Management of late seroma in patients with breast implants: The role of the radiologist.

Management of late seroma in patients with breast implants: The role of the radiologist. Poster No.: C-0800 Congress: ECR 2015 Type: Authors: Keywords: DOI: Educational Exhibit L. Graña Lopez, M. Vázquez Caruncho; Lugo/ES Prostheses, Puncture, Ultrasound, MR, Interventional nonvascular, Breast 10.1594/ecr2015/C-0800 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 16

Learning objectives 1. To show the US and MR findings of periprosthetic late seroma. 2. To describe the role of the radiologist in the management of this unusual complication. Background Late periprosthetic fluid collections are a very rare complication of the breast augmentation surgery. Their prevalence can be estimated around 1%. They are arbitrarily defined as the occurrence of any periimplant fluid collection (blood,serum,pus) appearing later than a year after the surgery. No consensus has been reached on recommended treatment of late seroma. However, increasing concern about the management of such collection and the heightened awareness of the possibility of associated malignancy has lead to various new recommendations for its management. These algorithms recommend conservative treatment first and the radiologist has an important role in this first step. Findings and procedure details Patients diagnosed with late seroma may be asymptomatic, but they usually present with breast swelling or breast asymmetry, breast tenderness and possible palpable fluid collection around the breast. Physical examination is not sensitive enough for the differential diagnosis between rupture of the implant or other complications such as hematoma or seroma. Ultrasound is usually the initial imaging technique, which demonstrates an anechoic fluid collection around the breast implant. MRI should be performed to exclude prosthesis rupture. Infection is one of the most common possible causes of periprosthetic collection. Besides, a fluid collection surrounding the implant has been reported accompanying breast lymphoma. To rule out infection and malignancy, aspiration of the fluid, culture and cell counts are recommended. Ultrasound facilitates the periprosthetic fluid drainage. The aspiration procedure is performed on an outpatient basis using a 21G sterile needle Page 2 of 16

without local anesthesia. The aspiration needle should be flushed with a small amount of liquid (Cytolyt ) and sent for cytological analysis. Some of the fluid obtained should be sent for culture in sterile bottles. (Fig 1) Fig. 1: The aspiration procedure is performed on an outpatient basis using a 21 G sterile needle without local anesthesia. The aspiration needle should be flushed with a small amount of liquid (Cytolyt ) and sent for cytological analysis. Some of the fluid obtained should be sent to the laboratory in sterile bottles References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Over a period of five years, six late seromas were identified in our institution, four in the last year. Page 3 of 16

Fig. 2: A 54-year-old woman underwent bilateral breast augmentation 15 years previously. She complained of right breast increasing size occurring during four weeks. The clinical examination showed a moderate increased size of the right breast. On US, the implant was located under the pectoral muscle. An anechoic collection was seen around the implant (arrow). No ultrasonographic signs of rupture were seen (A). Axial silicone-suppression MRI sequence (B) and axial silicone-excited image (C) showed an intact implant with a collection around it (arrow). References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Page 4 of 16

Fig. 3: A 55-year-old woman in whom bilateral breast augmentation with retropectoral muscle implantation of silicone gel prostheses was performed in 2007 after mastectomy secondary to breast cancer. Six years after the procedure, incidentally during a routine follow-up ultrasound (A), a left periprosthetic fluid collection was detected (arrow). Magnetic resonance imaging - axial silicone-excited sequence (B) and post-contrast sagittal T1-weighted fat satured image (C)- showed the fluid collection (arrow) and the appearance of the contents did not suggest hemorrhage or silicone leakage. References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Page 5 of 16

Fig. 4: A 53-year-old woman presented with enlargement, tightness and heat feeling of the right breast. Six years before, the patient underwent augmentation mammoplasty, with gel-filled silicone prostheses placed below the glandular tissue. Ultrasound scan of the breast showed a large volume of fluid surrounding the implant (arrow) (A). Postcontrast sagittal T1-weighted fat satured MR image (B) and axial diffusion weighted image (C) demonstrated the periprosthetic fluid collection (arrow). Axial silicone-excited sequence showed an intact implant. References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Page 6 of 16

Fig. 5: A 35-year-old woman with bilateral breast augmentation performed 5 years previously complained of acute mild pain and a heat feeling in her left breast. The clinical examination was normal. The patient had no fever. An MRI (Axial siliconesuppresion image (A) and axial silicone-excited sequence (B)) showed a periimplant collection (arrow) without signs of implant rupture. References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Fig. 6: A 29-year-old woman underwent bilateral augmentation mammoplasty 8 years previously. The patient experienced pain and enlargement of the left breast. Ultrasonography showed a small amount of anechoic fluid surrounding the implant (arrow) (A). We performed an ultrasound-guided aspiration of the fluid and the diagnosis of seroma was confirmed by negative results from bacteriologic and cytological examination (B). An MRI performed 4 months after the diagnosis demonstrated spontaneous resolution of the periprosthetic collection. Axial T2 STIR image (C). References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES Page 7 of 16

Fig. 7: A 39-year-old woman presented with enlargement, pain and heat feeling of the right breast. Two years before, the patient underwent augmentation mammoplasty. On US, an anechoic collection was detected around the implant (arrow) (A). Axial T2- weighted fat satured MR image showed the periprosthetic seroma (arrow) (B). Axial silicone-excited sequence demonstrated no signs of implant rupture. References: Radiology, Lucus Augusti hospital, Lucus Augusti - Lugo/ES All of them were initially managed conservatively by ultrasound-guided drainage. Cultures and cytological studies were negative in all of them. The outcome of the patients with late seroma after augmentation mammoplasty is variable. In the cases we are presenting, the symptoms improved or the collection disappeared after the aspiration and treatment with NSAIDs; however, it is published that some periprosthetic fluid collection are refractory and a total capsulectomy (including implant removal) is necessary. Images for this section: Page 8 of 16

