What is the management plan for a patient with a right breast implant showing sonographic evidence of intracapsular rupture, stepladder sign, and subcapsular lines sign, but no evidence of malignancy and benign findings (BI-RADS-2)?

Management of Intracapsular Breast Implant Rupture

Given the presence of multiple sonographic signs of intracapsular rupture (stepladder sign and subcapsular lines sign), confirmatory MRI without contrast should be obtained before proceeding to surgical consultation, as the ACR recommends that when more than 2 signs of rupture are detected on ultrasound, findings can be acted upon, but MRI remains the gold standard for confirming intracapsular rupture. 1, 2

Diagnostic Confirmation Strategy

The current ultrasound demonstrates two specific signs of intracapsular rupture (stepladder sign and subcapsular lines sign), which according to recent ACR guidelines suggests a high likelihood of true rupture. 1

When to proceed with ultrasound findings alone:

• When more than 2 signs of implant rupture are detected on ultrasound, findings can be acted upon directly without MRI confirmation, as ultrasound in this context has demonstrated diagnostic accuracy of 94.7%, sensitivity of 98.3%, and specificity of 89.2%. 1

When MRI confirmation is recommended:

• When only 1 sign of implant rupture is found on ultrasound, MRI should be obtained for confirmation, as ultrasound has variable accuracy (ranging from 30-98% sensitivity depending on the number of signs present). 1

In this case with 2 signs present, you are at the threshold where either approach is reasonable, but MRI without contrast remains the gold standard with sensitivity of 87% and specificity of 89.9% for confirming intracapsular rupture. 1, 2

Critical Diagnostic Pitfalls

Several ultrasound mimics of intracapsular rupture exist that can produce false-positive findings, including: 1

• Reverberation artifacts
• Normal radial folds (common normal finding of implant infolding)
• Silicone implant impurities creating spurious echoes

Recent case reports have documented false-positive diagnoses where stepladder signs and subcapsular line signs were seen on imaging, but intraoperative examination revealed intact implants with only fluid retention or fibrinous deposits within the capsule. 3

MRI Findings to Confirm Rupture

If MRI is performed, look for: 1, 2

• Complete intracapsular rupture: "linguini" or "wavy-line" sign (most specific finding)
• Incomplete intracapsular rupture: "inverted-loop sign," "keyhole sign," "teardrop sign," or "hang noose sign"

Surgical Referral and Management

Refer to plastic surgery for evaluation and surgical planning within 2-4 weeks. 4

Key counseling points for the patient: 4

• Intracapsular ruptures (where the fibrous capsule remains intact) are typically asymptomatic and pose minimal immediate health risk
• There is no consensus requiring urgent surgery in asymptomatic patients with intracapsular rupture alone
• The absence of current symptoms does not eliminate the need for surgical evaluation when rupture is documented
• Clinical examination is unreliable for detecting implant rupture

Surgical options to discuss: 4

• Explantation without replacement
• Explantation with replacement
• Observation (though this may complicate future breast imaging and cancer detection)

Post-Surgical Monitoring

If a new implant is placed after explantation, the FDA recommends ongoing monitoring with MRI or ultrasound every 2-3 years to detect any future complications such as silicone migration or implant rupture. 2, 4

Breast Cancer Screening Considerations

Continue routine breast cancer screening according to age-appropriate guidelines, as the FDA recommendations for implant rupture evaluation do not replace additional imaging warranted based on the patient's medical history. 1 The BI-RADS-2 (benign) assessment appropriately addresses the absence of malignancy in this case.