Medical Imaging of Inflammations and Infections of Breast Implants
Abstract
:1. Introduction
2. Radiological Imaging
2.1. Mammography (MX)
2.2. Ultrasound
2.3. MRI
3. Nuclear Medicine Imaging
3.1. Scintigraphic Imaging
3.2. PET
4. Discussion and Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Authors | Publication Year | Nuclear Medicine Imaging Technique | No. of Patients | Main Findings |
---|---|---|---|---|
Hudson A et al. [19] | 2022 | [99mTc]Tc-diphosphonates Scintigraphy | 1 | Implant rupture |
Wang Y et al. [20] | 2022 | 131Iodine Scintigraphy | 1 | Aspecific implant uptake |
Vedala K et al. [21] | 2021 | [18F]FDG PET/CT | 1 | Granulomatosis |
Khakbaz E et al. [22] | 2021 | [18F]FDG PET/CT | 1 | Granulomatosis |
Verde F et al. [23] | 2020 | [18F]FDG PET/MRI | 1 | BIA-ALCL |
Pandika V et al. [24] | 2020 | [18F]FDG PET/CT | 4 | BIA-ALCL |
Mescam L et al. [25] | 2020 | [18F]FDG PET/CT | 3 | BIA-ALCL |
Phan S et al. [26] | 2020 | [18F]FDG PET/CT | 1 | Granulomatosis |
Montes Fernandez M et al. [27] | 2019 | [18F]FDG PET/CT | 1 | BIA-ALCL |
Siminiak N et al. [28] | 2019 | [18F]FDG PET/CT | 2 | BIA-ALCL |
Palot Manzil FF et al. [29] | 2018 | [18F]FDG PET/CT | 1 | Granulomatosis |
Dominguez ML et al. [30] | 2018 | [18F]FDG PET/CT | 1 | Granulomatosis |
D’hulst L et al. [31] | 2016 | [18F]FDG PET/CT | 1 | Granulomatosis |
Acevedo-Banez I et al. [32] | 2015 | [18F]FDG PET/CT | 1 | BIA-ALCL |
Karnatovskaia LV et al. [33] | 2014 | [18F]FDG PET/CT | 1 | Nodular Lymphoid Hyperplasia |
Ulaner GA et al. [34] | 2013 | [18F]FDG PET/CT | 1 | Granulomatosis |
Soudack M. et al. [35] | 2013 | [18F]FDG PET/CT | 12 | Granulomatosis |
Ho L et al. [36] | 2010 | [18F]FDG PET/CT | 1 | Granulomatosis |
Chen C et al. [37] | 2009 | [18F]FDG PET/CT | 1 | Granulomatosis |
Bhargava P et al. [38] | 2006 | [18F]FDG PET/CT | 1 | Capsular rupture |
Hurwitz R et al. [39] | 2003 | [18F]FDG PET/CT | 1 | Granulomatosis |
Leslie K et al. [40] | 2000 | [67Ga] Gallium-citrate Scintigraphy | 1 | Implant infection |
Ellenberger P et al. [41] | 1985 | [99mTc] Tc-HMPAO-labeled leukocytes Scintigraphy | 1 | Implant infection |
Hartshorne MF et al. [42] | 1982 | [67Ga] Gallium-citrate Scintigraphy | 1 | Capsular contracture |
Imaging Technique | Normal Findings | Abnormal Findings | Comments |
---|---|---|---|
Mammography (MX) | - Regular-shape opacities; - Density dependent on the used material, up to radiolucent in liquid material. | - Regular round or oval opacities; - Double-implant contour, sign of pericapsular fluid collection; - Calcified irregular opacities, sign of granulomas; - Lobulated dense opacities, sign of siliconomas with surrounding inflammatory reaction; - Calcifications with or without mass opacity, signs of parasitic infections; - Asymmetrical dense fat tissue, sign of mastitis, with or without cutaneous thickening; - Cutaneous thickening, common sign of mastitis and/or after radiosurgery; - Periprosthetic fluid collection, glandular edema, and cutaneous thickening, signs of late infection; - Capsular contracture may mimic infection, specific signs of contracture include implants deformation, capsular thickening, and presence of calcifications. | Worldwide diagnostic technique for breast assessment, but in case with breast implants the accuracy is reduced. Combination of standard and projections with Eklund’s maneuvers increases the diagnostic accuracy. Not possible in patients with large or extra-large breast implants. |
Ultrasound (US) | -Regular, linear echogenic implant wall, oval or round in shape; -A second chamber is always found in breast expanders and in double-lumen implants; -The peri-prosthetic capsule is depicted as two parallel echogenic lines; -Implant wall folding “ripples” can be normally present as regular wall waves; - Minimal layers of peri-capsular hypoechoic liquid can be normally present; -A single round regular interruption of the parallel lines consists in the valve, present in all breast expanders on the upper-external side. A single-lumen implant valve is positioned on the posterior side and usually not visible on US. | - Abnormally echoic or abundant peri-prosthetic fluid collection is a sign of inflammation, infection, or implant rejection; - Large peri-prosthetic focal seromas or hematomas can be commonly found in the immediate post-surgical period; -Signs of capsular contracture such as inhomogeneous thickened capsule and irregular ripples are uncommonly visible on US; - Siliconomas are shown as hyperechoic regular/oval-shaped nodules; - Fat edema or fat necrosis can be identifiable on US as signs of liponecrosis, infection, or post-radiation changes; - The “snowstorm sign” is a rare but typical sign of extracapsular rupture; - Intracapsular rupture can be seen as regular hyperechoic intra-prosthetic lines; - Capsular hypervascularization is always a sign of active inflammation or malignancy; - Contrast-enhanced ultrasound (CEUS) can improve the demonstration of hypervascularization; - Elastosonography can detect the presence and estimate the degree of capsular fibrosis, for example in capsular contracture; - In the differential diagnosis between infection and inflammation, US-guided fine-needle aspiration biopsy (FNAB) can play a crucial role. | Widely available diagnostic technique, considerably operator-dependent: a high level of expertise in the evaluation of breast implant abnormalities and breast focal lesions is required. Ancillary techniques, such as color/power-Doppler, US contrast agent administration, and elastosonography, can significantly improve the diagnostic accuracy. US is the most simple and affordable tool to be used as a guide for diagnostic invasive procedures, such as FNAB and core biopsy. |
