Coming of Age: Breast Implant-Associated Anaplastic Large Cell Lymphoma After 18 Years of Investigation

Updates on Breast Reconstruction: Surgical Techniques, Challenges, and Future Directions

The increasing global incidence of breast cancer underscores the significance of breast reconstruction in enhancing patients' quality of life. Breast reconstruction primarily falls into two categories: implant-based techniques and autologous tissue transfers. In this study, we present a comprehensive review of various aspects of implant-based reconstruction, including different types of implants, surgical techniques, and their respective advantages and disadvantages. For autologous breast reconstruction, we classified flaps and optimal harvest sites and provided detailed insights into the characteristics, benefits, and potential complications associated with each flap type. In addition, this review explores the emerging role of fat grafting, which has received increasing attention in recent years. Despite advancements, there remains substantial scope for further improvements in breast reconstruction, emphasizing not only aesthetic outcomes, but also a reduction in complications and postoperative recovery. By offering a comprehensive overview of the historical evolution, current landscape, and future prospects of breast reconstruction, this review aims to provide readers with a comprehensive understanding of breast cancer management strategies.

A Case Report of Breast Implant-Associated Anaplastic Large-Cell Lymphoma in a PALB2 Mutation-Positive Woman

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma composed of anaplastic pleomorphic T cells. The first case was reported in 1997 but was not recognized until 2016 by the World Health Organization. The exact incidence is unknown but is estimated to be 0.1 to 0.3 per 100,000 women with implants. Almost every case has been found in women with textured breast implants. The median time of onset after implantation is 10.7 years. Patients presenting with localized disease, most commonly manifesting as breast enlargement, can be managed solely with surgical resection and have a 100% survival rate. This report describes a PALB2 mutation-positive woman with a strong family history of breast cancer who underwent prophylactic bilateral nipple-sparing mastectomy with textured silicone implant placement. She was diagnosed with BIA-ALCL less than 4 years later after seroma aspiration. She was treated with implant removal and capsulectomy; but, surprisingly, final surgical pathology did not show any malignancy.

[Breast implant-associated squamous cell carcinoma: a systematic literature review]

BACKGROUND

Breast implant-associated squamous cell carcinoma (BIA-SCC) is being discussed as a distinct malignant tumour entity originating from the implant capsule. The FDA and the ASPS published a safety communication on BIA-SCC in 2022, with a first case report of BIA-SCC having been published in the 1990s. This manuscript summarises the current scientific data on this rare tumour entity.

MATERIAL AND METHODS

This systematic literature review from two independent databases includes all publications of cases with histopathologically confirmed BIA-SCC. Data extraction included study design, demographic data, implant information and details regarding diagnosis and treatment.

RESULTS

Nineteen cases of BIA-SCC with a mean age of 57±10 years were reported in 16 publications. In most cases, the indication was aesthetic augmentation (n=13). Both silicone (n=11) and saline (n=7) implants with different surfaces (smooth n=3, textured n=3, polyurethane n=1) were used. Symptoms such as unilateral swelling (n=18), pain (n=14) and erythema (n=5) occurred on an average of 23±9 years after implantation. Imaging showed fluid collection (n=8) or a tumour mass (n=4) around the breast implant. The most common surgical treatment was explantation with capsulectomy. Metastasis was described in 6 cases.

CONCLUSIONS

BIA-SCC is a malignant tumour entity associated with breast implant capsules. Based on current low-quality data (level of evidence class V), no definitive conclusion regarding correlation and causality of SCC in patients with breast implants can be drawn. There is an urgent need for national and international breast implant and breast cancer registries to obtain valid data on the incidence, pathogenesis and clinical presentation of rare tumour entities.

Feasibility of Imaging Modalities Combined with a Silicone Gel-Filled Breast Implant in Korean Women

With the occurrence of breast implant crises in Korea, it has become increasingly important to detect complications earlier in patients receiving a device. We have therefore combined imaging modalities with an implant-based augmentation mammaplasty. In this study, we assessed the short-term treatment outcomes and safety of the Motiva ErgonomixTM Round SilkSurface (Establishment Labs Holdings Inc., Alajuela, Costa Rica) in Korean women. A total of 87 women (n = 87) were included in the current study. We compared preoperative anthropometric measurements between the right side and the left side of the breast. Moreover, we also compared the thickness of the skin, subcutaneous tissue and the pectoralis major measured on a breast ultrasound preoperatively and 3 months postoperatively. Furthermore, we analyzed the incidences of postoperative complications and the cumulative complication-free survival. Preoperatively, there was a significant difference in the distance from the nipple to the midline between the left and right side of the breast (p = 0.000). Both sides of the breast showed significant differences in the thickness of the pectoralis major preoperatively and 3 months postoperatively (p = 0.000). A total of 11 cases (12.6%) of postoperative complications occurred; these included five cases (5.7%) of early seroma, two cases (2.3%) of infection, two cases (2.3%) of rippling, one case (1.1%) of hematoma and one case (1.1%) of capsular contracture. Time-to-events were estimated at 386.68 ± 27.79 days (95% CI 334.11-439.27). Here, we describe our experience with imaging modalities in combination with the Motiva ErgonomixTM Round SilkSurface in Korean women.

