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in symptoms following an explant. In 9 of
52 women showed a significant decrease
and colleagues [2] reported that 36 out of
ment of systemic manifestations. Maijers
prosthesis removal following the develop-
detailed evaluation of the effect of silicone
Only a few studies have provided a
silicone migrating out of the implants.
observing any significant adjuvant effects by
from 1 month to 39 years) is needed before
implant surgery and onset of symptoms (i.e.,
which suggests that a long interval between
is consistent with the current literature,
mately 2 years in both cases. This time frame
and the onset of symptoms was approxi-
between silicone breast implant placement
rupture. The amount of time that elapsed
associated with silicone breast implant
We present two cases of ASIA syndrome
have rarely been reported.
mune adverse reactions related to silicone
highly heterogeneous. Systemic autoim-
disorders. The clinical manifestations are
be classified as classic connective tissue
tions of autoimmune diseases that cannot
both non-specific and specific manifesta-
risk of autoimmunity. Patients develop
silicone-filled breast implants increase the
is currently still being debated whether
adjuvant substance, including silicone. It
tions linked to previous exposure to an
syndrome incorporates several condi-
Shoenfeld and Agmon-Levin [1]. The
drome was first described in 2011 by
A Induced by Adjuvants (ASIA) syn-
utoimmune/inflammatory Syndrome
131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Cyan
#131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Black
131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Yellow
131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Magenta
implant, silicone
autoimmune syndrome, breast
adjuvant substances, ASIA syndrome,
KEY WORDS:
#
Original articles Original articles 118 (100) 1 (0.8) 1 (0.8) 8 (6.8) 23 (19.5) 47 (39.8) 38 (32.2) n (%) Of the 52 patients who underwent percutaneous biopsy Fifty-two patients (44.1%) underwent percutaneous biopsy Total Hand Thigh Cervical Intraperitoneal Inguinal Axilla Anatomical Site Table 2. Anatomical distribution of the surgical lymph nodes biopsies (0.8%), and leukemia in 1% of patients [Table 3]. metastatic lymphadenopathy in 2
Surgical Biopsy of pathologically Enlarged lymph and periprosthetic fibrosis, although with high doses of corticosteroids (prednisone tests showed a normal blood cell count.
nodes: A Reappraisal no clear signs of rupture. A breast magnetic 50 mg/day) combined with symptomatic Blood chemistry and urine analyses were
treatment with oxycodone/naloxone.
within normal ranges. The autoimmune
resonance imaging (MRI) revealed the pres-
ence of intra-capsular prosthesis rupture In September 2015, bone scintigraphy profile, including antinuclear antibodies,
Tatiana Dorfman MD , Mariya Neymark MD , Julia Begal MD and Yoram Kluger MD FACS 1,3 [Figure 1A]. Symptomatic treatment with was performed and showed the presence anticentromere, anti-SSA/Ro, anti-SSB/La,
1,2
1
1
indobufen and colchicine was started, which of diffuse cervical-dorsal-lumbar arthritis. anti-Scl70, anti-Jo-1, anti-Sm, anti-dsDNA,
1 Division of General Surgery, Ambulatory and Breast Surgery Service and Surgical Oncology Service, Rambam Health Care Campus, affiliated with Rappaport Faculty of resulted in a partial response. The fever dis- Based on the persistence of acute pain and rheumatoid factor were negative.
3
2
Medicine, Technion–lsrael Institute of Technology, Haifa, Israel
appeared after administering medium-high and the radiologic findings, the patient Inflammatory indices were within normal
doses of corticosteroids. A further discus- was hospitalized for further examination. ranges. Based on these results, close follow-
sion of the case led to the diagnosis of ASIA Laboratory tests revealed an increase in up alone was proposed, together with the
as the patient fulfilled the criteria set for the both CRP levels (37.8 mg/dl, cut-off value continuation of symptomatic treatment
circumstances, tissue extraction via core needle biopsy is not syndrome, including fever, the presence of 0.5 mg/dl) and high ESR rate (21 mm/h, (oxycodone/naloxone 5 mg/day and ibu-
ABSTRACT: Background: Enlarged lymph nodes (ELN) pose a great diag- adequate or tissue architecture is ruined and therefore diagnosis autoantibodies, chronic fatigue syndrome, cut-off value 15 mm/h). Total spine MRI profen 600 mg as needed).
