MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference Report

Neoadjuvant Immunotherapy and De-escalation of Surgery in Locally Advanced Breast Implant-associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma diagnosed in patients with a history of breast implants. Most patients develop a periprosthetic effusion at early stages of disease while less common presentations include a palpable mass, severe capsular contracture, lymphadenopathy, or cutaneous erythema. Due to the complex nature of this disease, a multidisciplinary approach is necessary for optimal management, particularly in locally advanced disease or inoperable patients. We present the successful use of neoadjuvant therapeutic protocols in two cases of locally advanced BIA-ALCL. The first case was a 52-year-old patient with a left breast mass-like stage III disease who underwent combined targeted immunotherapy and chemotherapy (brentuximab vedotin [BV]-cyclophosphamide, doxorubicin, prednisone [CHP]). Following a complete radiological and metabolic response, the patient underwent bilateral implant removal, right total intact capsulectomy, left en bloc capsulectomy, and skin resection from the left inframammary fold in continuity with the capsule. The second case was a 65-year-old patient with right breast swelling and mass-like stage IIA disease who received targeted immunotherapy, BV. Following a complete metabolic response, she underwent bilateral implant removal and en bloc capsulectomy. A literature review and the reported cases suggest the effectiveness of targeted immunotherapy as monotherapy or in combination with chemotherapy in locally advanced BIA-ALCL in disease downstaging, surgical de-escalation, reduction of significant postoperative complications, and an acceptable tolerance profile. Although surgery is an essential part of treatment, the timing and type of intervention should be carefully planned, especially when primary, radical resection is uncertain.

Implants versus autologous tissue flaps for breast reconstruction following mastectomy

BACKGROUND

Women who have a mastectomy for breast cancer treatment or risk reduction may be offered different options for breast reconstruction, including use of implants or the woman's own tissue (autologous tissue flaps). The choice of technique depends on factors such as the woman's preferences, breast characteristics, preoperative imaging, comorbidities, smoking habits, prior chest or breast irradiation, and planned adjuvant therapies.

OBJECTIVES

To assess the effects of implants versus autologous tissue flaps for postmastectomy breast reconstruction on women's quality of life, satisfaction, and short- and long-term surgical complications.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registries in July 2022.

SELECTION CRITERIA

We included studies that compared implant-based reconstruction with autologous tissue-based reconstruction following mastectomy for breast cancer treatment or risk reduction. The minimum eligible sample size was 100 participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data using standard Cochrane procedures. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Thirty-five non-randomised studies with 57,555 participants met our inclusion criteria. There were nine prospective cohort studies and 26 retrospective cohort studies. We judged 26 studies at serious overall risk of bias and the remaining studies at moderate overall risk of bias. Some studies measured quality of life and satisfaction using the BREAST-Q (scale of 0 to 100, higher is better). Implants may reduce postoperative psychosocial well-being compared with autologous tissue flaps (mean difference (MD) -4.26 points, 95% confidence interval (CI) -4.91 to -3.61; I² = 0%; 6 studies, 3335 participants; low-certainty evidence). Implants may reduce or have little to no effect on postoperative physical well-being compared with autologous tissue flaps, but the evidence is very uncertain (MD -1.92 points, 95% CI -4.44 to 0.60; I² = 87%; 6 studies, 3335 participants; very low-certainty evidence). Implants may reduce postoperative sexual well-being compared with autologous reconstruction (MD -6.63 points, 95% CI -7.55 to -5.72; I² = 0; 6 studies, 3335 participants; low-certainty evidence). Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the breast, but the evidence is very uncertain (MD -8.17 points, 95% CI -11.41 to -4.92; I² = 90%; 6 studies, 3335 participants; very low-certainty evidence). This outcome refers to a woman's satisfaction with breast size, bra fit, appearance in the mirror (clothed or unclothed), and how the breast feels to touch. Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the reconstruction (MD -5.96 points, 95% CI -10.24 to -1.68; I² = 62%; 4 studies, 1196 participants; low-certainty evidence). This outcome refers to whether the aesthetic outcome has met the woman's expectations, the impact surgery has had on her life, and whether she thinks she made the right decision to have the reconstruction. Implants may reduce or have little to no effect on the risk of short-term complications compared with autologous tissue flaps, but the evidence is very uncertain (risk ratio (RR) 0.80, 95% CI 0.63 to 1.03; I² = 91%; 22 studies, 34,244 participants; very low-certainty evidence). Implants may increase long-term complications compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.56, 95% CI 1.09 to 2.22; I² = 94%; 17 studies, 26,930 participants; very low-certainty evidence). Implants may have little to no effect on the need for reintervention compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.23, 95% CI 0.91 to 1.68; I² = 93%; 15 studies, 14,171 participants; very low-certainty evidence). Implants may reduce the duration of surgery compared with autologous tissue flaps, but the evidence is very uncertain (MD -125.04 minutes, 95% CI -131.41 to -118.67; I² = 0; 2 studies, 836 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review show that autologous tissue-based reconstruction compared with implant-based reconstruction may improve participant-reported outcomes such as psychosocial well-being, sexual well-being, and satisfaction with the reconstruction. There is also very uncertain evidence to suggest that autologous tissue-based reconstruction increases satisfaction with the breast and reduces the risk of long-term complications compared with implants. Implant-based reconstruction may be a shorter procedure, but the evidence is very uncertain. Despite the growing demand for breast reconstruction, the best technique has not been adequately studied in randomised controlled trials (RCTs), and the evidence provided by non-randomised studies is often unsatisfactory. There is no superior breast reconstruction technique for all women. Future research should focus on the definition of decisional drivers to guide an evidence-based shared decision-making process in reconstructive breast surgery.

