Covered by
SCI-Expanded
|
|
[ Summary ]
[ PDF ]
[ Mail to Author ]
[ Mail to Editor ]
|
| CT features of foreign body granulomas after cosmetic paraffin injection into the cervicofacial area |
| Dong Hyeon Gu, Dae Young Yoon, Suk Ki Chang, Kyoung Ja Lim, Ji Hyeon Cha, Young Lan Seo, Eun Joo Yun, Chul Soon Choi, Sang Hoon Bae |
| From the Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University, College of Medicine, Seoul, Republic of Korea |
| Keywords: • face • neck • foreign bodies • computed tomography, X-ray |
| DOI: 10.4261/1305-3825.DIR.2936-09.0 |
| Summary |
PURPOSE
Cosmetic injection of paraffin into cervicofacial tissues has
been practiced in the past, especially in Asia, resulting in
foreign body granuloma (paraffinoma). The purpose of this
study was to describe the computed tomography (CT) findings
of cervicofacial paraffinomas.
MATERIALS AND METHODS
CT images of 5 patients (4 women and 1 man; age range,
54-80 years; mean age, 67.6 years), who had received direct
paraffin injections into cervicofacial tissues, were reviewed retrospectively.
RESULTS
The lesions were bilateral and located in the subcutaneous fat
layer of the cheek (n = 5), buccal space (n = 2), periorbital area
(n = 1), periauricular area (n = 1), neck (n = 1), and nose (n =
1). The predominant CT features were speckled mass formation
(n = 3), fat-density nodule (n = 5), high-density nodule
(n = 5), nodular calcification (n = 5), and rim calcification (n
= 4).
CONCLUSION
Paraffinomas in the cervicofacial region have specific CT features
that are distinct from other soft tissue masses. |
Top
Summary
Introduction
Methods
Results
Disscussion
References
|
| Introduction |
Paraffinoma, defined as a granulomatous foreign body reaction,
is a well-recognized late complication of paraffin injection[ 1– 8].
Paraffin is a mixture of purified, saturated hydrocarbon extracted
from crude oil. Direct injection of liquid paraffin has been used for soft
tissue augmentation throughout the world during the first half of the
20th century[ 1]. Although this practice was abandoned in many countries
because of numerous complications, it continued to be performed
by unqualified practitioners in the Far East until the 1980s[ 2, 3]. Most
patients are initially asymptomatic after injection of paraffin. Gradually,
however, various complications including cellulitis, tissue necrosis,
ulceration with sinus tracts, and foreign body granulomatous reaction
develop[ 3, 4].
Paraffin has been injected into various parts of the body, and in particular
into the female breasts for their augmentation[1–3] and into the
male genital regions for enhancement of virility[5]. Paraffin has also
been injected into the cervicofacial area to flatten wrinkles and to produce
an artificial augmentation of cheek volume for cosmetic purposes[6,7].
Although there are several previous reports of the radiological findings
of breast paraffinomas[1,3,4,8], to our knowledge, the imaging
features of paraffinomas in the cervicofacial area have not been previously
reported. The purpose of this study was to describe the computed
tomography (CT) findings of paraffinomas in the cervicofacial
area. |
Top
Introduction
Methods
Results
Disscussion
References
|
| Materials and Methods |
This study is based on a retrospective review of the hospital information
system and the radiology information system in our institution
from September 2003 to July 2008. We identified 10 patients with
possible granulomatous reaction to foreign body, which was injected
for cosmetic reasons, who underwent CT of the cervicofacial area. A
history of paraffin injection was confirmed by the patient at a second
visit or by means of telephone interview. Five patients were excluded
from the study either because they could not be reached (n = 3) or did
not remember the kind of injected material (n = 2). The remaining 5
patients who admitted that they had received direct paraffin injections
composed the study population. There were 4 women and 1 man with
ages ranging from 54 to 80 years (mean age, 67.6 ± 10.4 years). The
time interval between the injection and the imaging study ranged from
20 to 45 years.
