24 Botros M et al. / Recurrent breast cancer and breast implant rupture of recurrent breast cancer. To our knowledge, this is the first reported case of breast cancer recurrence presenting as a ruptured implant. It is possible that the rupture was secondary to cancer growth. Case report A 50-year-old post-menopausal woman was di- agnosed with a stage IIB (T2N1M0) right breast cancer and subsequently years later developed an unusual recurrence that was diagnosed following rupture of one of her breast prostheses. Following initial diagnosis, she underwent a right modified radical mastectomy and review of surgical pathol- ogy revealed a grade 4 (of 4) invasive lobular car- cinoma, nuclear grade 2 (of 3), forming a 2.2 x 2 x 1.8 cm mass. No definite vascular invasion was noted apart from the central tumor mass, although lobular carcinoma in-situ with extension into ad- jacent ducts was seen. Lactiferous ducts beneath the nipple showed pagetoid spread of carcinoma cells. One of 14 right axillary lymph nodes was positive for metastatic involvement with focal ex- tranodal extension of disease. Tumor cells were ER/PR positive. Following surgery, she received six months of chemotherapy with cyclophospha- mide, methotrexate and 5-fluorouracil (CMF). A subsequent prophylactic left simple mastectomy with bilateral breast reconstruction was performed 4 months following completion of chemotherapy. Approximately 4 months after surgery, tamoxifen therapy was started and administered for 5 years. Of note, this patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorecto- my a year after breast reconstructive surgery. The patient had regular follow up without evi- dence of disease recurrence. Approximately 12 years after her breast reconstructive surgery, she developed a deflated right breast implant. She was scheduled for bilateral implant exchange surgery. During preoperative evaluation, she was found to have evidence of mitral valve regurgitation due to a flail mitral valve posterior leaflet, and subse- quently underwent mitral valve repair. The car- diothoracic surgeon informed the patient that her sternum was found to be “somewhat mushy” dur- ing her sternotomy. About 5 months after open heart surgery, the patient had developed a neck lump and back pain. Imaging studies with CT revealed postoperative mastectomies with implants. However, the right breast implant was ruptured with extensive soft tissue mass and nodularity involving the anterior Radiol Oncol 2012; 46(1): 23-27. chest wall, predominantly anterior to both sides of the sternum but slightly more marked on the right with subcutaneous nodularity throughout the right mastectomy site (Figure 1). This was noted to be inseparable from the adjacent pectoralis muscles along with right subpectoral adenopathy and right neck base adenopathy consistent with tumor recur- rence. The anterior chest wall mass extended pos- teriorly through the chest wall into the hemithorax and was also associated with internal mammary adenopathy. Partial lytic lesions were seen in the mid sternum. In addition, there was bulky anterior mediastinal adenopathy and tumor extending infe- riorly along the anterior pericardium and anterior to the right atrium and right ventricle as well as to the root of the aorta (Figure 2). Nodularity was noted in the right upper lung pleura and left lung base pleura. There were bulky soft tissue masses in both costophrenic angles. Tumor nodularity was noted anterior to the liver representing peritoneal implants. Skin thickening was noted over both anterior chest walls but greater on the right. Bony metastases were noted in the T5 and L1 vertebral bodies, the right temporal bone of the skull, and the right anterior iliac bone. The patient underwent a T10 vertebroplasty and then subsequent palliative radiotherapy to T8 through L1 vertebral bodies. During palliative ra- diotherapy, she developed right hip pain and was found to have a destructive metastasis in the right femoral head and neck requiring surgery with a right hip replacement followed by palliative ra- diotherapy to bilateral hips and the right femur. She went on to receive palliative chemotherapy but ultimately expired from disease progression approximately 11 months following diagnosis of metastatic disease. Discussion Breast cancer recurrence is a challenging event that is associated with morbidity and shortened surviv- al.5,6 Herein, we described the course of a patient who developed locoregional and distant metas- tases of ILC. Although ILC makes up a minority of breast cancer cases, its incidence is believed to be on the rise.7 These tumors are less likely to result in a reactive process and are also less likely to have microcalcifications.8,9 Thus, they are occasionally missed on screening mammography and clinical examination. As reported in previously published stud- ies, the prognosis of ILC as compared to IDC has