This has been a thing for a few years now and it continues to annoy the hell out of me. I recently wrote an article about implant surveillance, and I touched on MRI scans so I figured it would be worth talking more about.
Many women who contact us about explant surgery want to know whether I will require them to have an MRI of their breasts before a consultation. And I know that there are a bunch of surgeons out there who (needlessly) make all women considering explant have an MRI.
Which is absurd.
If used in the setting of a routine explant procedure, an MRI is an expensive imaging study which does not alter the surgery required, or performed, in any way. At all. Which means it's pointless. And expensive. So you don't need it.
MRI is only useful in very selected cases. MRI done routinely to "detect possible rupture" is a waste of time and money.
So let's talk about those cases where MRI may be indicated.
This is the main one for most surgeons to think about. And it is probably why there are surgeons who just make every patient have an MRI as some sort of defensive posture. Which doesn't make that less stupid, but perhaps it makes it more understandable.
So, the most common way for BIA-ALCL to present is as a single breast swelling with fluid around the implant. What a patient will notice is that one breast is suddenly larger than the other. That is a concerning sign and warrants investigation.
However, MRI is not the first step.
The first investigation here is ultrasound. An ultrasound will show fluid around an implant, and if that fluid can be seen, it can be drained with a needle and sent for testing. ALCL remains very rare, and so 9.9 times out of 10 that fluid will NOT be ALCL, but we do need to find the 0.1. Remember, the risk of ALCL depends on the type of implant (more common with agressive surface texture) and the risk is anywhere from 1:1800 (with polyurethane) to 1:18,000 (with Mentor Siltex). The Allergan devices that were so common in Australia have a risk of about 1:2400. Those numbers are changing but worth keeping in mind.
There is no recommendation for screening women with breast implants for ALCL. Breast implant surveillance is important, but unless you present with a change in the breast, further investigation is not warranted.
It is worth me saying that not all ALCL presents as fluid around an implant. There are even rarer cases (of an already rare condition) in which ALCL will present as a mass within the capsule itself. This may also present as a unilateral breast swelling. Ultrasound won't show a drainable collection. In these cases, I use my brain, and I think about the likelihood of ALCL and I would then order an MRI if I think it would influence the way in which I would do surgery. Basically, if I can't diagnose ALCL based on a fluid sample, but I think there is still a chance of there being something sinister going on, MRI might provide enough information to push me to do something like a true en-bloc capsulectomy.
This is rare. I have seen it a couple of times. Most surgeons will never see this. But when it presents, an MRI is important to demonstrate just what is going on.
Extracapsular rupture with dissemination is one of those things that makes patients scared of implant rupture. But implant rupture (in the common sense of the term) and even extracapsular rupture (in the way it usually presents) is not a major concern. Extracapsular rupture associated with silicone dissemination is something else entirely.
Quick recap of extracapsular rupture:
When a breast implant ruptures, it implies that the outer shell of the implant has a breach, and silicone can then"leak" out of the implant. This "leak" is typically contained by the scar capsule that the body naturally makes in response to the implant, and it goes no further.
Extracapsular rupture occurs when the scar capsule itself then has a breach, and the previously intracapsular silicone can get out of the capsule. This normally occurs in response to some kind of breast trauma resulting in the breach in the capsule, but not always. The extracapsular silicone however then stimulates a scar response in the tissues which is similar to the response to the implant itself. The body naturally walls off an extracapsular leak and at the time that a breast implant is then removed, this may look like a little extra "appendage" on the capsule itself.
Something like this:
If this little dangly bit was palpable, then it might be cause for concern as some sort o breast lump (see below). So an MRI is not an unreasonable thing to consider after an ultrasound (but not as the first investigation).
On the other hand, dissemination is a different beast. This is a rare situation where the silicone travels wide and far through the tissues and isn't walled off in a little appendage to the capsule. In these cases, the silicone travels along tissue "planes"and can end up in odd places. I have seen silicone that has travelled around under the Latissimus dorsi (the 'Lats') almost to the spine. I have seen silicone sitting in a sort of sausage shaped collection on the hip bone. This is really, really rare.
