Imaging of breast implants -a pictorial essay
Poster No.:
C-1084
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
A. Sraj , S. Sripathi ; Westcliff-on-Sea/UK, Manipal/IN
Keywords:
Breast, Mammography, Ultrasound, MR, Screening, Surgery,
Multidisciplinary cancer care
DOI:
10.1594/ecr2015/C-1084
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Page 1 of 73
Learning objectives
To illustrate the spectrum of imaging findings ( Mammography, Ultrasound and MRI) in
breast implants.
To demonstrate role of MRI in assessing implant rupture.
Background
The common indications for breast implants include cosmetic augmentation and breast
reconstruction after mastectomy. Mammography and ultrasound are the initial modalities
used for evaluation of breast implants. MRI has a higher spatial resolution and
sequences which can suppress or enhance the signal from Silicone, hence it is used
for characterization and assessment of integrity of breast implants. It also demonstrates
breast diseases not related with implants.
Findings and procedure details
Breast implants are composed of saline, silicone or a combination of both and are
placed in sub-glandular or sub-pectoral location. To determine whether the implant is
retroglandular or sub-muscular , the medio-lateral oblique (MLO) view on mammogram
is more useful as it shows optimum imaging of pectoralis muscle. Breast implants may
be used in conjunction with breast reconstruction after mastectomy. The simplest type of
breast reconstruction uses the available tissues of the chest wall, with an implant placed
beneath the musculofascial layer (sub-pectoral). (Fig. 1 on page 40 ) ( Fig. 2 on page
40)
Page 2 of 73
Fig. 1: A) Line diagram of mammogram showing sub-pectoral and sub-glandular
location of implants and B) Line diagram of cross section of MRI showing the
type of implants- single lumen and double lumen implants.
References: Radiology, The Breast Unit (Nightingale Centre), Southend
University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Page 3 of 73
Fig. 2: A) Mammogram- Mediolateral oblique (MLO) view showing sub-glandular
implant and B) Cranio-caudal (CC ) view showing sub-pectoral implant location.
References: Breast Unit, Southend University Hospital, United Kingdom.
The various types of implants[1] are as follows:
•
•
•
Single-lumen gel: silicone gel-filled
Single-lumen adjustable: silicone gel-filled, to which can be added a variable
amount of saline at time of placement
Standard double-lumen: silicone gel inner lumen, saline outer lumen
Reverse double-lumen: saline inner lumen, silicone gel outer lumen
Reverse-adjustable double-lumen: silicone gel inner and outer lumens,
variable amount of saline added to inner lumen at time of placement
Gel-gel double-lumen: silicone gel inner and outer lumen
•
Triple-lumen: silicone gel inner and middle lumens, saline outer lumen
•
•
•
Once the implant is placed in position , there is formation of a thin fibrous tissue around
the implant. Sometimes this capsule becomes thickened leading to capsular contracture.
Early post-operative complications of breast implant include infection and hematoma[2]
formation. Implant rupture is the most common cause of implant removal and commonly
occurs 10-15 years after implantation [3]. The clinical diagnosis of implant rupture is
difficult because of non-specific findings such as palpable nodules, tenderness and
asymmetry [4] and sometimes the patients may be asymptomatic.
Page 4 of 73
Mammography: Mammography was done on a digital mammography unit (Siemens
MAMMOMAT inspiration) using standard Cranio-caudal (CC) and Medio-lateral Oblique
(MLO) views for routine evaluation. Eklund view can be done to demonstrate more breast
parenchyma in patients with implants. It is named after G W Eklund [5] who introduced
this new technique in 1988. Since the x-rays used for mammography cannot penetrate
silicone or saline implants properly to show the overlying or underlying breast tissue,
therefore, some breast tissue will not be seen on the mammogram. In Eklund view, the
implant is pushed back against the chest wall postero-superiorly and the breast is pulled
forward over it showing more of breast parenchyma. This view should not be done in
patients with capsular contractures. (Fig. 3 on page 41 ) ( Fig. 4 on page 41) ,(
Fig. 5 on page 42 )
Fig. 3: Line diagram showing A) Normal implant position B) Eklund technique-the
implant is pushed back against the chest wall and the breast is pulled forward over it so
that more of the breast parenchyma is included.
