Screening and diagnosis of breast cancer in augmented women

Recognizing and Managing Breast Implant Complications: A Review for Healthcare Providers Who Treat Women Who Underwent Breast Implant-Based Surgery

Given the prevalence of breast implants, healthcare providers treating women should be familiar with potential complications that may result from breast augmentation and implant-based reconstruction surgeries and the appropriate management strategies to adopt for each. Familiarity with risk factors and variables involved in complications and an understanding of the patient's surgical history and implant type/characteristics is key. This article provides an overview of implant types and surgical approaches and potential complications related to surgery that physicians treating women may encounter during routine clinical practice. It describes potential implant complications such as hematoma, implant rupture, infection, seroma, rare capsular lymphomas, capsular contracture, implant malposition, rippling, and animation deformity. This article also describes systemic symptoms that patients sometimes attribute to breast implants, such as fatigue, brain fog, joint pain, anxiety, hair loss, depression, rash, autoimmune diseases, inflammation, or gastrointestinal symptoms. Rare conditions, such as breast implant-associated anaplastic large cell lymphoma and squamous cell carcinoma in the capsule around breast implants, are also presented. Diagnostic criteria are summarized, with photographic examples, and management strategies and referral recommendations across the range of potential complications are provided. This article provides information to support healthcare providers who treat women in detecting breast implant complications and guiding their patients to an appropriate treatment and referral strategy.

Breast imaging characteristics in Thai transgender women: mammography and ultrasound outcomes in a pilot study

Background

Breast cancer screening in transgender women, particularly those undergoing hormone therapy, remains understudied. Limited screening guidelines exist for transgender individuals, creating a need for tailored recommendations. This study addresses breast cancer screening outcomes in Thai transgender women using mammography and ultrasound.

Objectives

To assess breast imaging characteristics and screening outcomes in transgender women in Thailand and identify factors associated with breast density.

Design

A descriptive correlation study with a cross-sectional design.

Methods

Sixty-six transgender women over 40 years of age, who had been on hormone replacement therapy for at least 5 years, were recruited from three clinics. Participants underwent mammography and breast ultrasound, with imaging analyzed using the Breast Imaging-Reporting and Data System (BI-RADS) system. Data were analyzed with descriptive statistics and Spearman's correlation.

Results

The average age of participants was 49.2 years, with an average of 16.3 years of hormone use. Of the participants, 80.3% had undergone breast augmentation. Most participants (86.4%) were classified as BI-RADS 2 and dense breast tissue. Screening findings were mostly negative or benign (94%), with the remaining 6% demonstrating probably benign findings. No signs of malignancy were detected. There was no significant correlation between age, BMI, hormone use duration, BI-RADS, and breast density.

Conclusion

Breast cancer screening among transgender women in Thailand showed high rates of dense breast tissue and low abnormality detection. Moreover, most of them have previously undergone breast augmentation. Therefore, screening guidelines should use both mammography and ultrasound for early detection.

Photon-counting CT of degenerative changes and rupture of silicone breast implants: a pilot study

BACKGROUND

Accurate assessment of breast implants is important for appropriate clinical management. We evaluated silicone properties and diagnostic accuracy for characterizing silicone implants and detecting degenerative changes including rupture in photon-counting computed tomography (PCCT).

METHODS

Over 16 months, we prospectively included patients with silicone implants and available breast magnetic resonance imaging (MRI) who received thoracic PCCT performed in prone position. Consensus reading of all available imaging studies including MRI served as reference standard. Two readers evaluated all implants in PCCT reconstructions for degenerative changes. In a subgroup of implants, mean density of silicone, adjacent muscle, and fat were measured on PCCT reconstructions. Contrast-to-noise ratios (CNRs) were calculated for implant-to-muscle and implant-to-fat.

RESULTS

Among 21 subjects, aged 60 ± 13.1 years (mean ± standard deviation) with 29 implants PCCT showed the following: high accuracy for linguine sign, intraimplant fluid (all > 0.99), peri-implant silicone (0.95), keyhole sign (0.90), and folds of the membrane (0.81); high specificity for linguine sign, intraimplant fluid, keyhole sign, folds of the membrane (all > 0.99), and peri-implant silicone (0.98); and high sensitivity for linguine sign and intraimplant fluid (all > 0.99). In a subgroup of 12 implants, the highest CNR for implant-to-muscle was observed on virtual unenhanced reconstructions (20.9) and iodine maps (22.9), for implant-to-fat on iodine maps (27.7) and monoenergetic reconstructions (31.8).

