Augmentation mammoplasty: normal and abnormal findings with mammography and US.

A retrospective review of 133 patients who had undergone augmentation mammoplasty (n = 122), reconstructive mammoplasty (n = 10), and silicone injections (n = 1) was undertaken to establish the normal appearance of various types of implants, to establish a range of normal variations (wrinkles, valves, minor bulges), and to recognize true implant complications (collapse of a saline prosthesis, leakage of silicone gel, capsular contracture, capsular calcification, and deformities). The detection and evaluation of breast parenchymal abnormalities in the presence of a radiopaque implant are more difficult, and frequently ultrasound (US) or special mammographic views in conjunction with physical examination are required. Coned-down compression spot views are suggested for asymmetric opacities or ill-defined mammographic masses, and magnification views are recommended for microcalcifications: Both should be obtained with the Eklund implant displacement technique. Tangential or other special views combined with US are best for the evaluation of palpable abnormalities and suspected silicone implant rupture.     

Prevalence of rupture of silicone gel breast implants revealed on MR imaging in a population of women in Birmingham, Alabama

OBJECTIVE. Silicone gel breast implants have been reported to rupture, but the prevalence of implant rupture in an unreferred population of women is not known. The objective of this study was to assess the prevalence of implant rupture and the presence of extracapsular silicone gel in an unreferred population of women without regard to the absence or presence of any local or systemic symptoms. SUBJECTS AND METHODS. Women identified as part of a National Cancer Institute cohort study on breast implants, living in the Birmingham, AL, area were invited to undergo MR imaging of their current silicone gel breast implants at the Kirklin Clinic at the University of Alabama at Birmingham. Three radiologists independently examined and rated all MR images for signs of implant rupture and extracapsular silicone. RESULTS. A total of 344 women with silicone gel breast implants underwent MR imaging. Breast implant rupture was reported by at least two of three radiologists for 378 (55.0%) of the 687 implants in this study. Another 50 implants (7.2%) were rated as indeterminate (suspicious) for rupture. A majority of women in this study, 265 (77.0%) of 344, had at least one breast implant that was rated as ruptured or indeterminate. Radiologists also agreed that silicone gel could be seen outside the fibrous capsule that forms around the implant in 85 (12.4%) of the 687 implants affecting 73 women (21.2%). Factors that affected implant rupture were implant age and location (submuscular or subglandular). The median implant age at rupture was estimated to be 10.8 years with a 95% confidence interval of 8.4-13.9 years. CONCLUSION. The prevalence of silent or occult silicone gel breast implant rupture is higher than was previously suspected. Most women in this study had MR imaging evidence of at least one ruptured silicone gel breast implant.     

Radiological findings of screen-detected cancers in a multi-centre randomized, controlled trial of mammographic screening in women from age 40 to 48 years

AIM: To elucidate the mammographic findings of screen-detected cancers in women screened between 40-48 years, and to establish the frequency and nature of abnormal findings on previous mammograms in women with screen-detected cancers. METHODS: A radiology review panel consisting of three experienced breast radiologists viewed the screening mammograms in chronological order, confirming that any abnormalities detected corresponded to the cancers detected at later screens. An analysis correlating mammographic features with median invasive size and the proportion measuring less than 10 and 15mm was performed. RESULTS: Two hundred and thirty-two women had screen-detected invasive cancers with mammograms available for review. The most frequent features seen at diagnosis were spiculate mass, ill-defined mass, granular calcification, deformity and comedo calcification. Thirty-four percent of mammograms showed calcification. The mammographic sign associated with smallest median size was calcification. Calcification was also the mammographic abnormality most frequently associated with cancers <10mm in size. In total there were 147 abnormal previous screens of 87 women. The most commonly missed features were granular microcalcification, deformity and ill-defined mass. Of the missed abnormalities 20% were classified as malignant, 43% as subtle change and 32% as non-specific. CONCLUSION: Compared with older women, screen-detected cancer in younger women more commonly manifests as calcification and less frequently a spiculate mass. Calcification is the sign most frequently associated with invasive cancers <10mm in size. Calcification and deformity are the signs most frequently seen on the previous mammograms of women with screen-detected cancer.     

Mammographic appearance following implant removal.

Potential complications of augmentation mammaplasty with silicone gel breast implants have been the subject of much recent debate in the medical and lay communities. Some women have undergone implant removal, and others may follow. The mammographic appearance following submammary implant removal in four women and the histologic appearance in one case are described. Bilateral symmetric soft-tissue masses posterior to the glandular tissue with accompanying calcifications should suggest the diagnosis. The radiologist should be familiar with the mammographic appearance following implant removal. Such knowledge may prevent unnecessary concern and unwarranted biopsy.     

