Final opinion on the safety of breast implants in relation to anaplastic large cell lymphoma: Report of the scientific committee on health, emerging and environmental risks (SCHEER)

Inflammatory response to various implant surfaces in murine models: A systematic analysis

Breast implants (BIs) are commonly used in cosmetic and reconstructive breast surgery but are linked to several complications such as capsular contracture, implant rupture, and potential malignancies. The key to mitigating these issues is the exploration of host-implant interactions, especially in response to the diverse BI surface textures, classified under ISO 14607:2018 standards. We aimed to systematically analyze the effects of different BI surface textures on inflammatory response and capsule formation in murine models, to improve BI design and clinical outcomes. A PRISMA-guided systematic review was conducted across 4 databases, focusing on murine model studies related to BI surface variations. Non-murine, human studies and those involving physical or pharmacological interventions were excluded. Implant surfaces were categorized per ISO 14607:2018, including smooth, microtextured, macrotextured, and polyurethane foam-coated (PU) BI, and compared with new ISO 14607:2018. Outcomes were assessed on capsule characteristics, inflammatory patterns, and biomechanical properties. Smooth-surfaced implants were linked to thinner, more orderly capsules, with a subdued inflammatory reaction. Microtextured implants elicited a moderate response with varying tissue integration and inflammation levels. Macrotextured implants showed pronounced tissue reaction. PU implants induced a robust inflammatory response, characterized by increased neoangiogenesis and thicker, more cellular capsules. Data inconsistencies across studies highlighted the complexity of biological responses to different implant surfaces. In conclusion, smooth implants developed thinner capsules and lower inflammation. Increasing surface texture resulted in denser capsules and more abundant inflammatory patterns, highlighting the significant role of BI surface texture in influencing host responses.

Capsular Contracture After Breast Augmentation: Our Approach to Prevent Reoccurrence with Combined Total Capsulectomy and Implantation of Motiva Ergonomix® Implants

BACKGROUND

Breast augmentation is the second most common aesthetic surgery worldwide. Capsular contracture, a prevalent complication which affects up to 30% of patients post-surgery, often leads to further necessary surgeries.

OBJECTIVES

This study investigates the effectiveness of total capsulectomy combined with Motiva Ergonomix® implant replacement in resolving capsular contracture and minimizing recurrence rates.

METHODS

We conducted a retrospective study of 1067 patients and enrolled 51 women with capsular contracture post-breast augmentation. Patients were treated between 2014 and 2023 in a single center by three surgeons. Capsular contracture severity was graded using Baker's classification. Surgical interventions included total capsulectomy and implant replacement, using various incision techniques and changes in implant anatomical planes. Patients were followed up for a minimum of 12 months to a maximum of 9 years.

RESULTS

A total of 51 patients with grade III or IV capsular contracture underwent revisional surgery, involving the implantation of 102 Motiva Ergonomix® prostheses; 77 explanted implants resulted intact, 15 exhibited silicone bleeding, and 10 showed ruptured. Capsular contracture recurrence was observed in only 1.96% of cases during the follow-up period.

CONCLUSIONS

The combination of total capsulectomy and implantation of Motiva Ergonomix® implants significantly reduces the recurrence rate of capsular contracture. Despite the study's limitations, including its single-center design and a small sample size, our results suggest that this approach is a viable and effective solution to manage this common complication in breast augmentation patients. Further multicentric studies are recommended to validate these results.

LEVEL OF EVIDENCE V

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 https://www.springer.com/00266 .

Behind the Title, Nothing! Reply to: "The (In-)Ability to Effectively Critique a Method Undermines the Validity of the Criticism"

Level of Evidence V 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 .

The impact of Breast Implant-Associated Anaplastic Large Cell Lymphoma on breast implant surgery: A European survey-based study

BACKGROUND

Over the 27 years following the first report of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), significant changes have been made in breast implant surgery trends. This study aimed to determine breast implant selection changes among European plastic surgeons.

METHODS

The European Association of Plastic Surgeons (EURAPS) promoted a digital survey to 31 national plastic surgery societies across Europe, which spread it to their members. The survey included 37 questions covering demographics, BIA-ALCL perception, current clinical practices, implant selection considerations, and satisfaction with information from health authorities and scientific societies. Anonymous responses were collected from February to April 2024.

RESULTS

A total of 904 surgeons from 33 countries participated, 41.5% reported that BIA-ALCL concerns affected patient decisions. Awareness of BIA-ALCL was high (97.2%), with more than 85% approving the quality of information from European scientific societies. The awareness influenced implant texture preferences in both aesthetic and reconstructive breast surgery (p<0.001), in the first with a notable drop in the use of macrotextured implants from 32.6% to 1.8%, while the use of smooth implants (ISO 14607:2018) increased from 11.3% to 44.6%. Similar trends were observed in reconstructive surgery regarding implant texture, but 33.1% of surgeons considered performing autologous reconstruction more often than using implants. Surgeons who encountered BIA-ALCL were more prone to using smooth implants. The recognized causal relationship between implant texture and BIA-ALCL is the main explanation to these changes.

CONCLUSION

Efforts in BIA-ALCL education have heightened surgeons' awareness, improved patient communication, and influenced clinical practices toward safer choices.