Clinical Implications and Management of Non-BIA-ALCL Breast Implant Capsular Pathology

SUMMARY

The breast implant capsule is a dynamic structure that forms following the implantation of a device. Although normally benign, increased awareness of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) highlights that disease may arise from the capsule. BIA-ALCL presents as a late seroma or mass but explains few of the late seromas found in breast implant patients. To date, many of these seromas lack a clear cause and are often described as "idiopathic." Several benign and malignant breast implant capsular diseases can cause a late seroma or mass, including breast implant-associated squamous cell carcinoma. Similar to early reports of BIA-ALCL, these conditions are rare and largely limited to case reports or series. The purpose of this special topic is to present a narrative review highlighting capsular abnormalities that contribute to the formation of late seroma or mass in an attempt to broaden the differential diagnosis and help plastic surgeons identify the cause. Specifically, we review the presentation and management of BIA-ALCL, synovial metaplasia, capsular epithelialization, late hematoma, double capsule, breast cancer, squamous cell carcinoma, mesenchymal tumor, and B-cell lymphoma. Although rare, plastic surgeons should consider these capsular conditions as causes of late seromas and masses. Usually, these conditions may be diagnosed by following the National Comprehensive Cancer Network screening guidelines for BIA-ALCL. Thorough evaluation and workup of late seromas and masses may lead to improved characterization of these rare breast implant capsular conditions and improve our understanding of their pathophysiology and management.

Current Understanding of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Every year, breast implants are inserted worldwide for reconstructive or aesthetic reasons. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rather uncommon type of T cell lymphoma that is positive for the CD30 biomarker. Despite being far more common than other primary breast lymphomas, BIA-ALCL has a very low incidence. Textured types of implants have been linked to almost all cases. The majority of patients have a favorable prognosis after the removal of implants and capsules. Nevertheless, the chance of a fatal outcome is higher with capsular invasion and tumor bulk. Although the exact cause of BIA-ALCL is unknown, it has been suggested that persistent infections or toxins related to the implants may play a role. Therefore, physicians must be aware of breast implants' rare but potentially significant side effects. Before surgery, patients with verified instances should be directed to a breast medical oncologist or lymphoma specialist for oncologic assessment. Total en-bloc capsulectomy, a surgical procedure that removes the implant and the surrounding capsule, is usually adequate. In other cases, a late diagnosis necessitates more invasive surgery and systemic therapies, which, while typically effective, have been linked to poor outcomes and even fatalities. Since it is a recently described entity and the "denominator" (i.e., the total number of breast implant procedures) is unknown, it is challenging to determine the risk of development. In this review, we hope to emphasize the elements of etiology, demography, clinical features, and current treatment approaches for BIA-ALCL. In doing so, we hope to increase the medical professional's knowledge of the recognition and treatment of BIA-ALCL.

Comprehensive Evaluation of the Current Knowledge on Breast Implant Associated-Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently spotlighted T-cell origin non-Hodgkin's lymphoma with an increasing incidence of over 800 cases and 33 deaths reported worldwide. Development of BIA-ALCL is likely a complex process involving many factors, such as the textured implant surface, bacterial biofilm growth, immune response, and patient genetics. As the incidence of BIA-ALCL is expected to increase, it is important for all surgeons and physicians to be aware of this disease entity and acquire thorough knowledge of current evidence-based guidelines and recommendations. Early detection, accurate diagnosis, and appropriate treatment are the foundations of current care.

Smooth versus Textured Implant Breast Reconstruction: Patient-Reported Outcomes and Complications

BACKGROUND

The association between textured surface breast implants and breast implant-associated anaplastic large cell lymphoma has led to an increase in surgical procedures to exchange textured devices to smooth surface implants. Because patient satisfaction is an integral part of breast reconstruction, the purpose of this study was to compare patient-reported outcomes between smooth and textured implant recipients.

METHODS

Patients aged 18 years or older who underwent implant-based postmastectomy breast reconstruction with either smooth or textured devices from 2009 to 2017 and completed the BREAST-Q patient-reported outcome measure following reconstruction were included in this analysis. The primary outcomes of interest were mean and median BREAST-Q scores and postoperative complications.

RESULTS

Overall, 1077 patients were included-785 who underwent breast reconstruction with smooth implants and 292 who underwent breast reconstruction with textured implants. No statistical differences were observed between the textured and smooth implant groups for any of the BREAST-Q domain scores at any of the early (3-month) to late (2-year) postoperative time points. Smooth implant recipients reported significantly more rippling (p = 0.003) than textured implant recipients. In contrast, textured implant recipients had a higher rate of cellulitis than smooth implant recipients (p = 0.016).

CONCLUSIONS

These data suggest that postoperative satisfaction with breasts or health-related quality of life following immediate postmastectomy implant-based breast reconstruction is likely independent of implant surface type. However, smooth breast implants may result in more rippling. The authors' findings represent an important aid in counseling patients who have questions about the risks and benefits of replacing their textured implants with smooth surface devices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Gram-Negative Bacterial Lipopolysaccharide Promotes Tumor Cell Proliferation in Breast Implant-Associated Anaplastic Large-Cell Lymphoma

