Diagnostic and management challenges of late chest wall mass following implant-based breast reconstruction: a case report

Peri-prosthetic late hematoma following breast implant procedure is defined as a hematoma presenting longer than 6 months after operation and is a rare complication with sporadic cases reported throughout literature. We present a case of an 85-year-old patient who developed a spontaneous late hematoma nearly 20 years following implant-based breast reconstruction and adjuvant chemotherapy to illustrate the importance of maintaining a wide differential when approaching a chest wall mass that cannot be biopsied in a patient who has previously received breast implants. MRI revealed a peri-implant effusion with a heterogeneous mixed signal partially enhancing mass measuring 3.2 x 4.3 x 1.7 cm, posterior to the left breast implant. The patient had bilateral Mentor smooth, round, silicone, 350 cc implants in the submuscular plane. Ultrasound-guided biopsy was attempted and unsuccessful due to inability to displace the implant and access the mass, indicating the need for an open biopsy. The patient underwent radical left chest wall mass excision of the posterior implant capsule, removal of the left implant, and closure of the anterior capsule. Final pathology confirmed the diagnosis of organized hematoma. Immunophenotyping flow cytometry was utilized to rule out BIA-ALCL or BIA-SCC. Our case is unique in that biopsy was unable to be obtained given retro-implant position of the mass and that the diagnosis and etiology of late hematoma formation following smooth round silicone implants has been infrequently discussed in literature. Providing a comprehensive workup considering patient history, physical exam findings, imaging, and pathology ensures a wide differential optimizing patient outcomes.