CONCLUSIONS

Our findings demonstrate that silicone breast implants exhibit distinct contrast properties at PCCT, which may provide incremental information for detection of degenerative changes and rupture of implants.

RELEVANCE STATEMENT

Thoracic photon-counting computed tomography is a promising modality for the diagnostic assessment of silicone breast implants.

KEY POINTS

• Thoracic photon-counting computed tomography demonstrates unique contrast properties of silicone breast implants. • Iodine map reconstructions reveal strong contrast-to-noise ratios for implant-to-muscle and implant-to-fat. • Thoracic photon-counting computed tomography shows high diagnostic accuracy in detecting implant degeneration and rupture.

TRIAL REGISTRATION

German Clinical Trials Register number DRKS00028997, date of registration 2022-08-08, retrospectively registered.

Diagnostic value of a spiral breast computed tomography system equipped with photon counting detector technology in patients with implants: An observational study of our initial experiences

To evaluate the value of a breast computed tomography (CT) (B-CT) in assessing breast density, pathologies and implant integrity in women with breast implants.This retrospective study was approved by the local ethics committee. B-CT images of 21 women with implants (silicone/saline; 20 bilateral, 1 unilateral) who underwent opportunistic screening or diagnostic bilateral B-CT were included. Breast density, implant integrity, extensive capsular fibrosis, soft tissue lesions and micro-/macrocalcifications were rated. In 18 of the 21 women, an additional ultrasound and in two patients breast magnetic resonance imaging was available for comparison. The average dose was calculated for each breast using verified Monte Carlo simulations on 3D image data sets.Breast density was nearly completely fatty (ACR a) in two patients, scattered fibroglandular (ACR b) in five, heterogeneously dense (ACR c) in ten and very dense (ACR d) in four women. In three women showed a unilateral positive Linguine sign indicative of an inner capsule rupture. Extensive capsular fibrosis was found in three women. In three women, soft tissue lesions were depicted, which revealed to be cysts (n = 2) and lymph nodes (n = 1) on subsequent sonography. Diffuse, non-clustered microcalcifications were found in nine women. Eleven women showed cutaneous or intramammary macrocalcifications. Average dose was 6.45 mGy (range 5.81-7.28 mGy).In women with implants, B-CT presents a promising modality for evaluating breast density, implant integrity, extensive capsular fibrosis, soft tissue lesions and micro-/macrocalcifications without the need of breast compression utilizing a lower dose compared to doses reported for conventional four-view mammography.

Current practice in mammographic imaging of the augmented breast in Australia

AIM

This study seeks to document the imaging series used in contemporary Australian practice for imaging the augmented breast, with a secondary focus on differences in practice and opinion between BreastScreen Australia and diagnostic imaging services.

METHODS

A SurveyMonkey link was distributed through the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) and was assessable during December 2017 and January 2018. The questionnaire investigated: years of experience, facility type and location, image acquisition systems, appointment times, patients imaged per week, technique and imaging series used, use of limited compression views, rationale for variation in imaging series and the use of ultrasound. Descriptive statistics were produced for all variables with chi-squared tests used for comparisons between categorical variables.

RESULTS

The most frequently used series was the eight-image Eklund ID technique 64% and 59% (submuscular) and 68% and 58% (subglandular) for BSA and diagnostic services, respectively. Eighteen different combinations of projections were reported with eight combinations common to both subglandular and submuscular imaging. The majority of participants attributed imaging series preferences to dose reduction and radiologist preference.

CONCLUSION

This research has demonstrated varied approaches to the routine imaging of women with breast implants and identified the need for the establishment of dedicated evidence-based imaging protocols to ensure that regardless of which setting a woman attends that they receive standardised imaging with minimal dose and maximum breast coverage. This is a reassurance that is not applicable to current practice.

Consensus about image quality assessment criteria of breast implants mammography using Delphi method with radiographers and radiologists

Aims

To identify image quality criteria that can be applied to assess breast implant (BI) mammograms according to radiologists and radiographers’ perspectives and to explore the level of agreement about criteria priority.

Methods

A two-round Delphi method using a questionnaire was applied to identify the level of agreement between experts, asking them to rank each image criteria available for mammography according to 4 possible answers (1 = need to have, 2 = nice to have, 3 = not pertinent/appropriate, 4 = do not know). Criteria for craniocaudal (CC), mediolateral-oblique (MLO) and lateral (ML), with and without Eklund manoeuvre, were included. This process was repeated after removing the less relevant criteria.

Results

Between first and second rounds, different results were obtained regarding the criteria to assess CC and MLO images. Details for anatomic areas were considered the most relevant by radiographers during the first round, while general criteria were prioritised during the second round. Radiologists focused more on analysis of the spread of the breast tissue, if the breast was aligned with detector’s centre and level of contrast. The analysis of implant flow, the BI anterior edge and the maximum retropulsion of BI when Eklund manoeuvre is performed were the specific aspects of BI imaging considered as relevant for assessment.

Conclusions

The importance of each criterion used to assess BI mammograms was not the same between radiographers and radiologists, suggesting the two groups of experts are looking for different requirements from the image. Further education and training is necessary to align strategies for assessing BI mammograms, and some criteria need to be adapted to reduce subjectivity.

Study of breast implants mammography examinations for identification of suitable image quality criteria

PURPOSE

To characterise the mammography technique used in breast cancer screening programmes for breast implants (BI) and to identify if the image quality (IQ) criteria available in literature are applicable to BI imaging.

METHODS

The study was conducted in two phases: literature review to find IQ criteria used in mammography combining keywords in several sources; and assessment of 1207 BI mammograms using the criteria that was identified previously to see if they were achieved or not. An observation grid was used to collect information about positioning, beam energy, compression force, and exposure mode. Descriptive statistics and Student's t test and χ2 test were performed according to the nature of the variables.

RESULTS

Forty-seven out of 2188 documents were included in the analysis, with 13 items identified to assess the quality of positioning, 4 for sharpness, 3 for artefacts, and 2 for exposure parameters. After applying the criteria to BI mammograms, retroglandular fat was not included in 37.3% of the images. The "Pectoral-Nipple-Line" criterion was achieved in 35% of MLO/ML images. The placement of the implant (subpectoral/subglandular) or performing the Eklund had significant influence on the visible anatomy (p = < 0.005), alongside whether the breast was aligned to the detector's centre.

CONCLUSIONS

Some of the criteria used to assess standard mammograms were not applicable to BI due to implant overlap. The alignment of the image with the detector's centre seems to have an impact on the amount of visible tissue. Further studies are necessary to define the appropriate protocol, technique, and suitable quality criteria to assess BI mammograms.

Radiographer mammographers' attitudes towards implementing new techniques for imaging the augmented breast, after viewing a training DVD or receiving cascade training: A survey

INTRODUCTION

Mammographers in the NHSBSP are required to implement the Eklund ('Pushback') technique after viewing a training DVD or receiving cascade training. This study aims to evaluate Radiographers' attitudes towards imaging the augmented breast following viewing the training DVD or receiving cascade training.

METHODOLOGY

Questionnaires containing both open and closed questions collected quantitative and qualitative data across three breast screening units. A total of 60 radiographers were targeted. Their responses were analysed using Pearson's Chi-Square. An evaluation of likelihood and association of variables was performed using inferential statistics.

RESULTS

Of the 60 mammographers targeted, 38 (63%) completed the questionnaires. Quantitative results indicated that most mammographers (78%) had watched the DVD. Of these responders, (51.14%) found the DVD somewhat helpful in raising their confidence to attempt the new techniques. When inferential statistics was used to evaluate if confidence was associated with location or level of qualifications, these showed no significance ('p' = 0.085 and 0.312 respectively). Results indicated that longer years of practice had an association with ability to attempt techniques, however, this was not statistically significant (χ² = 3.939, df = 6, p = 0.685). Qualitative responses indicated that cascade training increased confidence more than viewing the DVD. Both qualitative and quantitative data indicated that cascade training in addition to the DVD is required.

CONCLUSION

Although the DVD was a helpful training tool, it did not sufficiently raise confidence for all viewers. Cascaded training in addition to the DVD was required to effectively raise confidence.

Assessing Transgender Patient Care and Gender Inclusivity of Breast Imaging Facilities Across the United States

PURPOSE

To evaluate transgender patient care, gender inclusivity, and transgender health-related policies at breast imaging facilities across the United States.

METHODS

A survey on breast imaging facilities' policies and practices regarding transgender care was distributed to the membership of the Society of Breast Imaging, consisting of approximately 2,500 breast radiologists across the United States. The survey was conducted by e-mail in January 2018.

RESULTS

There were 144 survey respondents. Responses showed that 78.5% of facilities have gender-neutral patient bathrooms, 9.0% have a separate waiting area for transgender patients, and 76.4% do not have dominant pink hues in their facilities, although 54.2% have displays with female gender content. Also, 58.0% of intake forms do not ask patients to provide their gender identity, although 25.9% automatically populate with female phrases. Within the electronic health record, 32.9% lack a distinct place to record patients' preferred names and 54.9% lack a distinct place to record patients' gender pronouns. The majority (73.4%) do not have explicit policies related to the care of transgender patients. Only 14.7% of facilities offer lesbian, gay, bisexual, and transgender training.

CONCLUSION

Our national survey demonstrates that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor provide inclusive environments for transgender patients. All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies and foster more inclusive environments.

Current Trends in the Oncologic and Surgical Managements of Breast Cancer in Women with Implants: Incidence, Diagnosis, and Treatment

Breast augmentation is the most common cosmetic surgery in the United States, and thousands of augmented patients develop breast cancer each year. The possible effects of implants on cancer incidence, diagnosis, and treatment usually generate a disarming confusion. The present paper represents an update of the more recent oncologic and surgical strategies, aiming to support plastic and general surgeons in such challenging aspects. Several aspects of breast cancer management in augmented women are investigated, including (1) risk estimation and cancer characteristics, stage at diagnosis, and prognosis; (2) cancer diagnosis with clinical examination, mammography, ultrasound, and magnetic resonance imaging; (3) cancer treatment including breast conservation, intraoperative radiotherapy, sentinel node biopsy and mastectomy, and reconstruction. A brief resume of recommendations and conclusions is suggested, elucidating correct trends in the oncologic management of augmented patients and refusing well-established misconceptions: (1) breast augmentation does not increase the risk of breast cancer incidence, and it does not influence the prognosis; (2) possible risks exist in cancer detection due to technical difficulties; (3) sentinel lymph node detection is feasible; (4) intraoperative radiotherapy represents a good chance for conserving treatment; (5) immediate reconstruction with submuscular-subfascial implants is the most common procedure after mastectomy, and biological substitutes could support this procedure. Breast clinicians should be alerted because of high expectations of this subgroup of patients, accustomed to emphasize the aesthetic result.

LEVEL OF EVIDENCE V

This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Breast carcinoma in augmented breasts: MRI findings

OBJECTIVE

The objective of our study was to characterize the MRI features of breast carcinomas detected in augmented breasts.

MATERIALS AND METHODS

A review of the MRI database identified 54 patients with biopsy-proven breast carcinoma in augmented breasts. The images were reviewed for the type and location of the implant and for the characteristics of the carcinoma. The cases included 46 (85%) invasive cancers (invasive ductal carcinoma, n = 35; invasive lobular carcinoma, n = 7; and mixed features, n = 4) and eight (15%) ductal carcinomas in situ.

RESULTS

The median age of the patients at diagnosis was 49 years (range, 28-72 years). Thirty-eight of the 54 cancers (70%) were palpable. The mean tumor size was 2.8 cm (range, 0.6-9.6 cm). Of the 54 cancers, 34 (63%) presented as masses and 20 (37%) as nonmass enhancement on MRI. There was no detectable difference between implant position and lesion morphology (p = 0.55) or tumor size (p = 1.00). Twenty of 54 (37%) carcinomas abutted the implant, 13 (24%) abutted the pectoralis major muscle, and two (4%) invaded the pectoralis major muscle. Of the tumors abutting the implant, 18 of 20 (90%) spread along the implant capsule for more than 0.5 cm. This pattern of tumor spread was more common in breasts with retroglandular implants (9/16, 56%) than in those with retropectoral implants (9/38, 24%) (p = 0.03). MRI detected the index carcinoma in 16 of 54 (30%) cases, showed a greater extent of disease than was visible on mammography or ultrasound in 21 of 52 (40%) cases, and detected an unsuspected contralateral carcinoma in three of 54 (6%) cases.

CONCLUSION

In augmented breasts, breast cancer often contacts either the implant or the pectoralis major muscle. Tumor spread along the implant contour is more often seen with retroglandular implants than with retropectoral implants. MRI should be considered to assess disease extent in women with augmented breasts before surgery.

Breast care in the transgender individual

INTRODUCTION

Transgender individuals undergo hormone therapy and/or alter their breasts or genitals to facilitate a transition from male to female or female to male. Changes in the breast tissue from hormone therapy, breast binding, mastectomy, or breast augmentation are of specific interest to women's health care providers. To provide competent care, providers must be knowledgeable about unique aspects of breast health in this vulnerable population, including screening guidelines and client education. The purpose of this integrative literature review is to compile the current research on breast health for transgender individuals and to serve as a resource for providers.

