Figure 1
TSE T2w fat-sat axial image
Fluid effusion below deep surface of the breast implant.
Diagnostic pitfalls in MRI of broken breast implants: silicone bleeding or intracapsular rupture?
SectionBreast imaging
Case TypeClinical Cases
Authors
Benigni C, De Stefano T, Cristiano L, Caporilli Razza F, Guglietta MA, Argento G.
Dept of Radiology, Sant’Andrea Hospital, Sapienza University Rome
Connected authors
52 years, female
Clinical History
A 52-year-old women was referred to our hospital complaining of an intense pain in her left breast that started a few weeks before. The patient did not report any trauma.
The physical examination revealed a swollen, erythematous breast and a palpable nodular mass in the QSE.
The physical examination revealed a swollen, erythematous breast and a palpable nodular mass in the QSE.
Imaging Findings
Two years before the patient underwent a radical left mastectomy with emptying of the ipsylateral axilla for an infiltrating ductal carcinoma, subsequently an implant was placed in her left breast.
The patient underwent breast MRI, with T2w fat suppression images, IR water and fat suppression T2w images, T1w fat-sat perfusion images.
In the left submammary breast implant there were multiple low signal lines (linguine sign of intracapsular implant rupture).
A rim with high signal intensity surrounding the implant was seen on T2w fat-sat and IR T2w with water suppression images, due to the extra-capsular silicone bleeding.
Substraction images also showed an extra-capsular nodule with contrast-enhancement that was interpreted as inflammatory; histological examination demonstrated that it was an inflammatory lymph-node. The Patient underwent surgery and after removal of the implants, the evaluation of the surface showed a tiny micro-lesion of the capsule (silicon bleeding occured)
The patient underwent breast MRI, with T2w fat suppression images, IR water and fat suppression T2w images, T1w fat-sat perfusion images.
In the left submammary breast implant there were multiple low signal lines (linguine sign of intracapsular implant rupture).
A rim with high signal intensity surrounding the implant was seen on T2w fat-sat and IR T2w with water suppression images, due to the extra-capsular silicone bleeding.
Substraction images also showed an extra-capsular nodule with contrast-enhancement that was interpreted as inflammatory; histological examination demonstrated that it was an inflammatory lymph-node. The Patient underwent surgery and after removal of the implants, the evaluation of the surface showed a tiny micro-lesion of the capsule (silicon bleeding occured)
Discussion
Rupture of silicone breast implants is caused by stress on the implant at the time of surgical placement, trauma, defects in manufacture, long-term repetitive stress such as exercise, mammographic compression, and long-term deterioration of the implant
The fibrous capsule that forms around implants usually keeps silicone gel from spreading into the surrounding breast even when the implant shell fails.
Aside from presumed increased risk of extracapsular spread of silicone, the clinical significance of intracapsular rupture is not clear.
When silicone gel spreads beyond the capsule, however, it usually incites scar and granuloma formation that can result in painful masses. No definite association has been shown between classic autoimmune syndromes and silicone implants, nor to fibromyalgia.
Moreover the rupture of breast implants can depend on the surgical position of the implant; in fact implants placed under the muscle may break more easily than the subglandular ones.
MR has a sensitivity of 95% and specificity of 93% and it is accurate in the detection of both intracapsular and extracapsular ruptures.
Intracapsular rupture is seen either as a serpiginous dark line traversing the substance of the implant or as a serpiginous dark line just underneath the fibrous capsule.
Extracapsular rupture instead is seen as a break in the fibrous line with silicone migration into the breast parenchyma or lymph nodes.
When the rupture is contained by the fibrous scar or capsule, it is of unclear clinical significance.
Extracapsular rupture or spread of the gel into the surrounding breast or beyond is difficult to remove and may increase the risk of connective-tissue diseases Recognition of extracapsular silicone can be challenging on MR imaging.
It usually manifests as local spread of silicone in contiguity with the implant, which is often not well depicted on fast spin-echo T2-weighted images.
Water-suppressed IR T2w images are often needed to identify such spread of gel and should be performed whenever there is high suspicion for extracapsular silicone.
In this case surgery is important for the replacement of the implant because it avoids the migration of the silicone in the surrounding tissues and in the lymphatic system.
The fibrous capsule that forms around implants usually keeps silicone gel from spreading into the surrounding breast even when the implant shell fails.
Aside from presumed increased risk of extracapsular spread of silicone, the clinical significance of intracapsular rupture is not clear.
When silicone gel spreads beyond the capsule, however, it usually incites scar and granuloma formation that can result in painful masses. No definite association has been shown between classic autoimmune syndromes and silicone implants, nor to fibromyalgia.
Moreover the rupture of breast implants can depend on the surgical position of the implant; in fact implants placed under the muscle may break more easily than the subglandular ones.
MR has a sensitivity of 95% and specificity of 93% and it is accurate in the detection of both intracapsular and extracapsular ruptures.
Intracapsular rupture is seen either as a serpiginous dark line traversing the substance of the implant or as a serpiginous dark line just underneath the fibrous capsule.
Extracapsular rupture instead is seen as a break in the fibrous line with silicone migration into the breast parenchyma or lymph nodes.
When the rupture is contained by the fibrous scar or capsule, it is of unclear clinical significance.
Extracapsular rupture or spread of the gel into the surrounding breast or beyond is difficult to remove and may increase the risk of connective-tissue diseases Recognition of extracapsular silicone can be challenging on MR imaging.
It usually manifests as local spread of silicone in contiguity with the implant, which is often not well depicted on fast spin-echo T2-weighted images.
Water-suppressed IR T2w images are often needed to identify such spread of gel and should be performed whenever there is high suspicion for extracapsular silicone.
In this case surgery is important for the replacement of the implant because it avoids the migration of the silicone in the surrounding tissues and in the lymphatic system.
Differential Diagnosis List
Breast implant rupture with silicone migration
Mastitis
Neoplasm recurrence
Final Diagnosis
Breast implant rupture with silicone migration
References
[1] Berg WA et al (2002) MR Imaging of extracapsular silicone from breast implants. AJR 2002 178: 465-472 (PMID: 11804919)
[2] Everson LI et al (1994) Diagnosisi of breast implant rupture: imaging findings and relative efficacies of imaging techniques. AJR 1994 163:57-60 (PMID: 8010248)
[3] Brown SL et al (2001) Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women. J RHEUMATOL 28:996-1003 (PMID: 11361228)
Case information
| URL: | https://www.eurorad.org/case/9212 |
| DOI: | 10.1594/EURORAD/CASE.9212 |
| ISSN: | 1563-4086 |
Figure 2
Sagittal TSE T2w image
Irregular capsular margins on left breast implant, which may resemble the \"linguin sign\", typical of intra-capsular rupture.
TSE T2w fat-sat axial image
Fluid effusion below deep surface of the breast implant.
Sagittal TSE T2w image
Irregular capsular margins on left breast implant, which may resemble the \"linguin sign\", typical of intra-capsular rupture.