Emerging Non-Breast Implant-Associated Lymphomas: A Systematic Review

Background: Medical devices used for functional or esthetic purposes improve health and quality of life; however, they are not risk-free. Anaplastic large-cell lymphoma (ALCL), associated with breast implants, is a well-known and recognized distinct lymphoma entity. More recently, additional lymphomas have been reported in relation to prosthesis other than breast implants, as these allow the pericyte to develop into a clone that undergoes a maturation process, progressing toward full malignancy. Methods: We performed a systematic review with a descriptive analysis of data extracted from primary studies following PRISMA guidelines, including the search string "(IMPLANT* OR PROSTHES*) AND LYMPHOM*" in the PubMed, Scopus, Embase, and Google-Scholar databases. Data such as patient sex, age, implant site, prosthesis material, and lymphoma type were analyzed. Statistical methods, including Student's t-test and Fisher's exact test, were employed to compare lymphoma characteristics, with significance set at a p-value < 0.05. Results: From a total of 5992 studies, we obtained 43 case reports and series on a total of 52 patients diagnosed with prosthesis-associated lymphomas. The majority of implant-related lymphoma cases (85%) were of the B-cell type, mostly fibrin-associated large B-cell lymphoma (LBCL). This lymphoma type was more associated with biological (non-human-derived biological tissue), metallic, and synthetic implants (synthesized from non-organic components) (p-value = 0.007). Patients with ALCL had equal frequencies of metal and silicone prostheses (37.5%, 3 cases each), followed by synthetic prostheses (25%, 2 cases). ALCL cases were most common at skeletal (50%) and muscular-cutaneous sites (25%), whereas B-cell lymphomas were predominantly found in cardiovascular implants (50%), followed by skeletal (27%) and muscular-cutaneous (21%) sites. Death attributed to lymphoma took place in 67% of the cases, mostly LBCL occurring in cardiovascular sites. Conclusions: Because the included studies were limited to case reports and series, a potential non-causal link might have been documented between different implant materials, implant sites and lymphoma types. This underscores the importance of further comprehensive research and monitoring of non-breast implants.

Breast implant-associated anaplastic large cell lymphoma in Romania: First case series of all documented cases

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon malignancy, was linked to textured breast implants by moderate evidence in 2021. Documenting Romanian cases provides valuable insights into the epidemiology, management, and outcomes, thereby, enhancing global understanding and informing clinical practices. Our objective was to analyze BIA-ALCL cases in Romania, focusing on patient demographics, implant characteristics, clinical presentation, diagnostic methods, treatment, and outcomes. We conducted a retrospective review of all known BIA-ALCL cases in Romania by examining patient demographics, implant details, clinical presentation, diagnostic methods, and outcomes. Data sources included medical records, surgical reports, follow-up data, and implant characteristics such as shape, texture, and manufacturer of implants. The mean age at diagnosis was 44.4 years. All 5 patients had textured implants and no replacements, 4 for aesthetic indication and 1 for reconstruction. The mean time from implantation to diagnosis was 7.2 years. Clinical presentations were primarily late seromas, diagnosed through fine needle aspiration and immunohistochemistry. Treatment involved multidisciplinary teams, with bilateral en-bloc explantation for all patients, and adjuvant therapies in 2 cases. One patient had immediate reconstruction with smooth implants and acellular dermal matrix. Notably, no disease recurrence was observed post-treatment. The low BIA-ALCL prevalence in Romania estimated at 1:44,500 compared to the mean of 1:13,745 in Europe indicates the need for increased awareness and tracking. Establishing mandatory national implant registries, pathology databases, and enhancing physician and patient education will help identify potential cases. All cases involved textured implants, highlighting the need for ongoing research to identify risk factors and guide surgeons consulting patients with textured implants.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Case Report About a Patient with Cytology Negative for Malignancy

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare lymphoma primarily linked to textured breast implants. Symptoms are often non-specific (e.g., breast swelling, pain, or fluid collection). When imaging detects fluid around the implant, cytological examination is the first diagnostic approach. However, this method has limited sensitivity and may yield false-negative results. In this case, a 41-year-old woman presented with swelling, pain, and itching in her left breast six years after bilateral textured breast implant placement. Ultrasonography (US) revealed peri-implant fluid collection around the left implant. A following magnetic resonance imaging (MRI) scan ruled out an implant rupture. Due to persistent pain and the peri-implant effusion on the left side, open surgery was performed. During implant removal, the seroma was drained, and multiple suspicious masses were found on the left side. The cytology of the seroma fluid was negative and intraoperative frozen sections of the excised masses were inconclusive. A complete capsulectomy was conducted due to the suspicion of malignancy. Histological examination ultimately confirmed the diagnosis of BIA-ALCL. This case highlights the diagnostic challenges associated with this rare condition. Therefore, BIA-ALCL should always be considered in the differential diagnosis of breast implant-associated seroma.

Comparison of POLYTECH MESMO and Motiva Ergonomix Breast Implants With Focus on Displacement Issues: A Single Surgeon's Experience with 329 Patients

BACKGROUND

Nanotextured breast implants (classified as smooth implants by the latest ISO 14607:2018) have been described as possibly reducing major textured implant-related complications such as capsular contracture and breast implant-associated anaplastic large cell lymphoma. On the other hand, microtextured breast implants benefit from an optimal safety profile based on a much larger body of literature.

OBJECTIVES

The aim of this study was to directly compare the incidence of complications between Motiva Ergonomix (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) and POLYTECH MESMO (POLYTECH Health & Aesthetics GmbH, Dieburg, Germany) breast implants, especially regarding the displacement issues that might arise after breast augmentation.

METHODS

Consecutive patients who previously underwent surgery by the same physician for placement of Motiva Ergonomix and POLYTECH MESMO implants were included in this study. They were divided into 2 groups according to the type of implant. The onset of complications was assessed through survival analysis.

RESULTS

Data were collected from 329 patients, 185 (56.2%) with POLYTECH MESMO and 144 (43.8%) with Motiva Ergonomix implants. The median follow-up was 8 months for both groups. Of the 42 women (12.8%) who experienced at least one complication, 26 belonged to the Motiva Ergonomix subgroup (P = .013). The most represented complications during this period resulted from displacement issues, with a clear prevalence of bottoming out in the Motiva Ergonomix cohort: 15 cases vs 0 cases in the POLYTECH MESMO cohort (P < .001). For 7 patients, a reoperation was required, more frequently for patients with Motiva Ergonomix implants (4.2% vs 0.5%; P = .046).

