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morbidity and an acceptable diagnostic yield [1-3]. In some
are minimally invasive procedures that are associated with low
biopsies are the gold standard for tissue sampling because they
Currently, ultrasound or computed tomography (CT)-guided
occasionally required.
A surgical lymph node biopsy for the purpose of diagnosis is
E cal finding of an illness, specifically of hematologic origin.
nlarged lymph nodes (ELN) are sometimes the first clini-
A
lymphoma, percutaneous biopsy
enlarged lymph nodes (ELN), lymphadenopathy,
KEY WORDS:

lymphoma recurrence.
necessary diagnostics, especially in patients with suspected
cantly reduce the length of investigation and prevent un-
clinical evaluation of patients with ELN. Surgery may signifi-
Conclusions: Surgical biopsy of ELN still has a place in the
in patients who were referred directly for surgery (P < 0.0001).
sis was 3 months in patients who had NB but only 1.25 months
In 2014, 2 years after the surgical proce-
ficity was 71%. The investigative time period until final diagno-
of malignancy, sensitivity for lymphoma was 68% and speci-
In patients with lymphadenopathy but with no previous history
NB of ELN yielded a sensitivity of 67% and specificity of 79%.
patients. In patients with a previous diagnosis of lymphoma,
Lymphoma was diagnosed by NB in 24 (46%) of the referred
ELN, only 52 (44%) had a needle biopsy (NB) before referral.
Results: Of 118 patients who underwent surgical biopsy of
of ELN from January 2004 to December 2013.
collected data from patients who underwent surgical biopsy
Methods: A retrospective study was conducted of prospectively
referral, and to determine the number of ELN.
surgical biopsy of ELN and diagnostic steps to follow until
Objectives: To analyze indications for a patient’s referral for
surgical excisional biopsy is not often considered.
diseases. Because many patients undergo percutaneous biopsy,
indication of a wide range of infectious and non-infectious
of a hematologic disease or other malignancy and may be an
nostic challenge. They may represent the first clinical finding
Background: Enlarged lymph nodes (ELN) pose a great diag-
ABSTRACT:
2
1,2
Case CommuniCations Case CommuniCations B Further discussion of the case led to the be granulomatous inflammation confined cal mechanism of kidney damage seems to in the literature. The main pathophysiologi- unusual. Renal failure has been described type of clinical symptom presentations are for the diagnosis of ASIA [1]. However, the Our two cases fulfilled Shoenfeld’s criteria COMMEnT in regular physical activity. taking medication and was able to
#
ASIA Syndrome Following Breast Implant Placement eters. Diagnostic measurements using sensitivity and specificity pERCuTAnEOuS nEEDlE BIOpSIES
statistics were conducted to assess how often the preoperative Prior to being referred for surgical lymph node biopsy, the
Roberta Fenoglio MD, Irene Cecchi MD and Dario Roccatello MD pathological needle biopsy diagnostic results agreed with those patients underwent a wide range of investigations [Table 1].
from the final surgical lymph node biopsy. Mann–Whitney U Sixty-six patients (56%) were sent for surgery after investi-
CMID – Division of Nephrology and Dialysis (ERK-net member), St. Giovanni Bosco Hospital and University of Turin, Turin, Italy test was used for demonstrating differences among groups. gations without any attempt at percutaneous biopsies. In
P < 0.05 was considered as statistically significant. these cases, the indications were lymphadenopathy in 47% of
patients, previous history of lymphoma in 19.7%, nonspecific
symptoms in 16.7%, FUO in 15.2%, and a history of cancer
the 36 cases, symptoms had completely therapy combining methylprednisolone RESULTS in 1.5%.
