Breast cancer is common in women and often treated with radiation therapy to the chest wall, which is known to cause injury to the underlying ribs. It is also common for these women to undergo reconstructive surgery of the breast. We believe this is the first reported case of over filling of a breast implant causing pleural effusion without the implant rupturing. The mechanism was from abnormal pressure within the chest wall impairing normal lymphatic drainage.
The patient is a 48 year old female who was diagnosed three years earlier with left sided breast cancer. She underwent a lumpectomy with lymph node dissection because of a positive sentinel node. She had subsequent chemotherapy and radiation therapy. Recently, because of biopsy proven DCIS on the left side, she underwent total mastectomy with contra lateral prophylactic mastectomy. Bilateral breast reconstruction was performed with saline filled implants. The left breast required multiple additional saline installations every couple of weeks over several months, because of asymmetry in breast size. This was caused by fracture and inward displacement of an underlying atrophic rib injured from radiation therapy. She then developed shortness of breath and was found to have a large left sided pleural effusion. A Chest CT scan of the chest showed the implant was bulging into and compressing the left mid lung. Aside from the effusion, there was no other sign of malignancy. Several days later a thoracentesis was cancelled because a radiograph performed prior to the procedure showed a significant decrease in size of the effusion. A follow up film two weeks later showed the effusion had again increased in size, so a thoracentesis was performed. The fluid was negative for malignancy. It was not bloody, ruling out trauma as a cause. Leakage of saline was also excluded as a cause because surgery was able to recover all of the saline used to fill the implant. After the implant was completely emptied of saline, within one week the effusion resolved with total resolution of symptoms.
The treatment of breast cancer is associated with a number of complications related to surgery as well as radiation. Surgery is associated with local complications including infection, hematoma, implant rupture, seroma, lymphedema of the arms, muscle and nerve destruction, and chest wall injury. Radiation therapy is known to cause complications to the skin, lungs, and ribs. Breast implants have only been reported to cause pleural effusion when the implant ruptured.
Because the normal drainage of pleural fluid occurs through the lymphatic drainage of the parietal pleura, we believe the mechanism of this exudative effusion was due to partial obstruction of the lymphatic drainage from increasing pressure in the chest wall caused by over filling of the implant. Contributing factors were the atrophic radiated rib and possibly the previous lymph node dissection. This is supported by waxing and waning of the effusion, possibly due to positional changes. The complete recovery of all the fluid used to fill the implant ruled out rupture, and the absence of hemothorax ruled out trauma from the broken rib as causes for the effusion.
Mihaela Sescioreanu, None.