TOPICS IN MAMMOGRAPHY

Transcription

1 TOPICS IN MAMMOGRAPHY ð COMPLEMENTARY WEBSITE COURSE IMAGING BREAST IMPLANTS A Self- Directed Program by RadComm, Inc. JEANETTE R. JOYCE, BFA, RT(R)(M) COPYRIGHT 2012

2 Follow these instructions to complete this course. Once downloaded, we recommended you print the post-test questions, personal information page, and accompanying answer sheet at the end of the course. After reading the course, please complete the post-test. May we make a suggestion? Following each section in the course, you will find a group of study questions. We recommend that you find the corresponding question on the post-test and complete the post-test as you read the material. This will assist you in completing the post-test. Or you may choose to read the course material and then print the personal information page and accompanying answer sheet at the end of the course. The information page and completed answer sheet can be faxed, scanned and ed, or mailed to our physical address. Please submit only the answer sheet and personal information page together for correction. It is important to keep a copy of the answer sheet for your records. Upon receipt of your answers sheet, a certificate of completion will be promptly ed or faxed as evidence of approved continuing education. This course has been approved for One Category A credit by the American Healthcare Radiology Administrators (AHRA), an ARRT-Recognized Continuing Education Evaluation Mechanisms (RCEEM). It has been a pleasure serving you and we trust you will be satisfied with the quality of our materials. If you have any questions or concerns, please do not hesitate to contact us at [email protected] or We look forward to receiving your completed test. Our fax number is THIS POST-TEST MUST BE COMPLETED AND RETURNED BY MAY 31, RadComm, Inc. Jeanette R. Joyce, B.F.A.,R.T.(R)(M) 2

3 MISSION STATEMENT It is my goal to provide the mammographer with informative self-study units on breast imaging. Through extensive research, I have compiled interesting and challenging information for today s mammographer. This unit of study is intended to provide the mammographer with an overview of the various types of breast implants available to our patients. Special implant positioning techniques that are valuable for the early detection of breast cancer will also be introduced. This knowledge will result in improved patient care. This continuing education study unit will enable the mammographer to perform a quality mammogram on an implant patient, as well as identify clinical findings specific to breast implant. My soul finds rest in God alone; My salvation comes from Him. He alone is my rock and my salvation; He is my fortress. I will never be shaken. Psalm 62:1, 2 COURSE CREDIT: AHRA (The Association for Medical Imaging Management) has approved this post-test for 1.0 Category A Continuing Education Credit. AHRA is a Recognized Continuing Education Evaluation Mechanism (RCEEM) and has been approved by the ARRT to grant Category A CE credit. THIS POST-TEST MUST BE COMPLETED AND RETURNED BY MAY 31, RadComm, Inc. 20 Rancho Verde Tijeras, NM (888) FAX (505) PERSONAL PROFILE: Jeanette R. Joyce is the founder of RadComm, Inc., a company dedicated to providing initial training and continuing education to mammography technologists. In her role as a breast imaging consultant and breast health educator, she has traveled the country instructing fellow mammographers in the fine art of mammography. She has been a registered radiologic technologist (ARRT) since 1975 and received certification in mammography in She holds a bachelor s degree from Mundelein College (of Loyola University), Chicago. She is a member of the New Mexico Society of Radiologic Technologists (NMSRT). Jeanette was diagnosed with breast cancer in 1998 on an annual screening mammogram at the age of 42 and understands that knowledge of the disease is our most important weapon. 3

4 IMAGING BREAST IMPLANTS LEARNING OBJECTIVES Upon successful completion of this unit, the radiographer will be able to: 1. Identify the growing trend in breast augmentation. 2. Explain the difference between breast augmentation mammoplasty and breast reconstruction. 3. Identify the approximate percentage of women in the U.S. with breast implants. 4. List the factors known to influence the effectiveness of breast imaging with implants. 5. Discuss the results of the DMIST study that compared analog with digital mammography. 6. Discuss MQSA regulations regarding imaging of patients with breast implants. 7. Discuss the possibility of breast implant replacement surgery for the augmented patient. 8. Identify some common disadvantages of breast implants. 9. List the surgical sites for incision and the advantages/disadvantages associated with each location. 10. Discuss post-surgical scarring and its ramifications on routine screening mammography. 11. Review the mammographic image routine for a patient with breast augmentation. 12. Explain the required technique for breast compression when examining a patient with breast implants. 13. Identify those areas of the breast that typically remain mammographically hidden on the implant patient. 14. Explain the condition of capsular contraction and the necessary changes to routine imaging. 15. Identify alternative views when examining a patient with capsular contracture. 16. Identify patients according to location of implant placement who may be more likely to develop capsular contracture. 17. Discuss MR imaging in the examination of breast implants. IMAGING BREAST IMPLANTS COURSE OUTLINE I. Introduction II Breast Surgery Procedures A. Augmentation mammoplasty B. Reconstruction III. Breast Implant Key Events Timeline A to 2012 IV. Breast Augmentation in the United States A. Swimming in breast implants statistics 4

5 V. Breast Implant Placement A. Sub-glandular placement B. Partial Sub-muscular placement C. Complete Sub-muscular placement D. Sub-fascial placement VI. Film-Screen (Analog) versus Digital Mammography A. MQSA National Statistics as of May 1, 2012 VII. MQSA Regulations Regarding Implant Patients and Mammographer Training A. Background B. Facility compliance C. Technologist compliance VIII. Types of Breast Implants Available in the United States A. Fill 1. Saline filled 2. Silicone-gel filled 3. Cohesive gel B. Shell surface 1. Smooth 2. Textured C. Size, shape, diameters, and profiles IX. Location of the Surgical Incision A. Inframammary B. Periareolar C. Transaxillary D. Umbilical X. Imaging Breast Implants A. Current guidelines for the early detection of breast cancer B. Routine CC & MLO C. Implant-Displaced (ID) CC & MLO D. Alternate views for capsular contracture XI. Complications of Breast Implants A. Capsule contracture resulting from fibrous scar tissue B. Leakage of silicone C. Rupture D. Difficulty in performing mammography XII. Contributing Factors Related to Capsular Contracture XIII. Baker s Classification for Capsular Contracture XIV. Magnetic Resonance Imaging (MRI) of Breast Implants XV. Conclusion XVI. Acknowledgement XVII. Breast Implant Patient Advisory/Consent for Mammography Form XVIII. Glossary of Terms XIX. References XX. Self-Assessment Test 5