One-Stage Implant-Based Breast Reconstruction With Polyurethane-Coated Device: Standardized Assessment of Outcomes

BACKGROUND

Nipple-sparing mastectomies (NSMs) and implant-based breast reconstructions have evolved from 2-stage reconstructions with tissue expansion and implant exchange to direct-to-implant procedures. In this study, we tested safety and efficacy of polyurethane-based implants according to standard assessment tools.

OBJECTIVES

This study aimed to test safety and feasibility of polyurethane-coated implants with standardized assessment employing internationally acknowledged evaluation criteria.

METHODS

Cases of NSMs followed by breast reconstruction in 1 stage with immediate prepectoral polyurethane-coated implant placement were retrospectively reviewed. Preoperative characteristics of the population have been collected. Adherence to quality assurance criteria of the Association of Breast Surgery-British Association of Plastic Reconstructive and Aesthetic Surgeons was verified. Complications were assessed with the Clavien Dindo classification, modified for the breast. Rippling, implant rotation, and malposition were also evaluated.

RESULTS

Sixty-three consecutive patients underwent 74 NSMs and immediate breast reconstruction with micro polyurethane foam-coated anatomic implants. In 5 cases we had unplanned readmissions with return to the operating room under general anesthesia (6.7%) and implant loss within 3 months from breast reconstruction (5 implants, 6.7%). Postoperative complications according to Clavien Dindo were grade 1 in 6 cases (8.1%), grade 2 in 3 cases (4%), and 3b in 5 cases (6.7%).

CONCLUSIONS

Polyurethane-coated implants may prevent rotation and malposition and capsular contracture in the short term. Unplanned readmission rates and implant loss rates in the short term may be slightly higher.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, Chinese, and Taiwanese online here: https://doi.org/10.1093/asj/sjad301.

LEVEL OF EVIDENCE: 4

Thoraco-dorsal artery perforator flap for totally autologous primary breast reconstruction. Assessment of feasibility with standard reporting scales

This study reports on feasibility and applicability of totally autologous primary breast reconstructions based on TDAP flaps using a standard set of internationally approved reporting scales. We reviewed 15 cases in patients with a good donor area in the back not suitable for implant or free flaps reconstructions. Complications according to Clavien Dindo were: 1 Grade 1 (seroma in the back). The ABS-BAPRAS quality assurance indicators 10, 11, and 12 were entirely fulfilled. No pedicled flap loss occurred; no unplanned return to theatre and no unplanned readmission within 3 months. Breast-related quality of life values are reported at 3 months and one year in four domains of the BREAST Q v. 2.0 (breast reconstruction post-op questionnaire). At 1 year the mean Q-score for satisfaction with breast was 70.5, for psychosocial well-being was 72.3; for sexual well-being was 58.8; for physical well-being (chest wall) was 70.60. The TDAP based totally autologous breast reconstruction reported to be a feasible and safe alternative to implant based or free flaps reconstructions according to consolidate international outcome reporting measures.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies

BACKGROUND

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction.

METHODS

O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported.

RESULTS

Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m². Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7 g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis.

CONCLUSIONS

The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

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.