CONCLUSIONS

POLYTECH MESMO devices provided a more favorable outcome. Motiva Ergonomix devices revealed a concerning incidence of displacement issues during the first postsurgery years, with no advantage over other major complications.

LEVEL OF EVIDENCE: 3

Breast Implants and the Risk of Squamous Cell Carcinoma of the Breast: A Systematic Literature Review and Epidemiologic Study

Squamous cell carcinoma may arise primarily from the breast parenchyma (PSCCB) or from the periprosthetic capsule in patients with breast implants (breast implant-associated squamous cell carcinoma [BIA-SCC]). A systematic literature review was performed to identify all PSCCB and BIA-SCC cases, and to estimate prevalence, incidence rate (IR), and risk. Studies up to November 2023 were searched on PubMed, Web of Science, Google Scholar, and Cochrane Library for predefined keywords. The numerator for PSCCB and BIA-SCC was the number of cases obtained from the literature; the denominator for PSCCB was the female population aged from 18 to 99, and the denominator for BIA-SCC was the population with breast implants. Overall, 219 papers were included, featuring 2250 PSCCB and 30 BIA-SCC cases. PSCCB prevalence was 2.0 per 100,000 (95% CI, 0.2:100,000 to 7.2:100,000) individuals, with a lifetime risk of 1:49,509 (95% CI, 0.2:10,000 to 5.6:10,000); and BIA-SCC prevalence was 0.61 per 100,000 (95% CI, 0.2:100,000 to 1.3:100,000), with a lifetime risk of 1:164,884 (95% CI, 0.2:100,000 to 5.6:100,000). The prevalence of BIA-SCC is 3.33 times lower than that of PSCCB, while the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is 3.84 times higher than that of primary breast ALCL. When comparing the BIA-SCC prevalence of 1:164,910 individuals with breast implants regardless of texture to the BIA-ALCL prevalence of 1:914 patients with textured implants, the BIA-SCC risk is 180 times lower than the BIA-ALCL risk. BIA-SCC occurs less frequently than PSCCB and considerably less than BIA-ALCL. The association between textured implants and BIA-SCC cases is relevant for patient education regarding uncommon and rare risks associated with breast implants, and ongoing vigilance, research, and strengthened reporting systems remain imperative.

BIA-ALCL and BIA-SCC: Updates on Clinical Features and Genetic Mutations for Latest Recommendations

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and Breast Implant-Associated Squamous Cell Carcinoma (BIA-SCC) are emerging neoplastic complications related to breast implants. While BIA-ALCL is often linked to macrotextured implants, current evidence does not suggest an implant-type association for BIA-SCC. Chronic inflammation and genetics have been hypothesized as key pathogenetic players, although for both conditions, the exact mechanisms and specific risks related to breast implants are yet to be established. While the genetic alterations in BIA-SCC are still unknown, JAK-STAT pathway activation has been outlined as a dominant signature of BIA-ALCL. Recent genetic investigation has uncovered various molecular players, including MEK-ERK, PI3K/AKT, CDK4-6, and PDL1. The clinical presentation of BIA-ALCL and BIA-SCC overlaps, including most commonly late seroma and breast swelling, warranting ultrasound and cytological examinations, which are the first recommended steps as part of the diagnostic work-up. While the role of mammography is still limited, MRI and CT-PET are recommended according to the clinical presentation and for disease staging. To date, the mainstay of treatment for BIA-ALCL and BIA-SCC is implant removal with en-bloc capsulectomy. Chemotherapy and radiation therapy have also been used for advanced-stage BIA-ALCL and BIA-SCC. In-depth characterization of the tumor genetics is key for the development of novel therapeutic strategies, especially for advanced stage BIA-ALCL and BIA-SCC, which show a more aggressive course and poor prognosis.

Safety, efficacy and health impact of electronic nicotine delivery systems (ENDS): an umbrella review protocol

BACKGROUND

Electronic nicotine delivery systems (ENDS), commonly known as e-cigarettes or vapes, have witnessed a rise in popularity, particularly among the youth. Although they were initially introduced as an alternative to traditional smoking, the design and function of ENDS vary. The potential health effects of ENDS, especially in comparison to traditional cigarettes, are a matter of ongoing debate. Given the increasing number of clinical studies and systematic reviews on this topic, there exists a demand for an umbrella review that offers a comprehensive assessment. The goal of this study is to perform an umbrella review of systematic reviews and meta-analyses to assess the safety, efficacy, health implications and potential gateway effect associated with ENDS.

METHODS AND ANALYSIS

This umbrella review will adhere to the Joanna Briggs Institute (JBI) framework and the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A planned literature search will be executed across databases such as OVID, PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science. The inclusion criteria are systematic reviews that discuss ENDS and e-liquids in the context of safety, efficacy and health outcomes. The exclusion criteria include narrative reviews, non-systematic reviews and studies not in English. Quality of the selected studies will be evaluated using the AMSTAR V.2 Scale. An overlap assessment will be done using the Corrected Covered Area, and data synthesis will be presented both narratively and in tabulated forms ETHICS AND DISSEMINATION: Ethics approval is not required for this study, as it does not involve the collection of original data. The results will be disseminated through peer-reviewed publication. The findings will offer crucial insights for stakeholders, policy-makers and the general public, underlining the health implications and the role of ENDS in tobacco cessation.

Reply: Comment on BIA-ALCL: Comparing the Risk Profiles of Smooth and Textured Breast Implants

Level of Evidence V 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 .

Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma in the United States: A Systematic Review

BACKGROUND

Although textured implants represent fewer than 10% of implants used in the United States, the country reports the highest incidence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

OBJECTIVES

The aim of this study was to perform a systematic literature review on US-based epidemiology to update knowledge on BIA-ALCL in the United States.