6 INTRODUCTION Despite the poor reports on the nightly news about our sluggish economy, the plastic surgery market continues to demonstrate significant growth for the past two years. The most recent statistics available from the American Society of Plastic Surgeons (ASPS) indicate that 13.8 million cosmetic plastic surgery procedures were performed in the United States in 2011, an increase of 5% since An additional 5.5 million reconstructive plastic surgery procedures were also performed, up 5% since ASPS President Malcolm Z. Roth, M.D. remarked, While the rate of economic recovery in the U.S. is still uncertain, 2011 proved to be a good year for plastic surgery. In this unit of study, we will examine the most recent statistics on breast augmentation and reconstructive surgeries. With an increasing number of women choosing to increase their breast size, the mammographer will encounter patients with breast implants more often. Problems associated with breast implants and clinical presentation will also be covered. We will also discuss the special technique required to mammographically image the augmented breasts with an emphasis on the inclusion of maximum breast tissue for the early detection of breast cancer BREAST SURGERY PROCEDURES Breast augmentation mammoplasty increased 4% from 2010 to 2011 to 307,000 procedures. This number represents women who desired to increase their breast size and is considered elective surgery. Breast reconstruction, which improves the patient s appearance following mastectomy, increased 3% from 2010 with more than 96,000 procedures. Insurance coverage for breast reconstruction is required by law and the industry is seeing more women placing their trust in board-certified plastic surgeons to reconstruct their breast following a diagnosis of breast cancer with mastectomy.!"##$%&'$()*+$,&-.+%),$-/01),23$'0&,+4/0+-!"#$%&'()*+#,&$&-.,!"#$""" /.%#'0#%1$2-,* %&&$""" 3-2.%)4&-., %"'$""" 89#6-:';)"*#"9 ()*$""" 5$4#6-7& (()$""" -"#$%&'#()*)!"#$%&'#()*) +,"#$%&'#()*) *"#$%&'#()*) +."#$%&'#()*) /&0%123#4'2%5167#/&15289#&$#:;6<851#/0%=2&7< > 6

7 rgery ort lastic Surgeons graphics. "#$%&'()*$(+,#-.)%$#/*)#'-.#)0%)1#/-+&!233 4-!233!232 4-! :!233-,';-!232 2,640,712 48% 2,560,474 48% 3%!"#$%&'( 1,978,994 36% 1,921,375 36% 3% )*++,#&'-.%-/01234('&"*5064*/%7'(0)'7%(%&5 911,083 16% 825,387 16% 10% 2011 Reconstructive Breast Procedures (with age distribution) ><>7D- B"<5:C?":= 3EF3G!2F!G E2FEG H2FIH II-78C-<A:" Breast reconstruction 96, ,524 11,587 48,913 32,685 Saline implants 13, Silicone implants 62, Other implant Implant alone 6, Tissue expander and implant 69, TRAM fl ap 6, DIEP fl ap 6, Latissimus dorsi fl ap 6, Breast reduction (Reconstructive patients only)^^ 62,828 * * * * * Breast implant removals (Reconstructive patients only) 15, ,035 3,050 7,163 4,346 g rg STUDY QUESTIONS: 1. Identify the trend in breast augmentation from 2010 to Identify the trend in breast reconstruction from 2010 to are projected for only. y ASPS Member as well as other -recognized boards. BREAST IMPLANT KEY EVENTS TIMELINE The American Society for Aesthetic Plastic Surgery and The American Society of Plastic Surgeons 1962 Breast implants are introduced Congress gives FDA authority to regulate medical devices. Pre-existing devices are grandfathered in pending further evaluation FDA puts silicone breast implants on its review schedule CBS-TV s Face to Face with Connie Chung episode generates concern about silicone breast implants FDA issues moratorium on silicone gel breast implants and restricts their use to breast reconstruction and clinical studies Global Settlement talks begin with manufacturers Payouts to women from revised Global Settlement begin FDA issues breast implant risk information booklet Saline breast implants receive formal FDA market approval FDA reviews Inamed Corp. s silicone breast implant pre-market application (PMA) The FDA deferred action and determined that the PMA for Inamed Corp. s silicone gel-filled breast implant is not approvable, calling for additional information.!! 2005 The FDA sends approvable letter with conditions to Mentor Corporation regarding its silicone breast implants The FDA sends approvable letter with conditions to Inamed Corporation regarding its silicone breast implants The FDA grants final approval to Mentor Corp. and Inamed Corp. for silicone breast implants and reverses a 14-year-old decision that restricted access The FDA approved the silicone gel filled implant manufactured by Sientra, Inc. with conditions to conduct post-approval studies to assess long-term safety and effectiveness outcomes, as well as the risks of rare disease outcomes. 7

8 BREAST AUGMENTATION IN THE UNITED STATES Millions of women in the United States have undergone breast augmentation mammoplasty to enhance their natural shapes and improve their confidence. When a woman feels that her breasts are too small for her body or that she lost breast size after pregnancy, breast-feeding or significant weight loss, she has the option of having breast surgery. As demonstrated in the statistics above, breast augmentation is the most popular plastic surgery in this country. According to San Francisco-based plastic surgeon Dr. Donald Brown, the U.S. saw a sharp increase in breast implants between 2000 and In January of 2012, Dr. Brown released an infographic called, Swimming in Breast Implants, containing the most current facts and trends on breast augmentation. Below are some of Dr. Brown s interesting findings: As of 2010, 4.93% of women in the United States have breast implants (5,083,717). More than $2 billion ($2,099,611, to be exact) was spent on breast augmentation in More than 1/3 of breast augmentations are performed in the Western states of the U.S. - Washington, Oregon, California, Nevada, Idaho, Montana, Wyoming, Utah, Colorado, Arizona, and New Mexico. 36% of women get their breast implants between the ages of 30 and 39, with an average age of 34 years. 90% of women get their breast implants after having children. 79% of patients report they are pleased with the results of their breast implants. Enough breast implants have been created since 1997 to fill an Olympic-sized swimming pool. Breast implants have been the #1 surgical cosmetic plastic surgery procedure in the U.S. and the world for over a decade. As a mammographer, I find this information valuable. It proves that I not only feel like I am performing more mammograms on patients with breast implants, I actually am! It also tells me that if I am a mammographer living in the Western United States, a higher percentage of my patients will have breast implants. I find it disturbing 8