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a distinct malignancy associated with textured breast implants. We investigated whether bacteria could trigger the activation and multiplication of BIA-ALCL cells in vitro. BIA-ALCL patient-derived BIA-ALCL tumor cells, BIA-ALCL cell lines, cutaneous ALCL cell lines, an immortal T-cell line (MT-4), and peripheral blood mononuclear cells (PBMC) from BIA-ALCL, capsular contracture, and primary augmentation patients were studied. Cells were subjected to various mitogenic stimulation assays including plant phytohemagglutinin (PHA), Gram-negative bacterial lipopolysaccharide (LPS), Staphylococcal superantigens enterotoxin A (SEA), toxic shock syndrome toxin-1 (TSST-1), or sterilized implant shells. Patient-derived BIA-ALCL tumor cells and BIA-ALCL cell lines showed a unique response to LPS stimulation. This response was dampened significantly in the presence of a Toll-like receptor 4 (TLR4) inhibitor peptide. In contrast, cutaneous ALCL cells, MT-4, and PBMC cells from all patients responded significantly more to PHA, SEA, and TSST-1 than to LPS. Breast implant shells of all surface grades alone did not produce a proliferative response of BIA-ALCL cells, indicating the breast implant does not act as a pro-inflammatory stimulant. These findings indicate a possible novel pathway for LPS to promote BIA-ALCL cell proliferation via a TLR4 receptor-mediated bacterial transformation of T-cells into malignancy.

Comparison of the Incidence of Capsular Formation in Two-Stage, Implant-Based Breast Reconstruction Using an Insertion Funnel and Sizer

Purpose

Capsular formation around breast implants can produce various complications, including erythema, tenderness, discomfort, and breast deformation. Moreover, the capsule is thought to be correlated with breast implant-associated anaplastic large cell lymphoma. The proposed technique of capsule reduction can prevent some of these complications. Thus, the authors suggest a no-touch technique in two-stage, implant-based breast reconstruction. Patients and Methods. This single-center retrospective study evaluated the medical records and digitalized pathological slides of patients who underwent two-stage, implant-based breast reconstruction between February 2018 and May 2019. The selected patients were divided into group A and group B. Group A underwent a no-touch technique that included the following two steps: (1) using a sizer as the frame to create the submuscular and acellular dermal matrix (ADM) pocket for expander insertion and (2) inserting the expander through the funnel. After the second stage of implant insertion, the capsule was harvested for biopsy of the ADM, chest wall, and muscle.

Results

This study included 33 breasts (31 patients): 18 in group A and 15 in group B. The capsular thicknesses of the ADM, the chest wall, and the muscle of group A were significantly thinner than those in group B. Pearson's correlation coefficient indicated negative correlations between capsular thickness and age; underlying disease; lesion side; interval of two-stage implant insertion; size of the expander; and radiotherapy, chemotherapy, or hormone therapy.

Conclusion

To reduce the incidence of capsular formation following breast reconstruction using prostheses, a no-touch technique that uses a funnel and sizer to avoid implant contact is both efficient and beneficial.

Cellular and Molecular Mechanisms of Breast Implant-Associated Anaplastic Large Cell Lymphoma

SUMMARY

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and highly treatable cancer of the immune system that can form around textured-surface breast implants. Although the underlying cause has yet to be elucidated, an emerging theme-linking pathogenesis to a chronic inflammatory state-continues to dominate the current literature. Specifically, the combination of increasing mutation burden and chronic inflammation leads to aberrant T-cell clonal expansion. However, the impetus remains largely unknown. Proposed mechanisms include a lipopolysaccharide endotoxin response, oncogenic transformation related to viral infection, associated trauma to the breast pocket, particulate matter digestion by capsular macrophages, chronic allergic inflammation, and genetic susceptibility. The Janus kinase-signal transducer and activator of transcription 3 (JAK-STAT3) pathway is a major signaling pathway that regulates a variety of intracellular growth and survival processes. Constitutive activation of JAK-STAT3 has been implicated in several malignancies, including lymphomas, and has recently been identified as a potential key mediator in BIA-ALCL. The purpose of this article is to review the cellular and molecular mechanisms of BIA-ALCL with a focus on the role of oncogenic JAK-STAT3 signaling in BIA-ALCL tumorigenesis and progression. Selected experimental work from the authors' group on aberrant JAK-STAT3 signaling in BIA-ALCL is also included. The authors discuss how an inflammatory microenvironment may facilitate malignant transformation through the JAK-STAT3 pathway-highlighting its potential mechanistic role. The authors' hope is that further investigation of this signaling pathway will reveal avenues for using JAK-STAT3 signaling as a prognostic indicator and novel therapeutic target in the case of advanced disease.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Clinical Update

ABSTRACT

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized malignancy of T-lymphocytes that is linked to certain types of textured breast implants. Although rare, the increasing awareness of the disease is resulting in more case reports and heightened anxiety in patients with textured breast implants. This review aims to summarize the available BIA-ALCL data, including the existing theories of etiopathogenesis, the diagnostic work-up for BIA-ALCL patients, BIA-ALCL treatment recommendations, the epidemiologic challenges, and the current opinions surrounding the use of textured breast implants.

Breast Implant-associated Anaplastic Large Cell Lymphoma: An Evidence-based Systematic Review

OBJECTIVE

This evidence-based systematic review synthesizes and critically appraises current clinical recommendations and advances in the diagnosis and treatment of BIA-ALCL. This review also aims to broaden physician awareness across diverse specialties, particularly among general practitioners, breast surgeons, surgical oncologists, and other clinicians who may encounter patients with breast implants in their practice.

BACKGROUND

BIA-ALCL is an emerging and treatable immune cell cancer definitively linked to textured-surface breast implants. Although the National Comprehensive Cancer Network (NCCN) consensus guidelines and other clinical recommendations have been established, the evidence supporting these guidelines has not been systematically studied. The purpose of this evidence-based systematic review is to synthesize and critically appraise current clinical guidelines and recommendations while highlighting advances in diagnosis and treatment and raising awareness for this emerging disease.