The relevance of reported symptoms in a breast screening programme

AIM: Although the National Health Service (NHS) Breast Screening Programme is aimed at asymptomatic women, inevitably patients attending screening report symptoms. The study aim was to assess the usefulness of recall based on clinical symptoms. MATERIALS AND METHODS: Information on breast symptoms is recorded at screening and radiologists can make recall decisions based on mammography and symptom history. We identified 1394 women with significant symptoms, between 1991 and 1996. The majority (54%) complained of a lump, 21% had breast distortion, 18% breast pain alone and 6% reported nipple discharge. RESULTS: Of the 1394 women, 262 were recalled because of mammographic suspicion and of these, 45% had breast cancer. The other 1132 women had symptoms and benign mammograms and 44% of these were recalled. Seven breast cancers were diagnosed; all had complained of a breast lump. In two the cancer would have been seen on two-view mammography. Of 638 not recalled, five women went on to develop an interval cancer. CONCLUSION: The results indicate that collecting details on symptoms is useful given the high rate of breast cancer in those with mammographic abnormality. When mammography is benign, however, the low rate of cancer detection means recall should be selective based on only the most relevant symptoms.     

Ruptured gel-filled silicone breast implants: sonographic findings in 19 cases.

OBJECTIVE. The purpose of this study was to describe and illustrate the sonographic appearances of 19 ruptured silicone gel breast implants. MATERIALS AND METHODS. We retrospectively reviewed the sonograms of 16 patients with 19 ruptured silicone gel implants from two institutions. The ruptured implant was confirmed at surgery in 17 cases and by mammographic and clinical findings of a ruptured implant combined with biopsy findings of a silicone granuloma in two cases. Breast sonograms were available for review in all patients. The clinical presentation of each patient was recorded. The sonograms and mammograms were reviewed, and the findings were correlated with the surgical findings. In 16 of the 19 ruptured implants, mammographic findings suggested rupture, including lobulation of the contour of the implant and/or silicone extrusion into the breast parenchyma or axilla. In two ruptured implants, mammographic findings were normal, and in one case, no mammogram was available. In those three patients, palpable masses and clinical findings were suggestive of rupture. RESULTS. Sonography showed a unique echogenic appearance called echo-dense noise, in 17 of the 19 ruptured implants; in 10 of the 17, sonograms showed hypoechoic masses of extruded silicone also. In two ruptured implants, sonograms showed only the hypoechoic masses of extruded silicone gel. CONCLUSION. Our experience suggests that echogenic noise is a unique sonographic sign of ruptured silicone gel breast implants and may be caused by phase aberration related to the speed of sound being slower in silicone than in soft tissue.     

Bilateral breast carcinomas: do they have similar mammographic features?

AIMS: This study compared the mammographic appearance, site and histological features of synchronous and metachronous bilateral breast carcinomas. METHODS: Site, type of abnormality and background pattern seen on the diagnostic mammograms of 63 women with bilateral breast carcinoma were compared. The histological type and grade of all the carcinomas were verified by histological review. RESULTS: There was a tendency for the contralateral tumour to have similar mammographic features to those of the initial tumour. In patients in whom the first carcinoma was visible purely as a mass, the contralateral carcinoma had a similar appearance in 82% (P < 0.001). When the original tumour showed mammographic calcification the contralateral tumour did so in 65% (P< 0.001). Normal mammography or calcification alone were seen almost exclusively in women with a dense background pattern (100% and 92% respectively) while masses and calcification with masses were seen in women with dense and fatty patterns (58% and 35% dense respectively). When the mammographic site of the contralateral tumour was compared with that of the first tumour no significant correlation could be demonstrated. There was a significant trend for contralateral carcinomas to be of the same histological grade (P < 0.005) but not histological type. CONCLUSIONS: Contralateral carcinomas often have a similar mammographic appearance to the first tumours. Two factors may be responsible: (i) the tendency for contralateral carcinomas to be of the same histological grade and (ii) the influence of mammographic background pattern on the radiological appearance of breast carcinoma. This knowledge may assist in the interpretation of follow-up mammography in patients with a previous breast carcinoma.     