KEY WORDS: adjuvant substances, ASIA syndrome, disappeared. Other retrospective studies (3 bolus doses of 15 mg/kg followed by A total of 118 patients underwent a diagnostic surgical lymph Fifty-two patients (44.1%) underwent percutaneous biopsy
autoimmune syndrome, breast also reported that removing the implants oral prednisone, 50 mg for 2 weeks, which node biopsy during the study period. The most common prior to surgical consultation. Reasons included lymphade-
implant, silicone resulted in an improvement in symptoms was rapidly tapered to 5 mg in 2 months) indication for surgical biopsy was lymphadenopathy, which nopathy in 44.2% of patients, previous history of lymphoma
131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Magenta
such as fatigue, arthralgia, myalgia, sicca, with cyclophosphamide (two pulses of 500 was reported in 54 (46%) patients. Other reasons for initiating in 34.6%, history of cancer in 9.6%, and FUO in 3.8%. One
IMAJ 2018; 20: 714–716
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:-- | Black
and pyrexia in most patients. However, in mg, 2 weeks apart) in conjunction with investigations included a previous history of lymphoma in 31 patient presented with nonspecific symptoms and one had
131118-COHANIM - 131118-COHANIM | 2 - A | 18-11-13 | 11:24:13 | SR:-- | Cyan
other cases, improvement in the disease rituximab (4 weekly doses of 375 mg/m 2 ). patients (26.3%), fever of unknown origin (FUO) in 14 patients been diagnosed with HIV.
course was seen with medical treatment Renal function improved (SCr 1.2 mg/dl) (12%), and a history of cancer in 6 patients (5%). Twelve patients Of the 52 patients who underwent percutaneous biopsy
utoimmune/inflammatory Syndrome alone [3-4]. and proteinuria dropped to < 1 gr/day. (10%) presented with nonspecific symptoms, and one patient 75% experienced one attempt at the procedure, 9 patients
A Induced by Adjuvants (ASIA) syn- Recently, Dagan and co-authors [3] sug- In August 2015, the patient started to was diagnosed with human immunodeficiency virus (HIV). (17%) endured two attempts, and 4 patients (7.7%) under-
drome was first described in 2011 by gested that medical treatment alone should experience systemic symptoms and both Patient demographics and main indications for referral are went more than two biopsies. The distribution of the site
Shoenfeld and Agmon-Levin [1]. The be the first approach. If the patient fails to her general condition and renal function shown in Table 1. of percutaneous biopsy was inguinal in 38% (20/52), axil-
syndrome incorporates several condi- recover with medical treatment, she should worsened. A kidney biopsy confirmed lary in 23% (12/52), intraperitoneal in 23% (12/52), cervi-
tions linked to previous exposure to an be provided with up-to-date information to the previous diagnosis of membranous Table 1. Patient demographics and indications for referral cal in 17% (9/52), and other sites in 4% (2/52) of patients.
adjuvant substance, including silicone. It help her decide whether to explant. Both of nephropathy. Dialysis and administration of n (%) Twenty-four (46%) of these 52 patients were diagnosed with
is currently still being debated whether our patients received the most up-to-date low doses of corticosteroids were resumed. Patient Male 65 (55.1) new lymphoma, while in 12 patients (23%) the pathologic
silicone-filled breast implants increase the information about their condition, and Due to persistent arthralgia and recurrent demographics Female 53 (44.9) result was non-diagnostic. One patient’s pathology showed
risk of autoimmunity. Patients develop one patient decided to remove the implants episodes of fever that did not respond to Age in years, mean ± standard deviation 49 ± 18 granulomatous infection, while 29% of patients showed no
(range 18–83)
both non-specific and specific manifesta- while the other decided not to. Both of them intravenous antibiotic therapy, in December Indications for Lymphadenopathy 54 (46) identifiable pathology [Table 1]. No statistical difference
tions of autoimmune diseases that cannot showed good overall clinical response. 2015, she was hospitalized for further referral Lymphoma 31 (26.3) was found in patients who underwent percutaneous biopsy
be classified as classic connective tissue examinations. On admission, the patient FUO 14 (12) before surgery and those who did not, with regard to disease
Nonspecific symptom
disorders. The clinical manifestations are presented with a temperature of 38–38.5°C Cancer 12 (10) history.