METHODS

Publications on US BIA-ALCL epidemiology were searched between September 2022 and March 2023 on MEDLINE (National Institutes of Health; Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), Web of Science (Clarivate, London, UK), and SCOPUS (Elsevier, Amsterdam, the Netherlands). The US numerator was obtained by averaging the FDA MAUDE database and the PSF PROFILE registry, while the denominator was estimated from chest X-rays, and included female transgender individuals. Prevalence and risk were assessed accordingly, but the incidence rate (IR) could not be updated due to the lack of available follow-up data.

RESULTS

Out of 987 identified manuscripts, 10 were included. The US prevalence of BIA-ALCL in the literature ranged from 1:300 to 1:500,000 and the IR from 4.5 per 10,000 to 31.1 per 100 million persons per year. A mean value of 453.5 BIA-ALCL cases was calculated. From a denominator of 4,264,618 individuals, which includes all breast implant surfaces, we calculated 414,521 individuals with textured implants, indicating a textured prevalence of 109.4 cases per 100,000 individuals and a risk of 1:913.

CONCLUSIONS

BIA-ALCL IR, prevalence, and risk has increased when calculated exclusively for patients with textured devices. Although US macrotextured implants were recalled by the FDA, these findings may influence the surveillance of existing patients and the use of macrotextured implants in other parts of the world where they remain widespread.

LEVEL OF EVIDENCE: 4

Implant replacement and anaplastic large cell lymphoma associated with breast implants: a quantitative analysis

Introduction

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma associated with breast reconstruction post-mastectomy or cosmetic-additive mammoplasty. The increasing use of implants for cosmetic purposes is expected to lead to an increase in BIA-ALCL cases. This study investigated the main characteristics of the disease and the factors predicting BIA-ALCL onset in patients with and without an implant replacement.

Methods

A quantitative analysis was performed by two independent researchers on cases extracted from 52 primary studies (case report, case series, and systematic review) published until April 2022 and searched in PubMed, Scopus, and Google-Scholar databases using "Breast-Implant" AND/OR "Associated" AND/OR "Anaplastic-Large-Cell-Lymphoma". The statistical significance was verified by Student's t-test for continuous variables, while Fisher's exact test was applied for qualitative variables. Cox model with time-dependent covariates was used to estimate BIA-ALCL's onset time. The Kaplan-Meier model allowed the estimation of the probability of survival after therapy according to breast implant exposure time.

Results

Overall, 232 patients with BIA-ALCL were extracted. The mean age at diagnosis was 55 years old, with a mean time to disease onset from the first implant of 10.3 years. The hazard of developing BIA-ALCL in a shorter time resulted significantly higher for patients not having an implant replacement (hazard ratio = 0.03; 95%CI: 0.005-0.19; p-value < 0.01). Patients with implant replacement were significantly older than patients without previous replacement at diagnosis, having a median time to diagnosis since the first implant of 13 years (7 years in patients without replacement); anyway, the median time to BIA-ALCL occurrence since the last implantation was equal to 5 years.

Discussion

Our findings suggest that, in BIA-ALCL patients, the implant substitution and/or capsulectomy may delay the disease's onset. However, the risk of reoccurrence in an earlier time should be considered in these patients. Moreover, the time to BIA-ALCL onset slightly increased with age. Selection bias, lack of awareness, misdiagnosis, and limited data availability could be identified as limits of our study. An implant replacement should be considered according to a risk stratification approach to delay the BIA-ALCL occurrence in asymptomatic patients, although a stricter follow-up after the implant substitution should be recommended.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023446726.

BIA-ALCL Epidemiology in an Aesthetic Breast Surgery Cohort of 1501 Patients

BACKGROUND

Epidemiologic studies on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) currently estimate the risk between 1:300 and 1:30,000, assessed mainly in large breast reconstruction populations.

OBJECTIVES

The aim of the study was to assess BIA-ALCL epidemiology in a cohort of patients who have received textured implants for cosmetic indications.

METHODS

In a prospective cohort observational study, 1501 patients who received a cosmetic breast augmentation between 2006 and 2016 were monitored, recording any implant-related complications, including BIA-ALCL. Cross-checking of clinical, pathology, and external records data identified cases. Prevalence, implant-specific prevalence (I-SP), incidence rate (IR), event-free time (EFT), and the Kaplan-Meier survival estimate were calculated.

RESULTS

All but 2 patients received macrotextured or microtextured devices bilaterally. Mean follow-up was 3.2 years (1 months to 16.4 years). Five BIA-ALCL cases were investigated. Prevalence was 1:300 patients; I-SP was 6.9 cases/1000 individuals/Allergan BIOCELL devices and 1.3 cases/1000 individuals/Mentor Siltex devices; and IR was 1.07 cases/1000 females/year. Mean (SD) EFT was 9.2 years.

CONCLUSIONS

When using a denominator based on a cohort of cosmetic patients, BIA-ALCL occurrence is higher than previously reported, particularly with macrotextured devices. Given the similar IRs in reconstructive and cosmetic cohorts, their even distribution could be consequent to underreporting due to poorer follow-up and lower awareness in the latter group. The genetic predisposition in the oncologic cohort reasonably affects the early onset more than the IR. The importance of accurate follow-up is confirmed. Stratification risks analysis can guide surgeons during patient counseling regarding the decision for prophylactic explantation.

LEVEL OF EVIDENCE: 4

Oncological Outcomes After Multidisciplinary Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

INTRODUCTION

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of non-Hodgkin lymphoma, associated with breast implant capsules. Despite improvements in our understanding of BIA-ALCL, communicating the prognosis to patients remains challenging due to limited long-term follow-up data. This has important implications for decision-making, including recommendations for subsequent reconstructive procedures. The aim of this study was to assess the longer-term oncological outcomes of patients receiving multidisciplinary treatment for BIA-ALCL.

