Rare Lymphoma Linked to Breast Implants

What you need to know

BIA-ALCL is a term that keeps appearing in recent news regarding breast implants and its association with an atypical lymphoma, with scary headlines shouting: “Breast implants cause rare cancer”.

But what exactly is BIA- ALCL? Should you be worried about it and is it avoidable?

Dr Isabel Do Vale explains:

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare subtype of non-Hodgkin lymphoma that has been found linked to breast implants in a small number of cases worldwide. In other words, it is a cancer that affects immune system cells, specifically T-cells. The disease can occur in multiple parts of the body, including the lymph nodes and skin – yet it must be noted that while it can occur in breast tissue, it is not, in fact, breast cancer.

BIA-ALCL: Cause and effect

Although the exact causes of BIA-ALCL are unknown, it is thought to be related to bacterial biofilm within the capsule surrounding a textured implant, which, over a prolonged time period, results in BIA-ALCL in some patients (a genetic predisposition may also exist).

Current theories suggest that bacterial antigens result in a sustained T-cell immune response and chronic inflammation that may lay dormant for years, until BIA-ALCL develops and becomes symptomatic. As such, plastic surgeons pay special attention and take specific steps to minimise the risk of bacterial contamination. It is likely that there are other factors that also contribute to the development of BIA-ALCL, with extensive research still ongoing.

Fortunately, BIA-ALCL is treatable if caught early. Women who undergo surgical removal of the capsule and implant can make a full recovery. But if it’s left untreated on the other hand, it can spread and become life-threatening.

Recent rulings on textured implant use

Now, while the French authority ANSM has banned the use of textured implants (and suggested that surgeons use smooth implants instead while the links between textured breast implants and BIA-ALCL are being investigated), the US FDA has, just recently, ruled that based on current available data, it does not believe there is enough evidence to ban textured implants. It will, therefore, allow the continued use of textured implants from Allergan, Mentor and Sientra.

Is the risk equal for all kinds of breast implants?

To date, all known cases of BIA- ALCL have been related to textured and polyurethane breast implants. There are a number of different textured implants available, each with a different risk of BIA-ALCL. Textured implants were developed to reduce movement and rotation of the implants, specifically for shaped implants where movement could result in visible asymmetry of the breasts. Textured implants also have other benefits in reducing certain complications that might require reoperation and are, therefore, often selected over smooth implants in specific patients.

While it’s difficult to discern the exact risk of BIA-ALCL, a recent comprehensive study of all Australia and New Zealand’s BIA-ALCL cases that combined data from implant manufacturers revealed that highly macrotextured implants carry a higher risk compared with that of less aggressively textured implants. Moreover, it is currently accepted that the risk of BIA-ALCL in woman who have/had textured breast implants is between 1 in 3 800 to 1 in 50 000, depending on the specific type of textured implant used. No cases to date are reported with the sole use of smooth implants.

To put this risk into perspective, it is important to note that the risk of breast cancer is 1 in 8 for all women, regardless of whether or not they have implants. Furthermore, in terms of silicone- versus saline-filled implants, there is little difference in the risks of developing BIA-ALCL, as the disease is related to the implant shell and not

The FDA has reported at least 457 known cases of BIA-ALCL, with nine related deaths since it was first reported in 2011. This is 457 known cases on a global scale out of an approximate 10 million women who’ve had breast implants the fill.

What are the signs or symptoms?

Usually, the first sign of BIA- ALCL is swelling of one breast compared to the other, signifying a build-up of fluid (seroma) between the implant surface and the capsule. This may be accompanied by irritation or inflammation of the breast. Occasionally, BIA-ALCL may be associated with localised capsule thickening, or a small lump in the breast or armpit (although the capsule commonly appears entirely normal except for the seroma). And while the disease often appears years after implant placement (with studies showing that patients tend to present on average eight years after implant placement), it may also occur as early as one year post surgery.

Another point that needs to be remembered is that unilateral breast swelling or a late seroma is not a definitive indication of BIA-ALCL, as it may also be a result of infection, trauma, haematoma, implant rupture, double capsule, breast cancer and idiopathic causes. These factors are indeed far more common than BIA-ALCL, but they do still require treatment, so patients should be on the look-out for any changes around the surgical area and consult with their plastic surgeon immediately. Any patient with non-resolving peri-implant fluid should be further evaluated by their plastic surgeon, who will request an ultrasound and aspiration of fluid for histological analysis, perform an MRI scan and then involve an experienced multidisciplinary breast team if BIA-ALCL is confirmed.

The Association of Plastic Reconstructive and Aesthetic Surgeons of South Africa (APRASSA) is affiliated to international bodies investigating, registering and following BIA-ALCL cases and research. Any new cases of BIA-ALCL should be reported to APRASSA by the treating plastic surgeon.

Should breast implants be removed just in case?

If you already have breast implants, there is no need to panic. The total implants will develop BIA-ALCL. BIA-ALCL is a condition that can be identified and treated. Regulatory authorities worldwide (including the French ANSM) are currently not recommending that asymptomatic women with breast implants have their implants removed due to the overall low risk of BIA-ALCL, and the fact that removing implants from women who have no symptoms places them at unnecessary risks for other surgical complications. It is not possible to predict which women with textured implants might develop BIA-ALCL.

It is advisable though, that women with breast implants have regular annual check-ups and a breast ultrasound (especially if you haven’t been checked recently).

What about people who want to get breast implants?

BIA-ALCL is a very rare disease so women who are considering breast implants simply need to be aware of the risks and benefits of textured and smooth implants.

They need to be told that BIA-ALCL exists, what the symptoms are, and what to do about it. Patients should consult with an APRASSA member plastic surgeon who will cover all these points, as well as explain which implant type is best suited to your reconstructive or cosmetic requirements, body shape and soft-tissue covering.

It is additionally important to know and keep a record of which implants you have, and to have regular check-ups to screen for implant- related complications, breast cancer as well as BIA-ALCL.

BIA-ALCL can be identified and treated. It is advisable that women with breast implants have regular annual check-ups and abreast ultrasound (especially if they haven’t been checked recently).

This article was written by Dr Isabel Do Vale and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine June 2019 Edition (Issue 30).

References:

https://www.fda.gov/medicaldevices/ productsandmedicalprocedures/implantsandprosthetics/breastimplants/ ucm239995.htm https://associationofbreastsurgery.org.uk/clinical/ bia-alcl/

Loch-Wilson, A et al. Breast Implant–Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk. Plast Reconstr Surg. 2017 Oct;140(4):645-654

Arianna Di Napoli. Achieving Reliable Diagnosis in Late Breast Implant Seromas: From Reactive to Anaplastic Large Cell Lymphoma. Plast Reconstr Surg. 2019 Mar; 143(3S):15S-22S

file://localhost/Users/isabel/Zotero/storage/SVHC3G6E/breast-implants-and-anaplastic-large-cell-lymphoma.html

https://www.theguardian.com/society/2018/nov/26/rare-cancer-linked-breast-implant-used- by-millions-women-lymphoma