Radiopaque artifacts at mammography: How to recognize
them
Poster No.:
C-0571
Congress:
ECR 2017
Type:
Educational Exhibit
Authors:
R. A. E. K. Matsumoto, C. F. de Andrade Corona, P. C. Moraes, N.
de Barros; São Paulo/BR
Keywords:
Education and training, eLearning, Catheters, Biopsy, Ultrasound,
MR, Mammography, Breast, Anatomy
DOI:
10.1594/ecr2017/C-0571
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Learning objectives
•
•
to describe the imaging characteristics of radiopaque materials found in
mammographic studies;
to facilitate the description of these materials, avoiding misinterpretations and
consequently, providing a more reliable report.
Background
Mammography is the imaging method of choice for breast cancer screening and
evaluation of mammary lesions. The main objective is the early diagnosis of
malignant tumors in asymptomatic patients, with special focus on nodules, asymmetries,
architectural distortion and calcifications. Sometimes, high-density findings can be
encountered on mammography that may obscure or simulate breast lesions. Those are
often related to breast percutaneous procedures, surgery or direct trauma to the breast.
It´s important to know their appearence on mammoghapy in order to avoid incorrect
interpretations and unnecessary biopsies.
Findings and procedure details
Among the possible hyperdense materials to be found on mammographies, we
highlighted the most frequent ones, such as breast implants, free silicone, radiopaque
clips inserted during percutaneous procedures, wires and preoperative localization
needles, surgical clips, radiopaque markers of skin changes or clinically palpable masses.
In addition, we can see objects not related to breast diseases, such as drug infusion
devices or ventricular shunt catheters, pacemakers, even unusual findings, such as
gauze, nails and synthetic fabrics for aesthetic purposes.
BREAST-RELATED MATERIALS
The most common radiopaque materials found in mammographies are related to the
breast. Breast implants and post-biopsy clips are frequent findings, and it is important to
recognize some of its different subtypes.
- BREAST IMPLANTS
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Nowadays, its is extremely common to face a mammography with breast implants. It is
important to recognize it as a single or double lumen and the localization of the implant
regarding the pectoral musculature. The differentiation between a single or double lumen
can be made using post processing image windowing. A inner shell can be seen in double
lumen implants that is absent in single lumen implants. Implants for aesthetic purposes
can be inserted in pre or retropectoral positions. Sometimes it is difficult to differentiate
between these 2 types, but a careful observation of the pectoral muscle shadow can
be useful. Pre-pectoral implants form a "external"-acute angle with the pectoral muscle.
Retropectoral implants, however, form an "internal"-acute angle. On sonography, two
useful spots to recognize the position of the implants are the upperinner and upperouter
quadrants.
- TISSUE EXPANDERS
Tissue expanders are commonly used in a two-step breast reconstruction. Expanders
are usually inserted behind the pectoral muscle and then filled with a saline solution.
After adequate stretching of the soft tissues, a silicon implant replaces the expander and
its valve. Recognizing the filling valve (with windowing of the mammographic images)
associated with a less dense than silicone filling content of the implant are essential to
correct identification of a expander.
- FREE SILICONE
Free silicone can be seen in an actual or previous extracapsular implant rupture or after
a direct injection of the material in the breast tissue. The imaging findings are typical, with
hyperdense masses throughout the breast. On sonography these masses produces an
intense diffuse posterior acoustic shadowing reducing the field of view to evaluate the
breast. When MRI is performed, the free silicone "masses" shows low signal on T1W and
hyperintensity on T2W images.
- BIOPSY CLIPS
There is a wide range of different types of biopsy markers inserted during percutaneous
procedures. The main objective of these markers is to provide an accurate identification
of the biopsy site for a subsequent surgical procedure or imaging follow-up. Each
manufacturer has markers with different shapes.