METHODS

This evidence-based systematic review evaluated primary research studies focusing on the diagnosis and treatment of BIA-ALCL that were published in PubMed, Google Scholar, and other scientific databases through March 2020.

RESULTS AND CONCLUSIONS

The clinical knowledge of BIA-ALCL has evolved rapidly over the last several years with major advances in diagnosis and treatment, including en bloc resection as the standard of care. Despite a limited number of high-quality clinical studies comprised mainly of Level III and Level V evidence, current evidence aligns with established NCCN consensus guidelines. When diagnosed and treated in accordance with NCCN guidelines, BIA-ALCL carries an excellent prognosis.

Advising patients about breast implant associated anaplastic large cell lymphoma

The United States Food and Drug Administration (FDA) recently recognized the necessity for improved patient education and public awareness of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). BIA-ALCL is an uncommon T-cell lymphoma that can arise years after placement of a textured breast implant or tissue expander. Patients and providers would greatly benefit from a broader awareness of BIA-ALCL and how it presents with both common and rare symptoms. Disease awareness can be improved with specific steps moving forward. This includes improved counseling about annual recommendations from the FDA, standard of care guidelines, current estimates of disease prevalence, and manufacturer-specific risk for developing the malignancy. Informed consent for implant-based breast surgery should include a discussion of BIA-ALCL, symptoms, inherent risks and alternatives. Consideration should be given for reasonable efforts to retroactively contact patients with textured implants to inform them of recent regulatory actions as well as the risk of developing the disease and the signs and symptoms to watch for. Where risk can be reduced, all steps should be taken to ensure patient safety. In keeping with our commitment to patient safety, the strategies moving forward for implant-based breast surgery should be marked by patient awareness, physician vigilance, and defined by evidence-based diagnosis and treatment.

A Cautionary Tale and Update on Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large T-cell lymphoma (BIA-ALCL) was first recognized by the World Health Organization in 2016. The total number of cases worldwide continues to increase, with >800 cases confirmed through a combination of Food and Drug Administration data, verified reports, and registries. To date, 33 deaths have been reported. Typical presentation includes a late seroma containing monoclonal T cells that are CD30 positive and anaplastic lymphoma kinase negative. We present a review of the current literature and report on 3 cases of BIA-ALCL at our institution, which serve to illustrate our approach to diagnosis and management of this disease. In 2 cases, the diagnosis of BIA-ALCL was not initially confirmed due to an incomplete workup but was recognized upon explantation. The seroma fluid was sent for flow cytometry. Initially, the cells were reported as morphologically suspicious for malignancy with phenotypically normal T cells based on standard CD3+ T-cell gating. Subsequent cytology specimens were reported as consistent with recurrent adenocarcinoma. However, upon regating of flow-cytometry data, a population of CD30+, CD3- T cells was noted and the diagnosis of BIA-ALCL was confirmed by immunohistochemical stains of the excised breast capsule specimen. Given the increasing incidence of this disease, as plastic surgeons we must stay informed to order the correct workup to avoid misdiagnosis and be prepared to appropriately refer affected patients to centers with multidisciplinary teams experienced in the management of BIA-ALCL.

LEVEL OF EVIDENCE: 4

Breast Prosthesis Syndrome: Pathophysiology and Management Algorithm

The cosmetic use of devices like prostheses to increase breast volume is nothing new. It is calculated that millions of people have been exposed to silicone in several ways, including breast implants, and since 1964 there has been uncertainty regarding their safety. We did not find in the literature any studies that reported the appearance of a specific immunological disease in patients with silicone breast implants. Furthermore, there are also neither case-control studies nor reports of patients proving that symptoms of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) occurred after the placement of silicone implants nor that the patients had pre-existing symptoms. Several studies link silicone to allergic reactions and the development of systemic autoimmune diseases; however, other studies deny this association. There are currently several theories about the effect of silicone on the body. One theory with greater acceptance proposes an adjuvant effect of silicone on the development of autoimmune diseases in genetically predisposed patients. However, the variety of symptoms occurring in patients who develop these pathologies leads to doubts about the relationship between the adjuvant effects of a silicone prosthesis may have with a specific autoimmune disease or a mix of these diseases. The lack of consensus on this topic obliges a full review of what has already been reported in the literature to integrate the knowledge and propose a focus for new research on this matter. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstructive trends following mastectomies in Scotland: A comparison with England

INTRODUCTION

In England there has been a substantial increase in the use of immediate implant-based reconstruction, accounting for over half of all immediate reconstructions (IR). Less than one third of patients in England undergo autologous reconstruction IR. Our aim was to examine IR trends in Scotland.

METHODS

Data was extracted from the Scottish Morbidity Record held at the Information Services Division of the NHS National Services Scotland. All patients discharged from Scottish hospitals between 2011 and 2016 who had a diagnosis of breast cancer including DCIS and underwent mastectomy were identified. Patients undergoing IR were identified by coding at the time of mastectomy to identify who had IR and what method was used.

