Volume 132, Number 6 • Viewpoints REFERENCES 1. Karen JK, Hale EK, Geronemus RG. A simple solution to the common problem of ecchymosis. Arch Dermatol. 2010;146:94–95. 2. DeFatta RJ Krishna S Williams EF III Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11(2):99–103.
A New, Simple Method to Describe Magnetic Resonance Imaging of Silicone Breast Implants: Silicone Implants Reporting and Data System Sir:
W
Fig. 3. Resolved and resolving ecchymoses 2 days after one treatment using pulsed-dye laser.
within the plastic surgery community.1,2 Furthermore, to date, we are unaware of a report of such resolution within a matter of hours. The theory behind laser-assisted resolution of these lesions is the preferential absorption of the 595nm wavelength by oxyhemoglobin in the extravasated blood, or ecchymosis. This would explain why the results were best in areas of bruising that were violaceous to erythematous in color compared with the more sallow-appearing areas, which represented the degradation to bilirubin. In our practice, postoperative treatment with a 595-nm pulsed-dye laser has been proven to be a rapid, safe, and effective option for ecchymoses that patients have come to greatly appreciate. DOI: 10.1097/PRS.0b013e3182a980d1
Jeremy A. Brauer, M.D. Roy G. Geronemus, M.D. Laser & Skin Surgery Center of New York, and Ronald O. Perelman Department of Dermatology New York University Langone Medical Center New York, N.Y. Correspondence to Dr. Brauer Laser & Skin Surgery Center of New York 323 East 34th Street New York, N.Y. 10016 [email protected]
DISCLOSURE The authors have no financial interest in the products or devices mentioned in this article.
e would like to share with colleagues a newly designed method to record radiologist’s magnetic resonance imaging findings on silicone breast implant condition in two categories, to avoid subjective interpretation of inconclusive text, called Silicone Implants Reporting and Data System (SI-RADS). We designed this tool to re-evaluate magnetic resonance images in our ongoing studies of women previously implanted with Poly Implant Prothèse implants. Magnetic resonance imaging silicone breast implant screening studies have been criticized for not using a uniform terminology on implant condition or status. We also found a somewhat disappointing accuracy of magnetic resonance imaging screening in asymptomatic women with Poly Implant Prothèse breast implants1 when compared with a recent magnetic resonance imaging validation study.2 Validation studies, however, use multiple radiologists who are assigned to the sole task of evaluating the images for research purposes, which improves sensitivity and specificity but is not often applicable to common daily practice. In our daily clinical practice, we noticed a broad spectrum of terminology used by individual radiologists to describe implant condition. Terms such as “leaking” and “fluid seen” or “released” provided by radiologists are left to plastic surgeons to interpret as implants being ruptured or not. The decision to advise explantation is often based on these, at times not conclusive, magnetic resonance imaging reports. Unlike the diagnosis of a bone fracture, the radiologic diagnosis of a ruptured implant is subject to different degrees of confidence of the reporting radiologist. In breast cancer, one has an identical problem regarding the confidence in the interpretation of the radiologic findings in individual patients. The Breast Imaging Reporting and Data System (BI-RADS) was developed and introduced by the American College of Radiology to solve this problem and to provide a clear and simple radiologic describing system; it improved communication between physicians and can be used in the daily practice of decision making by the oncologic surgeon.3,4 This Breast Imaging Reporting and Data System methodology has been used successfully in the Dutch national breast cancer screening program for many years.5 Why not use an analogous system to screen silicone breast implant condition?
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Plastic and Reconstructive Surgery • December 2013 Table 1. Silicone Implant Reporting and Data System Assessment Category
Description
A. Implant integrity 0 Incomplete* 1 Intact 2 Probably intact 3 Probably ruptured 4 Ruptured B. Extracapsular leakage of silicone 0 Incomplete* 1 2 3 4
No extracapsular leakage Probably no extracapsular leakage Probably extracapsular leakage Extracapsular leakage
Clinical Management Additional imaging* None None Referral Referral Additional imaging* None None Referral Referral
SI-RADS, Silicone Implants Reporting and Data System. *If the magnetic resonance image is inconclusive, either additional imaging or a second opinion from a radiologist colleague should be sought.
