Case Report
Intraductal Extracapsular Rupture of Silicone Breast Implant
Carl Seynnaeve* and Wendie Berg
Department of Radiology, University of Pittsburgh Medical Center, USA
*Corresponding author: Carl Seynnaeve, Department of Radiology, University of Pittsburgh Medical Center, 259 Mt Nebo Pointe Dr, Pittsburgh, PA 15237, USA
Published: 05 Jun, 2017
Cite this article as: Seynnaeve C, Berg W. Intraductal
Extracapsular Rupture of Silicone
Breast Implant. Ann Clin Case Rep.
2017; 2: 1369.
Abstract
Complications of silicone implant rupture are commonly encountered, both clinically and by imaging. An unusual type of rupture with intraductal spread of silicone has only been described in a few case reports. The following is a case of intraductal spread of silicone illustrated by mammography, ultrasonography (US), and Magnetic Resonance (MR) imaging.
Case Presentation
Our case is a 69-year-old female who presented for a diagnostic mammogram in the summer
of 2015 with complaint of hardening of the right breast and implant for three weeks. She carried
a complex history of breast augmentation with multiple revisions, which started in her twenties.
Her most recent revision was in 2007, which included bilateral exchange of silicone implants
secondary to rupture with placement of bilateral silicone implants in a subglandular position. The
mammographictechnologist who performed thecurrent diagnostic mammogramnoted a small
amount of golden discharge from the right nipple during performance of the implant-displaced
views, which could not be reproduced by the radiologist physician at the time ofultrasound.
Mammography (Figure 1) and ultrasound (US) (Figure 2) demonstrated spread of silicone in the
soft tissues anterior to the implant in a ductal distribution. Because the patient desired implant
removal, Magnetic Resonance Imaging (MRI) was also performed (Figure 3), confirming intraductal spread of silicone.
The patient was subsequently seen in the Plastic Surgery office, where a small amount of
silicone gel was able to be extruded from the right nipple. Following evaluation, implant exchange
was recommended. For personal reasons, the patient delayed surgery and presented months later with evidence of a right breast infection and a sinus tract to the skin.
The patient then underwent removal of ruptured silicone implant
on the right and intact silicone implant on the left with bilateral
capsulectomy, as well as excision of the sinus tract and silicone
granulomas within the right breast. Following months of healing, she
underwent bilateral breast augmentation with silicone implants.The
patient has not undergone post-procedure breastimaging.
Figure 1
Figure 1
Magnification (a) Craniocaudal (b) mediolateral rightimplant-displaced mammograms show dense,
tubular material within multipleducts (arrows) leading to the nipple. Scar is also evident.
Figure 2
Figure 2
Ultrasound (US). Top image illustrates the typical “snowstorm” appearance of diffuse echogenic
extracapsular silicone with posterior shadowing near the nipple. Bottom image illustrates the “stepladder sign”
(arrows) indicative of collapse of the implant shell.
Figure 3
Figure 3
(a) Magnetic resonance imaging (MRI). Sagittal T2-weighted,water-suppressed silicone-brightimage (TR=3167, TE=53, TI=150) illustrates bright signal
within a lactiferous duct (arrow) that matches the signal of the silicone implant. There is gel outside the implant capsule (arrowhead), consistent with extracapsular
rupture and the hypointense implant shell (dotted arrow) has separated from the capsule. (b) Axial T1-weighted fat-and silicone suppressed, post-contrast sequence
(TR=7, TE=3) illustrates foci of signal void within the lactiferous ducts (arrows) that matches the signal of the silicone implant.
Discussion
Intraductal spread of silicone following implant ruptureis a known
but uncommonly seen entity. In the majority of implant ruptures, the
gel is contained by the fibrous capsule the body forms around the
implant, so-called “intracapsular ruptures”. When the gel spreads
outside the fibrous capsule, it can migrate to the axillae, the back, arms,
and even groin. Migration of gel is accompanied by inflammation and
silicone granuloma formation [1-3]. These granulomas represent a
natural host response to wall off a foreign substance, and silicone can
be a nidus for fistula formation and subsequent infection [4]. Thus,
diagnosis and subsequent timely removal of extracapsular silicone
is considered desirable so as to minimize complications, including
an increased risk of fibromyalgia [3]. Mammography, US, and MRI
are all useful modalities to help detect extracapsular silicone implant
rupture [5,6].
Mammography is reliable and readily available, with silicone
appearing as a dense opacity. Extracapsular silicone can be seen as
round or oval masses of varying size adjacent to or separate from
the implant. A tubular appearance due to intraductal spread as
seen in this case (Figure 1) is uncommon.Mammography does
have some limitations, including the inability to confidently
distinguish silicone from other high-density masses, and positioning
limitsmammographic evaluation to the breast and included portions
of the axilla [5]. Intracapsular silicone implant ruptureis nearly always
mammographically occult. Mammography, including implantdisplaced
views, remains the primary method of screening for breast
cancer, though a metaanalysis showed a slight increased risk (1.2-
fold) of late-stage diagnosisin women with implants, likely due to
masking of some cancers on mammography [7].
US is also reliable in depicting extracapsular implant rupture, is
widely available, and easier to correlate with physical examination
findings not limited to the breast itself. The classic US appearance
of extracapsular silicone is a highly echogenic pattern with a welldefined
anterior margin and loss of detail posteriorly with shadowing, commonly referred to as a “snowstorm appearance” (Figure 2) [8].
Collapse of the implant shell can be recognized at the anterior aspect
of the implant (“stepladder sign”) but may be focal or posterior and
not well seen on US and separation of the shell from the fibrous
capsule in uncollapsed rupture can be quite subtle on US; the
accuracy of the examination depends on the ability of the operator
to recognize and interpret the abnormal findings [5]. While MR
imaging is substantially more sensitive in the detection of implant
rupture, the advantage in mapping extracapsular silicone is less well
established [6,9]. One clear advantage of MR imaging is the ability
to perform silicone-specific sequences [10]. Silicone will present as
high signal on T2-weighted water-suppressed images (Figure 3a),
and low signal intensity foci on T1-weighted fat-suppressed images
(Figure 3b), though it is important to be aware of potential pitfalls
with MR imaging of implants [11]. MR imaging also affords a detailed
evaluation of the breast, axilla, chest wall, and the implant, and can
therefore be helpful for surgical planning purposes. A disadvantage
unique to MR imaging isthe increased cost of the examination
compared to mammography and US [5].
Our case of silicone implant rupture with intraductal spread
of siliconewas documented with all three modalities, including
mammography, US, and MR imaging, illustrating a rarely seen
imaging finding with clinical relevance.
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