Awareness of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) began to rise in 2011 when the FDA released a report on some of these cases. Since then, several studies confirmed this interlink with a recent Dutch population-based, case-control study adding crucial insights into it.
ALCL is a type of non-Hodgkin lymphoma which involves T-lymphocytes. This malignancy develops not within the breast tissue itself, but within the capsule which is formed around the implant. It can manifest as a seroma or a discrete mass originating from this fibrous capsule. The majority of patients present in stage I of the disease when the malignancy is confined to capsule only and capsulectomy alone is sufficient for proper management. Stages II+ imply more aggressive strategy with obligatory adjunctive chemotherapy.
Although the exact etiology of association of breast implants with ALCL is unknown, it is hypothesized that inflammatory reaction is the key event which leads to malignization. Biofilms formed on the surface of textured implants by bacteria might be the reason for such a reaction, but there is no strong evidence to support this theory.
The study by Dr. de Boer and colleagues is a case-control study based on the data of the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands which is a Dutch national registry that receives data from all 46 pathology laboratories in the Netherlands. The investigators identified 782 cases of a histologically or cytologically proven breast non-Hodgkin lymphoma in the period from 1990 to 2016. Among the pooled cases, 47 primary breast-ALCL cases were found. 146 patients with other types of breast non-Hodgkin lymphoma were taken as controls after the researchers received necessary information from the treating physicians of both groups.
Among 47 women with primary breast-ALCL, 32 had ipsilateral breast implants compared to 1 among 146 women in the control group. 82% of BIA-ALCL cases were associated with the macro-textured implants suggesting a stronger association with ALCL compared to microtextured ones.
The investigators also report risks of BIA-ALCL based on their study. The absolute risk of BIA-ALCL was found to increase with age: 1 in 35 000 at age 50 years, 1 in 12 000 at 70 years, and 1 in 7000 at 75 years. The cumulative risk shared this tendency: it was 29 per million at 50 years and 82 per million at 70 years. Such association might be attributed to the duration of implant exposure over time rather than to chronological age per se.
In the conclusion, the authors stress on that although there is a considerably increased relative risk of BIA-ALCL, the absolute risk remains extremely low.
In 2011, the FDA published a report in which summarized findings from 34 unique case studies and several small observational studies regarding the possible association between breast implants and ALCL. Since then, FDA releases an annual update on the BIA-ALCL in which discusses the most recent data on this condition.
With the available data, it is certain that textured implants possess a higher risk than smooth ones with only 7% of all BIA-ALCL reported to occur in association with smooth implants. Women with textured implants have a lifetime risk of BIA-ALCL of approximately 1:3817 - 1:30,000 according to different studies.
The discussed Dutch study confirms the stronger risk of textured implants regarding BIA-ALCL. Furthermore, it shows an increase of the risk with age. Further studies can be done to see if this age dependence is associated with the aging changes in the immune system or with the period of exposure to the implants. Dutch researchers also report that 3 BIA-ALCL cases among 47 pooled ones occurred in women with known BRCA mutations, so it would be interesting to investigate genetic predispositions for this condition.
Overall, although BIA-ALCL is a rare complication, it is important that medical care providers are aware of this condition. The facts which are already known allow for early diagnosis and treatment, and there are more pending studies which will shed light on new facts on BIA-ALCL.
Sources
1. American Society of Plastic Surgeons. (2018). BIA-ALCL Resources. [online] Available at: https://www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-physician-resources/by-the-numbers
2. de Boer, M., van Leeuwen, F., Hauptmann, M., Overbeek, L., de Boer, J., Hijmering, N., Sernee, A., Klazen, C., Lobbes, M., van der Hulst, R., Rakhorst, H. and de Jong, D. (2018). Breast Implants and the Risk of Anaplastic Large-Cell Lymphoma in the Breast. JAMA Oncology, 4(3), p.335.
3. Fda.gov. (2018). Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). [online] Available at: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm