0:00

We have reviewed this normal and, uh, abnormal appearance of, uh,

0:05

breast implant, um, mammogram, ultrasound, and m mri.

0:09

Now let's look at some uh, cases.

0:13

Case number 1 48 year old

0:17

presented with, uh, breast pain.

0:19

She was beaten up by her husband and she's concerned about, uh,

0:24

breast implant rupture. And, uh,

0:27

I'm just showing you her mammogram five years ago.

0:30

She has a nail breast mammogram.

0:32

So was there appropriate initial imaging evaluation for participation?

0:41

All right, um, let's look at it together.

0:45

The correct answer is, uh, actually a mammogram.

0:51

Um, because, um, we say that the patient has, based on the evening,

0:55

you know that the patient has a saline implant, right?

0:59

Mammogram is very good to detect the, uh, ceiling implant,

1:04

uh, rupture.

1:07

So mammogram are or obtained, and, uh,

1:11

what's the appropriate next step?

1:18

Okay, we are everywhere. And, um, let's, uh,

1:23

take a look over here. The correct answer I think is, uh,

1:29

is, uh,

1:30

ultrasound at this point because the patient's supposed to have a mammogram.

1:35

He had a mammogram before, but one,

1:37

we cannot see this mammogram over here since the patient is already over here.

1:42

In this case, we can just do ultrasound.

1:47

So ultrasound was performed. What is the most appropriate management?

1:56

Okay, this one I think we can just, uh, go with, uh,

2:00

clinical management because, uh, we know that this is the implant, uh,

2:05

rupture. Over here.

2:06

There is a disruption of the kind laminal line and, uh,

2:11

this is the, uh, step later sign over here. We identified this, uh,

2:16

seline implant over here, residual one. And, uh,

2:21

so I think the best way to manage that, uh,

2:24

will be for the patient to go back to plastic surgeon.

2:28

If a patient continue to have a pain, they may have to remove that.

2:33

I know in some cases the patient just has no, you know, uh, no pain,

2:37

no other symptoms, and they don't mind this, uh, um,

2:41

deformity and there asymetry in those breasts.

2:46

So I think, uh, it's better for the, uh,

2:48

patient to discuss this with, uh, her, uh, plastic surgeon.

2:55

Okay. What is the most common clinical

2:58

Presentation of the implant? Uh, rupture.

3:06

I think, uh, almost all of them get it right.

3:09

The most common clinical presentation is, uh, corn deformity.

3:14

And, um, if a patient has a silly implant,

3:16

normally they have a very dramatic presentation.

3:20

They can notice this kinda like deformity in asymmetry

3:25

in those breasts. And, um,

3:28

if a patient has a cell cell implant rupture is often, uh,

3:32

quite a startle. But anyway, con, uh,

3:36

based on a study or performed by, uh, uh,

3:40

tar over here and, uh,

3:43

0.2 deformity is the most common clinical presentation.

3:48

And of course,

3:49

the patient can operate to feel mass or pain or also symptoms.

3:55

So, uh, this slide we are going to talk about, uh,

3:58

a c r recommendation for evaluation of, uh,

4:03

breast seline implant integrity. And it depends on the,

4:08

um, patient's age implant type and the symptoms.

4:12

If a patient has no symptoms, there is no, uh,

4:16

imaging screening recommended by the acr. However,

4:20

if a patient has presented with the symptoms and, uh,

4:25

we need to recommend, uh, different, uh, initial evaluation,

4:29

imaging evaluation based on patient's age, but, um,

4:33

no MRI for those patient. For example, if the patient is, uh,

4:38

less than 30 year old and we recommend ultrasound as a starting point

4:43

for patient older than a 40 year old,

4:47

mammogram should be performed like in this case,

4:49

if we had before right that the patient has a seline implant rupture via

4:54

start with a mammogram, she,

4:55

cause she's more than 40 year old for the patient between the 30 and 40 year

5:00

old, you can either start with a mammogram and ultrasound.

5:04

So no m r I needed for D Selenium implant evaluation,

5:11

just case number one. Let's look at case number two.

5:16

A 59 year old woman filled a painful mass in the right breast

5:21

and a mammogram is performed over here.

5:24

She says she has a history of breast in, uh,

5:27

breast implant augmentation at age of 24. So what's the best, uh,

5:31

imaging evaluation for this condition?

5:39

Actually in this case, we don't need to do the, uh,

5:42

ultrasound because if you already know that is actual capsular rupture,

5:47

we need to, uh,

5:48

use the MRI without contrast because we know that the implant is quite old.

5:53

Patient already told you that you also found the calcification around the

5:57

capsule. You also worry about, uh, next, uh, the, uh, contralateral breast.

6:03

So for this one, I would recommend MRI without IV contrast.

6:09

And, uh, how about the silicone implant evaluation?

6:13

Was the MRI recommendation for the asy medical patient.

6:19

Again, aci, uh,

6:21

ACR recommend no imaging for symptomatic patient.

6:25

ACR recommend mri.

6:28

They think that it is appropriate for symptomatic patient of all age,

6:34

but alternatively, you can maybe think use the, uh,

6:37

ultrasound or mammogram depends on patient's age.

6:44

And, uh, I would like to point out that, uh,

6:46

f d a have different recommendation from, uh, um,

6:50

a C R and that f FDA's keeping updating the,

6:55

uh, recommendation in 2019.

6:59

F D A recommended MRI screening should begin

7:04

between the five to six years of postsurgery and

7:09

they should be done every two to three years. Uh, afterwards

7:14

for, uh, for asymptomatic patient,

7:17

if MRIs not is not available,

7:20

ultrasound can be an acceptable alternative.

7:23

That's a 2019 what they recommend. And then two, uh, 20,

7:28

20 last year. They also, uh,

7:32

add a recommendation for patient with, uh, symptoms.

7:37

They recommend MRI at any time.

7:40

Postly for PA for symptomatic patient or patient with, uh,

7:44

equivocal ultrasound. Okay,

7:48

case number three, c p or the woman with screening.

7:53

Mammogram was their most or appropriate recommendation.

7:58

This one is, uh, pretty subtle.

8:05

The correct answer is, uh,

8:07

m r i without a contrast why we recommend that because on the mammogram

8:12

you can tell that this, uh, patient has some undulation of this,

8:18

uh, um, silicone implant on the right side. Also,

8:21

it has no symptoms and you can tell there's a calcification around this, uh,

8:26

uh, implant. So it's quite old. There's underweight the undulation. So,

8:30

so they will worry about, uh, intracapsular rupture. So we recommend the,

8:35

um, uh, MRI without a contrast. And, uh,

8:40

what's your diagnosis based on this? Uh, mri?

8:47

Yes, you guys, uh, definitely right, those are the intracapsular rupture.

8:52

Alright,

8:53

case number 4, 38 year old woman with bilateral breast

8:58

pain and deformity.

8:59

She had a cone implant four months ago and the MRI is performed and

9:04

was the most likely diagnosis.

9:08

I just would like to point out that you may think this is a capsule, uh, sub,

9:12

sub capsule line, but it's not. It's video for like, uh,

9:15

I showed you before on the sagittal, so don't be confused.

9:18

The diagnosis is not here.

9:23

Let's look at the answer together. The correct answer is, uh, implant,

9:27

capsule or contraction. And, uh,

9:30

you can see that there is a significant deformity in the breast over here.

9:35

Patient can notice that. And also patient just had the, uh,

9:40

has both breast, uh, pain, uh,