9 that the majority of women getting breast implants are in their 30s, just a few years away from routine annual mammography screening, which should begin at the age of 40. Women should be informed about how their choice to get breast implants affects having a mammogram. Depending on the size of the implant chosen and its position within the breast, breast implants will result in the inability to visualize all the breast tissue on a mammogram. Implants can make detecting abnormalities or subtle breast changes more difficult to interpret on the mammogram. Factors known to influence the effectiveness of breast imaging with implants include: Location of surgical placement of the implant Film-screen versus Digital mammography Training and experience of the mammographer Women with breast implants are concerned about the integrity of their implants, the early detection of breast cancer, as well as radiation dose. These patients deserve quality mammography exams performed by experienced mammographers. BREAST IMPLANT PLACEMENT The surgeon has several options available regarding implant placement. Much will depend on the cosmetic affect desired by the patient as well as the patient s physical characteristics. There are four placement options: 1. Sub-glandular placement (sometimes referred to as Overs ) This describes placement of the breast implant behind the glandular tissue of the breast and in front of the perctoralis muscle. In other words, the implant is located in the retromammary fat space. The term, overs refers to its placement over the muscle. Sub-glandular Placement 2. Partial Sub-muscular placement (sometimes referred to as Dual Plan Placement) - This describes placement of the implant partially below the muscle. Partial Sub-muscular Placement 9

10 3. Complete Sub-muscular placement (sometimes referred to as Unders ) The breast implant is placed completely under the muscle. Also referred to as submuscular or subpectoral placement. Complete Sub-muscular Placement 4. Sub-fascial placement A small number of plastic surgeons offer this newer technique for placement. The thin layer of tissue covering the muscle is known as fascia. The surgeon seperates the fascia from the muscle and places the implant under the fascia. Sub-fascial Placement The majority of plastic surgeons and radiologists agree that partial submuscular or fully submuscular placement permits better visualization of the breast tissue during mammography. Similar placement also reduces the rate of capsular contracture, reduces visible rippling of the breast implant, better supports the implant resulting in less breast sagging over the long term, and often results in a more natural looking result. One exception to this rule is the woman weight-lifter who may see distortion of the implant due to the strength and flexion of the muscle. FILM-SCREEN (ANALOG) VERSUS DIGITAL MAMMOGRAPHY As of May 1, 2012, 84% of mammography facilities in the United States offer digital mammograms. 2 The Digital Mammography Imaging Screen Trial (DMIST) followed 49,528 asymptomatic women at 33 sites in the U.S. and Canada in order to analyze the differences between film-screen and digital mammography. The results of the DMIST study confirmed that digital mammography was more accurate in women under the age of 50, women of any age with dense breast tissue, and women around the age of menopause. 3 Digital mammography also results in a decreased radiation dose, faster exposure time, and improved image contrast. Digital images can be transmitted electronically from one facility to another, permitting improved patient care through better coordination between physicians. As you can observe on the images below, digital imaging is far superior to film-screen technology. 10

11 LCC & LMLO Analog Technology LCC & LMLO Digital Technology MQSA REGULATIONS REGARDING IMPLANT PATIENTS AND MAMMOGRAPHER TRAINING Congress enacted the Mammography Quality Standards Act (MQSA) in 1992 to ensure that all women have access to the high-quality mammograms necessary to detect breast cancer in its earliest, most treatable stages. As a result of MQSA, the FDA developed and implemented mammography quality standards regulations. According to MQSA, mammography facilities are required to have a procedure in place to inquire whether or not the patient has breast implants prior to the actual mammographic exam. The FDA also requires that patients with breast implants have mammographic views to maximize the visualization of breast tissue, unless contraindicated or modified by a physician s order. Upon inspection, the facility must demonstrate to the MQSA inspector that they ask their patients whether they have breast implants. This can be accomplished by showing the inspector the facility s patient information form that has this questioned answered by the patient. The facility must also demonstrate that they have a written procedure for inquiring, prior to the actual mammography exam, whether the patient has breast implants. 4 In order for a radiographer to be MQSA-compliant, she must complete 40 hours of specific initial mammography training. The content of the material must include special training in positioning patients with breast implants, as well as other important topics. If the facility does not have a required trained mammography technologist who is competent to perform a mammogram on an implant patient, they should refer the patient to another facility. 11

12 STUDY QUESTIONS: 1. In 2010, what is the estimated percentage of women in the U.S. with breast implants? 2. What factors are known to affect the effectiveness of mammography on women with implants? 3. Which women were found to benefit from digital mammography according to the DMIST study? 4. According to MQSA, when should the facility ask the patient whether she has breast implants? TYPES OF BREAST IMPLANTS AVAILABLE IN THE U.S. Up until March of 2012, there were only two companies permited to sell silicone-gel implants in the United States - Allergan and Johnson & Johnson. The FDA approved a third company, Sientra, to sell silicone-gel implants in March, In order to ensure patient safety, the FDA requires that Sientra track patients who receive their implants, conduct studies on long-term safety and performance, and report back to the FDA, as Allergan and Johnson & Johnson are also required to do. Plastic surgeons were pleased with the FDA s decision to approve Sentra s implants since it provides more implants from which to choose in order to tailor the procedure to each patient s individual body type needs for better results. Each of the three manufacturers offer saline-filled and silicone-filled implants. Multiple decisions our patients experience when they decide to have breast augmentation surgery. Once the patient has decided to have breast augmentation surgery, she and her surgeon will have to decide on several factors relating to the type of breast implant. The patient must be told that breasts implants, while designed to stay up to 25 years inside the body without any problem, may not last a lifetime and that means they will 12

13 most likely undergo a revision plastic surgery in later years. Breast implants are NOT lifelong devices! The first decision is the type of fill: saline or silicone. Both saline-filled breast implants and silicone-filled implants have an outer shell composed of silicone elastomer. A general composition for the silicone rubber shell is similar in all saline-filled and silicone-filled implants consisting of: Cured polymeric silicones (large) Approximately 20% finely powdered silica tightly bound to the silicone polymers Small amounts of smaller silicones Minute amounts of metals including a metal catalyst such as tin, zinc or platinum Traces of readily evaporating materials such as nylene and other organic compounds Saline-filled breast implants are filled with sterile saline (salt water). There are three types of saline implants: One type of saline implant is a single lumen implant consisting of a silicone rubber shell filled with a fixed amount of saline introduced through a valve. The second type of saline implant is a single lumen implant that is filled during surgery with saline through a valve. The volume of saline can be adjusted after the operation. A third type of saline implant is also a single lumen, however, this device is prefilled by the manufacturer with a fixed volume of saline. There is no opportunity to adjust the volume during or after the surgery. Silicone-gel filled implants are often preferred over saline-filled implants. There are three types of silicone gel-filled breast implants: The single lumen pre-filled by the manufacturer with a fixed volume of silicone gel The double lumen implant that consists of an inner lumen prefilled by the manufacturer with a fixed volume of gel and an outer lumen which is filled during surgery with a fixed volume of saline through a valve. The double lumen with an outer lumen prefilled by the manufacturer with a fixed volume of silicone gel and an inner lumen filled during surgery with saline through a valve. Saline adjustments are possible after surgery with this type of implant. Surgeons report that silicone-filled implants are smoother, softer and feel more like natural breast tissue. Wrinkling is a major disadvantage of saline implants. Silicone-gel implants are less likely to wrinkle or ripple. Thinner women with less breast tissue are more likely to complain that their saline-implant s wrinkles can be felt and seen. When a saline implant ruptures, it typically deflates over a period of several hours. On the other hand, silicone ruptures can be silent, meaning the patient is asymptomatic and reports no problem. A type of siliconefilled implant with a thicker filling, called a form-stable highly cohesive implant, or "gummy bear" breast implant, is currently under investigation and may one day provide another option for women undergoing breast augmentation with implants. 13