On physical examination, 4 patients were asymptomatic, and a patient
had painless hard masses at the sites of injections. No patient had skin
reactions, fistula formation, and enlarged cervical lymph nodes. The indications
for the CT study in these patients were facial trauma (n = 2), vocal cord palsy (n = 1), thyroid mass
(n = 1), and staging of skin cancer (n =
1). In a patient with skin cancer, partial
excision of paraffinoma was performed
because cancer had developed adjacent
to paraffinoma. Details of the clinical
condition of the patients are summarized
in Table 1.
The entire study protocol was approved
by our institutional review
board, and all patients gave written
consent.
Imaging was performed on the
five patients with CT (n= 5) and ultrasonography
(US) (n = 1). CT scans
were obtained using a 16 detector-row
CT scanner (MX8000 Infinite; Philips
Medical Systems, Best, The Netherlands)
with the following parameters:
3-mm section thickness, pitch of 1.5,
4×1.5-mm collimation, 120 kV and 200
mAs. The scanning range was planned
from the level of the maxillary sinus to
the tracheal bifurcation (n = 3) or from
the level of the frontal sinus to the
mandible (n = 2). Only unenhanced (n = 3) or enhanced (n = 2) CT scans were
obtained. US was performed using a
5–15 MHz linear array transducer of an
iU 22 ultrasound unit (Philips Medical
Systems, Bothell, Washington, USA).
CT images were retrospectively analyzed
by two radiologists (DHG. and
DYY) independently, and decisions on
the findings were reached by consensus.
CT images were evaluated for the
following characteristics: the distribution
and depth of the lesions, speckled
mass formation, fat-density nodule,
high-density nodule, calcification
(nodular or rim), extension into the
adjacent structures (skin or muscle),
and cervical lymphadenopathy. |
Top
Introduction
Methods
Results
Disscussion
References
|
| Results |
All paraffinomas were bilateral and
confined to the subcutaneous layer
without extension into adjacent tissue.
The lesions were located in the cheek
(n = 5), buccal space (n = 2), periorbital
area (n = 1), periauricular area (n = 1),
neck (n = 1), and nose (n = 1).
CT features of paraffinoma were as
follows: speckled mass formation (n =
3), fat-density nodule (n = 5), highdensity
nodule (n = 5), nodular calcification
(n = 5), and rim calcification
(n = 4). All CT scans showed paraffincontaining
cysts, manifested as multiple
well-defined variably sized fatdensity
nodules scattered through the
tissue. In addition, calcifications associated
with fat-density or high-density
nodules were also demonstrated
in all patients. In 4 patients the calcifications
were nodular and rim-like;
1 patient had only nodular calcifications
(Figs. 1a, 2a, and 2b). However,
abnormality in the adjacent skin or
muscle or cervical lymphadenopathy
was not seen in any of the cases.
Specific CT features of the lesions are
listed in Table 2.
Click to Enlarge |
Figure 1: a–c. A 76-year-old woman with history of paraffin
injection 20 years earlier who presented with painless masses in
bilateral cheeks (Case 2). Contrast-enhanced CT scan (a) shows
heterogeneous density solid masses in the subcutaneous fat layer
of bilateral cheeks (arrows). Multiple low density oil droplets with
nodular and curvilinear calcifications are seen within the masses.
Longitudinal sonogram of left cheek (b) shows multiple anechoic
masses (arrows) with posterior acoustic shadowing (arrowheads),
most likely representing oil-containing cysts with calcification
identified on CT images. Photomicrograph of the resected specimen
from the left cheek (c) shows numerous oil-depletion vacuoles
of varying sizes that are scattered throughout a background of
prominent fibrosis; note areas of calcification (arrows) within
vacuoles (hematoxylin-eosin stain; original magnification, x200). |
Click to Enlarge |
Figure 2: a, b. A 54-year-old asymptomatic woman with history of paraffin injection 30 years earlier (Case 3). Contrast-enhanced CT scans
show low density oil droplets with nodular and curvilinear calcifications in the subcutaneous fat layer of bilateral cheeks (large arrows) and nose
(small arrow and arrowhead, b). Note other calcifications in bilateral buccal spaces (black arrows, a). |
US in a patient revealed multiple
small anechoic nodules with posterior
shadowing and peripheral hyperechoic
rim in the subcutaneous fat layer (Fig.