- WIRE LOCALIZATION
This technique is used to help the surgeon identificate a non-palpable lesion during
surgery. The radiologist insert a needle / wire guided by mammography, ultrasound or
MRI in the center of the targeted breast lesion. Measurements and distances from the tip
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and the thickened part of the wire are important to the report and will guide the surgical
procedure.
- MESH
Although unusual, some aesthetic procedures uses synthetic meshes for breast lifting
and support. On mammography, we can observe a hyperdense radiopaque material
located between the subcutaneous fat and breast tissue that reduces the sensibility
to detect calcifications and masses. Sonographically, this synthetic tissue produces
posterior acoustic shadowing and some breast areas become impossible to be evaluated.
NON-BREAST RELATED MATERIALS
- DIALYSIS CATHETER
This catheter is used to perform an exchange of the blood of a patient and the
hemodialysis machine. It has an arterial and a venous lumen. The catheter is placed in
a large vein, and common sites are the superior vena cava and the subclavian vein. As
a consequence, when visible, the catheter is usually seen at the superior parts on MLO
(mediolateral oblique) incidences.
- PORT-O-CATH CATHETER
It is an device implanted in the subcutaneous tissues used to administer regular long-term
drugs, such as antibiotics and chemotherapy. It does not have any electrical components
and it is safe to use on MRI equipaments. The system consist on 2 parts: the reservoir
and the catheter. The reservoir is implanted under the skin in the upper chest area, and
as so, it can be seen at the superior aspect of some mammographic incidences. The
catheter connects the reservoir to a blood vessel, allowing access to a large central vein.
- VENTRICULAR SHUNTS
Ventricular shunts are usually found at the medial aspect of the breasts. The imaging
finding is similar to others catheters. Here, the personal history is essential to correct
categorization.
- PACEMAKER
It is a device which uses electrical impulses that estimulates the heart muscles to maintain
an adequate heart rate. The part of this system that can be seen on mammography is
the generator, placed between the skin and the pectoral muscle. Pacemakers should be
avoided on MRI equipments.
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- GAUZE
A gauze finding at the breast topograhy is usually an iatrogenic incident. The identification
of a gauze is possible due to the radiopaque line present in the middle of a ill-defined
dense area.
UNUSUAL MATERIALS
Other unexpected materials can appear on breast imaging studies, usually due to
accidents or other casualties and trauma. Here we show some examples of rare
examples found in our case database.
Often, the preparation of the report with these findings is simple and straightforward,
without many uncertainties about what type of material should be described. However,
the radiologist should be familiar with radiopaque possible findings in the thoracic region,
reducing misinterpretations.
Images for this section:
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Fig. 1: Single-lumen breast implants in pre pectoral position. The yellow line following
the shadow of the pectoral muscles forms a acute angle with the implant.
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
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Fig. 2: Breast implant at retropectoral position. The borders of the implants make a
"internal"-acute angle with the shadow of pectoral muscles, in contrast to the "external"acute angle of the prepectoral implants. On sonography, the implant (traced lines) are
completely surrounded by the pectoral muscle (continuous line). These findings are
corroborated by MRI.
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
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Fig. 3: Double lumen implant. On mammography, after wide windowing, it is possible to
see the inner shell and the valve tube (arrows). This inner compartment is filled with saline
solution through this valve. The sonographic finding is typical, with two compartments
visible, but it may be misdiagnosed as an implant rupture.
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
Fig. 4: Tissue expander in the right breast. The fill valve is visible after windowing the
mammographic images and on profile chest x-ray incidence (arrows). At sonography, the
fill valve is also visible.
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© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
Fig. 5: MRI images of a post-operatory removal of extracapsular rupture breast implants.
Architectural distortion related to the procedure can be seen. High-signal materials on
T2W, with intermediate signal on T1W images, representing free silicone. Mammographic
incidences of the left breast also show many hyperdense masses a free silicone.
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
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Fig. 6: Left magnified incidence with a biopsy marker in the format of a ribbon. At the
upper right corner, it is possible to see the original model of the marker.