METHODS

This was a retrospective cohort study of BIA-ALCL patients treated at a tertiary referral unit. The data are presented using simple descriptive statistics.

RESULTS

Between 2015 and 2022, 18 BIA-ALCL patients were treated at our institution. The median age at diagnosis was 48.5 (IQR 41-55) years. Ten patients developed BIA-ALCL after cosmetic breast augmentation, and 8 after breast reconstruction following mastectomy for cancer. All patients had a history of textured implant insertion. The median time from first implant surgery to diagnosis was 8.5 (IQR 7-12) years. All patients underwent en-bloc total capsulectomy with implant removal, and 2 received systemic therapy. Fifteen patients had Stage I (IA-IC) disease, 2 had Stage IIA and 1 Stage III BIA-ALCL, based on the TNM classification system. At a median follow-up of 45 (IQR 15-71) months, there were no episodes of local or systemic relapse or death.

CONCLUSIONS

Surgical management for BIA-ALCL is sufficient in early-stage disease, and associated with excellent oncological outcomes. This information is reassuring for patients when discussing recurrence risk.

Arbeitsgemeinschaft Gynäkologische Onkologie Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2023

Background

Each year the interdisciplinary Arbeitsgemeinschaft Gynäkologische Onkologie (AGO), German Gynecological Oncology Group Breast Committee on Diagnosis and Treatment of Breast Cancer provides updated state-of-the-art recommendations for early and metastatic breast cancer.

Summary

The updated evidence-based treatment recommendation for early and metastatic breast cancer has been released in March 2023.

Key Messages

This paper concisely captures the updated recommendations for early breast cancer chapter by chapter.

BIA-ALCL in patients with genetic predisposition for breast cancer: our experience and a review of the literature

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging non-Hodgkin's lymphoma that occurs exclusively in patients with breast implants. The estimated risk of developing BIA-ALCL from exposure to breast implants is largely based on approximations about patients at risk. There is a growing body of evidence regarding the presence of specific germline mutations in patients developing BIA-ALCL, rising interest regarding possible markers of genetic predisposition to this type of lymphoma. The present paper focuses attention on BIA-ALCL in women with a genetic predisposition for breast cancer. We report our experience at the European Institute of Oncology, Milan, Italy, describing a case of BIA-ALCL in a BRCA1 mutation carrier who developed BIA-ALCL 5 years after implant-based post mastectomy reconstruction. She was treated successfully with an en-bloc capsulectomy. Additionally, we review the available literature on inherited genetic factors predisposing to the development of BIA-ALCL. In patients with genetic predisposition to breast cancer (mainly TP53 and BRCA1/2 germline mutations), BIA-ALCL prevalence seems to be higher and time to onset appears to be shorter in comparison to the general population. These high-risk patients are already included in close follow-up programs allowing the diagnosis of early-stage BIA-ALCL. For this reason, we do not believe that a different approach should be followed for postoperative surveillance.

BIA-ALCL Epidemiological Findings From a Retrospective Study of 248 Cases Extracted From Relevant Case Reports and Series: A Systematic Review

BACKGROUND

The epidemiologic picture of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is unclear, with no high-level evidence, because only case reports and series are available.

OBJECTIVES

The aim of this study was to update knowledge on BIA-ALCL epidemiology by utilizing all available data through a systematic review of scientific literature.

METHODS

A search on PubMed, Scopus, and Web of Science was conducted between October 2021 and April 2022. Out of the 2799 available records, 114 pertinent articles were selected, featuring 248 BIA-ALCL cases which were retrospectively analyzed by means of descriptive statistics, incidence rate (IR), Kaplan-Meier survival curves, and Pearson correlation coefficients.

RESULTS

The United States, the Netherlands, Italy, and Australia were the countries reporting the most cases. The mean age at first implantation was 42 years, and the mean age at diagnosis was 53 years. Aesthetic indications were the reason for 52% of cases, and reconstruction for 48%; macrotextured surface was linked to 73.8% of cases, and seroma to 83%. Total follow-up was 492 months, and mean event-free time (EFT) to BIA-ALCL development was 129 months. The IR was 96 new cases/1,000 women per year after first implantation, and was directly correlated to the number of replacements. EFT was directly correlated to the number of replacements, implant rupture, and capsule contracture, and was inversely associated with patients' age at first implantation and to BRACA1/2 and TP53 mutations.

CONCLUSIONS

Macrotextured implant use in older patients and in patients with BRCA1/2 and TP53 mutations should be reconsidered, because this is associated with earlier disease onset. Implant replacement of asymptomatic, risk-stratified patients can be indicated due to its protective role against BIA-ALCL, reducing IR and risk, while increasing the EFT.

Study of the Effect of Different Breast Implant Surfaces on Capsule Formation and Host Inflammatory Response in an Animal Model

BACKGROUND

Breast implants are biomaterials eliciting a physiological and mandatory foreign body response.

OBJECTIVES

The authors designed an animal study to investigate the impact of different implant surfaces on the formation of the periprosthetic capsule, the inflammatory response, and the cellular composition.

METHODS

The authors implanted 1 scaled-down version of breast implants by different manufactures on 70 female Sprague Dawley rats. Animals were divided into 5 groups of 14 animals. Group A received a smooth implant (Ra ≈ 0.5 µm) according to the ISO 14607-2018 classification, Group B a smooth implant (Ra ≈ 3.2 µm), Group C a smooth implant (Ra ≈ 5 µm), Group D a macrotextured implant (Ra ≈ 62 µm), and Group E a macrotextured implant (Ra ≈ 75 µm). At 60 days, all animals received a magnetic resonance imaging (MRI), and 35 animals were killed and their capsules sent for histology (capsule thickness, inflammatory infiltrate) and immunohistochemistry analysis (cellular characterization). The remaining animals repeated the MRI at 120 days and were killed following the same protocol.

