34 | Radiology Key

Case 34

Indication: Screening.

History: Bilateral implants 30 years previously to correct anisomastia.

Risk profile: Not increased.

Age: 53 years.

Clinical Findings

Regular asymptomatic scars bilaterally.

Fig. 34.1 Ultrasound image, right breast.

Fig. 34.2 Ultrasound image, left breast.

Fig. 34.3a,b Digital mammograpy, MLO view.

Fig. 34.4a,b Digital mammography, CC view.

Fig. 34.5a–c Contrast-enhanced MRI of the breasts.

Fig. 34.6a–c Contrast-enhanced MRI of the breasts.

Fig. 34.7 Contrast-enhanced MR mammography. Maximum intensity projection.

Fig. 34.8a,b Signal-to-time curves.

Please characterize ultrasound, mammography, and MRI findings.

What kind of implants do you see?

What is your preliminary diagnosis?

What are your next steps?

Imaging of an asymptomatic woman with bilateral prostheses inserted 30 years previously to correct anisomastia.

Ultrasound

Ultrasound showed that the left prosthesis had a markedly smaller volume than the right. There were no other unusual findings. USBI-RADS right 1/left 1.

Mammography

Images showed a fibroglandular parenchyma, ACR type 2. There were no suspicious lesions and no architectural distortions. Mammography demonstrated no suspicious microcalcifications. Left mammography showed a collapsed prosthesis with clumped calcifications. BI-RADS right 1/left 1. PGMI is not defined for implantimages.

MR Mammography

MRI documented the collapsed left implant. It depicted a single-lumen saline-filled implant (no adequate signal in silicon sequences, Fig. 34.6b). MRI also depicted a well-defined, hypervascularized focus of 1 cm diameter in the upper outer quadrant of the right breast, which showed nonspecific signal behavior after contrast administration. T2 signal in the focal area was increased. This focus had a lipomatous central area in precontrast Tl -weighted imaging.

Have you been able to determine the type of prosthesis involved here?

MRI Artifact Category: 2

MRI Density Type: 1

MRM score	Finding right	Points
Shape	round	0
Border	well-defined	0
CM Distribution	homogenous	0
Initial Signal Intensity Increase	moderate	1
Post-initial Signal Intensity Character	plateau	1
MRI score (points)		2
MRI BI-RADS		2

Diagnosis

Left breast: Complete rupture of the implant (envelope and capsule). No differential diagnosis.

Right breast: Nonspecific lymphadenitis. No differential diagnosis.

BI-RADS Categorization
Clinical Findings	right 1	left 1
Ultrasound	right 1	left 1
Mammography	right 1	left 1
MR Mammography	right 2	left 1
BI-RADS Total	right 2	left 1

Procedure

None. This woman had saline-only prostheses in both breasts. No intervention was necessary following the complete rupture of the left implant, since the saline content was completely resorbed. The hypervascularized focus in the right breast could be clearly identified as a lymph node due to the fatty hilum visible at its center in MRI. This is therefore categorized as a harmless ancillary finding.

Remark

Luckily the rupture occurred in the larger breast. Aesthetically, no intervention was required. The uneven calcifications within the capsule did not show criteria of malignancy.