Breast Implant-Associated Anaplastic Large Cell Lymphoma

Ultrasonic elastography for the prevention of breast implant rupture: Detection of an increase with stiffness over implantation time

Breast implants are widely used after breast cancer resection and must be changed regularly to avoid a rupture. To date, there are no quantitative criteria to help this decision. The mechanical evolution of the gels and membranes of the implants is still underinvestigated, although it can lead to early rupture. In this study, 35 breast explants having been implanted in patients for up to 17 years were characterized by ex vivo measurements of their mechanical properties. Using Acoustic Radiation Force Impulse (ARFI) ultrasound elastography, an imaging method for non-destructive mechanical characterization, an increase in the stiffness of the explants has been observed. This increase was correlated with the implantation duration, primarily after 8 years of implantation. With an increase of the shear modulus of up to a factor of nearly 3, the loss of flexibility of the implants is likely to lead to a significant increase of their risk of rupture. A complementary analysis of the gel from the explants by mass spectrometry imaging (MSI) and liquid chromatography coupled to high resolution mass spectrometry (LC-HRMS) confirms the presence of metabolites of cholesterol originating from the breast tissues, which most likely crossed the membrane of the implants and most likely degrades the gel. By observing the consequences of the physical-chemical mechanisms at work within patients, this study shows that ultrasound elastography could be used in vivoas a quantitative indicator of the risk of breast implant rupture and help diagnose their replacement.

Incidental Bystander or Essential Culprit: A Systematic Review of Bacterial Significance in the Pathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct subtype of T-cell non-Hodgkin lymphoma that arises in the context of prolonged exposure to textured breast implants. The intent of this manuscript is to explore whether the bacterial presence in biofilms on these implants is a mere incidental finding or plays a pivotal role in the pathogenesis of BIA-ALCL. Our goal is to delineate the extent of bacterial involvement, offering insights into potential underlying mechanisms, and establishing future research priorities aimed at resolving the remaining uncertainties surrounding this complex association. A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. The electronic search identified 442 publications. After evaluation, six studies from 2015 to 2021 were included, encompassing 201 female patients aged 23 to 75. The diagnosis span post-implantation ranged from 53 to 135.6 months. Studies consistently found bacteria near breast implants in both BIA-ALCL cases and controls, with varied microbial findings. Both BIA-ALCL cases and controls exhibited the presence of specific bacteria, including Pseudomonas aeruginosa, Klebsiella oxytoca, Staphylococcus aureus, and Ralstonia spp., without any statistically significant differences between groups. The use of antiseptic and antimicrobial agents during implant insertion did not demonstrate any impact on reducing or altering the risk of developing BIA-ALCL. Our systematic review reveals that the current evidence is inadequate to link bacterial etiology as a central factor in the development of BIA-ALCL. The limitations in the existing data prevent a complete dismissal of the role of biofilms in its pathogenesis. The observed gap in knowledge underscores the need for more focused and comprehensive research, which should be structured in a multi-faceted approach. Initially, this involves the utilization of sophisticated genomic and proteomic methods. Following this, it is crucial to delve into the study of immunological reactions specifically induced by biofilms. Finally, this research should incorporate extended observational studies, meticulously tracking the evolution of biofilm development and its correlation with the emergence of BIA-ALCL. In light of the inconclusive nature of current findings, further investigation is not only justified but urgently needed to clarify these unresolved issues.

The Influence of BIA-ALCL on the Use of Textured Breast Implant and its Placement: A Survey of Dutch Plastic Surgeons

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and its association with macrotextured breast implants may have induced plastic surgeons to change their breast augmentation and breast reconstruction practice.

OBJECTIVES

The aim of this study was to survey Dutch plastic surgeons about the effects of BIA-ALCL on their choice of breast implant texture and placement technique.

METHODS

An online questionnaire was distributed to all members of the Dutch Association of Plastic Surgeons. Descriptive data were presented as frequencies and percentages. Technique alterations were analyzed by the marginal homogeneity test for paired nominal data.

RESULTS

A total of 63 plastic surgeons completed the questionnaire. The majority of respondents altered their use of textured implants due to BIA-ALCL concerns for both breast augmentation and reconstruction (75.4% and 69.8%, respectively; both being statistically significant, P < .001). Microtextured and smooth/nanotextured breast implants are now most frequently used. BIA-ALCL did not influence the placement technique in breast augmentation and reconstruction (87.7% and 94.3%, respectively). Dual-plane breast implant placement is still the most favored technique for breast augmentation, and submuscular placement is still most favored for breast reconstruction.

