Desmoid Tumor (Fibromatosis) of the Breast after Augmentation with Saline Implants

Abstract

Sir:FigureIn June of 2010, a 38-year-old Vietnamese woman returned to our plastic surgery clinic with complaints of a lump in the upper outer quadrant of her left breast. She had previously undergone bilateral augmentation mammaplasty with submuscular saline implants in 2006. On physical examination, she had a palpable mass in the 2-o'clock position near the anterior axillary line. However, it was not visually perceptible (Fig. 1). Magnetic resonance imaging revealed an enhancing soft-tissue mass (Fig. 2). Open capsulotomy was performed, and a 3.5 × 3 × 1.3-cm tumor was excised. The previous saline implants were intact, and they were exchanged for silicone implants bilaterally.Fig. 1: Bilateral saline implants and unresected left breast desmoid tumor.Fig. 2: T2-weighted magnetic resonance imaging scan with left breast desmoid tumor marked with a white arrow.Sectioning revealed an encapsulated rubbery tan mass. Microscopically, there were spindle cells against a background of scant collagen and occasional mitosis, consistent with a desmoid tumor (fibromatosis). Immunohistochemical staining for β-catenin was strongly positive, solidifying the diagnosis. Surveillance computed tomographic scans obtained at 6-month intervals for 12 months have remained unchanged with observation. There are fewer than 250 cases of breast desmoids in the literature. They are believed to arise from musculoaponeurotic structures; thus, when found in association with breast implants, the fibrous capsule that forms around the implant has been implicated as a possible source.1 There are only 24 cases of implant-associated breast desmoids in the literature. Among these, there are only seven cases following saline implants. There is one case where a patient's silicone implants were replaced with saline implants, and then a desmoid tumor subsequently developed. The remaining 16 cases occurred in association with silicone implants. Among the cases associated with saline implants, one case occurred following implant rupture,2 one case had a concurrent ductal carcinoma before complete surgical resolution,3 one case occurred 3 months after the additional surgical trauma of an unspecified revision procedure,4 and in two cases the implant was inserted after the additional surgical trauma of mastectomy.1,5 Our patient's desmoid developed spontaneously after saline implant augmentation without any of these confounding factors. It is important to note that among all the reported cases of breast desmoids, approximately 10 percent have occurred in patients with breast implants. Is there an association here to be uncovered? There has been very little written regarding a relationship between the biomaterial composition of the prosthesis and the risk of developing a breast desmoid. Because there is evidence that desmoids form after various different types of breast operations (e.g., excisional biopsies, lumpectomies, mastectomies, breast reductions), their development may simply be the result of a cellular transformation in association with postsurgical scarring. However, the possibility of such a transformation occurring because of the presence of foreign biomaterials is a distinct possibility that is a potential topic of further investigation. Interestingly, to date, there are no case reports of a desmoid tumor following purely autologous breast reconstruction. As the number of women electing to undergo breast augmentation increases and more cases are reported in the literature over the upcoming years, an association between breast implants and desmoid tumors, or the lack thereof, may become more apparent. Ziyad S. Hammoudeh, M.D. Department of Surgery, Wayne State University, Detroit, Mich. Vigen B. Darian, M.D. Division of Plastic Surgery, Department of Surgery, Henry Ford West Bloomfield Hospital, West Bloomfield, Mich.