1b). Anatomic details of the face or
neck tissue could not be assessed due
to increased echogenicity of the subcutaneous
tissue and marked posterior
acoustic shadowing.
Specimen of paraffinoma obtained
by surgical resection was available for
pathologic review in a patient. Histopathologically,
the striking feature
was the presence of multiple lipoid
vacuolated spaces of varying sizes with
surrounding multinucleated giant
cells, scattered throughout the background
of dense fibrous tissue. Various
amounts of calcium deposition
were present within the vacuoles (Fig.
1c). A fat-density nodule on CT images
and an anechoic nodule on US images were correlated with a lipoid vacuolated
space histologically. Histologic
features were suggestive of a granulomatous
reaction to exogenous oil material. Therefore, clinical history of the
patient in conjunction with histologic
findings supported the diagnosis of
paraffinoma. |
Top
Introduction
Methods
Results
Disscussion
References
|
| Discussion |
The clinical diagnosis of paraffinoma
can be difficult in the absence of clinical
history of previous paraffin injection. Paraffinomas are usually present
as bilateral hard masses in the face or
neck, which can sometimes be painful.
These lesions can be misdiagnosed as
cysts, tumors, fat necrosis, or calcified
lymph nodes.
The histopathologic findings of paraffinoma
have been described in several
articles[3,6,8,9]. The histological
features include chronic granulomatous
inflammation with foreign body
multinucleated giant cells and numerous
vacuolated spaces containing paraffin
oil and/or calcification, resulting
in the so-called “Swiss cheese” appearance,
as demonstrated in our study.
Interstitial infiltration by plasma cells
and fibroblastic reaction are consistently
present.
In this study, paraffinomas had characteristic
imaging features on CT that
correlated well with histopathologic
findings. The lesions were located most
commonly in the subcutaneous fat of
the bilateral cheeks. The predominant
CT features were speckled mass formation,
fat-density nodule, high-density
nodule, nodular calcification, and rim
calcification. These CT findings in our
series seem to correspond with those
reported previously.
Several previous reports have described
the mammographic, US, and
magnetic resonance imaging (MRI)
findings of paraffinomas associated
with the injection of paraffin into the
breast tissue for augmentation. The
spectrum of mammographic findings
of paraffinoma includes multiple
rounded opaque masses, bizarre
architectural distortion, and streaky
opacities indistinguishable from carcinoma.
Ring or rounded and flocculent
or amorphous calcifications may
be present within the breast and axilla[1,3,10]. On US, paraffinoma has
been described as diffuse echogenic
noise with a so-called snowstorm appearance
or multiple, round hypoechoic
nodules with calcifications[1,3,11]. As a result of prominent acoustic
shadowing associated with the fibrotic
changes, US may be of limited value in
the diagnosis of paraffinoma. On MRI,
paraffinoma has been described as
comprising two components: a paraffin-
containing round component that
is typically hypointense on both T1- and T2-weighted images and a fibrous
component that shows intermediate
intensity on T1- and hypointensity
on T2-weighted images[10]. Although
paraffin is expected to be bright on T1-
weighted images, it is thought that the
signal intensity of retained paraffin is
low on T1-weighted images because it
has undergone a transformation to a
semi-solid state[12].
There have been several previous
reports of granulomatous reactions
after injections of other cosmetic fillers;
liquid silicone had been the most
widely used for cervicofacial injection.
Silicone-induced granuloma is characterized
pathologically by numerous
round to oval cystic spaces, prominent
surrounding fibrosis, and foamy infiltrate
of multinucleated giant cells.
The cystic spaces are relatively small
and uniform. Calcifications are in the
form of irregular microcalcifications,
and small ring-like or large eggshell
calcifications[13–15]. These histologic
findings of foreign body granulomas
induced by liquid silicone might be
confused with those of paraffinoma.