The simple and structured Silicone Implants Reporting and Data System tool was developed with two categories: (A) implant status and (B) signs of extracapsular silicone leakage. The multiple-choice answers as a measure of confidence, inspired by the breast imaging system’s methodology, left no room for inconclusive or descriptive text (Table 1). The Silicone Implants Reporting and Data System methodology was then applied to re-evaluate the 2-year-old magnetic resonance images of 214 implants completed by two of the three original radiologists. The radiologists found the silicone implants tool easy to use and time sparing. An example of a clearly ruptured and partially collapsed silicone implant in the left breast is shown in
Fig. 2. View of the ruptured implant in the left breast on a sagittal water-suppressed STIR-T2–weighted image.
Figures 1 and 2. We compared the magnetic resonance imaging reports with the explantation results and found an improved sensitivity and specificity of from 80 and 91 percent to 93 and 93 percent, respectively, of magnetic resonance imaging screening in asymptomatic women with Poly Implant Prothèse breast implants when using the silicone implants tool, compared with the previous magnetic resonance imaging reporting. We would advise colleagues to implement this new Silicone Implants Reporting and Data System (SI-RADS) methodology of simple, uncomplicated, and uniform reporting of silicone implants in their daily practices, as we believe this would improve communication between radiologists and plastic surgeons. DOI: 10.1097/PRS.0b013e3182a9807d
Maria C. Maijers, M.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center
Franciscus B. Niessen, M.D., Ph.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center, and Medical Center Jan van Goyen
Jacob F. H. Veldhuizen, M.D. MRI Center Amsterdam
Marco J. P. F. Ritt, M.D., Ph.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center
Radu A. Manoliu, M.D., Ph.D. Fig. 1. Water-suppressed STIR-T2–weighted axial image of both breasts shows infolding of an intact implant in the right breast. Shell rupture and partial collapse of the implant in the left breast can also be seen. This was SI-RADS classified as Left: A4B1 and Right: A1B1.
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MRI Center Amsterdam Amsterdam, The Netherlands Correspondence to Dr. Maijers Department of Plastic, Reconstructive, and Hand Surgery VU University Medical Center
Volume 132, Number 6 • Viewpoints De Boelelaan 1117, PO Box 7057 1007 MB Amsterdam, The Netherlands [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. REFERENCES 1. Maijers MC, Niessen FB. The clinical and diagnostic consequences of poly implant prothese silicone breast implants, recalled from the European market in 2010. Plast Reconstr Surg. 2013;131:394e–402e. 2. Hölmich LR, Vejborg I, Conrad C, Sletting S, McLaughlin JK. The diagnosis of breast implant rupture: MRI findings compared with findings at explantation. Eur J Radiol. 2005;53:213–225. 3. Kallergi M, Gavrielides MA, He L, Berman CG, Kim JJ, Clark RA. Simulation model of mammographic calcifications based on the American College of Radiology Breast Imaging Reporting and Data System, or BIRADS. Acad Radiol. 1998;5:670–679. 4. Taplin SH, Ichikawa LE, Kerlikowske K, et al. Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography. Radiology 2002;222:529–535. 5. Timmers JM, van Doorne-Nagtegaal HJ, Zonderland HM, et al. The Breast Imaging Reporting and Data System (BIRADS) in the Dutch breast cancer screening programme: Its role as an assessment and stratification tool. Eur Radiol. 2012;22:1717–1723.