RESULTS

Between 2011 and 2016, 7358 patients underwent a mastectomy for breast cancer. 1845 patients (25%) had an IR. The percentage of patients undergoing IR increased from 22% in 2011 to 26% in 2016. The dominant annual procedure type was autologous reconstruction (free flap and pedicled flaps), accounting for 58% in 2011 and 54% in 2016. Pedicled flaps alone decreased from 40% in 2011 to 28% in 2016 and free flaps increased from 18% in 2011 to 26% in 2016. Implant based reconstruction rates were broadly consistent, 37% in both 2011 and 2016. Pedicled flaps with implant reconstruction decreased from 13% in 2011 to 5% in 2016.

CONCLUSIONS

Autologous reconstruction (with increasing trend for free flaps procedures) remains a constant preferred technique for IR in Scotland, accounting for over half of IR performed.

Rare Cancer on the Rise: An Educational Review of Breast Implant-associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare but increasingly important diagnosis as the incidence of breast implant placement, both elective and reconstructive, continues to rise. When detected and treated early, this indolent disease carries an excellent prognosis. However, because the clinical presentation is often nonspecific, it is crucial for radiologists to accurately identify the imaging findings associated with BIA-ALCL to facilitate a timely diagnosis. This article will provide radiologists with an overview of the diagnosis, imaging findings, and management of BIA-ALCL.

Analysis of Allergan's Biocell Implant Recall in a Major University Breast Center

Supplemental Digital Content is available in the text.

Background:

In May 2019, Health Canada released a national recall of all macrotextured breast implants that later became international in July 2019 regarding increasing accounts of suspected breast implant–associated anaplastic large cell lymphoma. In Canada, this recall targeted Allergan’s Biocell implants. This report presents the postmortem of this comprehensive single-center recall, which had to be undertaken in a limited time.

Methods:

Four months after the beginning of the recall, the authors analyzed the transcript of meetings to characterize the team assembled during the recall. Then, to reconstruct the systemic work plan as well as the crucial steps and actors of the recall process, a chronologic table of the 5 meetings held during the recall, agendas and transcripts of every meeting, electronic correspondences, and other documents created during the recall were consulted.

Results:

Between 1996 and 2018, 1260 women were affected by the recall, meaning that they received Allergan’s macrotextured implants. Ninety-two patients underwent explantation of the device or will undergo implant explantation. To this day, no patient was diagnosed with breast implant–associated anaplastic large cell lymphoma.

Conclusions:

Our center’s experience highlights the utmost importance of building a national breast implants registry. We recommend breast centers to develop preestablished crisis centers and train staff to better prepare for future device recalls and minimize waste of time. Finally, we believe that implants should be identified based on the characteristics rather than their brand name.

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Current Understanding and Recommendations for Management

Worldwide, millions of women live with breast implants. Therefore, it is important that physicians be aware of an uncommon but possibly serious complication arising from breast implants: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Breast implant-associated anaplastic large-cell lymphoma most commonly presents as a delayed fluid collection around a textured breast implant or as a mass in the capsule surrounding the implant. The exact pathogenesis of the disease remains unclear. The neoplastic cells of BIA-ALCL show strong uniform staining for CD30 and are consistently negative for activin receptor-like kinase 1. Patients with confirmed cases should be referred to a lymphoma specialist or breast medical oncologist for a complete oncologic evaluation before any surgical intervention. For disease confined to the fluid accumulation or capsule, or both, surgical removal of the implant and complete capsulectomy is the preferred treatment. Postoperative chemotherapy or radiation, or both, are not considered necessary for patients with limited-stage disease and are reserved for advanced disease stages. Generally, BIA-ALCL is a local disease that follows an indolent course and has an excellent prognosis. Although complete remission of disease has occurred in patients with BIA-ALCL, median overall survival is reduced. As of March 2018, approximately 529 unique, confirmed BIA-ALCL cases had been reported in 23 countries. To date, 16 patients have died from BIA-ALCL, and all had extracapsular involvement. The aim of this article is to summarize the diagnosis, evaluation, and management of BIA-ALCL, based on established guidelines, for all practitioners who may care for patients with breast implants.

Is breast implant-associated anaplastic large cell lymphoma a hazard of breast implant surgery?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) may occur after reconstructive or aesthetic breast surgery. Worldwide, approximately 1.7 million breast implant surgeries are performed each year. To date, over 500 cases of BIA-ALCL have been reported around the world, with 16 women having died. This review highlights the most important facts surrounding BIA-ALCL. There is no consensus regarding the true incidence rate of BIA-ALCL as it varies between countries, is probably significantly under-reported and is difficult to estimate due to the true number of breast prostheses used largely being unknown. BIA-ALCL develops in the breast mostly as a seroma surrounding the implant, but contained within the fibrous capsule, or more rarely as a solid mass that can become invasive infiltrating the chest wall and muscle, in some instances spreading to adjacent lymph nodes, in these cases having a far worse prognosis. The causation of BIA-ALCL remains to be established, but it has been proposed that chronic infection and/or implant toxins may be involved. What is clear is that complete capsulectomy is required for treatment of BIA-ALCL, which for early-stage disease leads to cure, whereas chemotherapy is needed for advanced-stage disease, whereby improved results have been reported with the use of brentuximab. A worldwide database for BIA-ALCL and implants should be supported by local governments.

Validation of a CD30 Enzyme-Linked Immunosorbant Assay for the Rapid Detection of Breast Implant-Associated Anaplastic Large Cell Lymphoma

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of non-Hodgkin lymphoma occurring in the fluid or capsule adjacent to textured breast implants. Diagnosis of BIA-ALCL of symptomatic patients requires demonstration of large anaplastic cells with uniform expression of CD30 protein on immunohistochemistry.

