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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00872-0
10.1016/j.radcr.2024.08.089
Case Report
Migrating foreign material mimicking metastatic soft tissue sarcoma in a patient with history of synthol injection
Jaber Rachid rashidjaber44@gmail.com
ab⁎
Azizi Lamia ab
Nasser Selim ab
Alameh Zouheir ac
Nassar Anis ab
Faddoul Sami ab
a Radiology Department, University of Balamand, Beirut, Lebanon
b Doctors Center Laboratory and Radiology, Hamra, Beirut, Lebanon
c Consulting and Diagnostic Clinics Aley, Lebanon
⁎ Corresponding author. rashidjaber44@gmail.com
13 9 2024
12 2024
13 9 2024
19 12 58285833
15 6 2024
15 8 2024
16 8 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Injecting substances like Synthol for cosmetic muscle enhancement is known, but its potential for causing severe systemic complications is less documented. This case highlights the risks of foreign material migration, initially presenting as a suspected malignancy. A 47-year-old male presented with dyspnea and bilateral diffuse airspace opacities on chest X-ray, initially raising suspicions for metastatic disease. The patient's medical history was unremarkable until further detailed questioning revealed the use of Synthol injections. Initial imaging suggested metastatic soft tissue sarcoma with bilateral lung and various soft tissue masses detected on PET-CT scans. However, subsequent detailed examinations, including a CT-guided biopsy of the lung lesions, revealed no evidence of malignancy but instead chronic inflammation and fibrosis indicative of a reaction to foreign material. This finding prompted a re-evaluation of the initial diagnosis, leading to the identification of Synthol migration as the underlying cause of the patient's symptoms. This case underscores the importance of considering foreign substance migration in the differential diagnosis for patients presenting with unexplained tissue masses and emphasizes the need for thorough history-taking in elucidating the etiology of atypical radiologic findings. Early detection and accurate diagnosis can prevent unnecessary invasive procedures and facilitate appropriate management.

Keywords

Case report
Migration
Foreign material
Synthol
Lung
==== Body
pmcIntroduction

The introduction of foreign materials into the human body, whether intentional or accidental, can lead to a myriad of medical complications. These materials can range from ingested objects, implanted medical devices, to substances injected for cosmetic enhancement, such as Synthol [1]. Among the potential risks associated with foreign bodies, their ability to migrate from the original site of introduction to other parts of the body is particularly concerning [2]. This migration can result in unusual clinical presentations, complicating diagnosis and management.

Foreign body migration is a well-documented medical phenomenon. It occurs across various scenarios: ingested objects may move through the gastrointestinal tract and perforate the bowel [3]; implanted medical devices such as catheters [4] or stents [5] can shift position; and injected substances like silicone or other fillers can travel through lymphatic or vascular channels [6]. The lungs are a common destination for migrating materials due to their extensive vascular supply and the high-pressure system which can carry materials from distant sites.

The migration of substances to the lungs can present with a range of symptoms from asymptomatic to severe respiratory distress, depending on the nature of the material, the volume, and the body's reaction to it. For instance, migrated foreign bodies can lead to granuloma formation, chronic inflammation, or fibrosis [1,[3], [4], [5]]. The same applies to migratory subcutaneous implants [[7], [8], [9]]. Such cases are challenging not only due to the rarity of the presentations but also due to the difficulty in establishing a diagnosis. Radiological findings can mimic more common pathologies such as tumors or infections, leading to misdiagnosis and inappropriate management.

One of these substances that has been reported in the literature is Synthol. It is a substance often used by bodybuilders for cosmetic muscle enhancement. It is a site enhancement oil (SEO) composed of a mixture of oils, benzyl alcohol, and lidocaine [10,11]. Bodybuilders inject Synthol directly into their muscles to increase their size and alter their shape without actually increasing muscle strength. The injected oil remains in the muscle, causing it to swell, and the cosmetic effect can be immediate, although the risks are significant. Synthol can cause severe complications [1], such as infection, nerve damage, and pulmonary embolism.

In the context of this case report, our patient's use of Synthol led to the migration of this foreign material, mimicking metastatic disease in the lungs, which was initially misdiagnosed as soft tissue sarcoma.

Case report

A 47-year-old male, previously healthy, presented to our healthcare facility complaining of progressive dyspnea on exertion that had been troubling him for the past month. His initial evaluation included a chest X-ray, which revealed bilateral diffuse air space opacities. Despite the concerning findings, the patient chose to defer further diagnostic procedures at that time.