Glomus Body Tumor of the Breast: A Rare Cause of Isolated Breast Pain Sir:
B
reast pain is common for most women. Focal, severe pain is uncommon and characteristic of a glomus body tumor of the breast. There are few reported cases, with the first declared in 2009 and only a few others since then.1 We present a case of glomus tumor of the breast with both clinical and immunohistological evidence. A 66-year-old white woman presented with complaints of severe localized tenderness in the left breast toward the axillary tail over the preceding 6 years. She experienced exquisite pain when she rubbed her arm across her breast. Focal pressure caused exacerbation of the pain. She had also noticed a bluish discoloration under the skin 1 year earlier. She was a G3P3 female with a family history of breast and lung cancer. A mammogram taken 2 months earlier showed an indeterminate left breast mass at 1:30 o’clock, 10 cm from the nipple. Ultrasound showed a palpable, 1.3-cm, lobulated hypoechoic mass. Believed to be a dermal cyst, a core biopsy was scheduled, but targeted real-time and color flow ultrasound were performed and showed
Fig. 1. (Above) Glomus tumor (left) with epidermis (right) shown on low-power hematoxylin and eosin stain; well-circumscribed, aggregate nests of glomulocytes associated with vasculature can be seen on their periphery. (Below) High-power hematoxylin and eosin stain shows small, round glomus cells with distinct nuclei, associated with small vessels in a hyaline/myxoid stroma. Glomulocytes are round or cuboidal, are small with scant cytoplasm, have distinct cell borders, and have features similar to those of smooth muscle cells.
considerable blood flow within the mass, contraindicating the biopsy. The patient was referred to the senior author for surgical biopsy. Physical examination prior to surgery confirmed a bluish cystic mass in the axillary tail; it was extremely tender to palpation, freely mobile, firm, nonpulsatile, and nonexpansile. Assessment of venous malformation was made, and outpatient excision under local anesthesia was performed. The mass was excised with a wide elliptical excision and noted to “shell out quite easily” with one small feeding vessel that was venous in nature. Pathologic analysis demonstrated a nonencapsulated tumor with a proliferation of atypical cells in between numerous vascular channels. The cells demonstrated round nuclei and conspicuous nucleoli with
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A New, Simple Method to Describe Magnetic Resonance Imaging of Silicone Breast Implants: Silicone Implants Reporting and Data System Sir:
W
Fig. 3. Resolved and resolving ecchymoses 2 days after one treatment using pulsed-dye laser.
within the plastic surgery community.1,2 Furthermore, to date, we are unaware of a report of such resolution within a matter of hours. The theory behind laser-assisted resolution of these lesions is the preferential absorption of the 595nm wavelength by oxyhemoglobin in the extravasated blood, or ecchymosis. This would explain why the results were best in areas of bruising that were violaceous to erythematous in color compared with the more sallow-appearing areas, which represented the degradation to bilirubin. In our practice, postoperative treatment with a 595-nm pulsed-dye laser has been proven to be a rapid, safe, and effective option for ecchymoses that patients have come to greatly appreciate. DOI: 10.1097/PRS.0b013e3182a980d1
Jeremy A. Brauer, M.D. Roy G. Geronemus, M.D. Laser & Skin Surgery Center of New York, and Ronald O. Perelman Department of Dermatology New York University Langone Medical Center New York, N.Y. Correspondence to Dr. Brauer Laser & Skin Surgery Center of New York 323 East 34th Street New York, N.Y. 10016 [email protected]
DISCLOSURE The authors have no financial interest in the products or devices mentioned in this article.