Ductal carcinoma in situ: computer-aided detection in screening mammography

PURPOSE: To retrospectively evaluate the sensitivity of computer-aided detection (CAD) in depicting ductal carcinoma in situ (DCIS) on screening mammograms by using biopsy proved lesion location as the reference standard. MATERIALS AND METHODS: Institutional review board approval was obtained, with a waiver of patient informed consent for this HIPAA-compliant study. Findings of all image-guided biopsies with a pathologic diagnosis of DCIS during a 1-year period were reviewed. Fifty-eight lesions in 55 women (average age, 61.41 years +/- 12.89 [standard deviation]) were available for review. The screening mammogram of the affected breast and, if available, the prior screening mammogram were digitized by the CAD system. An assessment was then made as to whether the CAD system marked the area of DCIS on the current and prior mammograms. Patient age, location and mammographic size of the lesion, type of lesion, and breast density were recorded and were analyzed by using chi2, Fisher exact, or Cochran-Mantel-Haenzel tests, where applicable. RESULTS: CAD identified DCIS in 53 (91%) of 58 lesions on craniocaudal (CC) and mediolateral oblique (MLO) views of screening mammograms obtained in the year of the diagnosis. On screening mammograms obtained prior to the year of the diagnosis (34 patients), no radiologically or CAD-detected lesion was present on 11 (32%) of 34 mammograms. CAD identified DCIS in 16 (70%) of 23 lesions on one of the two views. Seven (30%) of 23 lesions had mammographic findings at retrospective review that were not identified with CAD. CONCLUSION: CAD had a high sensitivity in the depiction of DCIS.     

Imaging breasts with silicone implants

Over the last two decades, the use of breast implants both for breast augmentation and for breast reconstruction following mastectomy has increased substantially. It is estimated that around two million women have undergone breast augmentation, while hundreds of thousands have had breast reconstruction surgery. Different types of material have been used for breast implants, but silicone gel implants have been the dominating implant type. Many implants can lead to complications, such as hardening and rupture, and may therefore need in vivo evaluation by imaging, particularly if they lead to clinical symptoms. They can also pose problems in the assessment of surrounding breast tissue by conventional mammography. In this respect, imaging modalities such as ultrasound, computed tomography and magnetic resonance imaging offer greater possibilities to assess a failing implant, as well as surrounding breast tissue. Several factors, mainly of a psychological nature, lead to requests for breast implants. In this review article, only the imaging aspects of breasts with silicone gel implants will be dealt with. Each modality is concisely presented with its possibilities and limitations. Received: 5 February 1998; Revision received: 18 May 1998; Accepted: 25 May 1998     

MR imaging of the augmented breast

Mammographic evaluation of the augmented breast is challenging, since breast implants obscure significant amount of breast tissue while diminishing the effect of compression. Posttherapeutic scarring can make mammographic interpretation even more difficult. MRI has thus evolved into the modality of choice for diagnosing implant complications as well as detection of primary or recurrent breast cancer in these patient population. The present article attemps to give an overview of the MR findings of different breast augmentation and reconstruction techniques, i. e. prosthetic breast implants, breast reconstruction with autogenous tissue, free silicone injections and fat grafts, and their complications. Received 16 April 1997; Revision received 28 July 1997; Accepted 29 July 1997     

Screening mammography-detected cancers: sensitivity of a computer-aided detection system applied to full-field digital mammograms

PURPOSE: To retrospectively evaluate the sensitivity of the performance of a computer-aided detection (CAD) system applied to full-field digital mammograms for detection of breast cancers in a screening group, with histologic findings as the reference standard. MATERIALS AND METHODS: This study had institutional review board approval, and patient informed consent was waived. A commercially available CAD system was applied to the digital mammograms of 103 women (mean age, 51 years; range, 35-69 years) with 103 breast cancers detected with screening. Sensitivity values of the CAD system according to mammographic appearance, breast composition, and histologic findings were analyzed. Normal mammograms from 100 women (mean age, 54 years; age range, 35-75 years) with no mammographic and clinical abnormality during 2-year follow-up were used to determine false-positive CAD system marks. Differences between the cancer detection rates in fatty and dense breasts for the CAD system were compared by using the chi(2) test. RESULTS: The CAD system correctly marked 99 (96.1%) of 103 breast cancers. The CAD system marked all 44 breast cancers that manifested as microcalcifications only, all 23 breast cancers that manifested as a mass with microcalcifications, and 32 (89%) of 36 lesions that appeared as a mass only. The sensitivity of the CAD system in the fatty breast group was 95% (59 of 62) and in the dense breast group was 98% (40 of 41) (P = .537). The CAD system correctly marked all 31 lesions of ductal carcinoma in situ (DCIS), all 22 lesions of invasive ductal carcinoma with DCIS, the single invasive lobular carcinoma lesion, and 45 (92%) of 49 lesions of invasive ductal carcinoma. On normal mammograms, the mean number of false-positive marks per patient was 1.80 (range, 0-10 marks; median, 1 mark). CONCLUSION: The CAD system can correctly mark most (96.1%) asymptomatic breast cancers detected with digital mammographic screening, with acceptable false-positive marks (1.80 per patient).     

