Management of Late Seroma in Patients with Breast Implants: The Role of the Radiologists

To the Editor: Breast augmentation is a common cosmetic surgery that is also used for breast reconstruction after cancerrelated mastectomy. It has been estimated that 20% of women will have problems after implant surgery (1). Late seromas are a very rare complication can be arbitrarily defined as the occurrence of any periimplant fluid collection appearing later than a year after the surgery (2). Increasing concern about the management of such a collection and the heightened awareness of the possibility of associated malignancy (3) has led to various new recommendations for its management that advice conservative treatment first. The radiologist has an important role in this initial step (2). From 2010 to 2015, we identified seven women with a late periprosthetic collection. The patients’ median age was 45 years (range 29–55). The indications for surgery were hypomastia in five cases and reconstruction after mastectomy in two cases. The average interval from the surgery to the seroma onset was 6 years (range 2–15 years). Six patients presented with inflammatory signs of the breast (pain, heat feeling, enlargement. . .). In one patient, the fluid collection was incidentally found during a routine follow-up (Table 1). Initially, all women underwent an ultrasound, which showed an anechoic fluid collection surrounding the implant, with a median size of 1.6 cm (range 1–2 cm) (Fig. 1). An MRI demonstrated an intact implant with a collection around it (Fig 2). Our next step was performing an ultrasound-guided aspiration of the fluid. The procedure was carried out on an outpatient basis using a 21G sterile needle without local anesthesia. Some of the fluid obtained was sent to the laboratory in sterile bottles. The aspiration needle was flushed with a small amount of liquid (Cytolyt) and was sent for cytologic analysis. The diagnosis of seroma was confirmed in all cases by negative results from bacteriologic and cytologic examination. After the aspiration of the fluid the symptoms improved in six women and none of them experienced seroma recurrence or needed reoperation with prosthesis removal during a median followup of 16.4 months (Interquartile range: 8.5–48.6). In one of the patients we diagnosed a contralateral implant rupture by US and MRI, so she underwent surgery and implants removal was performed (Fig 3). Late seroma is probably an underreported complication after breast implantation surgery (2,4). Its occurrence from individual case series ranges from 0.5% to 1.84% (5–7). The diagnosis of late periprosthetic collection can be confirmed by negative results from bacteriologic and cytologic examination at least 1 year after implant surgery (4). Further characteristics of late seroma formation are thickening of the capsule and implant movement within the cavity prepared for the breast implant (6). The etiology and pathophysiology of this entity is unknown but may include no mechanical factors (subclinical infection due to biofilm or chemical reaction) and mechanical factors. Synovial metaplasia resulting from mechanical shear forces or sliding surfaces generated by micromotions between the implant and the surrounding tissue may also give rise to periprosthetic fluid collection (4). Anaplastic large T-cell lymphoma is frequently associated with a late symptomatic swelling or seroma around the implant. In a case–control study examining the risk of this disease in women with breast implants, the incidence of this lymphoma was estimated at 1 per 1 million women per year (2). As far as we know, there are only 74 cases of late seroma published in the literature, including ours. In Address correspondence and reprint requests to: Luc ıa Gra~ na L opez, Lucus Augusti Hospital, Ulises Romero 1, 27002 Lugo, Spain, or e-mail: lu_rx@hotmail.com