e would like to share with colleagues a newly designed method to record radiologist’s magnetic resonance imaging findings on silicone breast implant condition in two categories, to avoid subjective interpretation of inconclusive text, called Silicone Implants Reporting and Data System (SI-RADS). We designed this tool to re-evaluate magnetic resonance images in our ongoing studies of women previously implanted with Poly Implant Prothèse implants. Magnetic resonance imaging silicone breast implant screening studies have been criticized for not using a uniform terminology on implant condition or status. We also found a somewhat disappointing accuracy of magnetic resonance imaging screening in asymptomatic women with Poly Implant Prothèse breast implants1 when compared with a recent magnetic resonance imaging validation study.2 Validation studies, however, use multiple radiologists who are assigned to the sole task of evaluating the images for research purposes, which improves sensitivity and specificity but is not often applicable to common daily practice. In our daily clinical practice, we noticed a broad spectrum of terminology used by individual radiologists to describe implant condition. Terms such as “leaking” and “fluid seen” or “released” provided by radiologists are left to plastic surgeons to interpret as implants being ruptured or not. The decision to advise explantation is often based on these, at times not conclusive, magnetic resonance imaging reports. Unlike the diagnosis of a bone fracture, the radiologic diagnosis of a ruptured implant is subject to different degrees of confidence of the reporting radiologist. In breast cancer, one has an identical problem regarding the confidence in the interpretation of the radiologic findings in individual patients. The Breast Imaging Reporting and Data System (BI-RADS) was developed and introduced by the American College of Radiology to solve this problem and to provide a clear and simple radiologic describing system; it improved communication between physicians and can be used in the daily practice of decision making by the oncologic surgeon.3,4 This Breast Imaging Reporting and Data System methodology has been used successfully in the Dutch national breast cancer screening program for many years.5 Why not use an analogous system to screen silicone breast implant condition?
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Plastic and Reconstructive Surgery • December 2013 Table 1. Silicone Implant Reporting and Data System Assessment Category
Description
A. Implant integrity 0 Incomplete* 1 Intact 2 Probably intact 3 Probably ruptured 4 Ruptured B. Extracapsular leakage of silicone 0 Incomplete* 1 2 3 4
No extracapsular leakage Probably no extracapsular leakage Probably extracapsular leakage Extracapsular leakage
Clinical Management Additional imaging* None None Referral Referral Additional imaging* None None Referral Referral
SI-RADS, Silicone Implants Reporting and Data System. *If the magnetic resonance image is inconclusive, either additional imaging or a second opinion from a radiologist colleague should be sought.
The simple and structured Silicone Implants Reporting and Data System tool was developed with two categories: (A) implant status and (B) signs of extracapsular silicone leakage. The multiple-choice answers as a measure of confidence, inspired by the breast imaging system’s methodology, left no room for inconclusive or descriptive text (Table 1). The Silicone Implants Reporting and Data System methodology was then applied to re-evaluate the 2-year-old magnetic resonance images of 214 implants completed by two of the three original radiologists. The radiologists found the silicone implants tool easy to use and time sparing. An example of a clearly ruptured and partially collapsed silicone implant in the left breast is shown in
Fig. 2. View of the ruptured implant in the left breast on a sagittal water-suppressed STIR-T2–weighted image.
Figures 1 and 2. We compared the magnetic resonance imaging reports with the explantation results and found an improved sensitivity and specificity of from 80 and 91 percent to 93 and 93 percent, respectively, of magnetic resonance imaging screening in asymptomatic women with Poly Implant Prothèse breast implants when using the silicone implants tool, compared with the previous magnetic resonance imaging reporting. We would advise colleagues to implement this new Silicone Implants Reporting and Data System (SI-RADS) methodology of simple, uncomplicated, and uniform reporting of silicone implants in their daily practices, as we believe this would improve communication between radiologists and plastic surgeons. DOI: 10.1097/PRS.0b013e3182a9807d
Maria C. Maijers, M.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center
Franciscus B. Niessen, M.D., Ph.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center, and Medical Center Jan van Goyen
Jacob F. H. Veldhuizen, M.D. MRI Center Amsterdam
Marco J. P. F. Ritt, M.D., Ph.D. Department of Plastic and Reconstructive and Hand Surgery VU University Medical Center
Radu A. Manoliu, M.D., Ph.D. Fig. 1. Water-suppressed STIR-T2–weighted axial image of both breasts shows infolding of an intact implant in the right breast. Shell rupture and partial collapse of the implant in the left breast can also be seen. This was SI-RADS classified as Left: A4B1 and Right: A1B1.