Fig. 2: A 54-year-old woman underwent bilateral breast augmentation 15 years previously. She complained of right breast increasing size occurring during four weeks. The clinical examination showed a moderate increased size of the right breast. On US, the implant was located under the pectoral muscle. An anechoic collection was seen around the implant (arrow). No ultrasonographic signs of rupture were seen (A). Axial silicone-suppression MRI sequence (B) and axial silicone-excited image (C) showed an intact implant with a collection around it (arrow). Page 9 of 16

Fig. 3: A 55-year-old woman in whom bilateral breast augmentation with retropectoral muscle implantation of silicone gel prostheses was performed in 2007 after mastectomy secondary to breast cancer. Six years after the procedure, incidentally during a routine follow-up ultrasound (A), a left periprosthetic fluid collection was detected (arrow). Magnetic resonance imaging - axial silicone-excited sequence (B) and post-contrast sagittal T1-weighted fat satured image (C)- showed the fluid collection (arrow) and the appearance of the contents did not suggest hemorrhage or silicone leakage. Page 10 of 16

Fig. 4: A 53-year-old woman presented with enlargement, tightness and heat feeling of the right breast. Six years before, the patient underwent augmentation mammoplasty, with gel-filled silicone prostheses placed below the glandular tissue. Ultrasound scan of the breast showed a large volume of fluid surrounding the implant (arrow) (A). Postcontrast sagittal T1-weighted fat satured MR image (B) and axial diffusion weighted image (C) demonstrated the periprosthetic fluid collection (arrow). Axial silicone-excited sequence showed an intact implant. Fig. 5: A 35-year-old woman with bilateral breast augmentation performed 5 years previously complained of acute mild pain and a heat feeling in her left breast. The clinical examination was normal. The patient had no fever. An MRI (Axial silicone-suppresion Page 11 of 16

image (A) and axial silicone-excited sequence (B)) showed a periimplant collection (arrow) without signs of implant rupture. Fig. 6: A 29-year-old woman underwent bilateral augmentation mammoplasty 8 years previously. The patient experienced pain and enlargement of the left breast. Ultrasonography showed a small amount of anechoic fluid surrounding the implant (arrow) (A). We performed an ultrasound-guided aspiration of the fluid and the diagnosis of seroma was confirmed by negative results from bacteriologic and cytological examination (B). An MRI performed 4 months after the diagnosis demonstrated spontaneous resolution of the periprosthetic collection. Axial T2 STIR image (C). Page 12 of 16

Fig. 7: A 39-year-old woman presented with enlargement, pain and heat feeling of the right breast. Two years before, the patient underwent augmentation mammoplasty. On US, an anechoic collection was detected around the implant (arrow) (A). Axial T2- weighted fat satured MR image showed the periprosthetic seroma (arrow) (B). Axial silicone-excited sequence demonstrated no signs of implant rupture. Page 13 of 16

Fig. 1: The aspiration procedure is performed on an outpatient basis using a 21 G sterile needle without local anesthesia. The aspiration needle should be flushed with a small amount of liquid (Cytolyt ) and sent for cytological analysis. Some of the fluid obtained should be sent to the laboratory in sterile bottles Page 14 of 16

Conclusion Late periprosthetic fluid collection is an underreported entity after breast implantation surgery and radiologists must be aware of it. The radiologist is involved in the initial management of this entity, which includes ultrasound-guided aspiration and analysis of the fluid with culture and cell count to exclude infection and malignancy. In the absence of a diagnosed infectious or neoplastic cause, some of these late fluid collections will resolve without surgery. Personal information References 1. Park BY, Lee DH, Lim SY, et al. Is late seroma a phenomenon related to textured implants? A report of rare complications and a literature review. Aesthetic Plast Surg. 2014 Feb;38(1):139-45. 2. Oefelein MG, Reisman NR, Spear SL, Jewell ML; Late Periprosthetic Fluid Collection after Breast Implant Working Group. Managing late periprosthetic fluid collections (seroma) in patients with breast implants: a consensus panel recommendation and review of the literature. Plast Reconstr Surg 2011;128:1-7. 3. Bengtson B, Brody GS, Brown MH, et al. Managing late periprosthetic fluid collections (seroma) in patients with breast implants: a consensus panel recommendation and review of the literature. Plast Reconstr Surg. 2011 Jul;128(1):1-7. 4. Hall-Findlay EJ. Breast implant complication review: double capsules and late seromas. Plast Reconstr Surg. 2011 Jan;127(1):56-66. 5. Pinchuk V, Tymofii O. Seroma as a late complication after breast augmentation. Aesthetic Plast Surg. 2011 Jun;35(3):303-14. 6. Gulyás G. Commentary on "Seroma as a late complication after breast augmentation" by V.D. Pinchuk, O.V. Tymofii. Aesthetic Plast Surg. 2011 Jun;35(3):315-8. 7. Mazzocchi M, Dessy LA, Carlesimo B, Marchetti F, Scuderi N. Late seroma formation after breast surgery with textured silicone implants: a problem worth bearing in mind. Plast Reconstr Surg 2010;125:176e-7e. 8. Bengtson BP. Complications, reoperations, and revisions in breast augmentation. Clin Plast Surg. 2009;36:139-56. Page 15 of 16

9. McArdle B, Layt C. A case of late unilateral hematoma and subsequent late seroma of the breast after bilateral breast augmentation. Aesthetic Plast Surg. 2009 Jul;33(4):669-70. 10. Chourmouzi D, Vryzas T and Drevelegas A. New spontaneous breast seroma 5 years after augmentation: a case report. Cases J. 2009; 2: 7126. Published online Sep 2, 2009. Page 16 of 16