References: Radiology, The Breast Unit (Nightingale Centre), Southend University
Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Page 5 of 73
Fig. 4: Mammogram of both breasts-CC view without Eklund technique shows
normal breast implants
References: Breast Unit, Southend University Hospital, United Kingdom.
Page 6 of 73
Fig. 5: Mammogram of both breast CC of the same patient as in Fig 4 done with
Eklund technique showing more breast parenchyma.
References: Breast Unit, Southend University Hospital, United Kingdom.
Annual mammograms are done to look for any change in shape and configuration of
implant. Mammography is mainly useful for assessing surrounding breast tissue, contour
deformity, free silicone and peri-prosthetic calcification. It is an extremely specific method
for the diagnosis of extracapsular rupture and can detect silicone gel migration through
the glandular parenchyma [6, 7-9]. Mammography has limited role in evaluating implant
Page 7 of 73
integrity, especially intracapsular rupture and hence is not considered to be the modality
of choice for diagnosing intracapsular implant rupture .
Ultrasound: Ultrasound was done on Toshiba Aplio 500 state of art ultrasound
machine using multi-frequency high resolution linear transducers. Ultrasound is operator
dependent and requires expertise to interpret the imaging findings. It is predominantly
used to evaluate morphology, contour and contents of implants along with examining
peri-implant tissue and axilla [10]. On ultrasound the normal implant appears anechoic in
appearance and shows intact implant shell as a thin and continuous echogenic line at the
paranchyma tissue-implant surface. Sometimes a simple infolding of the implant shell is
also noted or a small amount of peri-implant fluid is seen which are normal findings in
intact implants. Reverberation artefacts are noted along the anterior aspect of implants
which should not be confused with implant rupture. Radial folds are seen as echogenic
lines extending from periphery of implant to the interior of implant. Ultrasound has a
limitation as it cannot evaluate posterior most extent of implants. ( Fig. 6 on page 43
) ,( Fig. 7 on page 44 )
Page 8 of 73
Fig. 6: Ultrasound of right breast shows the normal anechoic implant with intact
echogenic implant shell seen as echogenic line at implant tissue interface.
References: The Breast unit, southend University, Westcliff on sea,UK
Page 9 of 73
Fig. 7: Line diagram of ultrasound findings in normal breast implant(A) Breast implant
located posterior to pectoralis (B) Implant with peri-implant fluid (C) Breast implant
showing normal radial folds and reverberation artefacts which is a normal finding.
References: Department of Radio-diagnosis, Kasturba Medical College, Manipal,
India.
The stepladder sign, has been described as a predictive sign of intracapsular rupture
[11] on ultrasound. This sign corresponds to the "linguine sign" found in Magnetic
resonance imaging and is seen as a series of parallel horizontal or curved echogenic
lines extending beyond the interior of the implant that correspond to ruptured elastomer.
One should not confuse the stepladder sign with normal radial folds.
The most useful sign of extracapsular rupture on ultrasound is the "echodense noise"
or snowstorm appearance[11] which shows the occurrence of diffusely increased
echogenicity in the mammary tissues because of free silicone. There may also be a loss
of normal implant parenchymal interface due to scattering of ultrasound beam. Studies
have shown that ultrasound has a low sensitivity for detection of implant rupture when
asymptomatic patients were included in the sample.
Page 10 of 73
MRI- MRI was done on a GE Signa Excite 1.5 tesla scanner having a 8 channel dedicated
breast coil. The patients were scanned in prone position. No intravenous contrast was
given and no cardiac gating was used as it would increase the scan time.