Breast Implanted-Associated Anaplastic Large Cell Lymphoma: A Case of Advanced Disease with Flow Cytometric Findings

Breast implant-associated anaplastic large cell lymphoma (breast implant-associated ALCL) is a recently described, distinct clinicopathological entity associated with macrotextured breast implants. The diagnostic workup of a patient suspected to have breast implant-associated ALCL includes cytological assessment of effusions and tissue biopsies of any masses or enlarged lymph nodes, with morphologic and immunophenotypic evaluation and possible flow cytometric and molecular testing. We report the case of a woman found to have breast implant-associated ALCL on fine needle aspirate and core biopsy, who on surgical resection, had extensive local disease with involvement of the resection margins and lymph nodes, requiring systemic treatment. We focus on the flow cytometric findings that identified a population of large cells on the CD30/side scatter dot plot and whose immunophenotype was consistent with breast implant-associated ALCL, highlighting the value of flow cytometry as an adjunct to morphological and immunophenotypic evaluation.

Conversion of Breast Implants into Natural Breast Reconstruction: Evaluating Lipofilled Mini Dorsi Flap

Background:

Autologous reconstruction techniques can provide a long-lasting natural breast reconstruction for patients. This study aimed to further investigate outcomes in the conversion of breast implant reconstruction into a lipofilled mini dorsi flap, focusing on reviewing its techniques, efficiency, and final results.

Methods:

Over 3 years, we performed a number of breast implant replacements via the lipofilled mini dorsi flap technique. The artificial implants were replaced to a deepithelized flap. The efficiency and tolerance of the technique were evaluated by the whole surgical team, and the achieved results were also analyzed by the patients in terms of postoperative pain, functional impact, and the softness of the reconstructed breast by comparing their prior condition to the lipofilled mini dorsi flap condition at least 9 months after operation.

Results:

Forty-seven consecutive operations were prospectively studied. The mean ± standard deviation volume of the removed implants was 348.66 ± 86.54 mL. The mean volume of fat injected was 284.13 ± 62.94 mL. The procedure’s average duration was 108.93 ± 17.65 minutes. The surgical team evaluated the results as very satisfactory in 32 cases (68.1%), satisfactory in 15 cases (31.9%), and moderately satisfactory or unsatisfactory in zero cases (0.0%). Eighteen patients (38.3%) evaluated their reconstruction as very good, while 20 patients (42.6%) considered their reconstruction as good, four (8.5%) as average, and zero (0.0%) as insufficient.

Conclusion:

According to our experience, the lipofilled mini dorsi flap is a simple, less invasive, and quick procedure to convert breast implants into natural breast reconstruction.

Smooth versus Textured Implants and Their Association with the Frequency of Capsular Contracture in Primary Breast Augmentation

BACKGROUND

Capsular contracture is the most frequent complication of breast implant augmentation. Although studies indicate that textured implants have a low incidence of contracture, they have been associated with anaplastic cell lymphoma, which influences the choice of surface. This study estimated and compared the annual capsular contracture rate of both smooth and textured implants in primary breast implants.

METHODS

Two hundred fifty-three patients (506 implants) were evaluated from January of 2017 to July of 2019; 42.2 percent of the implants were smooth and 57.8 percent were textured. The inframammary approach was used in the subfascial (55.3 percent) and submuscular (44.7 percent) pockets. The primary outcome was the appearance of capsular contracture (Baker grade II, III, and IV) within the first postoperative year.

RESULTS

Smooth implants had a higher capsular contracture rate at 1 year postoperatively compared with textured implants, although with borderline statistical significance (p = 0.06). Smooth surface breast implants in the subfascial plane had a 4-fold higher risk of contracture than those with a textured surface in the same plane (OR, 4.4; 95 percent confidence interval, 1.6 to 12.4). However, when placed in the submuscular plane, both textures had a similar contracture risk. The rate of contracture was similar after 2 years postoperatively (p = 0.21).

CONCLUSIONS

Using the inframammary approach and a standardized technique, there were no significant differences in the incidence of capsular contracture between the smooth and textured implants. In the subfascial plane, the contracture rate with smooth implants was higher than with textured implants. However, in the submuscular plane, there was no difference between the surfaces.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

Current trends in breast reconstruction

Breast reconstruction is nowadays a component of surgical treatment of breast cancer; therefore plastic surgeons are widely involved in breast reconstruction procedures either after mastectomy or after wide quadrantectomy. The aim is to reduce the distortion of breast shape and to improve the aesthetic outcome of the oncological procedure taking in account the symmetric appearance of the breasts. In post quadrantectomy reconstruction, breast reshaping with mammoplasty pattern could be applied in large and ptotic breast; otherwise flaps from lateral thoracic area could be used as well in post mastectomy reconstruction. In the case of mastectomy, the mastectomy procedure itself has become increasingly conservative, thus allowing an improvement in the aesthetic results of the reconstruction, especially if an implant is used. If adequate thickness of the mastectomy flap is preserved, the prosthesis can be placed in front of the muscle (prepectoral reconstruction), rather than behind the muscle (submuscular reconstruction). In prepectoral reconstruction the postoperative recovery is easier and less distressing for the patient and the postoperative appearance is more natural then in submuscular reconstruction. Autologous breast reconstruction implies the use of flaps (tissue taken from donor areas and used to reconstruct the breast area after appropriate molding), this technique allows to obtain a natural appearance of the breast with similar characteristics to the original one, and can be used in the radiated field. Different options of flaps include flaps from back area (local flaps) and flaps from distant areas (free flaps), basically from abdomen and inner tight.