MRI | Breast implants show different intensity signals due to their composition: -Silicone single lumen has an intermediate-to-high signal on T2W images, a high signal on the silicone-specific sequence, and a loss of signal in the silicone suppressed sequence; -Saline, single lumen has a high signal on T2W images; -Standard double lumen (outer saline, inner silicone); -Reverse double lumen (outer silicone, inner saline). A fibrous capsule hypointense in all sequences and a small periprosthetic fluid amount are paraphysiological findings. | Acute complications: -Hematoma —hyperintense on T1W images, decreasing over time; -Seroma—intermediate-to-hyperintense on T2W images; -Abscess—fluid collection with irregular, thick peripheral enhancement; -Ancillary signs—edema, skin thickening, and adenopathy. Late complications: -Capsular contraction—prosthetic contour alterations, peripheral enhancement; -Intracapsular breast implant rupture (uncollapsed rupture “keyhole sign”, minimal collapse “subcapsular line sign”, and partial-to-full collapse “linguine sign”); -Extracapsular breast implant rupture; -Rare, breast implant-associated anaplastic large-cell lymphoma, ALCL (peri-implant collection with an enhancing mass and lymphadenopathy). | Breast magnetic resonance imaging is the most accurate technique to assess prosthetic integrity in the clinical or ultrasound suspicion of rupture, but is not justified as a pure screening examination in asymptomatic women of all ages and with any type of prosthesis. Its parametric nature allows the typing of the content of periprosthetic fluid collections (seroma, hematoma) and, combined with the administration of contrast medium, the detection of periprosthetic neoplastic recurrences or complications (breast implant-associated anaplastic large-cell lymphoma, ALCL). |
[67Ga]Ga-citrate Scintigraphy | -No uptake around the implant. | -Different degree of radiopharmaceutical uptake in inflammatory/infected foci. | Since the introduction of [18F]FDG PET/CT, [67Ga]Ga-citrate scintigraphy can be proposed where PET/CT is not available. |
Radiolabeled leukocytes’ Scintigraphy | -No uptake around the implant. | -Increasing uptake over time in areas of leukocyte-mediated infection. | Radiolabeled leukocytes scintigraphy still represents a possible diagnostic option for breast implant infections and should be considered as a second-line imaging tool in cases that remain equivocal after first-line imaging. |
[18F]FDG PET/CT | -No uptake or only faint uptake around the breast implant. -No axillary lymph node uptake, or just faint uptake in normally-sized nodes, vascular hilum well-visible. | -Focal uptake around the implant and in axillary, mediastinal (usually internal mammary), and supraclavicular enlarged lymph nodes; -Pericapsular fluid collection may be present, with detectable faint activity; -Fluid effusion between the breast implant and the host fibrous capsule causing asymmetry and swelling of the breast can be a sign of breast implant-associated anaplastic large-cell lymphoma. | Even bearing in mind the clinical history of each patient, both visual and semiquantitative analysis (SUVmax) do not discriminate among inflammation, infection, and neoplastic foci, because they take up glucose similarly. The clinical setting of each focal uptake (implantation for oncological versus aesthetic reasons) and any morphological findings (see above) may lead the clinician to follow-up or to collect a biopsy specimen, and eventually fluid culturing, to rule out granuloma/infection versus node metastases or lymphoma or SCC associated with breast implants. |
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Giovannini, E.; Travascio, L.; Follacchio, G.A.; Bauckneht, M.; Criscuoli, B.; De Cataldo, C.; Iozzelli, A.; Cimini, A.; Ricci, M. Medical Imaging of Inflammations and Infections of Breast Implants. Diagnostics 2023, 13, 1807. https://doi.org/10.3390/diagnostics13101807
Giovannini E, Travascio L, Follacchio GA, Bauckneht M, Criscuoli B, De Cataldo C, Iozzelli A, Cimini A, Ricci M. Medical Imaging of Inflammations and Infections of Breast Implants. Diagnostics. 2023; 13(10):1807. https://doi.org/10.3390/diagnostics13101807
Chicago/Turabian StyleGiovannini, Elisabetta, Laura Travascio, Giulia Anna Follacchio, Matteo Bauckneht, Benedetta Criscuoli, Camilla De Cataldo, Andrea Iozzelli, Andrea Cimini, and Maria Ricci. 2023. "Medical Imaging of Inflammations and Infections of Breast Implants" Diagnostics 13, no. 10: 1807. https://doi.org/10.3390/diagnostics13101807