OBJECTIVES

The authors investigated a novel, rapid, office-based, and economic in-situ enzyme-linked immunosorbent assay (ELISA) for screening BIA-ALCL patients.

METHODS

A commercially available in-situ ELISA was standardized and validated for patients with confirmed BIA-ALCL diagnosis with clinical isolates. A panel of 9 pathologically confirmed BIA-ALCL patients was screened by serum, plasma, and periprosthetic effusion specimens and compared against serum, plasma, and nonneoplastic delayed seromas in 7 control patients. Statistical analysis demonstrated assay consistency and reliability.

RESULTS

All BIA-ALCL effusions demonstrated CD30 ELISA detection at full and all serial concentrations. BIA-ALCL serum specimens and all control specimens were negative at full concentration and serial dilutions (1:100, 1:250, 1:500, and 1:1000). BIA-ALCL plasma specimens were weakly positive at full concentration and revealed no activity with serial dilution.

CONCLUSIONS

This is the first study to demonstrate a viable alternative to CD30 immunohistochemistry for the screening of BIA-ALCL. Our study demonstrates 100% sensitivity in seroma fluid with no detectable CD30 in benign seroma samples. A CD30 ELISA represents a novel, low-cost screening test, which may be used to screen suspicious aspirations of delayed periprosthetic fluid collections in an office-based setting.

LEVEL OF EVIDENCE: 3

Gluteal Implant-Associated Anaplastic Large Cell Lymphoma

The association of anaplastic large cell lymphoma (ALCL) to breast implants (breast implant-associated ALCL) has brought back the discussion on the clinical safety of the use of silicone implants. A 63-year-old woman came to our institution in early 2015, reporting a gluteal augmentation with silicone implants in 2006 and a recent increasing volume and distortion of the left buttock. Radiologic imaging showed a large amount of fluid collection around the implant. The left side implant was removed and the capsule was left intact, presupposing a future reimplantation. The fluid collected was positive for Staphylococcus aureus. Three years later, she presented again with a new seroma on the explanted side and was submitted to total capsulectomy and fluid drainage, and the material was submitted to laboratory examination. Culture results were negative. Pathologic preparation and sections of the capsule and lumps showed large cells characterized by horseshoe-shaped nuclei. Immunohistochemistry was positive for CD30/CD4 and negative for anaplastic lymphoma kinase, confirming the presence of ALCL, then associated with gluteal implant, an event not described in literature. Positron emission tomography/computed tomography and bone marrow biopsy were performed, and neither showed any other sites involved. The same disease in a new location introduces important discussions about the understanding of this abnormality and poses certain risks and safety issues to clinical scenarios to be discussed. Regardless of whether it is a breast implant-associated ALCL or a gluteal implant-associated ALCL, now we are probably facing an implant augmentation-associated disease and a new international alert should be addressed to the scientific community. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Death by Implants: Critical Analysis of the FDA-MAUDE Database on Breast Implant-related Mortality

Since the 1992 moratorium by the Food and Drug Administration (FDA), the debate on the association of breast implants with systemic illnesses has been ongoing. Breast implant-associated anaplastic large cell lymphoma has also raised significant safety concerns in recent years.

Methods

A systematic search of the Manufacturer and User Facility Device Experience (MAUDE) database was performed to identify all cases of breast implant-associated deaths reported to the FDA.

Results

The search identified 50 reported cases of apparent implant-related mortality; breast implant-associated anaplastic large cell lymphoma comprised the majority of fatal outcomes (n = 21, 42%), followed by lymphoma (n = 4, 8%), breast cancer (n = 3, 6%), pancreatic cancer (n = 2, 4%), implant rupture (n = 2, 4%), and postoperative infections (n = 2, 4%). Single cases (n = 1, 2% each) of leukemia, small bowel cancer, lung disease, pneumonia, autoimmune and joint disease, amyotrophic lateral sclerosis, liver failure, and sudden death, and 2 cases (4%) of newborn deaths, to mothers with breast implants, were also identified. A literature review demonstrated that 54% of alleged implant-related deaths were not truly associated with breast implant use: the majority of these reports (82%) originated from the public and third-party sources, rather than evidence-based reports by health-care professionals and journal articles.

Conclusions

Although there exists a need for more comprehensive reporting in federal databases, the information available should be considered for a more complete understanding of implant-associated adverse outcomes. With only 46% of FDA-reported implant-related deaths demonstrated to be truly associated with breast implant use, there exists a need for public awareness and education on breast implant safety.

Finding Consensus After Two Decades of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and indolent, but potentially fatal cancer of the immune system that can develop around textured-surface breast implants. The World Health Organization first recognized BIA-ALCL as a unique clinical entity in 2016. To date, over 600 confirmed cases have been reported worldwide. BIA-ALCL most commonly presents with disease confined to the capsule, as a seroma or a mass adjacent to the implant. While BIA-ALCL has a fairly indolent clinical course, with an excellent prognosis in early stage disease, disseminated cancer and death have also been reported. In this review, the authors focus on the early diagnosis and treatment, including reconstructing the breast following BIA-ALCL, and also discuss recently updated National Comprehensive Cancer Network guidelines. They also review the current epidemiology and risk factors associated with BIA-ALCL. Finally, they discuss important medicolegal considerations and the bioethics surrounding the continued use of textured-surface breast implants.