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MRI Center Amsterdam Amsterdam, The Netherlands Correspondence to Dr. Maijers Department of Plastic, Reconstructive, and Hand Surgery VU University Medical Center
Volume 132, Number 6 • Viewpoints De Boelelaan 1117, PO Box 7057 1007 MB Amsterdam, The Netherlands [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. REFERENCES 1. Maijers MC, Niessen FB. The clinical and diagnostic consequences of poly implant prothese silicone breast implants, recalled from the European market in 2010. Plast Reconstr Surg. 2013;131:394e–402e. 2. Hölmich LR, Vejborg I, Conrad C, Sletting S, McLaughlin JK. The diagnosis of breast implant rupture: MRI findings compared with findings at explantation. Eur J Radiol. 2005;53:213–225. 3. Kallergi M, Gavrielides MA, He L, Berman CG, Kim JJ, Clark RA. Simulation model of mammographic calcifications based on the American College of Radiology Breast Imaging Reporting and Data System, or BIRADS. Acad Radiol. 1998;5:670–679. 4. Taplin SH, Ichikawa LE, Kerlikowske K, et al. Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography. Radiology 2002;222:529–535. 5. Timmers JM, van Doorne-Nagtegaal HJ, Zonderland HM, et al. The Breast Imaging Reporting and Data System (BIRADS) in the Dutch breast cancer screening programme: Its role as an assessment and stratification tool. Eur Radiol. 2012;22:1717–1723.
Glomus Body Tumor of the Breast: A Rare Cause of Isolated Breast Pain Sir:
B
reast pain is common for most women. Focal, severe pain is uncommon and characteristic of a glomus body tumor of the breast. There are few reported cases, with the first declared in 2009 and only a few others since then.1 We present a case of glomus tumor of the breast with both clinical and immunohistological evidence. A 66-year-old white woman presented with complaints of severe localized tenderness in the left breast toward the axillary tail over the preceding 6 years. She experienced exquisite pain when she rubbed her arm across her breast. Focal pressure caused exacerbation of the pain. She had also noticed a bluish discoloration under the skin 1 year earlier. She was a G3P3 female with a family history of breast and lung cancer. A mammogram taken 2 months earlier showed an indeterminate left breast mass at 1:30 o’clock, 10 cm from the nipple. Ultrasound showed a palpable, 1.3-cm, lobulated hypoechoic mass. Believed to be a dermal cyst, a core biopsy was scheduled, but targeted real-time and color flow ultrasound were performed and showed
Fig. 1. (Above) Glomus tumor (left) with epidermis (right) shown on low-power hematoxylin and eosin stain; well-circumscribed, aggregate nests of glomulocytes associated with vasculature can be seen on their periphery. (Below) High-power hematoxylin and eosin stain shows small, round glomus cells with distinct nuclei, associated with small vessels in a hyaline/myxoid stroma. Glomulocytes are round or cuboidal, are small with scant cytoplasm, have distinct cell borders, and have features similar to those of smooth muscle cells.
considerable blood flow within the mass, contraindicating the biopsy. The patient was referred to the senior author for surgical biopsy. Physical examination prior to surgery confirmed a bluish cystic mass in the axillary tail; it was extremely tender to palpation, freely mobile, firm, nonpulsatile, and nonexpansile. Assessment of venous malformation was made, and outpatient excision under local anesthesia was performed. The mass was excised with a wide elliptical excision and noted to “shell out quite easily” with one small feeding vessel that was venous in nature. Pathologic analysis demonstrated a nonencapsulated tumor with a proliferation of atypical cells in between numerous vascular channels. The cells demonstrated round nuclei and conspicuous nucleoli with
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