| Abstract|| |
Injectable silicone or microimplant has been extensively used for the soft tissue augmentation. Here we report a case of cystic granulomatous reaction to injectable tissue filler, possibly liquid silicone, used for tissue augmentation in the buttocks. Patient presented with a progressive painful swelling in the lower back over L4-L5 and S1 lumbosacral region of 4-month duration. The lump was excised and microscopic examination revealed multiple cystic spaces of variable size lined by foreign body giant cells and macrophages. There were proliferating spindle cells admixed with many multivacuolated mononuclear cells simulating lipoblasts. These morphologic features were highly reminiscent of atypical lipomatous tumor. To our knowledge, this is the second recorded case from the Middle East of such an unusual foreign body reaction. The dermatologists and pathologists should be aware of this unsual lesion. Although rare, this reaction can have important esthetic implication and the patient should be informed about their risk.
Keywords: Atypical lipomatous tumor, silicone granuloma, soft tissue augmentation
|How to cite this article:|
Singh NG, Kahvic M, Rifaat AA, Alenezi I. Foreign body reaction to soft tissue filler simulating atypical lipomatous tumor: Report of a case. Indian J Pathol Microbiol 2010;53:778-80
|How to cite this URL:|
Singh NG, Kahvic M, Rifaat AA, Alenezi I. Foreign body reaction to soft tissue filler simulating atypical lipomatous tumor: Report of a case. Indian J Pathol Microbiol [serial online] 2010 [cited 2014 Apr 23];53:778-80. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/778/72089
| Introduction|| |
The use of injec table silicone for cosmetic purposes is becoming increasingly popular. Over the past two decades, dermatologists, surgeons and dermatopathlogists have come into contact with a new diagnostic trap consisting of the granulomatous reactions from inert material, injected intracutaneously for cosmetic purposes. The incidence of the granulomatous reaction against the tissue filler depends on the type of substance used. ,,, Some of the tissue fillers used for cosmetic purposes are polymethylmethacrylate microspheres, hyaluronic acid, acrylic hydrogel particles and polylactic acid. 
Here we report a case of swelling lower back with a past history of cosmetic tissue filler injection in the gluteal region and cheeks. The case is interesting due to the long time that elapsed between the cosmetic procedure and the appearance of the clinical symptoms secondary to the filler and the unusual histologic features, which in the absence of the correct clinical history, might have led to an erroneous diagnosis of atypical lipomatous tumor. To the best of our knowledge, this is the second recorded case in the Middle East in English literature.
| Case Report|| |
A 29-year-old female presented to the surgical outpatient department with a complaint of a lump over lumbosacral region of 4-month duration. The lump was associated with severe progressive pain. The patient initially denied the use of any cosmetic procedure in the area despite it was clinically apparent that she had undergone cheeks filling. Later on, she admitted for a cosmetic procedure of injecting tissue filler in the cheeks and gluteal region, two years ago, in a private clinic. On examination, a hard lump measuring about 5 × 4 cm with restricted mobility was identified in the L4-L5 and S1 region. Fine needle aspiration cytology was attempted which revealed fibro-adipose tissue only.
Patient on follow-up reported 4 months later, with the same lump, which increased in size (9 × 6 cm) and pain also got worse. Her laboratory investigation was noncontributory. The patient underwent excisional biopsy of the lump. At surgery, a hard fibrotic and cystic mass measuring about 8 × 5 cm was seen, extending up to the right buttock. Foreign body reaction to the cosmetic soft tissue filler was suspected. The mass was subsequently excised under local anesthesia. Her postoperative period was uneventful and she recovered smoothly.
Gross and Microscopic Examination
Grossly the excised mass measured 7 × 5 × 2.5 cm. Cut sections of the mass displayed multiple cystic spaces of varying size measuring from 0.2 to 2 cm in diameter. The cysts were filled with clear gelatinous mucoid material [Figure 1]. Sections examined revealed an intimate mixture of fibroadipose tissue with multiple cystic spaces and areas of blend of spindle cell proliferation. The cystic spaces were lined by foreign body giant cells and macrophages. Adjacent fibroadipose tissue revealed many multivacuolated mononuclear cells with centrally placed nuclei. Some of these mononuclear multivacuolated cells showed scalloped hyperchromatic nuclei conferring a lipoblast-like appearance [Figure 2]. The immunohistochemical examination showed negativity for S100 protein and positivity for CD68 of the above-mentioned cells. A diagnosis of giant cell reaction to foreign body, possibly liquid silicone was given.