CONCLUSIONS

BIA-ALCL has had a significant impact on the use of macrotextured breast implants by Dutch plastic surgeons in both aesthetic and reconstructive breast surgery. Breast implant placement technique has not been affected.

LEVEL OF EVIDENCE: 4

Silicone Breast Implant Surface Texture Impacts Gene Expression in Periprosthetic Fibrous Capsules

BACKGROUND

Silicone breast implants with smooth outer shells are associated with higher rates of capsular contracture, whereas textured implants have been linked to the development of breast implant-associated anaplastic large cell lymphoma. By assessing the gene expression profile of fibrous capsules formed in response to smooth and textured implants, insight into the development of breast implant-associated abnormalities can be gained.

METHODS

Miniature smooth or textured silicone implants were surgically inserted into female rats ( n = 10) and harvested for the surrounding capsules at postoperative week 6. RNA sequencing and quantitative polymerase chain reaction were performed to identify genes differentially expressed between smooth and textured capsules. For clinical correlation, the expression of candidate genes was assayed in implant capsules harvested from human patients with and without capsular contracture.

RESULTS

Of 18,555 differentially expressed transcripts identified, three candidate genes were selected: matrix metalloproteinase-3 ( MMP3 ), troponin-T3 ( TNNT3 ), and neuregulin-1 ( NRG1 ). In textured capsules, relative gene expression and immunostaining of MMP3 and TNNT3 was up-regulated, whereas NRG1 was down-regulated compared to smooth capsules [mean relative fold change, 8.79 ( P = 0.0059), 4.81 ( P = 0.0056), and 0.40 ( P < 0.0001), respectively]. Immunostaining of human specimens with capsular contracture revealed similar gene expression patterns to those of animal-derived smooth capsules.

CONCLUSIONS

An expression pattern of low MMP3 /low TNNT3 /high NRG1 is specifically associated with smooth implant capsules and human implant capsules with capsular contracture. The authors' clinically relevant breast implant rat model provides a strong foundation to further explore the molecular genetics of implant texture and its effect on breast implant-associated abnormalities.

CLINICAL RELEVANCE STATEMENT

The authors have demonstrated that there are distinct gene expression profiles in response to smooth versus textured breast implants. Since surface texture may be linked to implant-related pathology, further molecular analysis of periprosthetic capsules may yield strategies to mitigate implant-related complications.

Understanding Breast Implant Illness: Etiology is the Key

Because breast augmentation is one of the most popular cosmetic procedures, the issue of implant-related complications has been widely debated ever since the FDA approved the use of implants in 1962. Although decades have passed, breast implant illness (BII) still represents a poorly defined and controversial complication. With ongoing nonscientific discussion in the mainstream media and on social media, revealing the etiology of BII is urgent because knowledge of this subject ultimately influences patients' decisions. Little or no scientific research is currently available on BII and no final conclusions regarding its etiology, clinical manifestations, diagnostic criteria, or treatment have been made. This review aims to give an overview of the hypotheses on the etiology of BII and seeks inspiration to improve the conditions of BII patients.

In Vitro Evaluation of Common Antimicrobial Solutions Used for Breast Implant Soaking and Breast Pocket Irrigation-Part 2: Efficacy Against Biofilm-Associated Bacteria

Background

Biofilm-associated bacteria have been observed in both breast implant revision and tissue expander-implant exchange surgeries. The utilization of antimicrobial solutions in breast surgery, especially those containing triple antibiotics (TAB) and/or 10% povidone-iodine (PI), may help reduce existing biofilm-associated bacteria, which is particularly important in a mature breast pocket that may contain residual bacteria from a previously colonized implant surface or, theoretically, bacteria that may arrive postoperatively through hematogenous spread.

Objectives

A series of in vitro assessments was performed to evaluate the antimicrobial utility of TAB and PI, either alone or in combination, against preformed biofilm-associated bacteria.

Methods

Preformed biofilm-associated gram-positive and gram-negative bacterial strains were exposed to TAB and PI ± TAB for up to 30 minutes in a bacterial time-kill assay. Efficacy of various dilutions of PI and the effects of serum protein on PI efficacy were also investigated.