Current Challenges in Breast Implantation

Breast implantation (BI) is the most common plastic surgery worldwide performed among women. Generally, BI is performed both in aesthetic and oncoplastic procedures. Recently, the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) or breast implant illness (BII) has aroused concerns. As a result, several countries, like Australia, Korea or the United Kingdom, introduced national registries dedicated to the safety and quality of BI surgeries. This narrative review aimed to focus on the clinical challenges, management and the current state of knowledge of BI. Both short and long-term outcomes of BI are determined by various alternatives and differences, which surgeons must consider during the planning and performing breast augmentation along with further complications or risk of reoperation. Proper preoperative decisions and aspects of surgical technique emerged to be equally important. The number of performed breast reconstructions is increasing, providing the finest aesthetic results and improving patient’s quality of life. Choice of prosthesis varies according to individual preferences and anatomical variables. A newly diagnosed cases of BIA-ALCL with lacking data on prevention, diagnosis, and treatment are placing it as a compelling medical challenge. Similarly, BII remains one of the most controversial subjects in reconstructive breast surgery due to unspecified diagnostic procedures, and recommendations.

BIA-ALCL diagnosis on CytoLyt fixed ThinPrep, cell block and immunohistochemistry

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is an emergent rare T cell non-Hodgkin lymphoma arising in association with a breast implant, particularly textured ones. Recent guidelines list cytopathological examination as the first essential step for diagnosis, routinely followed by CD30 immunohistochemistry (IHC) and flow cytometry (FC) for a T cell clone. The majority of BIA-ALCL literature regarding cytopathological evaluation describes morphology based on various preparation methods limited to cytospins and smears with the exception of at least one case report detailing cytomorphological and IHC findings on ThinPrep. This case report details initial diagnosis of BIA-ALCL rendered with CytoLyt prepared ThinPrep and cell block, including the specific antibodies used for IHC. The ThinPrep slide showed numerous singly dispersed large, atypical cells with abundant cytoplasm containing irregular nuclei with dispersed chromatin and prominent nucleoli in a background of macrophages, inflammatory cells and granular debris. TIA-1 and CD30 along with other T-cell markers, including specific antibodies, remains immunoreactive in tissue collected in CytoLyt solution. Cell size reduction, artifactual lymphoid cell aggregation and prominent nucleoli in benign and reactive conditions are among other ThinPrep cellular alterations pathologists should bear in mind.

Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative.

OBJECTIVES

In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease.

METHODS

This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement.

RESULTS

All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up.

CONCLUSIONS

In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.

Online Patient Resources for Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Readability Analysis

INTRODUCTION

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging issue facing the medical community. Government organizations such as the US Food and Drug Administration and specialty groups including the American Society of Plastic Surgeons have published online resources about BIA-ALCL for patients. Given the complexity of the diagnosis, it is important that patients can easily read these resources. In this study, we examined the readability levels of online BIA-ALCL patient resources using multiple verified reading scores.

METHODS

"BIA-ALCL" and "breast implant-associated anaplastic large cell lymphoma" were entered into 3 Internet search engines. The top 20 results for each were filtered by resource type and intended audience (physician vs patient). Published scientific articles, online database physician resources, and Web sites requiring subscriptions or fees were excluded. We then examined the readability of each with multiple verified reading scores, including the Flesch-Kincaid, Gunning-Fog, Coleman-Liau, Simplified Measure of Gobbledygook, and Automated Readability Index indices. Obtained data were analyzed using descriptive statistics and t test for independent samples.

RESULTS

Fifteen Web sites qualified for further analysis. For all texts, the average readability level was measured between 12 and 13 years of education on each readability index or approximately 18 to 19 years old. The Flesch-Kincaid Reading Ease average was 43.16 ±10.9 on a scale of 1 to 100, corresponding to a "difficult" designation. When compared by search criteria (spelled-out vs abbreviated), the results for the abbreviation "BIA-ALCL" had higher education requirements than those with the condition spelled out. However, these differences were not statistically significant. There was also great variation in word and sentence measurements. Twelve of the 15 Web sites contained more than 15% complex words, having more than 3 syllables, with breastcancer.org having the lowest (11%) and plasticsurgery.org the highest (20%).

