What is the recommended course of action for a patient with bilateral subpectoral silicone breast implants, scattered areas of fibroglandular density, a small asymmetry in the right breast, and benign rim calcifications?

Management of Breast Findings with Bilateral Subpectoral Silicone Implants

For a patient with bilateral subpectoral silicone breast implants showing scattered fibroglandular density, a small asymmetry in the right breast upper middle third, tissue markers in the upper outer quadrant, and benign rim calcifications, additional diagnostic imaging with spot compression magnification views and ultrasound is recommended to further evaluate the asymmetry. 1

Assessment of Mammographic Findings

• The scattered areas of fibroglandular density represent normal breast tissue and are part of the standard breast density classification 1
• The small asymmetry noted in the upper breast, middle third, on the MLO view with implant displacement requires further evaluation as asymmetries can sometimes indicate underlying pathology 2
• Tissue markers in the upper outer quadrant middle to posterior third indicate previous biopsies or procedures and should be correlated with patient history 1
• Benign rim calcifications are typically associated with the implant capsule and represent a known benign finding in patients with breast implants 3, 4

Recommended Diagnostic Approach

Step 1: Additional Mammographic Views

• Obtain spot compression and magnification views of the asymmetry to determine if it represents:
  • A true asymmetry (visible on multiple views)
  • A summation artifact (disappears with additional views) 1, 2
• Include both standard and implant-displaced views to optimize visualization of breast tissue 1

Step 2: Targeted Ultrasound

• Perform targeted ultrasound of the area of asymmetry to:
  • Characterize the finding (solid vs. cystic)
  • Determine if a correlating mass is present 1, 2
• Ultrasound is particularly valuable in patients with implants as it can evaluate areas that may be obscured on mammography 1

Step 3: Implant Assessment

• Evaluate the integrity of the silicone implants during the ultrasound examination
• Look for signs of implant rupture including:
  • Abnormal implant shell
  • Heterogeneous implant content
  • Extracapsular silicone 1

Interpretation of Findings

For the Asymmetry:

• If the asymmetry resolves with additional views, no further evaluation is needed 2
• If the asymmetry persists but no ultrasound correlate is found, short-term follow-up in 6 months may be appropriate 1
• If a suspicious mass is identified, biopsy should be performed 1

For the Benign Rim Calcifications:

• Rim calcifications around implants are typically benign and represent calcification of the implant capsule 3, 5
• These calcifications differ from those associated with malignancy, which are typically pleomorphic, varying in size and form 1
• Benign implant-associated calcifications typically appear as:
  • White-gray plaques on the inner surface of capsules
  • Ivory-colored, tenaciously adherent deposits on the anterior surface of the implant 4, 5

Special Considerations with Breast Implants

• The presence of implants can make mammographic interpretation more challenging due to:
  • Compression of breast tissue
  • Obscuration of portions of breast tissue 1
• Digital breast tomosynthesis (DBT) may provide better visualization of the breast tissue in patients with implants 1
• MRI may be considered if there is concern for implant rupture or if mammography and ultrasound findings are inconclusive 1

Common Pitfalls to Avoid

• Mistaking normal implant-related calcifications for suspicious microcalcifications 6, 5
• Failing to obtain adequate implant-displaced views, which are essential for visualizing breast tissue 1
• Overlooking the importance of correlating current findings with prior studies and clinical history 1
• Neglecting to evaluate the contralateral breast for comparison 1