The sequences that were used to assess implant rupture included:
•
•
•
•
•
Axial T1W
Axial STIR with fat suppression,
Axial T2W
Axial STIR with water suppression
Axial STIR with Silicone suppression.
MRI is the most important imaging modality to assess implant integrity. It has a high
sensitivity (80-90% ) and specificity (90-70%) for implant rupture[12]. The type of breast
implants seen on MRI were single lumen and double lumen implants.(Fig. 8 on page
45) , (Fig. 9 on page 46)
Page 11 of 73
Fig. 8: MRI axial sections of both breasts in a patient for implant evaluation showing
(A) T1W, (B) T2W (C) STIR and (D) Silicone suppressed sequences with intact single
chambered implants. No signs of rupture seen.
References: Breast Unit, Southend University Hospital, United Kingdom.
Fig. 9: MRI -axial section of left breast showing (A) T1W, (B) Silicone suppressed, (C)
STIR and (D)water suppressed sequences with intact double chambered implants.
References: Breast Unit, Southend University Hospital, United Kingdom.
The normal variants of implants seen on MRI include radial folds, thickening of fibrous
capsule which can also calcify and peri-implant fluid. The presence of folds indicates a
certain degree of capsular contraction or tense elastomer.( Fig. 10 on page 47), ( Fig.
11 on page 48 )
Page 12 of 73
Fig. 10: Line diagram showing variants of normal implants A) Peri-implant fluid
(arrow), B) Normal folds and C) Thickening of fibrous capsule of implant (arrowhead)
along with calcification( arrow).
References: Radiology, The Breast Unit (Nightingale Centre), Southend University
Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Page 13 of 73
Page 14 of 73
Fig. 11: MRI of left breast in a patient with suspected implant rupture. (A) Axial water
suppressed and ( B) Axial Silicone suppressed sequence shows peri-implant fluid,
however, there was no evidence of implant rupture.
References: Breast Unit, Southend University Hospital, United Kingdom.
There are two types of implant ruptures- intracapsular rupture and extracapsular rupture.
Intracapsular rupture is more common and is confined within the fibrous capsule where
there is no leakage of free silicone beyond the implant. An important sign seen in
intracapsular rupture on MRI is "Linguine sign" which is seen as multiple curvilinear low
intensity lines in high signal intensity silicone gel. The other signs which are seen in
intracapsular rupture are "Keyhole sign" or "Tear drop sign". While free silicone is seen in
extracapsular rupture, in tear drop sign there is entrapment of silicone inside a fold which
is seen as an inverted tear. An uncollapsed silicone implant rupture is defined as a tear of
the silicone implant shell and is considered an intracapsular rupture. The following figure
schematically represents the signs of intracapsular rupture ( Fig. 12 on page 50)
Fig. 12: Line diagram showing signs of implant rupture on MRI A) Implant deformity
B) Keyhole sign-Small invagination of shell where the two membranes do not touch
C) Teardrop sign- Invagination of shell containing Silicone droplet D)Linguine signcollapsed implant shell seen as folded wavy lines within the silicone gel E)Free silicone
and Siliconoma-There is disruption of shell and fibrous capsule with free silicone in
surrounding breast tissue.
References: Radiology, The Breast Unit (Nightingale Centre), Southend University
Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Page 15 of 73
One should be aware of the phenomenon called "gel bleed" where there is microscopic
silicone leakage through intact implant shell [2]. Therefore presence of silicone in regional
lymphnode may or may not be due to implant rupture but because of gel bleed.( Fig. 13
on page 50 )
Fig. 13: A)Mammogram MLO and CC view of right breast showing breast implant with
silicone in axillary lymphnode seen on MLO view .
References: Breast Unit, Southend University Hospital, United Kingdom.
Ultrasound showed anechoic implant and silicone in lymphnode (Fig. 14 on page 51)
(Fig. 15 on page 52)
Page 16 of 73
Fig. 14: Ultrasound of the right breast in same patient as in Fig 13 in lower quadrant
shows the anechoic implant with echogenic area within .
