What are the recommendations for mammography in a patient with breast implants (breast prosthesis)?

Mammography Recommendations for Patients with Breast Implants

Patients with breast implants should undergo the same breast cancer screening mammography as those without implants, with the critical addition of implant-displaced views (Eklund technique) in addition to standard views to maximize breast tissue visualization. 1, 2

Standard Screening Protocol

Core Mammographic Technique

• Both standard craniocaudal and mediolateral oblique views AND implant-displaced views must be obtained during every mammography examination to adequately visualize breast tissue behind the implant 1, 2
• The implant-displaced technique pushes the implant posteriorly against the chest wall while pulling breast tissue anteriorly, improving tissue visualization 1
• Anterior breast tissue is better visualized with displacement mammography, while posterior tissue is better seen with compression mammography 3

Age-Based Screening Guidelines

• Women aged 40 and older with breast implants should undergo screening mammography with digital breast tomosynthesis (DBT) or standard mammography as their primary screening modality, following the same intervals as women without implants 1, 2
• Women aged 30-39 may use either mammography/DBT or ultrasound for screening purposes 4
• Women under 30 should primarily use ultrasound for breast evaluation 4

Implant-Specific Considerations

Saline vs. Silicone Implants

• For asymptomatic patients with either saline or silicone implants, no additional imaging beyond standard breast cancer screening is recommended specifically for implant evaluation 4, 1
• Saline implant rupture is typically clinically obvious due to visible deflation and change in breast contour, making imaging less critical for rupture detection 4, 1
• Silicone implant rupture requires specialized imaging (MRI or ultrasound) when suspected, as clinical examination is unreliable 4, 2

Mammography Limitations with Implants

• Breast implants reduce the amount of visualizable breast tissue by approximately 25-44%, depending on implant placement (submuscular implants obscure less tissue than subglandular) 3
• Mammography can identify extracapsular silicone rupture (appearing as high-density material outside the implant shell) but cannot detect intracapsular rupture, which represents the majority of implant ruptures 4, 2
• Image quality may be compromised due to parenchymal scarring and implant-related artifacts 3

Evaluation of Suspected Implant Complications

When Implant Rupture is Suspected

Age 40 and older:

• Mammography or DBT is the first-line examination for suspected saline implant complications 4
• For silicone implants, MRI without contrast is the definitive study (sensitivity 87%, specificity 89.9%), though mammography/DBT can identify extracapsular rupture 4, 5

Age 30-39:

• Either mammography/DBT or ultrasound may be used as initial imaging for both saline and silicone implant complications 4

Under age 30:

• Ultrasound is the examination of choice for suspected implant complications 4, 5

Critical Comparison with Prior Studies

• Always compare current mammograms with prior studies, especially in patients with previous silicone implants, as high-density material outside the implant may represent residual silicone from prior explantation rather than new rupture 4, 1

Common Pitfalls and Caveats

Technical Considerations

• Failure to obtain implant-displaced views results in inadequate breast tissue visualization and compromised cancer detection 1, 2
• Clinical examination alone is unreliable for detecting implant rupture and should never be used as the sole diagnostic method 4, 2

Diagnostic Limitations

• Mammography has limited sensitivity (73%) and specificity (50%) for detecting implant abnormalities overall 4
• Intracapsular rupture, the most common type of silicone implant failure, is not visible on mammography and requires MRI for diagnosis 4, 2
• Capsular calcifications visible on mammography correlate with implant age but do not indicate rupture 5

Special Clinical Scenarios

Unexplained Axillary Adenopathy

• Patients with silicone implants (current or prior) and unexplained axillary adenopathy should undergo axillary ultrasound at any age 4
• For women 30 and older, mammography/DBT should be performed in conjunction with ultrasound as complementary examinations 4

Suspected Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

• Ultrasound is the initial examination of choice regardless of age or implant type when BIA-ALCL is suspected 4

FDA Surveillance Recommendations

• The FDA recommends routine surveillance imaging for silicone implant integrity starting at 5-6 years postoperatively, then every 2-3 years thereafter, using MRI or ultrasound (not mammography) 1, 5
• These FDA surveillance recommendations for implant rupture do not replace standard breast cancer screening mammography, which should continue according to age-appropriate guidelines 4