However, liquid silicone oil is relatively
hyperdense; its CT attenuation is
approximately 130 HU[16]. Based on
our cases, the injected paraffin had a
uniformly fat-density appearance, thus
it is easy to differentiate the two conditions
by CT imaging.
This study has some limitations, the
foremost being the lack of histopathologic
confirmation in four of five cases.
However, from the medical history and
the typical CT findings, the condition
is easy to diagnose, and should obviate
the need for biopsy. In addition, most
patients in this study were asymptomatic
and paraffinomas were incidentally
detected on CT performed for a variety
of reasons; this entailed the use of various
CT scanning parameters, including
differing fields of view and scanning
ranges. Contrast enhancement was also
variable: 3 studies were unenhanced
and 2 used enhanced scan only.
In conclusion, cervicofacial paraffinoma
has a typical distribution, shape,
and density on CT images. Knowledge
of the appearance of these patterns and
a careful investigation of history of the
patient may allow the correct diagnosis
and avoid unnecessary biopsy. |
Top
Introduction
Methods
Results
Discussion
References
|
| References |
1) Erguvan-Dogan B, Yang WT. Direct injection
of paraffin into the breast: mammographic,
sonographic, and MRI features of
early complications. AJR Am J Roentgenol
2006; 186:888–894.
2) Raven RW. Paraffinoma of the breast. Clin
Oncol 1981; 7:157–161.
3) Yang WT, Suen M, Ho WS, Metreweli C.
Paraffinomas of the breast: mammographic,
ultrasonographic, and radiographic appearances
with clinical and histopathologic
correlation. Clin Radiol 1966; 51:130–133.
4) Steinbach BG, Hardt NS, Abbitt PL, Lanier
L, Caffee HH. Breast implants, common
complications, and concurrent breast disease.
Radiographics 1993; 13:95–118.
5) Lee T, Choi HR, Lee YT, Lee YH. Paraffinoma
of the penis. Yonsei Med J 1994; 35:344–
6) van der Waal I. Paraffinoma of the face: a
diagnostic and therapeutic problem. Oral
Surg Oral Med Oral Pathol 1974; 38:675–
680.
7) Uchida Y, Yoshii N, Kubo H, Kanzaki T,
Kanekura T. Facial paraffinoma after cosmetic
paraffin injection. J Dermatol 2007;
34:798–800.
8) 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.
9) Alagaratnam TT, Ng WF. Paraffinomas of
the breast: an oriental curiosity. Aust N Z J
Surg 1996; 66:138–140.
10) Khong PL, Ho LWC, Chan JHM, Leong
LLY. MR imaging of breast paraffinomas.
AJR Am J Roentgenol 1999; 173:929–932.
11) Cho N, Kim EK, Oh KK, Kwak JY, Son EJ.
Migrated foreign body granulomas on
mammography after injection in the cervicofacial
area. Clin Radiol 2004; 59:835–
840.
12) Sinclair DS, Freedy L, Spigos DG. Altered
breast: paraffin injection with development
of paraffinomas. AJR Am J Roentgenol
2000; 175:864–865.
13) Travis WE, Balogh K, Abraham JL. Silicone
granulomas: report of three cases and review
of the literature. Hum Pathol 1985;
16:19–27.
14) Jensen SR, Mackey JK. Xeromammography
after augmentation mammoplasty. AJR
Am J Roentgenol 1985; 144:629–633.
15) Helbich TH, Wunderbaldinger P, Plenk H,
Deutinger M, Breitenseher M, Mostbeck
GH. The value of MRI in silicone granuloma
of the breast. Eur J Radiol 1997;
24:155–158.
16) Mathews VP, Elster AD, Barker PB, Buff BL,
Haller JA, Greven CM. Intraocular silicone
oil: in vitro and in vivo MR and CT characteristics.
AJNR Am J Neuroradiol 1994;
15:343–347. |
Top
Introduction
Methods
Results
Discussion
References
|
|
[ Top ]
[ Summary ]
[ PDF ]
[ Mail to Author ]
[ Mail to Editor ]
|
|
|
Ahead of Print)
)
)
)