PMC6159137_01
(a) Supraclavicular oblong mass (arrow) as noticed by patient at the time of presentation. (b) Hypoechoic, approximately 11-cm oblong mass in the left supraclavicular fossa demonstrated on 12-MHz linear probe ultrasound.
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A 46-year-old female presented to her general practitioner with a painless left supraclavicular mass (Figure 1a). Initial imaging was performed with both ultrasound (Figure 1b) and CT.
MRI on presentation, coronal reformats showing a (a) short tau inversion-recovery (STIR) hyperintense mass in the left supraclavicular fossa. Although no silicone-excited sequences were performed, the material was of the same intensity as the breast material and a diagnosis of silicone migration was made. (b) Pre-contrast T1 weighted TSE scan in which the isointense mass is evident, however, not clearly distinguishable from surrounding tissue. (c) Post-contrast T1 weighted TSE fat-saturated image that allows the mass and further components along the chest wall to be visualized. TSE, turbo spin echo.
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An MRI was performed (3T Siemens Trio Tim magnet; Siemens Healthcare, Erlangen, Germany) (Figure 2) to further define the mass and its vascularity before treatment. Imaging showed a well-defined, T2 and STIR high signal, complex cystic lesion extending from the lower anterior left neck posteriorly into the supraclavicular fossa (Figure 2a).
Images from the second presentation. (a) Schematic drawing from sonographer depicting the extent of the collection through the anterior chest wall, axilla and arm. (b) Ultrasound scan, transverse plane, shows large, heterogenous collection within the proximal medial portion of the left arm. It encases the NVB and displaces the biceps muscle. It is not characteristic for silicone, as it does not produce the typical "snow storm" artefact. (c) Post-contrast CT coronal reformat confirms a large wall-enhancing heterogenous collection extending between the neck and the swollen arm, as demonstrated in the previous ultrasound. NVB, neurovascular bundle.
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An ultrasound scan was performed to exclude abscess formation, and it demonstrated a complex, heterogenous collection with nodular internal echogenic material, extending from the left supraclavicular fossa into the left chest wall as well as along the proximal, medial part of the left arm (Figure 3a,b). After consenting to intravenous contrast administration, she progressed to have a CT of the neck and left upper limb with split bolus intravenous contrast (Figure 3c).
Axial non-contrast enhanced MR breast images. (a) T1 non-fat-saturated image showing isointense tissue in both breasts; note asymmetry with the right breast larger than the left and left lateral pectoral/anterolateral chest wall fullness. (b) T2 silicone-excited image shows high signal material in predominantly retroglandular location, also wrapping around the lateral edge of the right major pectoral muscle; slightly hyperintense tissue in the left chest wall adjacent to the pectoral muscle, different signal to intramammary tissue. (c) Turbo inversion recovery magnitude water-saturated silicone-excited scan allows to discriminate between silicone and other fluid; strongly hyperintense material represents silicone. The paucity of silicone within the left breast and the migration around the left pectoral muscle is noteworthy.
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The following day, an MRI was performed to delineate between the silicone and the infective process in the arm (Figure 4).
MRI coronal reformats from the neck and left arm demonstrating a large supraclavicular mass extending into the arm. (a) T1 weighted TSE pre-intravenous-contrast, (b) T1 weighted TSE sequence post-gadolinium contrast with fat saturation. The post-contrast study clearly shows the known silicone collection in the supraclavicular fossa tracking into the axilla and proximal arm and defines the planes between the collection and muscles. (c) T2 fat-saturated TSE scan and (d) post-contrast T1 TSE fat-saturated scan. TSE, turbo spin echo.
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The volume of silicone within the left breast had decreased significantly from the previous MRI, and silicone was identified throughout the supraclavicular fossa migrating into the biceps compartment of the left arm (Figure 5).