Imaging The Augmented Breast

In the breast cancer patient who has had a complete mastectomy with no reconstruction it may not be necessary to use mammography to diagnose recurrent carcinoma. The incision site and very small slips of tissue at the chest wall are the only sites for recurrent tumor in these cases. Physical examination and/or axial radiography (CT or MRI) should be adequate to evaluate these patients for recurrence. With myocutaneous flap reconstruction, mammography can be useful in diagnosing fat necrosis.

Breast cancer patients with Tram/flap or Augmentation reconstruction will require a full routine, bilateral mammogram to assess the tissue unseen and unfelt underneath the reconstructed site. Clinical evaluation is difficult with post mastectomy reconstruction.

In women who have had breast augmentation implantation for cosmetic reasons evaluation must be two-fold. First, we must carefully screen these patients for early occult breast cancer and then, we must assess the status of the implant.

We can identify occult cancers in the parenchyma of women with implants by using the now well known ‘implant displacement’ or ‘push-back’ technique introduced by G. W. Eklund. These views are obtained by gently moving the implant superiorly and posteriorly toward the chest wall while extending the anterior parenchyma onto the buckey and into the compression. These views, along with views obtained with the implant in the x-ray field, plus any necessary 90-degree lateral or axillary views make up a comprehensive screening exam for silicon/saline implant patients.

The status of silicone implants must be investigated on a regular basis. Implants should be evaluated year after year for contour changes, focal bulges, changes in position, capsular calcification, linguine sign rupture or any high-density material outside of the implant capsule. Comprehensive physical examination, xeroradiography (excellent for this purpose), ultrasound, CT and MRI scanning are all used to great advantage as tools to evaluate the integrity of breast implants.

Implant Displacement Mammography

Implant & Push-Back Images

A. B. C. D.

A. LMLO Push-Back Projection

B. LMLO Implant-in-Place Projection

C. LCC Push-Back Projection

D. LCC Implant-in-Place Projection

Extended Left CC Implant-in-Place view

Laterally extended LCC implant-in-place view shows a nodule only partially imaged in the routine LCC push-back view (C).

Coned-Compression Magnified Push-Back XLCCL View

Coned-compression magnification view in an extended LCCL push-back projection illustrates an ill-defined, irregular mass containing malignant type calcifications.

SUMMARY:

As always, knowledge is power. The more we know about the ins and outs of augmentation the better we are equipped to deal with the intricacies of imaging patients with this type of surgery. It is easy to miss a small cancer hiding adjacent to a dense silicon implant. What we don’t image nobody sees!