Approximately 1 month later, the patient returned with new symptoms, including notable soft tissue edema localized to the iliac fossa, shoulders, and chest. These symptoms prompted a referral to a peripheral hospital for more extensive evaluation. At this facility, an axial unenhanced computed tomography (CT) scan was performed on the chest, showing bilateral irregular masses in the lung with fat density (Fig. 1). The patient then underwent a positron emission tomography-computed tomography (PET-CT) scan, which showed fluorodeoxyglucose (FDG) avid soft tissue masses in the aforementioned areas (Fig. 2), and to a lesser extent in the chest (Fig. 3). Additionally, multiple FDG avid lesions were observed in the lungs, both shoulders, and in the iliac fossa bilaterally (Fig. 4). Based on these imaging findings, a preliminary diagnosis of metastatic soft tissue sarcoma was considered.Fig. 1 Axial unenhanced CT scan of the chest shows bilateral irregular lung masses with lipid attenuation.

Fig 1

Fig. 2 Axial FGD PET Scan shows bilateral avid uptake of the lung masses seen of the chest CT scan.

Fig 2

Fig. 3 Axial fused PET CT scan shows FDG avid bilateral lung lesions and avid soft tissue lesions within the anterior chest wall later attributed to inflammation.

Fig 3

Fig. 4 Coronal PET CT scan shows uptake in the soft tissues of the shoulders bilaterally and in the iliac fossa bilaterally. Additional uptake is also noted on the lung parenchyma.

Fig 4

Due to the gravity of the diagnosis, the patient was referred to our center for a second opinion. A detailed patient history was obtained, revealing that the patient had experienced a similar episode of soft tissue edema approximately 10 years prior, which had resolved spontaneously. Crucially, the patient disclosed a history of intramuscular injections of a body enhancing substance known as Pump & Pose (Synthol) during that period. This information was pivotal in guiding subsequent diagnostic steps.

Given the patient's history and the physical findings, a decision was made to perform an aspiration of the edematous shoulder tissue. The procedure yielded an oily material, likely related to the previously injected Synthol. Concurrently, a re-evaluation of the imaging studies, particularly focusing on the density of the lung lesions, revealed characteristics consistent with low-density fat rather than typical tumor tissue. These findings led to a significant shift in the diagnostic approach.

To further elucidate the nature of the lung lesions, a CT-guided biopsy was performed (Fig. 5). The biopsy (Fig. 6) results showed no evidence of malignancy but instead chronic inflammation with dense fibrosis and a histiocytic reaction to foreign material (Fig. 7). These pathologic findings, combined with the patient's history and clinical presentation, confirmed that the lung lesions were not metastatic tumors but rather complications arising from the migration of injected foreign material into the lung parenchyma.Fig. 5 CT guided biopsy of one of the lung lesions.

Fig 5

Fig. 6 Biospy specimen.

Fig 6

Fig. 7 Hematoxylin and Eosin staining showing lung parenchyma with marked fribrosis and oil-like materials with histiocytes and giant cell reaction: (A) 200x magnification power, (B) 400x magnification power.

Fig 7

This case underscores the importance of a thorough patient history and careful interpretation of imaging and histological findings to differentiate between potential diagnoses of metastatic disease and less common etiologies such as complications from foreign substances like Synthol.

Discussion

The migration of foreign materials within the body, particularly to the lungs, presents a complex diagnostic challenge often confounded by the material's origins—whether from medical interventions, cosmetic enhancements, or accidental ingestion. This case review and literature review discusses both animal studies involving Teflon (Polytetrafluoroethylene, PTFE) and human cases with Synthol, illustrating the systemic potential of foreign material migration.

Teflon injection studies in animals

Animal studies have provided valuable insights into the behavior of injected Teflon (Table 1). Malizia [12] observed that in dogs and monkeys, Teflon particles migrated to the lungs, brain, pelvic nodes, and spleen within 70 days postinjection, initiating a marked foreign-body giant-cell reaction with minimal fibrosis. Similar studies by Rames [13] and Aaronson [14] demonstrated Teflon migration from the bladder to the lungs and brain, confirming the material's potential to travel significant distances within the body, crossing anatomical barriers and resulting in organ-specific reactions. Miyakita [15] further documented this phenomenon, showing Teflon-induced granulomas in the brain and inconclusive lung involvement in mini-pigs and dogs.Table 1 A summary of animal studies that reported Teflon injection migration and the subsequent granulomatous reactions.

