Breast Implant Associated Cancer

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ACLC) has been in the news of late. Particularly given Allergan’s decision to recall their Biocell textured breast implants from the market in response to the known risk. This has stirred up quite a bit of discussion amongst plastic surgeons, women with cosmetic breast augmentation implants, and also women with breast reconstructive implants after therapeutic or prophylactic mastectomy.

Polyurethane "furry" implants - a type of textured implant

BIA-ALCL is a rare form of non-Hodgkin lymphoma (ie NOT breast cancer) and a distinct entity from standard Anaplastic Large Cell Lymphoma. The latter is not associated with breast implants, most commonly seen in children and young adults, and warrants more substantial treatment with a less favourable prognosis.

A few points about BIA-ALCL

• Associated with and develops in close approximation to breast implants

• Risk is estimated between 1 in 1000 and 1 in 14000 in women with implants

• Highest risk is with textured implants: Allergan macro textured implants which have recently been recalled from the market carry an estimated risk of 1 in 2000

• (This can be contrasted with an average woman’s lifetime risk of breast cancer - approximately 1 in 8)

• BIA-ALCL is essentially not seen in conjunction with smooth implants

• Most commonly shows up 3-14 years after implant surgery

• May affect one or both sides

• Probably due to chronic low grade infection and a subsequent “bio-film” which develops on the implant

Preventative Strategies

• Meticulous surgical technique / infection control at time of implant insertion

• Avoid peri-areolar incision where possible

• Consider smooth implant rather than textured implants

SMOOTH vs TEXTURED Implants

Testing for BIA-ALCL

• Routine screening for this rare disease in implant patients is not currently recommended

• Presents most commonly as swelling/fluid build-up around the implant, which can be confirmed and aspirated (sucked out) under ultrasound guidance

• Less commonly presents as a lump around the breast or axilla (armpit) which should be fully assessed with mammogram, ultrasound and/or breast MRI, as well as image guided biopsy

• Further testing may be recommended with CT and/or PET scan if a diagnosis of BIA-ALCL has been reached

Peri-implant fluid can be tested for BIA-ALCL

Treatment and Prognosis

• Confirmed cases warrant removal of the implants and surrounding capsules (both sides) under care of an appropriate surgeon and haematologist/oncologist

• Early detection and surgical treatment is usually curative

• Very rarely, BIA-ALCL may have spread elsewhere in the body

• At time of publication, there have been three deaths from BIA-ALCL in Australia

• (By contrast, about 3000 women succumb to breast cancer in Australia every year)

• At present and due to the low risk of BIA-ALCL, women with implants are not routinely recommended to remove/replacethem in the absence of a known problem – this can be discussed further with an appropriate surgeon

Discussion and a case study:

I’ve had a few patients attending to inquire about their situation. Perhaps they come to me rather than their/a plastic surgeon to receive an unbiased opinion of the risks involved and the options available. That said, a reputable, breast orientated plastic surgeon is likely to provide a similar opinion to mine.

One patient who comes to mind had undergone prophylactic mastectomies due to a moderate family history for breast cancer. She was well counselled by an experienced breast surgeon, and subsequently plastic surgeon. Prophylactic mastectomies along with textured implant reconstructions were performed.

Following recent media coverage, this patient became concerned she had merely swapped one set of risks (breast cancer) for another (BIA-ALCL) and was interested in her options. In short, I estimated this lady’s pre-surgery breast cancer risk at up to 1 in 4, her post-surgery breast cancer risk at approximately 1in 50, but with a new risk of BIA-ALCL at approximately 1 in 2000.

I counselled my patient about the risks involved and asked her to report any breast or armpit change – swelling, redness, lump – which should necessitate at very least breast ultrasound. I did not recommend any specific screening protocol nor that the implants necessarily warrant removal.

My patient was reassured and did not request anything further. She is aware however, conversion from implant reconstruction to autologous reconstruction (ie using her own tissue instead of an implant) is an option she can explore in the future if she really wishes.