Rare Lymphoma Linked to Breast Implants

BIA-ALCL is a term that keeps appearing in recent news around breast implants, along with scary headlines like “Breast implants cause rare cancer”. In recent reports, the French authority ANSM has banned the use of textured implants, and suggested that surgeons should use smooth implants instead whilst the links between textured breast implants and BIA-ALCL are being investigated.

So, what 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 sub-type of non-Hodgkin lymphoma which has been found in association with 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 while it can occur in breast tissue, it isn’t breast cancer.

The  U.S. Food and Drug Administration (FDA) has reported at least 457 known cases of the disease, with nine related deaths since BIA-ALCL was first reported in 2011. Now, that is 457 known cases on a global scale out of an approximate 10 million women who’ve had breast implants for either cosmetic or reconstructive reasons.

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 which 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.

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 which might require reoperation, and thus, are often selected over smooth implants in specific patients.

While it’s difficult to discern the exact risk of BIA-ALCL, a recentcomprehensive study of all Australia and New Zealand’s BIA-ALCL cases that combined data from implant manufacturers revealed that highly macro-textured 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 3800, 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 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 breast multi-disciplinary team if BIA-ALCL is confirmed.

The Association of Plastic Reconstructive and Aesthetic Surgeons of South Africa 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 number of cases is very low and not all women who have textured breast 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-ALCLexists, 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.

Written by Dr Isabel Do Vale
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:

1. https://www.fda.gov/medicaldevices/productsandmedicalprocedures/implantsandprosthetics/breastimplants/ucm239995.htm
2. https://associationofbreastsurgery.org.uk/clinical/bia-alcl/
3. 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
4. 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
5. file://localhost/Users/isabel/Zotero/storage/SVHC3G6E/breast-implants-and-anaplastic-large-cell-lymphoma.html
6. https://www.theguardian.com/society/2018/nov/26/rare-cancer-linked-breast-implant-used-by-millions-women-lymphoma