nostic challenge. They may represent the first clinical finding cannot be established [3,4]. If that is the case, surgical biopsy muscle weakness, arthralgia, and arthritis. revealed the presence of bilateral alterations Further discussion of the case led to the
of a hematologic disease or other malignancy and may be an is scheduled. Patients often wait substantially long periods of Based on the diagnosis, the indication was of the trabecular bone of the clavicle and of diagnosis of ASIA syndrome as the patient
indication of a wide range of infectious and non-infectious time for a biopsy and consequently diagnosis is deferred and to remove the prostheses, and the patient the sternal manubrium at the level of the fulfilled the criteria set for the syndrome,
diseases. Because many patients undergo percutaneous biopsy, treatment is delayed. Furthermore, a large percentage of patients chose to undergo the procedure. Over the sternoclavicular joint due to intraosseous including exposure to an external stimu-
surgical excisional biopsy is not often considered. undergo more than one core needle biopsy before eventually following months, the fever disappeared and edema. Moreover, total body PET showed lus prior to clinical manifestations and
Objectives: To analyze indications for a patient’s referral for requiring surgical biopsy to make a final diagnosis. Although she reported a significant improvement in diffuse fixation of the tracer predominantly the appearance of symptoms like chronic
surgical biopsy of ELN and diagnostic steps to follow until some patients who undergo surgical biopsy show no specific systemic symptoms and complete resolution near the left prosthesis and focal hyper- fatigue syndrome, myalgia, muscle weak-
referral, and to determine the number of ELN. pathology and do not require explicit treatment, it is neverthe- of arthralgia. fixation corresponding to multiple mam- ness, arthralgia, and arthritis. Therefore, on
Methods: A retrospective study was conducted of prospectively less important to improve patient pathways of care to allow for mary lymphadenopathies [Figure 2B]. this basis, the indication was removal of the
collected data from patients who underwent surgical biopsy the delivery of timely and appropriate treatment. We analyzed An ultrasound-guided breast biopsy was prostheses. However, the patient opted not
of ELN from January 2004 to December 2013. the pathways of care for patients referred for surgical diagnostic CASE 2 performed to characterize the lesions that to undergo the procedure at that time. In
A 36 year old Caucasian woman underwent
Results: Of 118 patients who underwent surgical biopsy of
ELN, only 52 (44%) had a needle biopsy (NB) before referral. lymph node biopsy at our institute. bilateral mastectomy for mammary carci- had previously been observed in the PET. August 2015, she reported a spontaneous
Lymphoma was diagnosed by NB in 24 (46%) of the referred noma in 2002. Since the sentinel lymph Histological results showed the presence of improvement in symptoms, so she stopped
patients. In patients with a previous diagnosis of lymphoma, PATIENTS AND METHODS node histology examination was negative, frustules of connective muscles with areas taking medication and was able to engage
NB of ELN yielded a sensitivity of 67% and specificity of 79%. hormonal therapy alone with tamoxifen of fibrosis and giant cell histiocytic reac- in regular physical activity.
In patients with lymphadenopathy but with no previous history The study was a retrospective cohort analysis of all patients and triptorelin was started. When she was tion. Mammary ultrasound revealed that
of malignancy, sensitivity for lymphoma was 68% and speci- who underwent surgical biopsy of for ELN at the general sur- 46 years of age, breast reconstruction using the prostheses appeared to be undamaged.
ficity was 71%. The investigative time period until final diagno- gery department at the Rambam Health Care Campus, Haifa, silicone prostheses was performed. One month later, the patient was referred COMMEnT
sis was 3 months in patients who had NB but only 1.25 months Israel, from January 2004 to December 2013. The files of all In 2014, 2 years after the surgical proce- to our center because of the persistence Our two cases fulfilled Shoenfeld’s criteria
in patients who were referred directly for surgery (P < 0.0001). patients who underwent surgical biopsy of lymph nodes to aid dure, at age 48 years, the patient presented of back pain, myalgia, and chronic fatigue for the diagnosis of ASIA [1]. However, the
Conclusions: Surgical biopsy of ELN still has a place in the diagnosis were collected from computerized hospital records. with acute pain on the right side of her face, syndrome characterized by the presence of type of clinical symptom presentations are
clinical evaluation of patients with ELN. Surgery may signifi- Patients were excluded if surgical lymph node biopsy or dis- which resolved spontaneously within a few severe asthenia, muscle weakness, irritabil- unusual. Renal failure has been described
cantly reduce the length of investigation and prevent un- section was performed as part of staging surgical procedures. days. One week later, she started to experi- ity, and sleeping disorders. On admission, in the literature. The main pathophysiologi-
necessary diagnostics, especially in patients with suspected Data collected from the prospective database included patient ence low back pain with lower limb irra- the physical examination was unremark- cal mechanism of kidney damage seems to
lymphoma recurrence. demographics, preoperative diagnoses, laboratory and imaging diation that was not responsive to medium- able. Serological evaluation and laboratory be granulomatous inflammation confined
IMAJ 2018; 20: 674–678 evaluations, preoperative pathological needle biopsy results, and
KEY WORDS: enlarged lymph nodes (ELN), lymphadenopathy, the anatomical site of the previous biopsy. Data about the surgi- figure 1. [A] Magnetic resonance imaging shows the intra-capsular rupture of the right prosthesis, [B] Total body positron emission tomography (PET) shows
lymphoma, percutaneous biopsy cal lymph node biopsy included the site and final pathological diffuse fixation of the tracer predominantly near the left prosthesis and focal hyper-fixation in correspondence to the adenopathies of the right internal
results as well as the elapsed period until surgical biopsy. The mammary chain (maximum diameter 17 mm) and of the left internal mammary chain, although lower down (maximum diameter 12 mm)
study was approved by the ethics committee of the Rambam A B
Health Care Campus.
nlarged lymph nodes (ELN) are sometimes the first clini-
E cal finding of an illness, specifically of hematologic origin. STATISTICS
A surgical lymph node biopsy for the purpose of diagnosis is Statistical analyses were performed using IBM Statistical
occasionally required. Package for the Social Sciences statistics software, version 21
Currently, ultrasound or computed tomography (CT)-guided (SPSS, IBM Corp, Armonk, NY, USA). Descriptive statistics
biopsies are the gold standard for tissue sampling because they in terms of mean, standard deviation, median, and percentiles
are minimally invasive procedures that are associated with low were applied to all parameters in the study. Fisher’s exact test
morbidity and an acceptable diagnostic yield [1-3]. In some was used to determine differences between categorical param-
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