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 17 of 73
Fig. 15: Ultrasound of right axilla in the same patient as above shows an echogenic
area with posterior acoustic shadowing suggestive of lymphnode with silicone.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
MRI confirmed that there was also uncollapsed implant rupture which was seen as a
focal silicone invagination between the inner shell and fibrous capsule called as "Keyhole
sign". A seroma was seen on post implant removal mammograms (Fig. 16 on page 53)
(Fig. 17 on page 54)
Page 18 of 73
Fig. 16: MRI of both breasts in the same patient was also performed. A) STIR axial
and B) Silicone suppressed sequence axial section show "Keyhole sign" on right
suggestive of Intracapsular rupture. The left implant is intact.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 19 of 73
Fig. 17: Post implant removal mammogram of right breast in the same patient shows a
seroma and silicone in right axillary lymph node.
References: The Breast Unit, Southend University Hospital, UK
As discussed earlier it is difficult to diagnose intracapsular rupture on mammograms but
sometime an intracapsular implant rupture is seen on mammogram as radiolucent linear
shadows. Ultrasound showed the anechoic implant with echogenic areas within. MRI
confirmed the above findings as it showed "Linguine sign" suggestive of intracapsular
rupture.
( Fig. 18 on page 54 ) ( Fig. 19 on page 55 ), Fig. 20 on page 56 ) (Fig. 21 on
page 57 ), ( Fig. 22 on page 58 )
Page 20 of 73
Fig. 18: Mammogram -MLO view of both breasts in a patient with breast implants
shows radiolucent linear shadows possibly representing folding of implant membrane
on both the sides.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 21 of 73
Fig. 19: Ultrasound of right breast in lower and outer quadrant in the same patient as
in Fig 18 shows anechoic implant with echogenic area within suggestive of snow storm
sign .
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 22 of 73
Fig. 20: Ultrasound of right breast in the same patient shows anechoic implant
with echogenic material in the interior of implant.A suspicion of implant rupture was
considered and MRI of breast was done for further evaluation.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 23 of 73
Fig. 21: MRI of both breasts in the same patient (A) Axial STIR and (B) axial STIR,
water saturated sequences show folded hypointense wavy lines "Linguine sign"
suggestive of Intracapular rupture of both breast implants.
References: Radiology, The Breast Unit (Nightingale Centre), Southend University
Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Page 24 of 73
Fig. 22: MRI of both breasts in same patient where Silicone suppressed sequence
shows hypointense silicone with " Linguine sign" s/o intracapsular rupture.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Hence the common signs of intracapsular rupture on MRI are "Keyhole", "Teardrop" and
"Linguine" signs , however Linguine sign is also seen in extracapsular rupture in some
cases.( Fig. 23 on page 58 )
Page 25 of 73
Fig. 23: Named signs of Intracapsular rupture on MRI (A) Keyhole sign (B) Teardrop
sign and (C) Linguine sign.
References: Radiology, The Breast Unit (Nightingale Centre), Southend University
Hospital NHS Foundation Trust - Westcliff-on-Sea/UK
Rarely there may be multiple hypointense foci on water suppressed sequence within the
implant called as "salad oil" sign and when this is seen then subtle signs of intracapsular
rupture should be looked for.
In Extracapsular rupture , there is rupture of both implant shell and fibrous capsule
and macroscopic silicone is seen beyond fibrous capsule as focal areas of high signal
intensity on silicone excited sequences. There may be false negative findings on MRI
which may be due to ruptured non-collapsed elastomer located outside the implant, while
keeping the homogeneous high signal intensity inside it.
Extracapsular rupture is relatively less common than intracapsular implant rupture and
can show free silicone in peri-implant region in breast parenchyma on mammogram.
Ultrasound and MRI confirm the above findings.