14 Visible rippling of the breast implant Saline Implant Silicone-gel Implant Cohesive gel Implant The second decision is the type of shell desired: smooth or textured. This shell is basically a flexible envelope that contains the implant filling. Smooth textured implants have a thinner shell than the textured ones. They may be less likely to cause rippling. Textured shell implants were designed to reduce the risk of capsular contracture, but research has failed to prove this to be true. The shell of the textured implant is thicker due to the rough, sandpaper-like surface. It is possible for patients with thin skin or small breasts to be able to palpate the textured surface. The third decision involves the plastic surgeon s choice from a variety of sizes, shapes, diameters, and profiles. Contoured implants, also referred to as anatomical or teardrop-shaped implants, are more shaped like the natural breast with a slope created when placed over the pectoralis muscle. However, it is possible that contoured implants can flip over if the surgeon does not disect the pocket correctly. Round breast implants result in the appearance of Victoria Secret s cleavage. If a round implant flips over, it will not create a misshapen breast. Breast implants are also available in low, moderate, and high profiles. This feature determines how far the implant will protrude from the chest wall. It is important that the patient discuss these options with her surgeon so her goals of augmentation can be realistically met. 14

15 Natrelle s Highly Cohesive Breast Implant (Gummy Bear Implants) are available in 16 basic shapes, and each shape comes in many sizes. During the patient history questioning, it is important to ask your patient for details concerning her implants. From my experience, some patients come equipped with ALL the features of their implants, including the serial number! Whereas other patients may only know they are saline-filled. Share whatever information is obtained from your patient with the radiologist on the patient history form. STUDY QUESTIONS: 1. How many years are breast implants designed to stay in the body with no problems? 2. Which type of implant are more likely to cause wrinkling? 3. Which type of implant can experience a silent rupture? LOCATION OF THE SURGICAL INCISION Today s surgeon has four choices in which to place the incision for the insertion of a breast implant. 1. Inframammary (in the inframammary fold) The inframammary incision is the most commonly used location in breast augmentation since it offers the surgeons the greatest degree of control with all implant types and sizes. 2. Periareolar (around the areola) Patients with a history of heavy scarring (hypertrophic) may benefit from the periareolar incision. Implants placed through a periareolar incision have more exposure to bacteria in breast tissue, although clinical trials have not proven a higher risk of infection or capsular contracture using this method. If periareolar placement is performed properly, breast feeding should not be compromised. However, reduced nipple sensation has been reported by some patients. 3. Transaxillary (in the armpit) Patients who prefer not to have any evidence of a scar on their breast may choose the transaxillary incision for placement of their breast implants. The surgeon creates the pocket using endoscopic instruments. It is reported that the scar is not visible in over 90% of patients with their arms raised over their head. 4. Umbilical (TUBA incision) This technique is also attractive to patients who desire no scar on their breast. However, it offers the surgeon much less control when creating the pocket compared to the other approaches available. Following an incision on the rim of the navel, a tunnel is created under the skin through the subcutaneous fat layer extending up to the breast region. An endoscope with a camera and surgical light is used to create the pocket that will hold the implant. The implant is then inserted through the incision, moved up to the breast area, and centered behind the nipple. As a mammographer, you realize that scar tissue on and around the breast can significantly affect the mammographic image. Post-surgical scarring can create a suspicious finding resulting in patient call-back following 15

16 a routine screening mammogram. It is very important that the mammographer indicate on the patient s history form the location of the surgical scar used during breast augmentation surgery. This information will assist the radiologist in accurate interpretation. 5 STUDY QUESTIONS: 1. What is the most common incision site for augmentation mammoplasty? 2. How might post-surgical scarring affect the routine screening mammogram? IMAGING BREAST IMPLANTS The American Cancer Society, the American College of Radiology, and the Society of Breast Imaging all recommend that women with breast implants follow the same guidelines for annual mammography screening beginning at the age of 40 for the early detection of breast cancer. Current guidelines for the early detection of breast cancer were revised in March of 2010 and are as follows: Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-exam (BSE) is an option for women starting in the 20s. In addition to the routine 4-view mammogram performed on women without breast implants, it is necessary to include special views to allow for visualization of the maximum amount of breast tissue and the implant. A mammogram performed on an implant patient will be more time consuming as a result of the additional implant views. For this reason, the mammography facility should be informed of the presence of breast implants when the exam is being scheduled. When examining a patient with breast implants, four views of each breast are typically performed: 2 CC views: One with the implant in the field of view (using minimal compression) and One with the implant displaced posteriorly as much as possible (using adequate compression). 2 MLO views: One with the implant in the field of view (using minimal compression) and One with the implant displaced posteriorly as much as possible (using adequate compression). 16