Breast augmentation and reconstructive surgery: MR imaging of implant rupture and malignancy

The purpose of this study was to assess the diagnostic accuracy of MRI in detecting prosthesis integrity and malignancy after breast augmentation and reconstruction. Forty-one implants in 25 patients were analyzed by MRI before surgical removal. Imaging results were compared with ex vivo findings. Magnetic resonance imaging of the breast was performed on a 1.5-T system using a dedicated surface breast coil. Axial and sagittal T2-weighted fast spin-echo as well as dynamic contrast-enhanced T1-weighted gradient-recalled-echo sequences were acquired. The linguine sign indicating collapse of the silicone shell or siliconomas indicating free silicone proved implant rupture, whereas early focal contrast enhancement of a lesion was suspicious for malignancy. The sensitivity for detection of implant rupture was 86.7% with a specificity of 88.5%. The positive and negative predictive values were 81.3 and 92.0%, respectively. The linguine sign as a predictor of intracapsular implant rupture had a sensitivity of 80% with a specificity of 96.2%. Magnetic resonance imaging revealed two lesions with suspicious contrast enhancement (one carcinoma, one extra-abdominal fibromatosis). Magnetic resonance imaging is a reliable and reproducible technique for diagnosing both implant rupture and malignant lesions in women after breast augmentation and reconstruction.     

隆乳术后的MRI表现

目的分析隆乳术后MRI表现，探讨其临床价值。方法对63例隆乳术后患者行MR扫描，分别分析置入假体和注射假体的MRI表现。结果40例80只乳房行双侧聚丙烯酰胺水凝胶注入，其中50只乳腺假体呈不规则团块游离于腺体内、胸肌内、皮下等各处。7例行双侧白体脂肪注入，其中12只乳内见纤维脂肪团块，6只乳内见脂液平面，6只胸大肌内见脂肪。16例行双侧乳腺假体置入，其中2例行生理盐水假体置入，2只盐水假体破裂；14例行硅胶假体置入，其中4只假体囊外破裂，10只假体囊内破裂。结论MRI是评价乳腺假体置入术后情况的理想方法。     

Challenges in mammography: part 2, multimodality review of breast augmentation--imaging findings and complications

OBJECTIVE: Breast augmentation is common throughout the world; however, there is variation in materials and surgical techniques. This review illustrates the mammographic, sonographic, and MRI characteristics of the different types of breast augmentation, including silicone, saline, polyacrylamide gel, and autologous fat augmentation. CONCLUSION: The imaging findings of complications such as implant rupture, free silicone, and fat necrosis in association with augmentation will be illustrated.     

Baseline screening mammography: one vs two views per breast

To compare the advantages of one-view vs two-view mammography screening, films were reviewed for 2500 consecutive asymptomatic women undergoing baseline mammography. To provide screening at low cost, examinations were limited to two radiographs per breast, one each in the craniocaudal and mediolateral oblique projections, with the understanding that those few patients with detected abnormalities would require additional mammograms, taken with an individually directed, problem-solving approach, at considerably higher cost. Two separate interpretations were made of each case, one using only the oblique projection images, the other using both oblique and craniocaudal views. Two-view interpretations not only identified more cancers than one-view readings (27 vs 25), they also required fewer additional mammograms to evaluate potential abnormalities (179 vs 642, 7% vs 26%). These advantages outweigh the additional radiation risk and added cost. Baseline screening mammography should be done with two views per breast.     

Diagnostic accuracy of commercial system for computer-assisted detection (CADx) as an adjunct to interpretation of mammograms