|Figure 1: Gross photograph of the serial sectioning of the mass revealing the cystic spaces of variable size, filled with clear mucoid material|
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|Figure 2: Photomicrograph of mononuclear vacuolated macrophages with central hyperchromatic scalloped nuclei conferring a lipoblast-like appearance (H and E, ×200)|
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| Discussion|| |
Various histological pattern of granulomatous reaction after the injection of tissue fillers have been described. They vary from typical foreign body type granulomatous reaction to cystic-macrophagic granulomatous reaction. ,,, Injections using hyaluronic acid in combination with acrylic hydrogel particles can induce extensive degeneration of elastic fibers under the atrophic epidermis. The dense granulomatous infiltrate consisting of amorphous eosinophilic material, surrounded by multinucleated giant cells and lymphocytes are usually seen located in the deeper dermal layer.  Polymethylmethacrylate microsphere induces intense granulomatous infiltrate involving the reticular dermis. Round, sharply circumscribed extracellular foreign body surrounded by multinucleated giant cells and lymphoplasmacellular infiltrate could be detected.  The use of questionably pure silicone may increase incidence of granulomatous inflammation with multiple cystically dilated spaces in the subcutaneous tissue, surrounded by lymphohistiocytic infiltration. ,
Our case revealed the characteristic cystic-macrophagic granulomatous reaction with many giant cells and multivacuolated macrophages infiltration around the cystic spaces. Many of these reactive macrophages revealed multivacuolated cytoplasm with centrally placed hyperchromatic nuclei and in some cells, pushing the nuclei peripherally, mimicking the lipoblasts. Even though the patient could not recognize the nature of the filler used, the histological appearance is extremely suggestive of a foreign body reaction to liquid silicone. Mustacchio et al, and Maly et al, reported similar findings in patients who underwent soft tissue augmentation using silicone. , To the best of our knowledge, our case is the second recorded case in Middle-East that revealed cystic granuloma with reactive macrophages mimicking lipoblast, succeeding a case, reported by Maly et al, from Israel.
It should be remembered that the common morphological denominator of liposarcoma is the lipoblast, which appears as a mononuclear or multinuclear cells with one or more cytoplasmic vacuoles containing fat. Some cells have their nucleus pressed to the side by the presence of single cytoplasmic va cuoles with a signet ring appearance. In some lipoblast, the nucleus maintains a central position with peripheral indentations caused by numerous multiple small vacuoles.  The present case displayed predominantly the latter type of cells. Immunohistochemistry revealed the cells to be negative for S100 but reactive to CD68, favoring reactive histiocytes.
With conventional histology, it can be very difficult to differentiate the lipoblasts of a liposarcoma from the vacuolated reactive histiocytes of a granulomatous reaction to soft tissue filler such as silicone. Thus without proper clinical evaluation including the past medical history, site of lesion and in the absence of the support of immunohistochemistry, it could be difficult to distinguish between the two cases. In this case, the patient denied any cosmetic procedure in the beginning, however later disclosed that both the cheeks and the buttocks had undergone cosmetic procedure using tissue filler. Thus, without proper clinical history, it would have been difficult to arrive at a proper diagnosis.
Awareness of this possible diagnostic pitfall may help the surgeons, dermatologists or dermatopatholgists to classify correctly this unusual lesion, secondary to injection of tissue fillers. Such adverse reaction of the tissue fillers should be explained prior to cosmetic procedures.
| References|| |
|1.||Rudolph CM, Soyer HP, Schuller-Petrovic S, Kerl H. Foreign body granulomas due to injec table aesthetic microimplants. Am J Surg Pathol 1999;23:113-7. |
|2.||Sankar V, McGuff HS. Foreign body reaction to calcium hydroxylapatite after lip augmentation. J Am Dent Assoc 2007;138:1093-6. |
|3.||Vargas-Machuca I, Gonzalez-Guerra E, Angulo J, del Carmen Farina M, Martin L, Requena L. Facial granulomas secondary to Dermalive microimplants: Report of a case with histopathologic differential diagnosis among the granulomas secondary to different injec table permanent filler materials. Am J Dermatopathol 2006;28:173-7. |
|4.||Wolfram D, Tzankov A, Piza-Katzer H. Surgery for foreign body reactions due to injec table fillers. Dermatology 2006;213:300-4. |
|5.||Schwartzfarb EM, Hametti JM, Romanelli P, Ricotti C. Foreign body granuloma formation secondary to silicone injection. Dermatol Online J 2008;14:20. |
|6.||Mustacchio V, Cabibi D, Minervini MI, Barresi E, Amato S. A diagnostic trap for the dermatopathologist: Granulomatous reactions from cutaneous microimplants for cosmetic purposes. J Cutan Pathol 2007;34:281-3. |
|7.||Maly A, Regev E, Meir K, Maly B. Tissue reaction to liquid silicone simulating low grade liposarcoma following lip augmentation. J Oral Pathol Med 2004;33:314-6. |
|8.||Weiss SW and Goldblum JR. Liposarcoma. In : Weiss SW and Goldblum JR editors Enzinger and Weiss's Soft tissue tumor. 4 th edition Mosby Philadelphia 2001 p 641-93. |
Naorem Gopendro Singh
Department of Pathology, Al-Jahra Hospital, P.O. Box 62276, Jahra 02153
[Figure 1], [Figure 2]