Results

TAB was ineffective at the timeframes tested when utilized alone; when utilized in conjunction with PI, significant log reduction of all biofilm-associated bacterial species tested was achieved when treated for at least 5 minutes. PI alone at a concentration of 25% or higher was also effective, although its efficacy was negatively affected by increasing serum protein concentration only for Staphylococcus epidermidis.

Conclusions

Our data indicate that PI-containing solutions significantly reduce biofilm-associated bacteria, suggesting potential utility for breast pocket irrigation during revision or exchange surgeries. Care should be taken to minimize excessive dilution of PI to maintain efficacy.

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases

Introduction

Capsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications.

Methods

Retrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery.

Results

Capsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal.

Conclusion

Significant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.

An Unusual Case of BIA-ALCL Associated with Prolonged/Complicated Biocell-Textured Expander, followed by Smooth Round Breast Implant Exposure, and Concurrent Use of Adalimumab

SUMMARY

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a malignancy associated with textured breast implants. BIA-ALCL is typically restricted to the periprosthetic capsule, presenting as a unilateral recurrent seroma years after placement of a textured breast implant. Current estimates suggest an incidence of one in 3300 for patients with Allergan Biocell textured implants. As of February 6, 2019, U.S. Medical Device Reporting associated with BIA-ALCL showed 457 unique cases of BIA-ALCL, with 24 "unverified and potentially inaccurate" cases associated with a nontextured implant. As of February of 2019, there were 688 reported cases to date worldwide. To date, there are no published case reports of BIA-ALCL associated exclusively with smooth implants or with smooth implants after textured expanders, and there has been no reported smooth-only case in any registry, database, or journal worldwide. The authors present a case of BIA-ALCL associated with smooth round implants and textured tissue expanders. A 56-year-old woman was treated for left stage IIA invasive ductal carcinoma with bilateral mastectomies and immediate reconstruction with bilateral subpectoral textured tissue expanders. She underwent exchange to Mentor smooth-round implants, and completed adjuvant chemotherapy. Magnetic resonance imaging and examination 4.5 years after implant placement showed no abnormal findings. The patient had left breast trauma 5 years following implant placement while taking adalimumab, and developed an open wound requiring explantation. A recurrent seroma developed, and tested positive for BIA-ALCL on cytology. Surgical pathologic examination after total capsulectomy demonstrated stage IA BIA-ALCL. To the authors' knowledge, this is the first case report of BIA-ALCL in a patient with textured expanders followed by prolonged exposure to smooth round implants.

Textured and Smooth Implant Use Reported in the Tracking Operations and Outcomes for Plastic Surgeons Database: Epidemiologic Implications for BIA-ALCL

Background:

Breast-implant–associated anaplastic large cell lymphoma (BIA-ALCL) is associated with prolonged exposure to textured implants. Current studies describing textured implant use are limited to single center/surgeon experiences. Using the Tracking Operations and Outcomes for Plastic Surgeons database, the study aims to characterize national trends in rates of smooth versus textured implant utilization. The hypothesis is that rates of textured implant use have decreased in the most recent time period.

Methods:

Tracking Operations and Outcomes for Plastic Surgeons was queried from 2007 to 2019 for CPT codes involving breast implant use in augmentation and reconstruction. The rate of smooth and textured implant utilization was calculated for each year per procedure type. Generalized additive models with a smoothing function and Pearson chi-square tests were used to assess the trends.

Results:

Textured implant use peaked in 2016, being utilized in 17.83% of cosmetic and 40.88% of reconstructive procedures. Textured implants were more commonly used for reconstructive compared with cosmetic cases for 2007–2009, 2011, and 2013–2019 (P < 0.02). Both cosmetic and reconstructive cases had nonlinear trends in textured implant use over the study period, with textured rates decreasing from 2017 to 2019 (P < 0.001). In 2019, textured implants were used in 2.15% of cosmetic and 7.58% of reconstructive cases.

Conclusions:

This is the first national study describing trends in textured versus smooth breast implant use in the United States. Textured implant utilization peaked in 2016. Based on a median time horizon of 10 years before development of BIA-ALCL, the peak number of cases can be anticipated in 2026 or thereafter.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Clinical Update

ABSTRACT

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized malignancy of T-lymphocytes that is linked to certain types of textured breast implants. Although rare, the increasing awareness of the disease is resulting in more case reports and heightened anxiety in patients with textured breast implants. This review aims to summarize the available BIA-ALCL data, including the existing theories of etiopathogenesis, the diagnostic work-up for BIA-ALCL patients, BIA-ALCL treatment recommendations, the epidemiologic challenges, and the current opinions surrounding the use of textured breast implants.

How microbes read the map: Effects of implant topography on bacterial adhesion and biofilm formation

Microbes have remarkable capabilities to attach to the surface of implanted medical devices and form biofilms that adversely impact device function and increase the risk of multidrug-resistant infections. The physicochemical properties of biomaterials have long been known to play an important role in biofilm formation. More recently, a series of discoveries in the natural world have stimulated great interest in the use of 3D surface topography to engineer antifouling materials that resist bacterial colonization. There is also increasing evidence that some medical device surface topographies, such as those designed for tissue integration, may unintentionally promote microbial attachment. Despite a number of reviews on surface topography and biofilm control, there is a missing link between how bacteria sense and respond to 3D surface topographies and the rational design of antifouling materials. Motivated by this gap, we present a review of how bacteria interact with surface topographies, and what can be learned from current laboratory studies of microbial adhesion and biofilm formation on specific topographic features and medical devices. We also address specific biocompatibility considerations and discuss how to improve the assessment of the anti-biofilm performance of topographic surfaces. We conclude that 3D surface topography, whether intended or unintended, is an important consideration in the rational design of safe medical devices. Future research on next-generation smart antifouling materials could benefit from a greater focus on translation to real-world applications.

A Cautionary Tale and Update on Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large T-cell lymphoma (BIA-ALCL) was first recognized by the World Health Organization in 2016. The total number of cases worldwide continues to increase, with >800 cases confirmed through a combination of Food and Drug Administration data, verified reports, and registries. To date, 33 deaths have been reported. Typical presentation includes a late seroma containing monoclonal T cells that are CD30 positive and anaplastic lymphoma kinase negative. We present a review of the current literature and report on 3 cases of BIA-ALCL at our institution, which serve to illustrate our approach to diagnosis and management of this disease. In 2 cases, the diagnosis of BIA-ALCL was not initially confirmed due to an incomplete workup but was recognized upon explantation. The seroma fluid was sent for flow cytometry. Initially, the cells were reported as morphologically suspicious for malignancy with phenotypically normal T cells based on standard CD3+ T-cell gating. Subsequent cytology specimens were reported as consistent with recurrent adenocarcinoma. However, upon regating of flow-cytometry data, a population of CD30+, CD3- T cells was noted and the diagnosis of BIA-ALCL was confirmed by immunohistochemical stains of the excised breast capsule specimen. Given the increasing incidence of this disease, as plastic surgeons we must stay informed to order the correct workup to avoid misdiagnosis and be prepared to appropriately refer affected patients to centers with multidisciplinary teams experienced in the management of BIA-ALCL.

LEVEL OF EVIDENCE: 4

Breast Implant-Associated Anaplastic Large Cell Lymphoma in Australia: A Longitudinal Study of Implant and Other Related Risk Factors

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging cancer that has been linked to the use of textured devices. The recent increase in number and frequency of cases has led to worldwide regulatory action.

OBJECTIVES

The authors aimed to longitudinally study BIA-ALCL in Australia since the index case was first reported in 2007.

METHODS

Confirmed historical cases were collected and then prospectively analyzed from October 2015 to May 2019. Clinical and implant exposure data were determined and compared with company sales data for 4 devices to generate implant-specific risk.

RESULTS

A total 104 cases of BIA-ALCL were diagnosed in Australia with exposure to 149 unique breast implants. The mean age of patients was 48.2 years (range, 22.4-78.5 years). They had an average time from implantation to diagnosis of 6.8 years. A total 51.7% of implants utilized in this cohort were Allergan Biocell devices. The indication for implant usage was for primary cosmetic augmentation in 70%, post-breast cancer reconstruction in 23%, and following weight loss/pregnancy in 7%. The majority of women presented with early (stage 1) disease (87.5%). The risk for developing BIA-ALCL ranged from 1 in 1947 sales (95% confidence interval = 1199-3406) for Silimed Polyurethane devices to 1 in 36,730 (95% confidence interval = 12,568-178,107) for Siltex imprinted textured devices.