PURPOSE: To evaluate the diagnostic accuracy of the commercial computer-aided detection CADx system for the reading of mammograms. MATERIALS AND METHODS: The study assessed the Second Look system developed and marketed by CADx Medical Systems, Montreal, Canada. The diagnostic sensitivity was evaluated by means of a retrospective study on 98 consecutive cancers detected at screening by double independent reading. The specificity and the positive predictive value (PPV) for cancer of the CADx system were prospectively evaluated on a second group of 560 consecutive mammograms of asymptomatic women not included in screening program. The radiologist who was present during the test assessed the abnormal mammographic findings by one or more of the following diagnostic procedures: physical examination, additional mammographic detail views with or without magnification, ultrasonography, ultrasound- or mammography-guided fine needle aspiration cytology, and core-biopsy. The exams first underwent conventional reading and then a second reading carried out with the aid of the CADx system. RESULTS: The overall diagnostic sensitivity of the CADx system on the 98 screening cancers was 81.6%; in particular it was 89.3% for calcifications, 83.9% for masses and only 37.5% for architectural distortion. The CADx markings for each mammography were 4.7 on average. Identification of invasive carcinoma was independent from tumour size. In the second group of 560 mammograms, the CADx system marked all cases identified as positive by conventional reading and confirmed by biopsy (7/7), but did not permit the detection of any additional cancer. The CADx markings per exam were 4.2 on average, the specificity was 13.7% and the PPV was 0.55% versus 13.7% recall rate of conventional reading. CADx reading led to a 1.96% (11/560) increase of the women necessitating further diagnostic investigation. CONCLUSIONS: The results of our study show that the diagnostic sensitivity of the CADx system is lower than that obtained by double independent reading at screening. Used in association with conventional reading of mammograms of asymptomatic women the CADx system did not increase diagnostic sensitivity.     

Imaging of the augmented and reconstructed breast: a retrospective study

The records of 71 patients with cosmetic breast implants or reconstructed breast following surgery for cancer were reviewed restrospectively. Of these 47 (66%) had cosmetic augmentation and 24 (33%) had reconstructive surgery. Analysis of radiological findings and correlation with clinical data showed recurrence of certain patterns and assessed their clinical relevance. Evaluation of mammographic views proposed by Eklund et al. [1] was also made. The role of US, CT, and invasive procedures was also discussed.     

Mammographic findings after breast cancer treatment with local excision and definitive irradiation

Following local excision and definitive irradiation of 163 breast cancers in 160 women, alterations in mammographic patterns were observed for up to 7 years. Skin thickening was observed in 96% of mammograms obtained within 1 year of completing therapy and was most pronounced in women treated with iridium implant, chemotherapy, or axillary dissection. In 76% of mammograms, alterations in the parenchymal pattern, including coarsening of stroma and increased breast density, were seen at 1 year. Neither skin nor parenchymal changes progressed after 1 year. Within 3 years of treatment the parenchymal density, which usually regressed, did not change in all patients. At 3 years skin thickness and the parenchymal pattern had returned to normal in less than 50% of the breasts of these women. Scars developed in approximately one-quarter of women. They were present on the initial post-treatment mammogram and remained unchanged on serial studies. Coarse, benign calcifications also developed in the breasts of about one-quarter of women. Microcalcifications developed in 11 breasts; biopsy specimens of six were benign. Benign microcalcifications may be related to therapy.     

Systematic ultrasonography in asymptomatic dense breasts

The purpose of this study was to evaluate the role of ultrasonography in breast cancer screening. 350 Bilateral ultrasound (US) were performed in 350 asymptomatic patients with dense breasts. 7.5, 10 And 13 MHz transducers were used (Esaote Biomedica, Italy). In 185/350 patients, sonograms were normal, abnormalities were seen in 165/350: cysts (117), solid nodules (44) and mixed echogenicity nodules (4). All but two solid lesions were benign. Both malignant lesions were invasive carcinomas, 18 and 11 mm in diameter. In retrospect, they were palpable, but not visible on mammograms. Retroprospective review revealed that 24.7 of cysts and 31% solid nodules could be seen on mammograms. In 4 patients with fibroadenomas, US made a false positive diagnosis of breast cancer. Follow-up was obtained for 6 to 18 months in 45% of patients. Routine supplemental US evaluation for patients with mammographically dense breasts does not appear to significantly contribute to the accuracy of the work-up.     

Breast cancer: mammographic and sonographic findings after augmentation mammoplasty

The authors retrospectively reviewed 11 cases of breast cancer in patients who had undergone augmentation mammoplasty. The mammogram or sonogram was abnormal in 10 patients, including six with an abnormal mammographic density or ultrasound study and four with calcifications. One patient had dense breasts and no suspicious findings at mammography. In four patients without palpable findings in the breast, the malignancy was initially detected by means of mammography. In five of six patients with a palpable breast mass, special mammographic views and sonography were helpful in evaluating the mass. Lymph nodes were not involved in six (60%) of the 10 patients with ductal carcinomas. The detection of breast cancer in the augmented breast by means of mammography is possible, even in patients without palpable findings. Modified-position views and sonography may be helpful in evaluating palpable masses. Patients with implants who develop cancer do not necessarily present at a more advanced stage.