DISCUSSION

Since the initial announcement in 2014 by the National Cancer Comprehensive Network, the medical community has begun educating ourselves and our patients about BIA-ALCL. Unfortunately, this study suggests that online patient resources on BIA-ALCL may be too complex for most readers, exceeding that of the average US resident (eighth grade) and Medicare beneficiary (fifth grade). Although the goal of learning more about BIA-ALCL and counseling patients appropriately remains paramount, we should continue to improve patient education materials given their vital role in healthcare decision-making.

Epstein-Barr Virus-associated Diffuse Large B-cell Lymphoma Identified in a Breast Implant Capsule: A New Breast Implant-Associated Lymphoma?

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma is a relatively uncommon T-cell lymphoma with about 900 reported cases worldwide to April 2020 according to the American Society of Plastic Surgeons Breast Implant-Associated Anaplastic Large Cell Lymphoma Physician Resources information.

CASE PRESENTATION

A 51-year old woman was found to have an Epstein-Barr virus-related diffuse large B-cell lymphoma (EBV-DLCBCL) in her left breast periimplant capsule at the time of a second revision breast implant surgery for recurrent severe capsular contractures following cosmetic breast augmentation 21 years previously. The first revision operation, 15 years earlier, had comprised simple implant exchange from smooth-saline to textured-silicone gel prostheses.

RESULTS

Histopathological and immunohistochemical analyses of the periimplant capsulectomy specimen confirmed a B cell lymphoma which was, in addition, positive for EBV-encoded RNA on in-situ hybridization. Staging investigations including positron emission tomography-computed tomography did not reveal any metastatic disease.

DISCUSSION AND CONCLUSION

Despite recommendations to the contrary (by 2 independent hematological malignancy multidisciplinary teams), the patient has declined explantation of her new breast implants choosing instead to be observed under a watch-and-wait protocol. She remains disease-free 2 years postdiagnosis. To date, a diffuse B-cell lymphoma has never been documented as arising in a breast implant capsule or in association with breast augmentation whether associated with EBV or not. This is the first such report in the world.

Biological and genetic landscape of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon form of non-Hodgkin lymphoma (cancer of the immune system) that can develop around breast implants. Breast implants are among the most commonly used medical devices for cosmetic or reconstructive purposes. In the past few years, the number of women with breast implants diagnosed with anaplastic large cell lymphoma (ALCL) has increased, and several studies have suggested a direct association between breast implants and an increased risk of this disease. Although it has been hypothesized that chronic stimulation of the immune system caused by implant materials and biofilms as well as a possible genetic predisposition play an important role in this disease, the cellular and molecular causes of BIA-ALCL are not fully understood. This review aims to describe the current understanding around the environmental and molecular drivers of BIA-ALCL as well as the genetic and chromosomal abnormalities identified in this disease to date.

The Use of Anatomic Implants in Aesthetic Breast Surgery

Anatomic implants were introduced in the late 1980s, gaining popularity through the 1990s and beyond. The moratorium on silicone meant that the use of theses devices was less diffuse in the US and has remained so. Fifth-generation devices had improved form stability with more aggressive texturization to enhance soft tissue interaction. The ability to vary height, width and projection independently creates much versatility in their use for complex anatomical situations producing natural results. The impact of BIA-ALCL has had a significant impact on their use.

Primary Breast Augmentation with Autologous Fat Grafting Alone: Evaluation of Patient Satisfaction Using the BREAST-Q

BACKGROUND

Autologous fat grafting (AFG) for primary aesthetic breast augmentation has grown in popularity over recent years but patient satisfaction has never been objectively evaluated.

OBJECTIVES

The aim of the present study was to use the standardized BREAST-Q questionnaire to evaluate satisfaction in patients who had received primary aesthetic breast augmentation with AFG alone.

METHODS

All recipients of primary aesthetic breast augmentation by AFG performed between 2013 and 2017 in our plastic surgery department were included. The primary endpoint was assessment of patient satisfaction with the standardized breast augmentation BREAST-Q questionnaire. Three additional questionnaires were used to evaluate patient and surgeon satisfaction.

RESULTS

In total, 42 patients (84 breasts) underwent breast augmentation by AFG. Mean patient age was 34 years (range, 23-53 years). The mean volume of reinjected fat was 312.2 mL per breast (range, 130-480 mL). We observed significant improvement in all BREAST-Q postoperative items (excluding physical well-being) with a mean increase of 39 points (95% confidence interval: 28.97, 49.03; P < 0.001) regarding patient satisfaction with breasts. Overall, 82% of patients were satisfied with the result of their liposuction. Minor complications were encountered in 6 of our patients (14%).