CONCLUSIONS

Implants with higher surface area/texture seem to be more associated with BIA-ALCL in Australia. Recent regulatory action to suspend, cancel, or recall some of these higher risk devices is supported by these findings.

LEVEL OF EVIDENCE: 2

Breast Implant-associated Anaplastic Large Cell Lymphoma Affecting a Neosubpectoral Pocket

The complications associated with breast implants are under perpetual scrutiny to maximize patient safety. In this era of plastic surgery, a new concern being addressed is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Patients with BIA-ALCL most commonly present several years after implant placement with a periprosthetic fluid collection. The body of literature and reports of BIA-ALCL continues to grow with additional nuances in proposed causes as well as management. Most recently, this has led to a recall of breast implants manufactured utilizing a specific texturing. We describe here the time course, diagnosis, and management of BIA-ALCL in a 52-year-old patient who underwent submuscular implant-based reconstruction and subsequent revision of that reconstruction with the creation of a neosubpectoral pocket. The patient was managed in accordance with current guidelines under the supervision of a multidisciplinary team. In our review of the literature, several case reports, case series, and guideline publications were identified. Current guidelines for management are based on the staging of BIA-ALCL at diagnosis and span from only surgical with implant removal, excision of the lymphoma, and excision of the surrounding fibrous capsule to addition of chemotherapeutic regimens or radiation for distant and locally advanced disease. 

The novel lncRNA BlackMamba controls the neoplastic phenotype of ALK- anaplastic large cell lymphoma by regulating the DNA helicase HELLS

The molecular mechanisms leading to the transformation of anaplastic lymphoma kinase negative (ALK^-) anaplastic large cell lymphoma (ALCL) have been only in part elucidated. To identify new culprits which promote and drive ALCL, we performed a total transcriptome sequencing and discovered 1208 previously unknown intergenic long noncoding RNAs (lncRNAs), including 18 lncRNAs preferentially expressed in ALCL. We selected an unknown lncRNA, BlackMamba, with an ALK^- ALCL preferential expression, for molecular and functional studies. BlackMamba is a chromatin-associated lncRNA regulated by STAT3 via a canonical transcriptional signaling pathway. Knockdown experiments demonstrated that BlackMamba contributes to the pathogenesis of ALCL regulating cell growth and cell morphology. Mechanistically, BlackMamba interacts with the DNA helicase HELLS controlling its recruitment to the promoter regions of cell-architecture-related genes, fostering their expression. Collectively, these findings provide evidence of a previously unknown tumorigenic role of STAT3 via a lncRNA-DNA helicase axis and reveal an undiscovered role for lncRNA in the maintenance of the neoplastic phenotype of ALK^-ALCL.

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.

The rapidly changing landscape in mature T-cell lymphoma (MTCL) biology and management

Historical advances in the care of patients with non-Hodgkin lymphoma (NHL) have been restricted largely to patients with B-cell lymphoma. The peripheral T-cell lymphomas (PTCLs), which are rare and heterogeneous in nature, have yet to experience the same degree of improvement in outcome over the past 20 to 30 years. It is estimated that there are approximately 80,000 and 14,000 cases, respectively, of NHL and Hodgkin lymphoma per year in the United States. As a subgroup of NHL, the PTCLs account for 6% to 10% of all cases of NHL, making them exceedingly rare. In addition, the World Health Organization 2017 classification describes 29 distinct subtypes of PTCL. This intrinsic diversity, coupled with its rarity, has stymied progress in the disease. In addition, most subtypes carry an inferior prognosis compared with their B-cell counterparts, an outcome largely attributed to the fact that most treatment paradigms for patients with PTCL have been derived from B-cell neoplasms, a radically different disease. In fact, the first drug ever approved for patients with PTCL was approved only a decade ago. The plethora of recent drug approvals in PTCL, coupled with a deeper understanding of the molecular pathogenesis of the disease, has stimulated the field to pursue new avenues of research that are now largely predicated on the development of novel, targeted small molecules, which include a host of epigenetic modifiers and biologics. There is an expectation these advances may begin to favorably challenge the chemotherapy paradigms that have been used in the T-cell malignancies.