17 Special problems and challenges exist for both the mammographer and the radiologist when examing an implant patient by mammography. The technologist must demonstrate significant sensitivity and skill to her patient when performing the implant-displaced maneuver. Effective communication skills are also necessary to ensure your patient s trust in you as an experienced professional. Minimal compression is required on the routine full breast CCs and MLOs in order to NOT damage the implant. The patient is positioned the same as in women without implants. Only enough compression to hold the breast in place and avoid motion is required. The breast tissue will not be described as taut when examining the full breast with the implant present under the compression paddle. Since the x-ray beam can not penetrate silicone or saline breast implants well enough to visualize underlying breast tissue, approximately 25% of the breast tissue will not be visualized on the mammogram. By adding four additional Implant-Displaced (ID) views to the routine study, we are able to appreciate more anterior breast tissue with better detail. The technique for performing the Implant-Displaced views includes pushing the breast implant back against the patient s chest wall, while the natural anterior and lateral tissue of the breast is pulled anteriorly. The mammographer will find that this manuever is easier to perform on women whose implants were placed under the pectoralis muscle in the submuscular location. Gray lined areas are NOT imaged during mammography on the implant patient. The Implant-Displaced technique for imaging patients with breast implants originated with Dr. G.W. Eklund and his staff mammography technologists in Portland, OR. An article in the American Journal of Roentgenology titled, Improved Imaging of the Augmented Breast, was published in September of After successfully examining 250 patients with breast augmentation by using the modified compression technique, the team confirmed a significant improvement in image quality, the amount of breast tissue visualized, and overall benefit of performing the modified technique. They concluded that modified positioning with the implant-displaced technique on women with breast implants substantially improved both image quality and the amount of breast tissue imaged. Although designed for subglandular implants, Silverstein, et al. confirmed that even in the submuscular position, the Implant-Displaced technique allows for the visualization of a greater amount of breast tissue. This special technique was once referred to as the Eklund technique, but has since been named the Implant-Displaced view (ID). 6, 7 17

18 Standard mammographic views, the CC and MLO, are taken with a minimal degree of compression to the breast tissue. Implant-Displaced views are obtained with the breast implant displaced posteriorly and superiorly against the chest wall. The compression paddle is applied using adequate compression to the anterior breast tissue, which has been pulled forward from the implant, for better visualization. RCC full breast to include implant versus RCC with Implant Displaced Technique RMLO full breast to include implant versus RMLO with Implant Displaced Technique Implant-Displaced views may not be possible to perform if the patient has a condition referred to as capsular contracture. This describes the formation of hard scar tisue surrounding the implant. Patients with capsular contracture may complain of pain or discomfort during attempted manipulation of the breast implant. The 18

19 condition restricts the amount of breast tissue that can be manipulated. If the technologist is unable to perform ID views because of this condition, it is recommended that bilateral 90-degree views be obtained for visualization of the superior and inferior breast tissue. When there is clinical concern for lesions cephalad to the implant between the 11 and 1 o'clock positions or caudad to the implant between the 5 and 7 o'clock positions, the 90-degree lateral view can be helpful (Heinlein and Bassett, 1997). STUDY QUESTIONS: 1. How many views of each breast are performed when examining an implant patient? 2. How much compression is applied to the full breast views that include the implant? 3. What is the approximate percentage of breast tissue obscurred by an implant during mammography? 4. Which condition hinders the performance of Implant-Displaced views POSITIONING FOR THE CRANIO-CAUDAL IMPLANT-DISPLACED VIEW (CC ID) 1. Instruct the patient to bend forward at the waist, which helps to separate the anterior breast tissue from the implant. 2. Gently pull the natural breast tissue forward while pushing the implant posteriorly. 3. When the tissue is fully pulled forward, ask your patient to stand up while keeping both your hands on her breast. 4. Instruct your patient to place her opposite hand on the rib cage directly under the breast in order to fill the gap between the edge of the image receptor and the patient s ribs when the implant is in the displaced position. 5. Position the anterior breast tissue on the image receptor. Your patient s hand will now be positioned between the receptor and her rib cage. The edge of the receptor will be holding the inferior aspect of the implant back. 6. Begin to apply compression while still holding the superior aspect of the implant back against the chest wall. At this point, you may choose to use a spatula to hold the implant in the posterior position. When adequate compression has been achieved, remove the spatula. The compression paddle is now holding the implant posteriorly. Final positioning for RCC ID view. 19

20 POSITIONING FOR THE MEDIO-LATERAL OBLIQUE IMPLANT-DISPLACED VIEW (MLO ID) 1. Once again, ask your patient to bend forward at the waist to separate the anterior breast tissue from the implant. 2. Gently pull the natural breast tissue forward while pushing the implant posteriorly. 3. When the tissue is fully pulled forward, ask your patient to stand up while keeping both your hands on her breast. 4. Position the junction from the anterior surface of the implant and the natural breast tissue against the edge of the image receptor. The edge of the receptor should be against the patient s breast and not in contact with her ribs. If the patient s ribs are in contact with the receptor, start over, because this is evidence that the implant is not sufficiently displaced. 5. Begin to apply compression while holding the anterior aspect of the implant back against the chest wall. You may choose to use a spatula at this point to hold the implant in position. 6. When adequate compression has been achieved to the anterior natural breast tissue, remove the spatula. The compression paddle is now securely holding the implant posteriorly in place. If your patient demonstrates capsule contracture / encapsulation, additional views may be necessary to demonstrate maximum breast tissue. You will find alternative views below: 90-DEGREE LATERAL (EITHER ML OR LM) The 90-degree lateral is an additional view that may be added to visualize a greater amount of breast tissue immediately above and below the posterior portion of the implant (at 12:00 and 6:00 positions). This area is obscured on the standard CC and MLO views, especially in patients with encapsulation. Minimal compression is used since the implant is located under the compression paddle. Left 90-degree Medial-lateral (LML) Right 90-degree Lateral-medial (RLM) 8 90-DEGREE LATERAL CHEST WALL VIEW The 90-degree lateral chest wall view can be used to visualize the posterior aspect of the silicone implant, the retromammary space, axilla, and superior structures of the breast. These areas are not visualized on routine or implant-displaced views. Place the tube in the 90-degree lateral position and position your patient in a true anteroposterior (AP) position. Turn the patient 10 to 30 degrees toward the receptor with the affected arm abducted away from the body at a 90-degree angle, elbow flexed and hand resting on the handlebar. The image receptor is raised to include the superior aspect of the head of the humerus. The patient s axilla, upper arm, posterior ribs and 20