METHODS

A search of the literature was performed using CINAHL, Ovid, and PubMed. Results were reviewed for relevant articles, and the reference lists of these were reviewed for additional resources. When available, studies specific to the transgender population are presented; studies of other populations are also included when relevant. Theories of human endocrinology, physiology, and anatomy will provide the foundation for the review and discussion.

RESULTS

Research into breast care for transgender individuals is limited. Often, practitioners must draw conclusions for practice from scattered case studies or research with nontransgender populations. Many of the procedures and practices transgender individuals choose to undergo, such as implantation, injection, binding, and mastectomy, carry serious risks.

DISCUSSION

Transgender individuals should be counseled on all the possible outcomes of their decisions, so they are capable of making informed choices. They must also be followed with careful consideration of these choices. More research in many areas of transgender breast care is necessary.

[Special considerations in breast cancer treatment of an augmented breast]

Breast augmentation surgery involving the use of implants has been one of the most popular plastic surgical procedures for decades. As the multi-million female population who received breast implants ages, the risk of cancer is increasing rapidly, therefore the incidence of malignant disease in association with breast implants will increase as well. Although there is no relationship between tumor development and implants, these cases require special considerations in diagnostics, therapy and follow-up methods. Appropriate multidisciplinary treatment of tumors in augmented breasts corresponding with modern oncoplastic principles can only be accomplished based on adequate oncological, breast and plastic surgical knowledge. Supposing a possible increase of this condition in Hungary, too, authors provide a wide review of the literature on the special oncological and esthetic considerations, for the first time in Hungarian language.

A review of breast imaging following mastectomy with or without reconstruction in an outpatient community center

Despite developments in surgical technique, radiation treatment, and chemotherapeutic agents, tumor recurrence and distant disease have remained a major concern in breast cancer management. Breast imaging after mastectomy in the screening arena remains a controversial topic for breast imagers. Many feel the yield of finding a recurrent cancer with imaging in the asymptomatic patient is too low to be beneficial; others believe imaging should be performed on these patients as the risk of recurrence exists. Patients after a mastectomy procedure are considered high risk and, when they present with clinical symptoms, will require evaluation by the radiologist. In this diagnostic/symptomatic scenario, imaging becomes the routine and current imaging tools, such as mammography, ultrasound, and magnetic resonance imaging (MRI), can easily be incorporated to diagnose recurrent cancer. Our facility has a large population of patients that undergo mastectomy after a carcinoma diagnosis as well as a number of patients that have undergone a mastectomy procedure because of their high-risk status (whether family history or genetic predisposition). A certain percentage of these patients have proceeded to reconstructive surgery. We image these patients routinely as part of our screening protocol. Over the years we have become familiar with the appearance of remaining tissue along the chest wall after mastectomy as well as the reconstructed breasts. This familiarity is important as the imaging of these patients with mammography and other modalities available today can be challenging. This manuscript will discuss the benefits and some limitations surrounding imaging these patients, in both the asymptomatic and symptomatic scenarios, as well as what imaging protocols can be integrated within a facility's standard evaluation.

Screening criteria for breast cancer

Breast cancer screening constitutes an integral part of surgical practice for many surgeons and is an important tool in the war against breast cancer. Among many modalities, mammography plays a central role, with MRI now being increasingly used for women with high risk for breast cancer. Current guidelines for screening are in the process of evolution as more scientific knowledge is gained. The challenge lies in developing cost-effective methods to reach the maximum number of the population at risk.

Imaging in patients with breast implants-results of the First International Breast (Implant) Conference 2009

BACKGROUND: The First International Breast (Implant) Conference was held by the EAoS® (European Academy of Senology) in cooperation with the German Society of Senology during its 29th annual meeting in Düsseldorf, Germany, on 13 June 2009. METHODS: It was performed as a whole-day interactive workshop in which the standards of implant surgery within reconstructive and aesthetic breast surgery were discussed and defined by telecommunication dialogue voting. RESULTS: This article describes the conference results concerning pre- and post-procedural imaging in patients with breast implants. Both before and after augmentation, imaging is mandatory and provides essential information concerning tissue and implant integrity. Whereas mammography is the first-line method before surgery, ultrasound is the mainstay of post-procedural imaging. Cancer screening in augmented breasts generally follows the same guidelines as for non-augmented breasts. CONCLUSION: Whereas agreement about the indications for mammographical and sonographical evaluations is largely unanimous, there was substantial disagreement as far as the application of magnetic resonance imaging is concerned. There is an obvious demand for an evidence-based evaluation of this modality and the implementation of appropriate guidelines.