( Fig. 24 on page 59 ) , ( Fig. 25 on page 59 ) ( Fig. 26 on page 60 ) ( Fig. 27
on page 61 ).
Page 26 of 73
Fig. 24: Mammogram of right breast(MLO view) in a 53 year old female shows
a small radio-opacity (arrow) in peri-implant region suggestive of Extracapsular
rupture of implant.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 27 of 73
Fig. 25: Mammogram of both breasts-MLO view in a 45 year old female show
extracapsular rupture of right implant with free silicone in right upper and outer
quadrant near the axillary region.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 28 of 73
Fig. 26: Ultrasound of right breast in the same patient as in Fig 25 in upper and
outer quadrant shows an echogenic area which is suggestive of free silicone due
to extracapsular rupture.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 29 of 73
Fig. 27: MRI of both breasts in a 42 year old female with suspected implant
rupture. (A) Axial T1W, (B) STIR fat suppressed (C) Axial water suppressed and
(D) Axial silicone suppressed sequences showed free silicone in postero-lateral
aspect of right breast suggestive of extracapsular implant rupture.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Other findings in breast implant evaluation: Sometimes additional findings may be
seen in women with breast implants ranging from benign to malignant pathology. The
benign findings include cysts, fibroadenoma , lipomas etc. ( Fig. 28 on page 62 ), (
Fig. 29 on page 63 ), ( Fig. 30 on page 64 ), ( Fig. 31 on page 65 )
Page 30 of 73
Fig. 28: Mammogram-MLO view of both breasts in a 46 year old female show normal
breast implants on both sides.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 31 of 73
Fig. 29: Ultrasound of left breast in the same patient as in Fig 28 shows normal
anechoic implant .
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 32 of 73
Fig. 30: Ultrasound of left breast in the same patient also shows a small well defined
simple cyst with posterior acoustic enhancement in the lateral quadrant.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 33 of 73
Fig. 31: MRI of left breast axial sections in the same patient shows a small well
defined lesion which was A) hypointense on T1W and B) hyperintense on STIR &
C) silicone suppressed sequence. The lesion is suppressed on D) water suppressed
sequence suggestive of simple cyst.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
The risk of breast cancer in women with breast implants is same as in other women and
should be looked for carefully. There is no difference in survival rates between women
with and without breast implants. Implants may interfere with early possible detection of
cancer because of difficulty in doing a physical examination.
( Fig. 32 on page 66 ), ( Fig. 33 on page 68 ), ( Fig. 34 on page 70 ), Fig. 35
on page 70 )
Page 34 of 73
Fig. 32: Mammogram of left breast (CC view) in a 41 year old female with breast
implants show an area of pleomorphic calcification .
Page 35 of 73
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 36 of 73
Page 37 of 73
Fig. 33: Mammogram of left breast (MLO) view in the same patient as in Fig 32 did not
show any abnormality or calcifications.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Fig. 34: Magnified image of CC view of left breast of the same patient shows
pleomorphic calcification clearly.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
Page 38 of 73
Fig. 35: Ultrasound of left breast in the same patient as above, in the region of interest
showed an ill-defined hypoechoic lesion situated 4 cm lateral to the nipple-areolar
region measuring 16.6 mm in maximum diameter. Wide bore needle sampling was
done from this which was suggestive of malignancy, this was followed by wide local
excision.
References: Breast Unit, Southend University Hospital,Westcliff -on-sea ,United
Kingdom.
The sensitivity of Mammography and ultrasound in breast cancer detection in women
with implants may be reduced [13] however the presence of implants does not decrease
sensitivity of MRI .
Page 39 of 73
Its important to remember that symptomatic patients after undergoing mammography
should undergo MRI to confirm or exclude rupture. MRI is not recommeded for screening
for implant rupture in asymptomatic patients.
Images for this section:
Fig. 1: A) Line diagram of mammogram showing sub-pectoral and sub-glandular location
of implants and B) Line diagram of cross section of MRI showing the type of implantssingle lumen and double lumen implants.
