What is the recommended screening protocol for breast cancer in patients with silicone implants?

Breast Cancer Screening Protocol for Patients with Silicone Implants

Patients with silicone breast implants should follow standard breast cancer screening protocols with additional specialized imaging techniques to account for the presence of implants.

Standard Screening Recommendations

• Patients with silicone implants should follow the same breast cancer screening protocols as those without implants, as outlined in the ACR Appropriateness Criteria on "Breast Cancer Screening" 1
• Both standard craniocaudal and mediolateral oblique views AND implant-displaced views should be obtained during mammography to maximize visualization of breast tissue 1

Specialized Imaging Considerations

Mammography/Digital Breast Tomosynthesis (DBT)

• Mammography with implant-displaced views is the primary screening modality for patients with silicone implants aged 40 and older 1
• Mammography can identify extracapsular silicone (silicone outside the implant shell) but cannot reliably detect intracapsular rupture 1
• Comparison with prior imaging is critical, especially in patients who have had previous silicone implants, to differentiate between new rupture and residual silicone 1

Ultrasound (US)

• Ultrasound may be used as a supplementary screening tool, particularly in younger patients (<40 years) or those unable to undergo mammography 1
• Ultrasound has shown sensitivity of 70% and specificity of 92% for implant rupture detection in some studies 2
• Recent research suggests ultrasound may be nearly as effective as MRI for detecting breast implant ruptures (accuracy 96%, sensitivity 95%, specificity 96%) 3
• Ultrasound may be superior to MRI for detecting silicone depositions in axillary lymph nodes 3

MRI

• MRI without IV contrast is the most accurate imaging modality for evaluating silicone implant integrity, particularly for detecting intracapsular rupture 1
• MRI has demonstrated sensitivity of 87% and specificity of 89.9% for implant rupture detection 1
• In symptomatic patients, MRI has shown sensitivity of 96%, specificity of 77%, and accuracy of 90% 1
• The FDA recommends MRI for evaluation of suspected implant rupture in symptomatic patients 1

Monitoring Protocol for Implant Integrity

• Patients with silicone breast implants should undergo routine screening for implant rupture with MRI or ultrasound 5-6 years after implantation and every 2-3 years thereafter 4
• For asymptomatic women with silicone implants under age 40, some experts recommend ultrasound as the initial screening tool, with MRI reserved for patients with abnormal sonographic findings 1

Special Considerations

• Clinical examination alone is unreliable for detecting implant rupture 1, 5
• Previous history of radiation therapy significantly increases the risk of capsular contracture 5
• Women with unilateral breast swelling should be evaluated with ultrasound for effusion that might indicate breast implant-associated anaplastic large cell lymphoma 4
• Patients with asymptomatic silicone-injected breasts (not implants) have a risk of underestimating breast cancer by palpation, mammography, or breast sonography and may benefit from enhanced breast MRI 6

Common Pitfalls and Caveats

• Mammography cannot reliably detect intracapsular rupture, which represents the majority of implant ruptures 1
• Several ultrasound intracapsular-rupture mimics exist, including reverberation artifact, radial folds, or silicone implant impurities 1
• Double-lumen implants may appear as false-positive results for rupture on sonography 2
• The FDA recommendations for implant rupture evaluation do not replace additional imaging warranted based on the patient's medical history or circumstances 1