One of the cases that I have seen presented with something very unusual: the skin was purple and hardened and I was worried about a rare form of tumour called a sarcoma. It turned out the silicone had extruded right under the skin, and this skin had to be removed at surgery to address the silicone leakage.
In these cases, which often present with odd bumps where there should be any, an MRI may be the first consideration. Normally, the MRI is to rule out nasty stuff like cancers, and we find the silicone dissemination almost by accident. But given the rarity of silicone dissemination, it shouldn't be used as justification for making every patient have an MRI.
A new breast lump is always scary for ladies, and always warrants due consideration by a GP or surgeon.
If a patient with a breast implant presents with a lump, we treat that patient EXACTLY as we would a patient without a breast lump.
The patient should be referred (by their GP typically) for ultrasound or mammogram initially. Those investigations may then suggest a requirement for a biopsy. There are also situations where the initial investigations are challenging, mostly for young ladies with dense breasts, and an MRI may then be recommended.
This is a situation where MRI may have nothing to do with the breast implant. But the MRI will also provide information about an implant, and there are circumstances where the implant is responsible for the feeling of a breast lump.
This one is increasingly common. It is something we have seen in the way the radiologists are reporting on breast imaging studies for ladies with implants.
It goes like this: lady has implants, sees a GP because she feels something or notices a change, GP refers for ultrasound, ultrasound report says "we can't really tell you much, so we recommend an MRI". Lady then gets an MRI.
The cynical part of me looks at this and says this is a combination of defensive medicine (from a medicolegal perspective) and a cash grab (because the MRI is worth more to the radiology practice) but I have to temper that with the fact that there simply are cases where ultrasound doesn't provide enough information and so an MRI is appropriate. Ultimately, a surgeon has to defer to the radiologist in this matter.
Something that shows up on ultrasound ALL THE TIME is the presence of silicone in lymph nodes. This plays heavily into the fear that people have about the health effects of silicone implants, and it is something that the BII "advocates" in forums get quite excited about (but shouldn't).
How does silicone get into a lymph node?
Typically, this relates to textured implants. We know that the surface texturing leads to small fragments of the roughened shell (called silicone "particulates") rubbing off over time - a bit like those little bits of an eraser that are formed when rubbing out a pencil line (I'm showing my age....there are probably some of my younger patients who don't even know what a real eraser is...good lord). Those little fragments can be taken up in the lymphatic vessels.
The other way silicone enters the lymphatic system is as a consequence of silicone "bleed" which is something we see in older implants. Silicone bleed is a bit like silicone "perspiring" out of the implant despite an intact shell. There is a layer of silicone external to the implant without rupture and this free silicone can then be taken up in the lymphatics. There isn't a lot of good data to tell us how common silicone bleed is, or whether it only relates to older non-cohesive implants. There are studies which suggest that silicone bleed is present in the vast majority of women with breast implants at a microscopic level; how this correlates with silicone in lymph nodes cannot be determined. Unfortunately, as with many of the negative aspects of silicone breast implants, there seems not to be sufficient incentive for large, robust studies to be performed.
Anyway, silicone in the lymphatics will travel (slowly) to lymph nodes where it is essentially filtered out of the lymphatic system and then accumulates in a little silicone granuloma in the node.
2 things to be clear about: silicone in a lymph node does NOT mean rupture, and silicone in a lymph node is NOT dangerous. More importantly, silicone in a lymph node is not an indicate for surgical removal of that lymph node.
But, once there is silicone in that node, it can be seen on ultrasound, and is often reported as a "snowstorm" appearance. It doesn't mean you need an MRI.
Silicone in lymph nodes can, in most cases, be ignored. At the time of explant, there is (almost) never an indication for a surgeon to go digging around in your armpit. I know it's happening, and its both stupid and dangerous.
There are very rare cases where silicone in a lymph node leads to symptoms of pain, swelling, or even (and this is vanishingly rare) ulceration of the skin. So hence, I say lymph nodes 'almost' never need treating...but again, these super rare phenomena do not mean we go doing dumb things to every patient.
So there you go.
If you have been told to have an MRI before a routine explant procedure, then maybe that is worth questioning.
Any investigation is only worthwhile if it actually changes management or improves outcomes. MRI before routine explant does neither of those things.
Have a lovely day 😊