CONCLUSIONS

Breast augmentation by AFG enhances patient satisfaction as measured by the BREAST-Q. This procedure has a high satisfaction rate and improves quality of life. Breast augmentation by AFG is a valid surgical option for moderate breast augmentation but is not an alternative to implants in large breast augmentation.

Level of Evidence: 4.

Is Breast Implant-Associated Anaplastic Large Cell Lymphoma Better Classified as a Lymphoproliferative Disorder and How Surgeons Reduce Risk?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a complex topic with evolving classification and etiology. Commonalities between BIA-ALCL and lymphoproliferative disorders exist, suggesting that BIA-ALCL may be better represented on a spectrum of disease from benign effusion to malignant metastatic lymphoma. Meticulous sterile surgical technique, involving the use of betadine-containing irrigation, should be used to decrease the biological burden introduced into the surgical field and possibly prevent future incidences of BIA-ALCL.

Advances and current concepts in reconstructive surgery for breast cancer

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.

Why Do We Need Anatomical Implants? the Science and Rationale for Maintaining Their Availability and Use in Breast Surgery

The choice between anatomical and round implants is an important decision in breast augmentation surgery; however, both have their place and the decision between them that should be made on a patient-by-patient basis, taking into account the patient's desires, anatomy, and surgical history. In some individuals, there are clear indications for using either anatomical or round devices, and there is good evidence that aesthetic outcomes are better with anatomical implants in some instances. When both types are an option, anatomical devices may offer increased flexibility and, despite a longer learning curve needed to properly manage them, they are associated with positive long-term outcomes and high levels of patient satisfaction. Concerns about implant rotation can be minimized with proper patient selection and surgical technique, and the overall complication rate may favor anatomical over round devices in appropriate patients. Breast implant-associated anaplastic large-cell lymphoma is an important issue, and while rare, it must be considered in the context of the entire patient risk profile. Both anatomical and round implants remain key elements of a complete surgical toolbox in breast augmentation. 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.

Breast implant-associated anaplastic large cell lymphoma: emotional impact and guidelines for psychological support

PURPOSE

During the last two decades, the number of breast implants used in aesthetic, oncologic, and risk-reducing surgery has increased substantially mainly due to the improvement and confirmed safety of these devices. Since the identification of the first case of anaplastic large cell lymphoma associated with a breast implant (BIA-ALCL) 20 years ago, there has been an increase in the number of reports of this very rare disease, demonstrating a clear association with breast implants. While the majority of cases are localized and cured by implant removal and full capsulectomy, a small percentage require chemotherapy and the mortality rate is very low. Nevertheless, the evidence linking BIA-ALCL to implant surface texturing has raised concerns about the long-term safety of these devices resulting in patient and regulatory authority concerns globally.

METHODS AND RESULTS

In this commentary, we report the current debate on BIA-ALCL and the main European government's actions, with a special focus on the emotional impact that media coverage has on cancer patients. We comment the emotional impact of such risk for patients with breast implant, the hard process of patient's acceptance for mastectomy and reconstructive surgery, and how this is an essential part of recovery and return to the normal living for many women.

CONCLUSION

We conclude by providing guidelines for patient-physician communication and patients' psychological support on this topic of delicate actuality. Our contribution aims at guiding the medical community in managing risk communication about BIA-ALCL with a multidisciplinary approach, according to the most recently available published evidence.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and the Textured Breast Implant Crisis

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell, CD-30+/ALK lymphoma. Late (9 years) periprosthetic fluid (seroma) is the most common presentation (90% of the cases). A combination of textured breast implant, bacterial contamination, and genetic predisposition seems to be necessary for BIA-ALCL to occur. There are 35 million patients with implants in the world, and at the present moment, 573 cases of BIA-ALCL have been reported. The risk of developing BIA-ALCL in Australia varies from 1:2832 to 1:86,029, with texture grades 3 and 4 seeming to pose a higher risk than grades 2 and 1. NCCN has established guidelines for diagnosis and treatment, and early diagnosis is the key to cure. At an early stage and for the vast majority of patients, the treatment consists of capsulectomy and implant removal. However, at stages II to IV, a systemic treatment is warranted, including chemotherapy, radiotherapy (residual disease), and brentuximab vedotin. The majority of patients can be cured, and complete capsular removal is the most important factor. So far, 33 patients have died from BIA-ALCL worldwide, with deaths related to delay in diagnosis and treatment. Textured implants have been in the midst of the current implant crisis, and Biocell was recalled worldwide after the latest FDA update on the disease. At the present moment, no medical society or regulatory agency has recommended implant removal. It is about time that we start robust breast implant registries to determine risks. Besides, based on scientific criteria, we must consider all the benefits and risks associated with the available breast devices.Level of Evidence III 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.