RESULTS

MRI showed a thinner capsule in the smooth implants (Groups A-C) at 60 days (P < .001) but not at 120 days (P = .039), confirmed with histology both at 60 days (P = .005) and 120 days (P < .001). Smooth implants (Groups A-C) presented a mild inflammatory response at 60 days that was maintained at 120 days and a high M2-Macrophage concentration (anti-inflammatory).

CONCLUSIONS

Our study confirms that smooth implants form a thinner capsule, inferior inflammatory infiltrate, and a cellular composition that indicates a mild host inflammatory response. A new host inflammatory response classification is elaborated classifying breast implants into mild, moderate, and high.

Breast Reconstruction after Breast Implant-Associated Anaplastic Large Cell Lymphoma Treatment: A Case Report and Literature Review

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma that occurs in patients with at least one prior textured breast implant. BIA-ALCL has a relatively good prognosis when treated promptly. However, data on the methods and timing of the reconstruction process are lacking. Herein, we report the first case of BIA-ALCL in Republic of Korea in a patient who underwent breast reconstruction using implants and an acellular dermal matrix (ADM). A 47-year-old female patient was diagnosed with BIA-ALCL stage IIA (T4N0M0) and underwent bilateral breast augmentation using textured breast implants. She then underwent removal of both breast implants, total bilateral capsulectomy, adjuvant chemotherapy, and radiotherapy. There was no evidence of recurrence at 28 months postoperatively; therefore, the patient wished to undergo breast reconstruction surgery. A smooth surface implant was used to consider the patient's desired breast volume and body mass index. The right breast was reconstructed with a smooth surface implant and an ADM in the prepectoral plane. Breast augmentation was performed on the left breast using a smooth surface implant. The patient was satisfied with the results and recovered fully with no complications.

Determining Breast Implant Prevalence: A Population Study of Italian Chest Radiographs

BACKGROUND

Current breast implant prevalence within the general population remains elusive. An accurate prevalence is critical to serve as the denominator for any assessment of breast implant-related complication. The purpose of this manuscript is to assess this prevalence in women aged 20-70 years in Italy.

MATERIALS AND METHODS

Eight reviewers, demonstrating a mean sensitivity of 87.0% and specificity of 97.0%, were recruited for retrospective identification of implants on chest radiographs from a tertiary academic hospital in a major urban setting. Three final reviewers were selected, and they assessed all eligible chest radiographs collected between January and December 2019. The hospital-based population was compared to epidemiological data at a local, regional and national level to demonstrate homogeneity of age structures using the phi correlation coefficient.

RESULTS

We identified 3,448 chest X-rays which yielded 140 implants, with an overall prevalence of 4.1% for women aged 20-70. Implants were bilateral in 76% of cases and unilateral in 24%. They were placed cosmetically in 47.1% cases and used for reconstruction in 52.9% cases. Phi correlation coefficient found no differences across hospital-based, local, regional and national populations.

CONCLUSION

A validated method was performed to estimate implant prevalence from an academic hospital in a major urban setting at 4.1% and was used to estimate national prevalence in Italy. The implications of this epidemiologic study may reach across national borders for improved understanding of breast implant epidemiology and in predicting the total number of patients within a given population that may be affected by device complications.

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 .

The Role of Microorganisms in the Development of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a variant of anaplastic large cell lymphoma (ALCL) associated with textured-surface silicone breast implants. Since first being described in 1997, over 1100 cases have been currently reported worldwide. A causal relationship between BIA-ALCL and textured implants has been established in epidemiological studies, but a multifactorial process is likely to be involved in the pathogenesis of BIA-ALCL. However, pathophysiologic mechanisms remain unclear. One of the hypotheses that could explain the link between textured implants and BIA-ALCL consists in the greater tendency of bacterial biofilm in colonizing the surface of textured implants compared to smooth implants, and the resulting chronic inflammation which, in predisposed individuals, may lead to tumorigenesis. This review summarizes the existing evidence on the role of micro-organisms and rough surface implants in the development of BIA-ALCL. It also provides insights into the most updated clinical practice knowledge about BIA-ALCL, from clinical presentation and investigation to treatment and outcomes.

Immediate Prepectoral Breast Reconstruction Using an ADM with Smooth Round Implants – A Prospective Observational Cohort Study

Prepectoral breast reconstruction using acellular dermal matrices (ADMs) is well established and used in candidates for nipple/skin-sparing mastectomies; it is based on many different matrices and a great variability in breast implant selection. We describe our experience and clinical outcomes using Braxon® ADMs and smooth round breast implants. Females aged 18-80 years who underwent mastectomies with immediate prepectoral reconstruction between April 2019 and April 2021 were prospectively included. Complications were classified as mastectomy-related (hematoma, necrosis) or reconstruction-related (seroma, infection, red breast syndrome). Binary logistic regression analysis was performed to assess correlation between complication rate and selected variables, which were analyzed per breast with Kruskal-Wallis H test. Fifty-eight patients (102 breasts) received 45 bilateral and 12 unilateral procedures. Drains collected 485.9 cc [range: 100-1260] and were removed 15.7 days [range: 6-29] postoperatively. We report 41 complications (40.2%): 33 mastectomy-related, 8 reconstruction-related. Reoperation occurred in 14 patients: 7 wound debridement and revisions under local anesthesia; and 7 explantation. Implant loss rate was 6.8%. Mastectomy and reconstruction complications were not correlated with any variable. In conclusion, we found prepectoral reconstruction with Braxon® ADMs and smooth round implants to be associated with acceptable complication rates that are not influenced by any patient- or surgery-related factors. Drainage volume is comparable to other breast implant reconstructive techniques, but drains are left in place for longer.