Breast Implant-Associated Lymphoma

BACKGROUND

There has been increasing evidence in recent years that breast implants can, in rare cases, be associated with the development of an anaplastic large-cell lymphoma (ALCL).

METHODS

This review is based on relevant publications retrieved by a selective search in PubMed for articles that appeared from the time of the initial description of breast-implant-associated ALCL onward (1997 to January 2018), and by a further search in German nationwide databases.

RESULTS

516 pathologically confirmed cases of breast-implant-associated (BIA) ALCL were documented around the world until February 2018; seven of these arose in Germany and were reported to the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM). In approximately 80% of the affected women, the BIA-ALCL manifested itself as a late-developing seroma at the implant site; in the rest, as a solid tumor with or without an accompanying seroma. The mean implant exposure time ranged from 7 to 13 years on average. 16 fatalities have been reported worldwide. Among the 7 cases reported in Germany, four women had undergone breast reconstruction with implants after breast cancer surgery, and two had undergone breast augmentation surgery. In all patients, the entire capsule-and-implant unit was resected. One patient underwent chemotherapy and one further patient underwent chemotherapy and adjuvant radiotherapy.

CONCLUSION

The risk that a woman with breast implants will develop a primary anaplastic large-cell lymphoma is estimated at 0.35 to 1 case per million persons per year. The incidence of implant-associated ALCL is thus very low, yet nevertheless markedly higher than that of other primary lymphomas of the breast. Because of the low case numbers, recommendations for the diagnostic evaluation and treatment of this entity have not been adequately evaluated. Treatment with primary curative intent for BIA-ALCL confers a much better prognosis than when performed for a systemic ALCL. Whenever a patient with a breast implant presents with a late-developing seroma, BIA-ALCL should be included in the differential diagnosis. This diagnosis is reportable.

Description of Two Cases of Anaplastic Large Cell Lymphoma Associated with a Breast Implant

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized provisional entity in the 2017 revision of the World Health Organization classification of lymphoid neoplasms. Although the majority of the cases described in the literature demonstrate an effusion confined to the capsule of the breast implant, this rare pathology can also invade the capsule and adjacent tissues and/or involve lymph nodes. We hereby report two new cases of BIA-ALCL in a 58-year-old and a 47-year-old Caucasian female who received a silicone breast implant. The first patient showed a sudden and rapid right breast volume increase 6 years after the implantation surgery. As for the second patient, a left breast volume increase was observed also suddenly and quickly 11 years after surgery. In both cases, an uncompressed mammography was performed allowing a new approach to highlight periprosthetic fluid reaction. Pathologic examination of the fluid collection revealed atypical cells positive for CD30 and CD45 and negative for ALK and CK7. This allowed pathologists to diagnose a breast implant-associated anaplastic large cell lymphoma. Patients were treated with bilateral capsulectomy with no additional local or systemic therapy. The development of breast augmentation may come with an increase in the frequency of this pathology. Radiologists and senologists must therefore be careful when women with breast implants show an increase of breast volume and all cases of BIA-ALCL must be recorded and reported.

Breast implant-associated anaplastic large cell lymphoma, an under-recognised entity

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of T-cell lymphoma, recently linked to the use of certain types of breast implants. Although rare, BIA-ALCL is being increasingly recognised and radiologists can play an important role in its early diagnosis. BIA-ALCL is thought to be related to chronic inflammation from indolent infection of the biofilm surrounding implants leading to malignant transformation of activated T cells in genetically susceptible individuals. Clinical features include breast enlargement or asymmetry, discomfort, heaviness and/or a palpable mass in the context of long-standing implant(s). Ultrasound is the primary imaging modality, and the presence of more than a trace of peri-implant fluid should prompt consideration of aspiration for cytology, flow cytometry and microbiological analysis. This article reviews the clinical, imaging and pathology features of BIA-ALCL. In addition, the current recommended management guidelines for suspected cases are discussed.

Breast implant-associated anaplastic large-cell lymphoma

In patients with suspected breast implant-associated anaplastic large-cell lymphoma, cytologic evaluation of fine-needle aspirate specimens from the peri-implant seroma, together with flow cytometric immunophenotyping and immunohistochemistry, represents a suitable preoperative diagnostic approach when planning for surgical management.

Breast Reconstruction Following Breast Implant-Associated Anaplastic Large Cell Lymphoma

BACKGROUND

Standard of care treatment of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) involves surgical resection with implant removal and complete capsulectomy. We report a case series of BIA-ALCL reconstruction with proposals for timing and technique selection.

METHODS

We retrospectively reviewed and prospectively enrolled all BIA-ALCL patients at 2 tertiary care centers and 1 private plastic surgery practice from 1998 to 2017. Demographics, treatment, reconstruction, pathology staging, patient satisfaction, and oncologic outcomes were reviewed.

RESULTS

We treated 66 consecutive BIA-ALCL patients and 18 (27%) received reconstruction. Seven patients (39%) received immediate reconstruction, and 11 (61%) received delayed reconstruction. Disease stage at presentation was IA (T1N0M0 disease confined to effusion or a layer on luminal side of capsule with no lymph node involvement and no distant spread) in 56%, IB in 17%, IC (T3N0M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement and no distant spread) in 6%, IIA (T4N0M0 lymphoma infiltrating beyond the capsule, no lymph node involvement and no distant spread) in 11%, and III in 11%. Types of reconstruction included smooth implants (72%), immediate mastopexy (11%), autologous flaps (11%), and fat grafting (6%). Outcomes included no surgical complications, but 1 patient progressed to widespread bone metastasis (6%); ultimately, all patients achieved complete remission. Ninety-four percent were satisfied/highly satisfied with reconstructions, whereas 6% were highly unsatisfied with immediate smooth implants.