© - São Paulo/BR
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Fig. 7: Right magnified mammography showing a biopsy radiopaque marker with anchor
shape.
© - São Paulo/BR
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Fig. 8: Pre-operatory wire localization. The targets are the biopsy markers, with open
coil and barrel shapes
© - São Paulo/BR
Fig. 9: U-shape clip marker in the left breast.
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© - São Paulo/BR
Fig. 10: A "M"-shape marker inserted after a vaccuum-assisted biopsy in the right breast.
© - São Paulo/BR
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Fig. 11: Pre operatory wire localization. The target was the coil-shaped biopsy clip in the
left breast. Surgical specimen showing that the clip was removed with the wire (Kopans),
located next to the middle third of the thickened part of the wire.
© - São Paulo/BR
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Fig. 12: Personal history of breast carcinoma in the left breast, treated with mastectomy.
The right brest was submitted to an aesthetic procedure, with implantation of a
polyurethane mesh.
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© - São Paulo/BR
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Fig. 13: Gold thread inserted for an aesthetic procedure in the right breast (arrows). This
type of filament is not used nowadays. Two anchor-shape biopsy clip markers (yellow
circle).
© - São Paulo/BR
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Fig. 14: Port-o-cath in the right breast. The inner round component is made of silicone,
where the needle is inserted to allow medication infusion.
© - São Paulo/BR
Fig. 15: A homemade explosive exploded and nails from this device entered the breasts
of this woman.
© - São Paulo/BR
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Fig. 16: Lead pellet used for skin lesion marking mimicking breast calcification
© - São Paulo/BR
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Fig. 17: MLO left breast mammography with a cardiac pacemaker projected in the axilla.
The pulse generator is characteristic, and do not cause too many misinterpretations.
© - São Paulo/BR
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Fig. 18: Dialysis catheter in the projection of the upper quadrants of the right breast. It is
possible to see the external two lumens (venous and arterious components).
© - São Paulo/BR
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Fig. 19: MLO mammography with a broken sewing needle projected in the left axilla.
© - São Paulo/BR
Fig. 20: Ventriculoperitoneal shunt (VPS) in the medial aspect of the left breast. The
catheter has imaging characteristics similar to others. One feature that can raise the
possibility of a VPS is its medial topography.
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© - São Paulo/BR
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Fig. 21: Ill-defined asymmetry with serpiginous radiopaque line located in the upper
quadrant of the right breast, next to the implant. A gauze was left behind during the
surgery.
© - São Paulo/BR
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Fig. 22: Hyperdense projectile from a gun shot.
© - São Paulo/BR
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Fig. 23: Bullet fragments (arrows) mimicking calcifications in the right breast. Imaging
features that can help exclude the breast nature of these findings are its distribution and
density.
© - São Paulo/BR
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Fig. 24: Broken acupuncture needle in the retroareolar region of the left breast. The
thicker part of the needle was removed, but the thin component remained in the breast.
© DEPARTMENT OF RADIOLOGY - HOSPITAL DAS CLINICAS DA FACULDADE DE
MEDICINA DA UNIVERSIDADE DE SAO PAULO
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Conclusion
The aim of this paper is to present the main radiopaque materials that can be found on
the breast during a mammography, allowing a better interpretation, understanding of its
possible causes and avoiding unnecessary additional exams and biopsies.
Personal information
Email: [email protected]
References
1. Geiser, WR, Haygood TM, Santiago L et al. Challenges in Mammography: Part I,
Artifacts in Digital Mammography. AJR 2011; 197:W1023-W1030
2. Chaloeykitti L, Muttarak M, Ng K H et al. Artifacts in mammography: ways to identify
and overcome them. Singapore Med J 2006; 47(7) : 634
3. Choi JJ, Kim SH, Kang BJ et al. Mammographic artifacts on full-field digital
mammography. J Digit Imaging. 2014 Apr;27(2):231-6
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