6 (5)
highly heterogeneous. Systemic autoim- pATIEnT DESCRIpTIOn with no evidence of infection, albeit with HIV 1 (0.8)
mune adverse reactions related to silicone CASE 1 arthralgias/knee arthritis and severe non- Clinical Chest X-ray 97 (82.2) SuRgICAl lyMpH nODE BIOpSIES
have rarely been reported. A 23 year old Caucasian woman under- hemolytic anemia. Microbiology tests investigations CT scan 72 (61) The anatomical distribution of the excised lymph nodes is
Ultrasound examination
65 (55.1)
We present two cases of ASIA syndrome went bilateral breast implant surgery in were persistently negative and C-reactive EUS 4 (3.4) detailed in Table 2. The most common locations for lymph-
associated with silicone breast implant 1998 for cosmetic reasons. protein (CRP) was within normal ranges PET/CT 44 (37.3) adenopathy were inguinal in 39.8% and axillary in 32.2% of
rupture. The amount of time that elapsed In 2000, at the age of 25 years, she devel- (0.5 mg/dl, cut-off value < 0.5 mg/dl), but MRI 7 (5.9) patients. Of the 118 patients, the dominant histopathology
BMB
36 (30)
between silicone breast implant placement oped membranous nephropathy (biopsy- the erythrocyte sedimentation rate (ESR) Blood tests 118 (100) diagnosis from surgical biopsy was lymphoma in 48 (40.7%).
and the onset of symptoms was approxi- proven) that was treated with corticoste- was high (86 mm/h, cut-off value 15/h). Reason Lymphadenopathy 31 (47) Other findings of surgical biopsy included nonspecific lymph-
mately 2 years in both cases. This time frame roids alone, resulting in complete remission. Immunological screening revealed only for surgery Lymphoma history 13 (19.7) adenopathy in 32 (27.1%), specific nontuberculous lymphad-
Nonspecific symptom
without
is consistent with the current literature, Nine years later (2009) the nephropathy weak positive (1:80) antinuclear antibod- previous FUO 11 (16.7) enitis in 29 (24.6%), tuberculous lymphadenitis in 3 (2.5%),
10 (15.2)
which suggests that a long interval between relapsed. She was treated with a conven- ies (ANA). Anti-centromere, anti-SSA/Ro, needle biopsy Cancer history 1 (1.5) metastatic lymphadenopathy in 2 (1.7%), non-diagnostic in 1
implant surgery and onset of symptoms (i.e., tional regimen of steroids with alkylating anti-SSB/La, anti-Scl70, anti-Jo-1, anti-Sm, Reason for Lymphadenopathy 23 (44.2) (0.8%), and leukemia in 1% of patients [Table 3].
from 1 month to 39 years) is needed before agents, again resulting in complete remis- and anti-dsDNA antibodies were negative, needle biopsy Lymphoma history 18 (34.3)
before surgery Nonspecific symptom
observing any significant adjuvant effects by sion. as were rheumatoid factor C3 and C4. FUO 1 (1.9) Table 2. Anatomical distribution of the surgical lymph nodes biopsies
4 (7.7)
silicone migrating out of the implants. Over the following years the patient Screening for fever of unknown origin and Cancer history 5 (9.6)
Only a few studies have provided a had two episodes of acute renal failure and tests for familial fevers were negative. Chest HIV 1 (1.9) Anatomical Site n (%)
detailed evaluation of the effect of silicone worsening of proteinuria. Following the X-ray, abdominal ultrasound, total body Pathology No pathology 15 (29) Axilla 38 (32.2)
Lymphoma
Inguinal
revealed by
24 (46)
prosthesis removal following the develop- first episode, she underwent hemodialy- positron emission tomography (PET), and needle biopsy Non-diagnostic 12 (23) Intraperitoneal 47 (39.8)
23 (19.5)
Granulomatous infection
Cervical
sis in another hospital and received three
echocardiography were negative. Due to
ment of systemic manifestations. Maijers
8 (6.8)
1 (2)
PERFECTOR and colleagues [2] reported that 36 out of methylprednisolone pulses followed by oral her implants, a breast ultrasound was per- BMB = bone marrow biopsy, CT = computed tomography, EUS = endoscopic Hand 1 (0.8)
Thigh
1 (0.8)
ultrasound, FUO = fever of unknown origin, HIV = human immunodeficiency
formed. The results showed abnormalities
steroids. For the second episode, she was
52 women showed a significant decrease
virus, MRI = magnetic resonance imaging, PET/CT = positron emission
Total
118 (100)
tomography/computed tomography
in symptoms following an explant. In 9 of
referred to our center and given a rescue
at the margins of the prosthesis (right side)
714 675