21 breast are in front of the image receptor. This view is performed using an aluminum filter, no compression, and a kvp range of between 25 to 45. LATERO-MEDIAL OBLIQUE (LMO) (REVERSE OBLIQUE) The Latero-medical oblique represents the exact reverse of the routine MLO. To perform the LMO, the X- ray beam is directed from the lower-outer aspect of the breast to the upper-inner breast. The same anatomy is visualized as in the MLO with better demonstration of the medial breast tissue. 9,10,11,12 LATEROMEDIAL OBLIQUE (LMO, True Reverse Oblique) STUDY QUESTIONS: 1. What additional views may be helpful when examining a patient with capsular contracture? 2. Identify those areas visualized on the 90-degree Lateral Chest Wall view. COMPLICATIONS OF BREAST IMPLANTS Almost from the very beginning, four problems related to implants became apparent: 1. Capsule contracture resulting from fibrous scar tissue 2. Leakage of silicone 3. Rupture 4. Difficulties in performing mammography. 13 When positioning the patient with breast implants, the most common problem encountered by the mammography technologist is capsular contracture. A hardening of the implant that is palpable on examination indicates a condition referred to as capsular contracture or implant encapsulation. This is the most common complication involving implants. Capsular contracture causes the breast to become hard and difficult to compress during mammography. It also makes breast self-examination and ultrasound more difficult. The body naturally forms a fibrous capsule or a hard scar tissue sack around the implant because it represents a foreign body. This is the body s natural response so it is normal and to be expected. A hard capsule walls off the implant from the rest of the breast. It is estimated that between 30% to 50% of patients with breast implants will develop capsular contraction. As the scar tissue shrinks, the capsule tightens and squeezes the implant. Hardening of the implant can happen at any time, but it is more common in the first several months following surgery. Capsular contracture is more common in patients with retroglandular implant placement. The incidence is lower in patients with submuscular placement

22 The causes of capsular contracture are still unclear. However, these conditions correlate with a higher risk: Germ contamination - Long term bacterial contamination can cause an inflammatory reaction and cause shrinkage of the capsule. Infection Seroma - May place the woman at higher risk Hematoma - Can also cause inflammatory reaction. Smoking - Decreases oxygen levels in the blood resulting in delayed healing and/or inflammatory reaction. Other factors may also influence the development of capsule contracture. It may be the result of surgical factors such as hematomas or an excessively small pocket for placement of the implant. Infection or leaking of silicone through the shell (gel bleed) may also be responsible for the formation of capsule contracture. 15 Capsule contracture can be corrected by replacing the implant and removing the scar tissue. Capsular contracture occurs when the scar tissue or capsule that normally forms around the implant tightens and squeezes the implant, resulting in a hard deformed breast. It may be more common following infection, hematoma, and seroma. A classification with four categories has been devised as a means to measure the degree of capsular contracture in the patient. This is known as the Baker classification or the Baker grading system. 16 Grade I the breast is normally soft and looks natural Grade II the breast is a little firm but looks normal Grade III the breast is firm and begins to appear distorted in shape Grade IV the breast is hard, painful, and looks abnormal (greater distortion) Grade IV Baker Classsification capsular contracture with subglandular implant placement. Chest radiograph demonstrating the calcified capsules. 22

23 Severe Capsular Contracture Note the distorted shape of the breasts on the image on the left. Following removal of the silicone implants and hard capsules, new silicone implants were placed demonstrating improved shape and size. Right saline implant rupture RCC & RMLO demonstrate deflated saline implant RCC demonstrating free extracapsular silicone from a ruptured breast implant LMLO demonstrating extracapsular rupture with silicone extruding superiorly from implant STUDY QUESTIONS: 1. What is the most common problem characterized by hardening of the implant? 2. Which surgical placement is more prone to capsular contracture? MAGNETIC RESONANCE IMAGING (MRI): Breast MR imaging is the most accurate imaging modality for examining the integrity of breast implants. MR imaging of the implanted breast has both advantages and disadvantages when compared to mammography. An important advantage is its ability to scan close to the implant and the chest wall providing tomographic visualization 23

24 of the complete tissues around the implant. Another advantage is its reproducibility factor as compared to ultrasound and clinical examination. It has also been found that MRI may be able to image breast malignancy and fibrosis based on their different enhancement behaviors. In patients with silicone implants, more than six months post-operative, MRI can significantly contribute to the early detection of malignancy within the areas of distorted scar tissue, or in areas behind the implant and differentiate between scarring and malignancy. Diagnostic confidence improves when MR is teamed with Ultrasound-guided needle biopsy. A key disadvantage is the high cost of the scan and the time necessary to scan patients. In cases of inflammatory changes or within six months post-operative, the accuracy of MRI is questionable. 17 MR image of Left breast Linguine sign is visualized as dark curvilinear line within silicone, indicating intracapsular implant rupture. No silicone is seen outside the implant to indicate extracapsular implant rupture. MR on 46-year-old with silicone implants: Keyhole sign in left breast (solid arrow) indicates intracapsular implant rupture. Normal radial folds (dashed arrow) are seen in the right breast. STUDY QUESTION: 1. Which imaging modality is the most accurate for examining the integrity of breast implants? CONCLUSION Mammography is a valuable tool for breast cancer screening on patients with breast implants. As the popularity for breast augmentation continues to grow, more women will present for routine mammograms. Mammography on a breast implant patient can present a challenge for the technologist. Establish trust by effective communication with your patient. By learning the proper technique of implant-displacement, the technologist will be able to obtain the best possible images with maximum visualization of breast tissue on implant patients and deliver quality patient care. ACKNOWLEDGEMENT Here s to you for all you do! Continuing learning all you can to be the brightest in your profession. Your patients deserve the best you can offer. 24

25 Breast Implant Patient Advisory/Consent for Mammography THIS FORM MUST BE COMPLETED PRIOR TO IMAGING OF BREAST IMPLANTS Mammography is currently the best method to detect a change in the breast that cannot be felt or to help clarify a change in the breast that can be felt. Breast implants require a special type of exam that includes more films than a regular mammogram. This is because the implant obscures some of the breast tissue. In most cases, the implant will be gently pushed back and out of the way of the tissue for some of the films while other films will include views of the implant on the film. As with all mammograms, some compression will be applied. In films with implants, compression will only be used to prevent motion, which can degrade the image. To see the breast tissue in front of the implant, compression will be applied, possibly causing some slight discomfort for a few seconds as is usual with any type mammogram. Problems caused by compression or moving the implant are extremely rare but cannot be excluded, especially for older or weakened implants. Mammography is one of the tools often used to help determine if there is a rupture of the implant. It is not unusual for an implant rupture that was not felt by you or your physician to first be noticed on a mammogram. Since this risk of rupture caused by the mammogram procedure is very low and the risk of breast cancer is greater, we hope that you understand the benefit of early cancer detection and proceed with your mammogram. If you agree with the following statement, please sign below and we will proceed with your mammogram. I have read the advisory and I understand the possible risk of damage to my implants that is associated with implant mammography. Any questions I have regarding this procedure have been answered to my satisfaction. I believe in the value of early detection and voluntarily consent to have the mammogram done. Patient Signature: Technologist Signature: Date: 25