Page 40 of 73
Fig. 2: A) Mammogram- Mediolateral oblique (MLO) view showing sub-glandular implant
and B) Cranio-caudal (CC ) view showing sub-pectoral implant location.
Fig. 3: Line diagram showing A) Normal implant position B) Eklund technique-the implant
is pushed back against the chest wall and the breast is pulled forward over it so that more
of the breast parenchyma is included.
Page 41 of 73
Fig. 4: Mammogram of both breasts-CC view without Eklund technique shows normal
breast implants
Page 42 of 73
Fig. 5: Mammogram of both breast CC of the same patient as in Fig 4 done with Eklund
technique showing more breast parenchyma.
Page 43 of 73
Fig. 6: Ultrasound of right breast shows the normal anechoic implant with intact
echogenic implant shell seen as echogenic line at implant tissue interface.
Page 44 of 73
Fig. 7: Line diagram of ultrasound findings in normal breast implant(A) Breast implant
located posterior to pectoralis (B) Implant with peri-implant fluid (C) Breast implant
showing normal radial folds and reverberation artefacts which is a normal finding.
Page 45 of 73
Fig. 8: MRI axial sections of both breasts in a patient for implant evaluation showing
(A) T1W, (B) T2W (C) STIR and (D) Silicone suppressed sequences with intact single
chambered implants. No signs of rupture seen.
Page 46 of 73
Fig. 9: MRI -axial section of left breast showing (A) T1W, (B) Silicone suppressed, (C)
STIR and (D)water suppressed sequences with intact double chambered implants.
Page 47 of 73
Fig. 10: Line diagram showing variants of normal implants A) Peri-implant fluid (arrow),
B) Normal folds and C) Thickening of fibrous capsule of implant (arrowhead) along with
calcification( arrow).
Page 48 of 73
Page 49 of 73
Fig. 11: MRI of left breast in a patient with suspected implant rupture. (A) Axial water
suppressed and ( B) Axial Silicone suppressed sequence shows peri-implant fluid,
however, there was no evidence of implant rupture.
Fig. 12: Line diagram showing signs of implant rupture on MRI A) Implant deformity
B) Keyhole sign-Small invagination of shell where the two membranes do not touch
C) Teardrop sign- Invagination of shell containing Silicone droplet D)Linguine signcollapsed implant shell seen as folded wavy lines within the silicone gel E)Free silicone
and Siliconoma-There is disruption of shell and fibrous capsule with free silicone in
surrounding breast tissue.
Page 50 of 73
Fig. 13: A)Mammogram MLO and CC view of right breast showing breast implant with
silicone in axillary lymphnode seen on MLO view .
Page 51 of 73
Fig. 14: Ultrasound of the right breast in same patient as in Fig 13 in lower quadrant
shows the anechoic implant with echogenic area within .
Page 52 of 73
Fig. 15: Ultrasound of right axilla in the same patient as above shows an echogenic area
with posterior acoustic shadowing suggestive of lymphnode with silicone.
Page 53 of 73
Fig. 16: MRI of both breasts in the same patient was also performed. A) STIR axial and
B) Silicone suppressed sequence axial section show "Keyhole sign" on right suggestive
of Intracapsular rupture. The left implant is intact.
Fig. 17: Post implant removal mammogram of right breast in the same patient shows a
seroma and silicone in right axillary lymph node.
Page 54 of 73
Fig. 18: Mammogram -MLO view of both breasts in a patient with breast implants shows
radiolucent linear shadows possibly representing folding of implant membrane on both
the sides.
Page 55 of 73
Fig. 19: Ultrasound of right breast in lower and outer quadrant in the same patient as
in Fig 18 shows anechoic implant with echogenic area within suggestive of snow storm
sign .
Page 56 of 73
Fig. 20: Ultrasound of right breast in the same patient shows anechoic implant with
echogenic material in the interior of implant.A suspicion of implant rupture was considered
and MRI of breast was done for further evaluation.
