What are the next steps for a patient with a small asymmetry in the upper breast, implant displacement, and benign rim calcifications on the Medial-Lateral Oblique (MLO) view, with 2 tissue markers in the upper outer quadrant?

Management of Small Breast Asymmetry with Implants and Benign Calcifications

For a patient with a small asymmetry in the upper breast, middle third, on the MLO view with implant displacement, tissue markers in the upper outer quadrant, and benign rim calcifications, the next appropriate step is targeted ultrasound of the asymmetric area to further characterize the finding.

Assessment of Mammographic Findings

• The small asymmetry noted on the MLO view represents a finding that requires additional evaluation, as asymmetries can sometimes be the first sign of malignancy, though most are benign 1
• Benign rim calcifications are typically considered Category 2 (Benign Finding) according to BI-RADS classification and are not usually concerning 2, 3
• The presence of tissue markers in the upper outer quadrant indicates previous biopsies or procedures in that area, which is important context for interpretation 2
• Implant displacement views are standard technique for evaluating breast tissue in patients with implants, but can sometimes create apparent asymmetries due to positioning 2

Recommended Next Steps

1. Targeted Ultrasound Evaluation

• Ultrasound is the recommended next step to further characterize the asymmetry seen on mammography 2
• Ultrasound is complementary to mammography and can help distinguish between solid masses and fluid collections 2
• Breast ultrasound should be performed using a high-resolution, real-time linear-array scanner with an adjustable focal zone and a transducer with a minimum center frequency of 10 MHz 2

2. Additional Mammographic Views (if needed)

• If ultrasound is inconclusive, additional mammographic views with spot compression may be helpful to determine if the asymmetry represents:
  • A summation artifact (will disappear with spot compression) 1
  • A true asymmetry (persists on additional views) 2
  • A focal asymmetry or developing mass 2

3. Assessment Based on Combined Findings

• If ultrasound shows a simple cyst or definitively benign finding, no further evaluation is needed 2
• If ultrasound reveals a solid mass with suspicious features, image-guided core biopsy should be performed 2
• If ultrasound is negative but the asymmetry persists on additional mammographic views, consider:
  • Short-term follow-up in 6 months if features are probably benign (BI-RADS 3) 2
  • Biopsy if features are suspicious (BI-RADS 4) 2

Special Considerations for Patients with Implants

• Evaluation of breast tissue in patients with implants can be more challenging due to:

  • Limited visualization of breast tissue on standard mammographic views 2
  • Potential implant displacement or distortion creating apparent asymmetries 2, 4
  • Capsular contracture potentially causing tissue distortion 4

• When evaluating asymmetries in patients with implants:

  • Compare with prior studies when available to assess for stability 2
  • Evaluate implant contour for signs of complications like rupture or capsular contracture 2
  • Consider the relationship between the asymmetry and the implant (whether the finding is related to the implant itself or represents a separate finding in the breast tissue) 2

Pitfalls to Avoid

• Dismissing asymmetries without complete evaluation - while most are benign, asymmetries can represent early malignancy 1
• Over-relying on mammography alone for patients with implants - ultrasound provides complementary information 2
• Failing to correlate with prior studies, which is essential to determine if an asymmetry is new, growing, or stable 2
• Not considering that tissue markers from previous biopsies can create apparent asymmetries or distortions 2
• Neglecting to evaluate the implant itself for complications that might be causing the asymmetric appearance 2, 4