26 GLOSSARY OF TERMS ARCHITECTURAL DISTORTION: A change in the architecture of the breast detected on the mammogram. This can be associated with benign or cancerous conditions. AUGMENTATION MAMMOPLASTY: Plastic reconstruction of the breasts performed for the implantation of breast implants. AUTOMATIC EXPOSURE CONTROL (AEC): Phototiming device. AXILLA: The armpit or underarm area which contains lymph nodes and channels, blood vessels, muscles, and fat. Axillary region refers to its location. BAKER CLASSIFICATION: Four categories used as a means to measure the degree of capsular contracture in the patient. CAPSULE CONTRACTURE / ENCAPSULATION: A hardening of the implant that is the result of the formation of a fibrous capsule (scar tissue) around the implant; when the capsule squeezes the implant, capsular contracture occurs. CAPSULECTOMY: Surgical removal of the scar tissue capsule around the implant. CAPSULORRHAPHY: Surgical stitching of a tear in the scar tissue capsule around the implant. CLOSED CAPSULOTOMY: Physical manipulation of the implant in an attempt to disrupt the fibrous capsule around the implant. CYST: Any sac or capsule, normal or abnormal, containing a liquid or semi-solid material; usually harmless and can be removed by aspiration. DISPLACEMENT: Movement of the implant from the usual or proper place. DOUBLE-LUMEN: Implant providing two chambers and described as an implant within an implant. EKLUND VIEWS: Modified position views / Implant-displaced (ID) / Push-back views. Improved technique for imaging the augmented breast. EXTRUSION: Skin breakdown with the pressing out of the implant through the surgical wound or skin. FATIGUE FRACTURES: Spontaneous rupture of the silicone envelope occurring at seams, valves, and wrinkles. FOOD AND DRUG ADMINISTRATION (FDA): A government agency whose primary responsibility is to determine if the benefit of a drug / product outweighs the risk. 26

27 FULLY SUBMUSCULAR: Refers to the placement of the breast implant under the pectoralis major muscle and also under non-pectoral muscles at the lower aspect of the implant. GEL BLEED: The leakage of silicone through the shell of the implant. LATISSIMUS DORSI FLAP: Method of breast reconstruction following mastectomy whereby an area of skin, muscle, fat, and blood vessels are transferred surgically from the back to the breast area. LUMPECTOMY: A breast conserving surgical method that involves removing only the cancerous area and the surrounding tissue. MALPOSITION: Occurs when the implant is not in the correct area in the breast. Could result from incorrect placement of the implant during surgery or to shifting of the implant position over time. MAMMOPLASTY: Plastic reconstruction of the breasts. AUGMENTATION MAMMOPLASTY: Performed for the implantation of breast implants. MASTECTOMY: Surgical removal of all or part of the breast and sometimes adjoining structures typically done for breast cancer. MICROCALCIFICATIONS: Tiny white specks of calcium salt sometimes imaged on mammograms. Can be associated with both benign breast changes and early invasive cancer. OPEN CAPSULOTOMY: Surgical procedure whereby the fibrous capsules are broken up and the implants are replaced. PARAFFINOMAS: Hard masses of paraffin dispersed throughout the breasts as a result of direct injection of paraffin into the breast tissue. PERIAREOLAR: Referring to the area around the areola. PERIUMBILICAL: Referring to the area around the umbilicus. PTOSIS: Breast sagging that is usually the result of normal aging, pregnancy, or weight loss. REVISION AUGMENTATION: Refers to the correction or improvement of a primary augmentation. Surgical removal and replacement of breast implants that were placed originally for breast augmentation. SALINE: A solution of sodium chloride and distilled water used in the manufacturing of breast implants. SCAR REVISION: Surgical procedure to improve the appearance of a scar. 27

28 SENSITIVITY: An estimate of the probability of diagnosing cancer when a cancer exists, or the proportion of patients found to have breast cancer within one year of screening who were correctly diagnosed at screening. SEROMA: Pocket of clear serous fluid in the breast tissue. SILICONE: Any of a group of polymeric organic silicon compounds used in the manufacturing of breast implants. SILICONE GRANULOMAS: Formations resulting from migrating silicone into adjacent breast tissue. SPECIFICITY: The probability of a normal mammogram when no cancer exists, or the percentage of all patients found not to have cancer within one year of screening who were correctly identified as normal at the time of screening. STACKED IMPLANTS: Two or more implants placed in one breast to create very large breasts. SUBGLANDULAR: Referring to the area behind the glandular tissue in the breast and in front of the pectoralis muscle. SUBPECTORAL: Referring to the area below the muscle. In augmentation mammoplasty, the implant is placed behind the pectoralis major. However, the implant is only partially behind the muscle. The inferior half of the implant is not covered by muscle in this type of placement. SYMPTOMATIC RUPTURE: A breast implant that is associated with symptoms such as lumps, persistent pain, swelling, or hardening. Some silicone breast implant ruptures are symptomatic, but most are silent. TDA (2-toluene diamine): A chemical compound produced by the breakdown of polyurethane in foam-coated implants. TISSUE EXPANDER: Implant used in the mastectomy patient to prepare the skin and soft tissues for reconstructive surgery. TRAM PROCEDURE: Transverse rectus abdominis myocutaneous - Surgical procedure of breast reconstruction following mastectomy involving the use of musculocutaneous flaps to reconstruct the breast. (Terminology is a collection from all reference sources.) 28

29 IMAGING BREAST IMPLANTS REFERENCES 1. Performed-in-2011.html. Accessed on May 1, EmittingProducts/MammographyQualityStandardsActandProgram/FacilityScorecard/ucm htm. Accessed on May 1, Digital Mammography Imaging Screen Trial (DMIST). New England Journal of Medicine, Vol. 353, pgs , Oct. 27, EmittingProducts/MammographyQualityStandardsActandProgram/ConsumerInformation/ucm htm. Accessed on May 1, Eklund GW, Busby RC, Miller SH, et al. Improved imaging of the augmented breast. AJR Am J Roentgenol Sep;151(3): Bondurant S, Ernster V, Herdman R. Safety of Silicone Breast Implants. The National Academies Press, 1999; American College of Radiology Committee on Quality Assurance in Mammography: Mammography Quality Control. Reston, VA, American College of Radiology, 1992, pp Prue LK. Atlas of Mammographic Positioning. Philadelphia, PA: WB Saunder Co.; 1994: 13, 19-23, ASRT Fundamentals of Mammography, The Quest for Quality. Positioning Handbook. 1993:14, 18, 43, Andolina VF, Lille SL, Willison KM. Mammographic Imaging, A Practical Guide. Philadelphia, PA: JB Lippincott Co.; 1992: Kamm B. The Mammographer s Role In Addressing Special Needs. Radiologic Technology. Sept Angell M. Science on Trial, The Clash of Medical Evidence and the Law in the Breast Implant Case. New York, NY: W.W. Norton & Co.; 1996: 22, 34-44, Leibman AJ. Imaging the Breast After Cosmetic Surgery. Applied Radiology. April, 1993: 45, Steinbach BG, Hardt NS, Abbitt PL, et al. Breast Implants, Common Complications, and Concurrent Breast Disease. Radiographics 1993; 13: 96-98, , 104, Brumbaugh JM, Ikeda DM, Waters LM. The Augmented Breast and its Evaluation. Applied Radiology. Sept. 1994: Heywang-Kobrunner SH. Contrast -Enhanced MRI of the Breast. Munich, Germany: HD Med. Information, Sektion Medizinische Redaktion, Schering. 1990:

30 SELF-ASSESSMENT TEST IMAGING BREAST IMPLANTS Items 1-20: Multiple Choice Each of the numbered items in this section is followed by answers. Select the ONE lettered answer that is BEST in each case and fill in the letter on the corresponding answer sheet. (1) Breast augmentation surgeries from 2010 to 2011 to 307,000 procedures. (A) increased 4% (B) decreased 4% (C) increased 14% (D) decreased 14% (2) Breast reconstruction, which, increased 3% from 2010 with more than 96,000 procedures. (A) is cosmetic surgery (B) is used to increase a patient s breast size (C) improves the patient s appearance following mastectomy (D) is also referred to breast augmentation (3) As of 2010, of women in the United States have breast implants. (A) 2.33% (B) 4.93% (C) 5.26% (D) 9.43% (4) Factors known to influence the effectiveness of breast imaging with implants include all of the following, EXCEPT. (A) the location of the surgical scar (B) the location of the implant (C) film-screen versus digital mammography technology (D) training and experience of the mammographer (5) The results of the DMIST study confirmed that digital mammography was more accurate in all of the following women, EXCEPT those. (A) under the age of 50 (B) women of any age with dense breast tissue (C) women around the age of menopause (D) women with no live births 30

31 (6) According to MQSA, mammography facilities are required to have a procedure in place to inquire whether or not the patient has breast implants. (A) at the time of patient scheduling (B) prior to the patient undressing for her mammogram (C) prior to the actual mammographic exam (D) when she physically enters the facility (7) The patient must be told that breasts implants, while designed to stay up to years inside the body without any problem, may not last a lifetime and that means they will most likely undergo a revision plastic surgery in later years. (A) 10 (B) 15 (C) 25 (D) 35 (8) Wrinkling is a major disadvantage of implants. (A) silicone (B) saline (C) cohesive-gel (D) peanut oil (9) ruptures can be silent, meaning the patient is asymptomatic and reports no problem. (A) Silicone (B) Saline (C) Silicone and saline (D) Cohesive-gel (10) The incision is the most commonly used location in breast augmentation since it offers the surgeons the greatest degree of control with all implant types and sizes. (A) transaxillary (B) inframammary (C) periareolar (D) umbilical 31

32 (11) Post-surgical scarring can create a suspicious finding resulting in following a routine screening mammogram. (A) patient call-back (B) MR imaging (C) surgical biopsy (D) core needle biopsy (12) When examining a patient with breast implants, views of each breast are typically performed. (A) two (B) three (C) four (D) five (13) compression is required on the routine full breast CCs and MLOs in order to NOT damage the implant. (A) No (B) Minimal (C) Adequate (D) Maximum (14) Since the x-ray beam can not penetrate silicone or saline breast implants well enough to visualize underlying breast tissue, approximately of the breast tissue will not be visualized on the mammogram. (A) 15% (B) 20% (C) 25% (D) 35% (15) Implant-Displaced views may not be possible to perform if the patient has a condition referred to as. (A) capsular contracture (B) intracapsular rupture (C) extracapsular rupture (D) linguine sign 32

33 (16) If your patient demonstrates capsule contracture / encapsulation,. (A) end the exam and cancel the mammogram order (B) refer the patient for a clinical breast examination (C) additional views may be necessary to demonstrate maximum breast tissue (D) none of the above (17) The 90-degree Lateral Chest Wall view is used to visualize the posterior aspect of the silicone implant, the retromammary space, axilla, and. (A) retroareolar region (B) inframammary fold (C) superior structures of the breast (D) Cooper s ligaments (18) A of the implant that is palpable on examination indicates a condition referred to as capsular contracture or implant encapsulation. (A) softening (B) hardening (C) displacement (D) wrinkling (19) Capsular contracture is more common in patients with implant placement. (A) retroglandular (B) partial submuscular (C) complete submuscular (D) sub-fascial (20) Breast is the most accurate imaging technique for examining the integrity of breast implants. (A) mammography (B) ultrasound (C) MR imaging (D) thermography 33

34 IMAGING BREAST IMPLANTS THIS POST-TEST MUST BE COMPLETED AND RETURNED BY MAY 31, (Minimum score for successful completion is 75%) NAME ARRT# STATE LICENSE# (ONLY FLORIDA REQUIRED) HOSPITAL OR AFFILIATE HOME ADDRESS CITY STATE ZIP CODE PHONE + AREA CODE Please keep a copy of these documents for your records. You may your post-tests to: [email protected] or FAX your post-tests to Mailing address: RadComm, Inc. 20 Rancho Verde Tijeras, NM Please or call with any questions: [email protected] (888) 4 XRAY CE (888) Certificate of Completion return options. PLEASE CHOOSE ONLY ONE. Please my certificate to: Address Please fax my certificate to: Fax Number 34

35 NAME RadComm, Inc Fax IMAGING BREAST IMPLANTS PLEASE COMPLETE WITH BLACK PEN OR MARKER THIS POST-TEST MUST BE COMPLETED AND RETURNED BY MAY 31, (1) (A) (B) (C) (D) (2) (A) (B) (C) (D) (3) (A) (B) (C) (D) (4) (A) (B) (C) (D) (5) (A) (B) (C) (D) (6) (A) (B) (C) (D) (7) (A) (B) (C) (D) (8) (A) (B) (C) (D) (9) (A) (B) (C) (D) (10) (A) (B) (C) (D) (11) (A) (B) (C) (D) (12) (A) (B) (C) (D) (13) (A) (B) (C) (D) (14) (A) (B) (C) (D) (15) (A) (B) (C) (D) (16) (A) (B) (C) (D) (17) (A) (B) (C) (D) (18) (A) (B) (C) (D) (19) (A) (B) (C) (D) (20) (A) (B) (C) (D) 35