Breast implant-associated anaplastic large cell lymphoma and effusions: A review with emphasis on the role of cytopathology

Breast implants are surgically implanted by the hundreds of thousands every year worldwide for reconstructive or aesthetic purposes. Complications related to breast implants include early and late effusions that are often submitted for cytopathological analysis, particularly to exclude the possibility of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a rare disease that generally follows an indolent clinical course, although it is becoming clearer that a subset of patients with adverse features have a poorer prognosis. Since a late-onset breast implant-associated effusion is the most common initial presentation of BIA-ALCL, cytopathological analysis of these effusions is considered the cornerstone and gold standard for rapid, efficient, reliable diagnosis and is critical for appropriate management and treatment. The National Comprehensive Cancer Network recently published clinical guidelines for the diagnosis and management of BIA-ALCL and stresses the essential role of cytopathological analysis, although it remains a matter of debate if all seromas should undergo immunocytochemistry or flow cytometry, particularly for assessment of expression of CD30 irrespective of morphological appearance on cytology. Herein, we review the current knowledge on BIA-ALCL, review the key cytological findings of reactive and malignant effusions related to breast implants, and present a comprehensive cytopathological workup with the presence of atypical cells as the key and pivotal element triggering further ancillary studies. We believe this approach will ensure appropriate and cost-effective management of effusion specimens from breast implants.

US FDA Breast Implant Postapproval Studies: Long-term Outcomes in 99,993 Patients

OBJECTIVE

To analyze the long-term safety and efficacy outcomes of patients with breast implants.

SUMMARY BACKGROUND DATA

Research is ongoing regarding the safety of silicone breast implants. Despite the number of patients with breast implants followed by United States Food and Drug Administration large postapproval studies (LPAS), this database has not been thoroughly analyzed or reported.

METHODS

This is a multicentered, cohort study. LPAS prospectively monitor long-term implant-related outcomes and systemic harms for silicone/saline implants from 2 manufacturers (Allergan and Mentor) placed for primary/revision augmentation/reconstruction. Systemic harms, self-harm, and reproductive outcomes are compared with normative data. Implant-related complications are analyzed by implant composition and operative indication in the short and long terms.

RESULTS

LPAS data includes 99,993 patients, 56% of implants were silicone for primary augmentation. Long-term magnetic resonance imaging surveillance is under 5%. Compared with normative data, silicone implants are associated with higher rates of Sjogren syndrome (Standardized incidence ratio [SIR]8.14), scleroderma (SIR 7.00), rheumatoid arthritis (SIR5.96), stillbirth (SIR4.50), and melanoma (SIR3.71). One case of BI-ALCL is reported. There is no association with suicide. In the short term, rupture is higher for saline (2.5% vs. 0.5%, P < 0.001), and capsular contracture higher for silicone (5.0% vs. 2.8%, P < 0.001). At 7 years, reoperation rate is 11.7% for primary augmentation, and 25% for primary/revision reconstruction. Capsular contracture (III/IV) occurs in 7.2% of primary augmentations, 12.7% primary reconstructions, and is the most common reason for reoperation among augmentations.

CONCLUSIONS

This is the largest study of breast implant outcomes. Silicone implants are associated with an increased risk of certain rare harms; associations need to be further analyzed with patient-level data to provide conclusive evidence. Long-term safety and implant-related outcomes should inform patient and surgeon decision-making when selecting implants.

Breast Implant Surfaces and Their Impact on Current Practices: Where We Are Now and Where Are We Going?

Most commercially available breast implants feature some degree of elastomer surface modifications to increase surface roughness, in part because several clinical series have demonstrated positive outcomes from texturizing. However, the literature shows that textured implants support higher rates of bacterial growth, and there is a clear association between increased bacterial contamination and host response in vivo, such as capsular contracture. Furthermore, the infectious theory related to bacterial contamination has recently been described as a potential cause in the etiology of anaplastic large-cell lymphoma. Recent research has focused on the physiology of breast implant surfaces advances and how they interact with the body, creating new surface technologies which have the potential to affect all aspects of breast surgery. Understanding how surface properties affect inflammatory cell response will be essential in designing implants that can provide an esthetic solution while also minimizing long-term clinical complications. This special topic highlights the current knowledge on silicone implant surfaces, as well as innovations that have shaped and will continue to change the silicone breast implant industry in the future. It also provides an overview of the principal surfaces that exist and may find clinical applications in esthetic and reconstructive breast surgery. As additional advances emerge, objective tools will be required to evaluate the different surfaces available on the market, along with the long-term efficacy of new technologies.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): an overview of presentation and pathogenesis and guidelines for pathological diagnosis and management