Table 1Author (YOP)	Sample	Examination	Injection material/Site	Diagnostic work-up	
Malizia (1984) [12]	Female dogs and male monkeys	Not clearly described	Polytef (Teflon) / Periurethral	The Polytef particles were found in 4 of the 7 lungs at 70 days and in all animals at 10 months. They were also present in the brain, pelvic nodes, kidneys (4 of 7), and spleen (2 of 7). Microscopic examination revealed marked foreign-body giant-cell reaction with minimal fibrosis. A few scattered black micro-spheres were observed.	
Rames (1991) [13]	5 dogs	The dogs were sacrified after 2 weeks of injection	Polytef paste 0.8-2.5 mL/Endoscopically into the bladder trigone	The lung and brain preparations showed foreign particles that were identical to the polytetrafluoroethylene present in the Polytef paste. Lung lesions were larger and more numerous than those of the brain. A few refractive particles were observed, representing incompletely digested tissue fragments and crystals	
Aaronson (1993) [14]	5 female mongrel dogs	Two animals were sacrified 14 days after injections	Polytef paste 0.4-1.25 mL/Bladder	The examination showed infiltrates in the lungs and the brains. Light microscopy revealed the polytetrafluoroethylene particles which were highly refractice with an irregular shape and markedly contoured surface.	
Miyakita (1994) [15]	4 mini-pigs and 4 dogs	Not clearly described	Polytef paste 0.3 mL/Left submucosal ureter	Gross and histological findings: Polytetrafluoroethylene implants were noted macroscopically on the left subureteral region. They were well-circumscribed masses with firm consistency. Microscopic examination: The particles were encapsulated by a thin layer of fibrous tissue with foreign body granuloma containing macrophages and multinucleated giant cells. Lungs: macroscopic examination was inconclusive with no abnormalities. The histological examination revealed the presence of a lung granuloma. In the brain, the particles were found in the cerebral vessels.	

Synthol injection cases in humans

In human cases, Synthol has been used primarily for cosmetic muscle enhancement, but similar to Teflon, it has demonstrated potential for migration and systemic effects. In 1 documented case [1], a 36-year-old woman developed granulomatous disease in the lungs and local granulomas in the gluteal region following Synthol injections, leading to secondary hypercalcemia and nephrocalcinosis. Another case involved a 31-year-old man who experienced recurrent painful edema and systemic infections in the biceps after Synthol injections, necessitating surgical intervention to remove damaged tissue showing foreign body giant cell reactions [2].

In our case, the patient was initially suspected of having metastatic soft tissue sarcoma based on the presentation of diffuse bilateral opacities and soft tissue masses across various body regions. The eventual diagnosis of migrating foreign material causing similar imaging findings underscores the critical need for a thorough medical history and awareness of such substances' potential systemic impacts. On the other hand, the case report by Alimoradi [1] experienced systemic effects manifesting as granulomatous disease in the lungs and secondary hypercalcemia likely triggered by the immune response to migrated Synthol. The involvement of the calcium metabolism pathway in this case is particularly notable, as it illustrates a severe biochemical disruption caused by the foreign material, leading to substantial diagnostic confusion with more common endocrine conditions. Meanwhile, the case by Siste [2] focused more on localized effects with periodic systemic infection symptoms due to the presence of foreign material in the biceps. This patient experienced recurrent inflammation and was managed with antibiotics and eventual surgical intervention, demonstrating the potential for ongoing complications from Synthol injections, even several years after administration.

Both reviewed cases and our current report demonstrate the body's robust inflammatory response to foreign materials. Migration from the injection site to distant organs such as the lungs can occur through lymphatic or hematogenous routes, facilitated by the small particle size of the injected material or its mechanical displacement through muscle activity [16]. The inflammatory response includes granuloma formation, a protective mechanism wherein the immune system attempts to isolate the foreign substance [6,12]. This can lead to tissue necrosis, chronic inflammation, and, as seen in our patient, mimicry of malignant processes on imaging studies.

In summary, this case-based discussion underscores the diverse clinical manifestations associated with Synthol use, from localized inflammatory reactions to systemic migration with significant physiological consequences. These cases advocate for increased awareness among clinicians regarding the potential complications associated with cosmetic injections, emphasizing the need for comprehensive history-taking and consideration of such etiologies in atypical presentations.

Declaration of generative AI and AI-assisted technologies in the writing process

The authors declare not using any AI or AI-assisted technologies in the preparation of this work or in the writing of the manuscript.

Patient consent

Complete written informed consent was obtained from the patient for the publication of this study and accompanying images.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments: This research did not receive any financial support from any organizational or nonorganizational institutions.
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