Breast lymphomas, breast implants and capsules The timeline of BIA-ALCL with respect to surgical consent: the UK perspective

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare type of T-Cell (non-Hodgkin's) lymphoma associated with the use of silicone breast implants. Recent widespread awareness has focused not only on the management of this condition but also in regards to potential litigation of surgeons, clinics, and breast implant manufacturers. Allegations of causation and inappropriate patient consent are being raised. The purpose of this article is to establish the timeline of relevant discoveries regarding this condition and associated implications with regards to appropriate informed patient consent.

Clinical recommendations for diagnosis and treatment according to current updated knowledge on BIA-ALCL

Shared strategies and correct information are essential to guide physicians in the management of such an uncommon disease as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). A systematic review of the literature was performed to collect the most relevant evidence on BIA-ALCL reported cases. A panel of multidisciplinary experts discussed the scientific evidence on BIA-ALCL, and updated consensus recommendations were developed through the Delphi process. The lastest reported Italian incidence of BIA-ALCL is 3.5 per 100.000 implanted patients (95% CI, 1.36 to 5.78), and the disease counts over 1216 cases worldwide as of June 2022. The most common presentation symptom is a late onset seroma followed by a palpable breast mass. In the event of a suspicious case, ultrasound-guided fine-needle aspiration should be the first step in evaluation, followed by cytologic and immunohistochemical examination. In patients with confirmed diagnosis of BIA-ALCL confined to the capsule, the en-bloc capsulectomy should be performed, followed by immediate autologous reconstruction, while delayed reconstruction applies for disseminate disease or radically unresectable tumor. Nevertheless, a multidisciplinary team approach is essential for the correct management of this pathology.

Mortality Rate in Breast Implant Surgery: Is an Additional Procedure Worthwhile to Mitigate BIA-ALCL Risk?

Background

Because of poor knowledge of risks and benefits, prophylactic explantation of high BIA-ALCL risk breast implant (BI) is not indicated. Several surgical risks have been associated with BI surgery, with mortality being the most frightening. Primary aim of this study is to assess mortality rate in patients undergoing breast implant surgery for aesthetic or reconstructive indication.

Materials and Methods

In this retrospective observational cohort study, Breast Implant Surgery Mortality rate (BISM) was calculated as the perioperative mortality rate among 99,690 patients who underwent BI surgery for oncologic and non-oncologic indications. Mean age at first implant placement (A1P), implant lifespan (IL), and women’s life expectancy (WLE) were obtained from a literature review and population database.

Results

BISM rate was 0, and mean A1P was 34 years for breast augmentation, and 50 years for breast reconstruction. Regardless of indication, overall mean A1P can be presumed to be 39 years, while mean BIL was estimated as 9 years and WLE as 85 years.

Conclusion

This study first showed that the BISM risk is 0. This information, and the knowledge that BI patients will undergo one or more revisional procedures if not explantation during their lifetime, may help surgeons in the decision-making process of a pre-emptive substitution or explant in patients at high risk of BIA-ALCL. Our recommendation is that patients with existing macrotextured implants do have a relative indication for explantation and total capsulectomy. The final decision should be shared between patient and surgeon following an evaluation of benefits, surgical risks and comorbidities.

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.

AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2022

Introduction

The AGO (Arbeitsgemeinschaft Gynäkologische Onkologie, German Gynecological Oncology Group) Task Force on Diagnosis and Treatment of Breast Cancer as an interdisciplinary team consists of specialists from gynecological oncology, pathology, diagnostic radiology, medical oncology, and radiation oncology with a special focus on breast cancer.

Methods

The updated evidence-based treatment recommendation 2022 for early breast cancer (EBC) and metastatic breast cancer of the AGO Task Force has been released.

Results and Conclusion

This paper captures the update of EBC.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL

BACKGROUND

Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL.

OBJECTIVES

The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance.

METHODS

A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement.

RESULTS

The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria.

CONCLUSIONS

BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

LEVEL OF EVIDENCE: 4

Invasive stage III breast implant-associated anaplastic large cell lymphoma successfully treated with incomplete resection

A woman with history of bilateral breast augmentation 15 years prior presented with right breast swelling, peri-implant effusion and a palpable inferomedial mass. Effusion aspiration demonstrated pleiomorphic cells consistent with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Further diagnostic studies confirmed stage III disease with a 4.7 cm right breast mass and fluorodeoxyglucose uptake in an internal mammary chain lymph node. The patient underwent surgery with incomplete resection due to invasion of the chest wall followed by chemotherapy and radiation therapy. BIA-ALCL typically presents as an indolent effusion, however advanced disease carries a worse prognosis. This case highlights successful treatment without recurrence past the one-year mark as well as the need for multidisciplinary management when dealing with advanced disease.

HISTORY OF BREAST IMPLANTS: BACK TO THE FUTURE

Modern breast implants are a staple of plastic surgery, finding uses in esthetic and reconstructive procedures. Their history began in the 1960s, with the first generation of smooth devices with thick silicone elastomer, thick silicone gel, and Dacron patches on the back. They presented hard consistency, high capsular contracture rates and the patches increased the risk of rupture. In the same decade, polyurethane coating of implants was implemented. A second generation was introduced in the 1970s with a thinner shell, less viscous gel filler and no patches, but increased silicone bleed-through and rupture rates. The third generation, in the early 1980s, featured implants with a thicker multilayered elastomer shell reinforced with silica to reduce rupture risk and prevent silicone bleed-through. A fourth generation from the late 1980s combined thick outer elastomer shells, more cohesive gel filler, and implemented for the first-time outer shell texturing. In the early 1990s, the fifth generation of devices pioneered an anatomical shape with highly cohesive form-stable gel filler and a rough outer shell surface. Surface texturing was hampered by the discovery of Breast Implant Associated-Anaplastic Large Cell Lymphoma and its link with textured devices. From the 2010s, we have the era of the sixth generation of implants, featuring innovations regarding the surface, with biomimetic surfaces, more resistant shells and variations in gel consistency. The road to innovation comprises setbacks such as the FDA moratorium in 1992, the PIP scandal, the Silimed CE mark temporary suspension and the FDA-requested voluntary recall of the Allergan BIOCELL implants.