CONCLUSIONS

Breast reconstruction following BIA-ALCL management can be performed with acceptable complications if complete surgical ablation is possible. Immediate reconstruction is reserved for disease confined to capsule on preoperative positive emission tomography/computed tomography scan. Genetic predisposition and bilateral cases suggest that BIA-ALCL patients should not receive textured implants. Autologous options are preferable for implant adverse BIA-ALCL patients. Patients with extensive disease at presentation should be considered for 6- to 12-month delayed reconstruction with interval positive emission tomography/computed tomography evaluation.

Current Risk Estimate of Breast Implant-Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

BACKGROUND

With breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL.

METHODS

All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed.

RESULTS

Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the "population" (implant type and characteristics) examined and increased awareness of the disease.

CONCLUSIONS

Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined-driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).

Association Between Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk and Polyurethane Breast Implants: Clinical Evidence and European Perspective

This article aims to present an overview on the use of polyurethane (PU) breast implants and the possible association with the risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), with a special look at the current situation in Europe. It is well known that the real cause of BIA-ALCL remains unknown. Although this is a rare disease, many interesting theories surrounding its development have been advanced; however, none of these theories has been able to demonstrate with statistical significance, as required by the criteria of evidence-based medicine, definitive clinical proof as to why BIA-ALCL develops. It is widely assumed that the implant surface plays a crucial role. Most BIA-ALCL cases are associated with macro-textured implants, but from a strictly scientific point of view, this link is not supported by any clear clinical evidence. A deeper discussion of the various implant surfaces indicates that adding further categories to the existing surface classification (smooth, micro-, and macro-textured) should be avoided. Moreover, one of the most common misunderstandings should be clarified: PU breast implants cannot be classified as macro-textured implants. The PU foam that covers breast implants provides a completely different surface, and the mechanisms of action related to tissue adhesion, as well as to fibrous capsule formation, differ substantially from those of smooth or textured implants.

How to Diagnose and Treat Breast Implant-Associated Anaplastic Large Cell Lymphoma

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease.

SUMMARY

The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant-associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant-associated anaplastic large cell lymphoma are discussed.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Case Report and Review of the Literature

We are reporting the case of a 58-year-old woman with history of bilateral silicone breast implants for cosmetic augmentation. At 2-year interval from receiving the breast implants, she presented with swelling of the right breast with associated chest wall mass, effusion around the implant, and axillary lymphadenopathy. Pathology confirmed breast implant-associated anaplastic large cell lymphoma (stage III, T4N2M0, using BIA-ALCL TNM staging and stage IIAE, using Ann-Arbor staging). The patient underwent bilateral capsulectomy and right partial mastectomy with excision of the right breast mass and received adjuvant CHOP chemotherapy and radiation to the right breast and regional nodes. Since completion of multimodality therapy, the patient has sustained remission on both clinical exam and PET/CT scan. We report this case and review of the literature on this rare form of lymphoma.

MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference Report

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon neoplasia occurring in women with either cosmetic or reconstructive breast implants. The actual knowledge about BIA-ALCL deriving from the literature presents several limits, and it remains difficult to make inferences about BIA-ALCL epidemiology, cause, and pathogenesis. This is the reason why the authors decided to organize an evidence-based consensus conference during the Maurizio Bruno Nava (MBN 2016) Aesthetic Breast Meeting held in Milan in December of 2016. Twenty key opinion leaders in the field of plastic surgery from all over the world have been invited to express and discuss their opinion about some key questions on BIA-ALCL, trying to reach a consensus about BIA-ALCL cause, pathogenesis, diagnosis, and treatment in light of the actual best evidence.

U.S. Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (ALCL) is a distinctive type of T-cell lymphoma that arises around breast implants. Although rare, all cases with adequate history have involved a textured breast implant. The objective of this study was to determine the U.S. incidence and lifetime prevalence of breast implant-associated ALCL in women with textured breast implants.

METHODS

This is a retrospective review of documented cases of breast implant-associated ALCL in the United States from 1996 to 2015. The incidence and prevalence were determined based on a literature and institutional database review of breast implant-associated ALCL cases and textured breast implant sales figures from implant manufacturers' annualized data.

RESULTS

One hundred pathologically confirmed breast implant-associated ALCL cases were identified in the United States. Mean age at diagnosis was 53.2 ± 12.3 years. Mean interval from implant placement to diagnosis was 10.7 ± 4.6 years. Forty-nine patients had breast implants placed for cosmetic reasons, 44 for mastectomy reconstruction, and seven for unknown reasons. Assuming that breast implant-associated ALCL occurs only in textured breast implants, the incidence rate is 2.03 per 1 million person-years (203 per 100 million person-years), which is 67.6 times higher than that of primary ALCL of the breast in the general population (three per 100 million per year; p < 0.001). Lifetime prevalence was 33 per 1 million persons with textured breast implants.

CONCLUSIONS

This study demonstrates a statistically significant association between textured breast implants and breast implant-associated ALCL. Although women with a textured breast implant have a low risk of developing breast implant-associated ALCL, the current U.S. incidence is significantly higher than that of primary ALCL of the breast in the general population.