AIMS

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon complication associated largely with textured implants. It is important that the symptoms associated with BIA-ALCL are recognised and that robust pathways are in place to establish the diagnosis. The aim of this paper is to review what is known of the incidence of the disease, current thoughts on pathogenesis, patterns of presentation and pathological features to provide standard guidelines for its diagnosis.

METHODS AND RESULTS

Systematic review of the literature via PubMed covering cases series, modes of presentation, cytological, histological and immunohistochemical features and disease outcome. Since 1997, 518 cases throughout 25 countries have been registered on the American Society of Plastic Surgeons PROFILE registry, with an estimated risk for women with an implant of one to three per million per year. It most frequently presents as a late-onset accumulation of seroma fluid, sometimes as a mass lesion. The neoplastic cells are highly atypical, consistently strongly positive for CD30, with 43-90% also positive for EMA, and all are ALK-negative. Behaviour is best predicted using a staging system for solid tumours.

CONCLUSION

BIA-ALCL is a rare but important complication of breast implants. While characterised by CD30-positive neoplastic cells this must be interpreted with care, and we provide pathological guidelines for the robust diagnosis of this lesion as well as the most appropriate staging system and management strategies. Finally, in order to generate more accurate data on incidence, we recommend mechanisms for the routine central reporting of all cases.

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Why Must We Learn About It?

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, breast implant-associated T-cell lymphoma in which CD30 is expressed and anaplastic lymphoma kinase (ALK) expression is absent. However, despite the low risk of developing the disease, more information on BIA-ALCL is necessary, because the number of women with breast implants has been increasing worldwide; Brazil is one of the main markets for this type of implant. The objectives of this review are to clarify the issue of BIA-ALCL occurrence after risk-reducing mastectomy, to show the importance of this disease, and to raise awareness among the medical community about this rare pathologic condition. In 2016, BIA-ALCL was included by WHO in the new classification of lymphomas, and this demonstrates the attention that medical entities should give to this disease. Thus, awareness about BIA-ALCL must be broadened among the medical societies and regulatory authorities, both to foster better approaches to this disease, which should be evaluated in a multidisciplinary manner, and to provide better knowledge among health care professionals and the target population about the use of implants.

Microbial detection in seroma fluid preceding the diagnosis of breast implant-associated anaplastic large cell lymphoma: a case report and review of the literature

The Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) represents a topic of great concern. We report the case of a patient with late-onset seroma, who was initially diagnosed with an implant-related infection of the breast due to microbial detection in the seroma fluid, thus delaying the diagnosis of BIA-ALCL.

Transcriptional analysis distinguishes breast implant-associated anaplastic large cell lymphoma from other peripheral T-cell lymphomas

Breast implant-associated anaplastic large cell lymphoma is a new provisional entity in the revised World Health Organization classification of lymphoid malignancies, the pathogenesis and cell of origin of which are still unknown. We performed gene expression profiling of microdissected breast implant-associated anaplastic large cell lymphoma samples and compared their transcriptional profiles with those previously obtained from normal T-cells and other peripheral T-cell lymphomas and validated expression of selected markers by immunohistochemistry. Our results indicate that most breast implant-associated anaplastic large cell lymphomas exhibit an activated CD4+ memory T-cell phenotype, which is associated with CD25 and FoxP3 expression. Gene ontology analyses revealed upregulation of genes involved in cell motility programs (e.g., CCR6, MET, HGF, CXCL14) in breast implant-associated anaplastic large cell lymphomas compared to normal CD4+ T-cells and upregulation of genes involved in myeloid cell differentiation (e.g., PPARg, JAK2, SPI-1, GAB2) and viral gene transcription (e.g., RPS10, RPL17, RPS29, RPL18A) compared to other types of peripheral T-cell lymphomas. Gene set enrichment analyses also revealed shared features between the molecular profiles of breast implant-associated anaplastic large cell lymphomas and other types of anaplastic large cell lymphomas, including downregulation of T-cell receptor signaling and STAT3 activation. Our findings provide novel insights into the biology of this rare disease and further evidence that breast implant-associated anaplastic large cell lymphoma represents a distinct peripheral T-cell lymphoma entity.