Successful Treatment of a Patient With Breast Implant-Associated Anaplastic Large Cell Lymphoma With Local Residual Disease: A Case Report

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a hematological malignancy that may occur in patients undergoing breast implant placement. It more commonly behaves as a solid tumor, and the criterion standard treatment consists in an en bloc capsulectomy, which may not always be possible, according to the location of the implant. When local residual disease is present, BIA-ALCL must be treated with adjuvant therapies.

CASE PRESENTATION

We describe the case of a 76-year-old woman who underwent unilateral placement of a breast implant after breast cancer surgery in 2004 and developed BIA-ALCL in 2019. A multidisciplinary team managed her case, and en bloc capsulectomy was indicated for the treatment of the malignancy. The histological report showed focal neoplastic infiltration of the posterolateral margin of resection, further supported by positron emission tomography/computed tomography scan, which showed a local uptake in the right anterolateral chest wall. Therefore, adjuvant radiotherapy treatment was indicated for the management of local residual disease, alongside a stringent follow-up protocol. More than 1 year later, imaging scans show no signs of BIA-ALCL recurrence.

CONCLUSIONS

Local residual disease in BIA-ALCL is bound to be a progressively more common occurrence, as awareness of BIA-ALCL increases and more cases are diagnosed worldwide. Currently, there is no established consensus on a standard approach for the treatment for patients with a higher risk of local recurrence. Our experience describes the protocol we used to successfully manage a case of BIA-ALCL with incomplete surgical margins, which hopefully can serve colleagues treating patients with similar cases.

Deep Vision for Breast Cancer Classification and Segmentation

Simple Summary

Breast cancer misdiagnoses increase individual and system stressors as well as costs and result in increased morbidity and mortality. Digital mammography studies are typically about 80% sensitive and 90% specific. Improvement in classification of breast cancer imagery is possible using deep vision methods, and these methods may be further used to identify autonomously regions of interest most closely associated with anomalies to support clinician analysis. This research explores deep vision techniques for improving mammography classification and for identifying associated regions of interest. The findings from this research contribute to the future of automated assistive diagnoses of breast cancer and the isolation of regions of interest.

Abstract

(1) Background: Female breast cancer diagnoses odds have increased from 11:1 in 1975 to 8:1 today. Mammography false positive rates (FPR) are associated with overdiagnoses and overtreatment, while false negative rates (FNR) increase morbidity and mortality. (2) Methods: Deep vision supervised learning classifies 299 × 299 pixel de-noised mammography images as negative or non-negative using models built on 55,890 pre-processed training images and applied to 15,364 unseen test images. A small image representation from the fitted training model is returned to evaluate the portion of the loss function gradient with respect to the image that maximizes the classification probability. This gradient is then re-mapped back to the original images, highlighting the areas of the original image that are most influential for classification (perhaps masses or boundary areas). (3) Results: initial classification results were 97% accurate, 99% specific, and 83% sensitive. Gradient techniques for unsupervised region of interest mapping identified areas most associated with the classification results clearly on positive mammograms and might be used to support clinician analysis. (4) Conclusions: deep vision techniques hold promise for addressing the overdiagnoses and treatment, underdiagnoses, and automated region of interest identification on mammography.

Assessment of Silicone Particle Migration Among Women Undergoing Removal or Revision of Silicone Breast Implants in the Netherlands

IMPORTANCE

Silicone breast implants have been on the market for breast augmentation or breast reconstruction for approximately 60 years but may lead to medical complications, also called breast implant illness.

OBJECTIVE

To evaluate the existence of silicone gel bleed and migration over a long time period, including the period in which the newer cohesive silicone gel breast implants were used.

DESIGN, SETTING, AND PARTICIPANTS

In this single-center case series, capsule tissue and lymph node samples were collected from women who underwent removal or revision of silicone breast implants from January 1, 1986, to August 18, 2020, and data were extracted from the pathological reports and revision of the histology if data were missing. All tissues were examined using standard light microscopy, some extended with modified oil red O staining and energy-dispersive radiographic spectroscopy. A total of 365 women had capsular tissue removed, including 15 patients who also had lymph nodes removed, and 24 women had only lymph nodes removed. Data were analyzed from January to May 2021.

EXPOSURES

Silicone breast implants.

MAIN OUTCOMES AND MEASURES

The main outcome was presence or absence of silicones inside or outside the capsule. One-way analysis of variance was used to determine significance between groups.

RESULTS

Among a total of 389 women with silicone breast implants (mean [SD] age, 50.5 [11.2] years), 384 women (98.8%) had silicone particles present in the tissues, indicating silicone gel bleed. In 337 women (86.6%), silicone particles were observed outside the capsule (ie, in tissues surrounding the capsule and/or lymph nodes), indicating silicone migration. In 47 women (12.1%), silicone particles were only present within the capsule. In 5 women (1.2%), no silicone particles were detected in the tissues. Patients were divided into 2 groups, with 46 women who received cohesive silicone gel breast implants and 343 women who received either an older or a newer type of breast implant. There were no differences in silicone gel bleed or migration between groups (silicone detected outside or inside capsule: 44 women [95.7%] vs 340 women [99.1%]; P = .19).

CONCLUSIONS AND RELEVANCE

In this case series including women with noncohesive or cohesive silicone gel breast implants, silicone leakage occurred in 98.8% of women, indicating silicone gel bleed, and in 86.6% of women, migration of silicone particles outside the capsule was detected.