granuloma, such vacuoles have also been described with Mycobacterium abscessus/chelonae infections.