Page 57 of 73
Fig. 21: MRI of both breasts in the same patient (A) Axial STIR and (B) axial STIR, water
saturated sequences show folded hypointense wavy lines "Linguine sign" suggestive of
Intracapular rupture of both breast implants.
Fig. 22: MRI of both breasts in same patient where Silicone suppressed sequence shows
hypointense silicone with " Linguine sign" s/o intracapsular rupture.
Page 58 of 73
Fig. 23: Named signs of Intracapsular rupture on MRI (A) Keyhole sign (B) Teardrop sign
and (C) Linguine sign.
Fig. 24: Mammogram of right breast(MLO view) in a 53 year old female shows a
small radio-opacity (arrow) in peri-implant region suggestive of Extracapsular rupture of
implant.
Page 59 of 73
Fig. 25: Mammogram of both breasts-MLO view in a 45 year old female show
extracapsular rupture of right implant with free silicone in right upper and outer quadrant
near the axillary region.
Page 60 of 73
Fig. 26: Ultrasound of right breast in the same patient as in Fig 25 in upper and
outer quadrant shows an echogenic area which is suggestive of free silicone due to
extracapsular rupture.
Page 61 of 73
Fig. 27: MRI of both breasts in a 42 year old female with suspected implant rupture. (A)
Axial T1W, (B) STIR fat suppressed (C) Axial water suppressed and (D) Axial silicone
suppressed sequences showed free silicone in postero-lateral aspect of right breast
suggestive of extracapsular implant rupture.
Page 62 of 73
Fig. 28: Mammogram-MLO view of both breasts in a 46 year old female show normal
breast implants on both sides.
Page 63 of 73
Fig. 29: Ultrasound of left breast in the same patient as in Fig 28 shows normal anechoic
implant .
Page 64 of 73
Fig. 30: Ultrasound of left breast in the same patient also shows a small well defined
simple cyst with posterior acoustic enhancement in the lateral quadrant.
Page 65 of 73
Fig. 31: MRI of left breast axial sections in the same patient shows a small well defined
lesion which was A) hypointense on T1W and B) hyperintense on STIR & C) silicone
suppressed sequence. The lesion is suppressed on D) water suppressed sequence
suggestive of simple cyst.
Page 66 of 73
Fig. 32: Mammogram of left breast (CC view) in a 41 year old female with breast implants
show an area of pleomorphic calcification .
Page 67 of 73
Page 68 of 73
Page 69 of 73
Fig. 33: Mammogram of left breast (MLO) view in the same patient as in Fig 32 did not
show any abnormality or calcifications.
Fig. 34: Magnified image of CC view of left breast of the same patient shows pleomorphic
calcification clearly.
Page 70 of 73
Fig. 35: Ultrasound of left breast in the same patient as above, in the region of interest
showed an ill-defined hypoechoic lesion situated 4 cm lateral to the nipple-areolar region
measuring 16.6 mm in maximum diameter. Wide bore needle sampling was done from
this which was suggestive of malignancy, this was followed by wide local excision.
Page 71 of 73
Conclusion
Mammography and Ultrasound are used for initial evaluation of breast implants.
MRI of breast is a more accurate imaging modality for assessing the type of implant,
integrity of implant and other breast lesions in the patient.
In patients who have undergone surgery for breast cancer, contrast enhanced MRI is
indicated to evaluate breast parenchyma.
With the increase in number of patients with breast implants, the radiologists must be
familiar with the imaging features of breast impants.
Personal information
Dr. Aron Sraj, Consultant Radiologist, Breast Unit, Southend University Hospital, United
Kingdom.
Email: [email protected]
Dr. Smiti Sripathi, Professor, Department of Radio-diagnosis, Kasturba Medical College,
Manipal, India.
Email: [email protected]
References
1. Middleton MS, McNamara MP Jr Breast implant classification with MR imaging
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