Finding Consensus After Two Decades of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant surface topography triggers a chronic-like inflammatory response

Breast implants are extensively employed for both reconstructive and esthetic purposes. However, the safety of breast implants with textured surfaces has been questioned, owing to a potential correlation with anaplastic large-cell lymphoma and the recurrence of breast cancer. This study investigates the immune response elicited by different prosthetic surfaces, focusing on the comparison between macrotextured and microtextured breast implants. Through the analysis of intraoperatively harvested periprosthetic fluids and cell culture experiments on surface replicas, we demonstrate that macrotextured surfaces elicit a more pronounced chronic-like activation of leucocytes and an increased release of inflammatory cytokines, in contrast to microtextured surfaces. In addition, in vitro fluorescent imaging of leucocytes revealed an accumulation of lymphocytes within the cavities of the macrotextured surfaces, indicating that the physical entrapment of these cells may contribute to their activation. These findings suggest that the topography of implant surfaces plays a significant role in promoting a chronic-like inflammatory environment, which could be a contributing factor in the development of lymphomas associated with a wide range of implantable devices.

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

BACKGROUND

 Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

METHODS

 A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

RESULTS

 Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

CONCLUSION

 CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Our Experience in Diagnosing and Treating Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell lymphoma detected in association with textured implants. It presents as a fluid accumulation around the implant, usually years after the implantation. We present our experience in diagnosing and treating four patients with BIA-ALCL, each widely differing from the other. Data on patients' surgical history, relevant medical information, and findings on pathological slides were retrieved from their medical charts and retrospectively reviewed. Each of the four patients was diagnosed with BIA-ALCL, one after breast augmentation, one after breast reconstruction with an implant, one after breast reconstruction with a latissimus dorsi flap and implant, and the fourth after the removal of breast implants. The cases were presented to a multidisciplinary team and subsequently underwent surgery. All four are currently free of tumors, as established by a negative follow-up via positron emission tomography-computed tomography. Although the incidence of BIA-ALCL is rare, these cases emphasize the need to rule out the diagnosis of BIA-ALCL in patients with textured implants or a history of implanted textured devices who present with symptoms such as late seroma or peri-implant mass. This pathology is typically indolent and slow-growing and heightened awareness for an early diagnosis could lead to quicker intervention and enhanced patient management.

The current use of tissue expanders in breast reconstruction: device design, features, and technical considerations

INTRODUCTION

The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons.

AREAS COVERED

In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations.

EXPERT OPINION

The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.

Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma in the United States: A Systematic Review

BACKGROUND

Although textured implants represent fewer than 10% of implants used in the United States, the country reports the highest incidence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

OBJECTIVES

The aim of this study was to perform a systematic literature review on US-based epidemiology to update knowledge on BIA-ALCL in the United States.

METHODS

Publications on US BIA-ALCL epidemiology were searched between September 2022 and March 2023 on MEDLINE (National Institutes of Health; Bethesda, MD), Embase (Elsevier, Amsterdam, the Netherlands), Web of Science (Clarivate, London, UK), and SCOPUS (Elsevier, Amsterdam, the Netherlands). The US numerator was obtained by averaging the FDA MAUDE database and the PSF PROFILE registry, while the denominator was estimated from chest X-rays, and included female transgender individuals. Prevalence and risk were assessed accordingly, but the incidence rate (IR) could not be updated due to the lack of available follow-up data.

RESULTS

Out of 987 identified manuscripts, 10 were included. The US prevalence of BIA-ALCL in the literature ranged from 1:300 to 1:500,000 and the IR from 4.5 per 10,000 to 31.1 per 100 million persons per year. A mean value of 453.5 BIA-ALCL cases was calculated. From a denominator of 4,264,618 individuals, which includes all breast implant surfaces, we calculated 414,521 individuals with textured implants, indicating a textured prevalence of 109.4 cases per 100,000 individuals and a risk of 1:913.

CONCLUSIONS

BIA-ALCL IR, prevalence, and risk has increased when calculated exclusively for patients with textured devices. Although US macrotextured implants were recalled by the FDA, these findings may influence the surveillance of existing patients and the use of macrotextured implants in other parts of the world where they remain widespread.

LEVEL OF EVIDENCE: 4

A Case Report of Breast Implant-Associated Anaplastic Large-Cell Lymphoma in a PALB2 Mutation-Positive Woman

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare peripheral T-cell lymphoma composed of anaplastic pleomorphic T cells. The first case was reported in 1997 but was not recognized until 2016 by the World Health Organization. The exact incidence is unknown but is estimated to be 0.1 to 0.3 per 100,000 women with implants. Almost every case has been found in women with textured breast implants. The median time of onset after implantation is 10.7 years. Patients presenting with localized disease, most commonly manifesting as breast enlargement, can be managed solely with surgical resection and have a 100% survival rate. This report describes a PALB2 mutation-positive woman with a strong family history of breast cancer who underwent prophylactic bilateral nipple-sparing mastectomy with textured silicone implant placement. She was diagnosed with BIA-ALCL less than 4 years later after seroma aspiration. She was treated with implant removal and capsulectomy; but, surprisingly, final surgical pathology did not show any malignancy.

Implant-based breast surgery and capsular formation: when, how and why?-a narrative review

Background and Objective

Implant-based breast surgery is a common procedure for both reconstructive and aesthetic purposes. Breast implants, like any foreign object, trigger the formation of a capsule around them. While generally harmless, the capsule can undergo fibrotic changes leading to capsular contracture, which can negatively impact surgical outcomes and patient well-being. Additionally, rare but serious complications, such as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and capsule-associated squamous cell carcinoma, have been reported. This paper aims to review the physiology of capsular formation, identify factors contributing to capsule-related pathologies, and discuss their clinical implications.

Methods

A review of relevant literature was conducted by searching databases for articles published between inception and September 2022. The search included but not limited to terms such as "capsular formation" and "capsular contracture". Selected articles were critically analyzed to address the objectives of this review.

Key Content and Findings

Capsular formation involves interactions between the implant surface, surrounding tissues, and the immune system. Factors influencing pathological changes in the capsule include genetic predisposition, bacterial contamination, implant characteristics, and surgical techniques. Capsular contracture, characterized by tissue hardening, pain, and implant distortion, remains the most common complication. Rare but life-threatening conditions, such as BIA-ALCL and capsule-associated squamous cell carcinoma, necessitate vigilant monitoring and early detection.

Conclusions

Understanding the physiology of capsular formation and its associated pathologies is crucial for healthcare providers involved in implant-based breast surgery. Efforts should focus on minimizing the risk of capsular contracture through improved implant materials, surgical techniques, and infection prevention. The emergence of BIA-ALCL and capsule-associated squamous cell carcinoma underscores the importance of long-term surveillance and prompt diagnosis. Further research is needed to uncover underlying mechanisms and develop preventive measures and treatments for these complications. Enhancing our knowledge and clinical management of capsular formation will lead to safer and more successful outcomes in implant-based breast surgery.

BIA-ALCL Epidemiology in an Aesthetic Breast Surgery Cohort of 1501 Patients

BACKGROUND

Epidemiologic studies on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) currently estimate the risk between 1:300 and 1:30,000, assessed mainly in large breast reconstruction populations.

OBJECTIVES

The aim of the study was to assess BIA-ALCL epidemiology in a cohort of patients who have received textured implants for cosmetic indications.

METHODS

In a prospective cohort observational study, 1501 patients who received a cosmetic breast augmentation between 2006 and 2016 were monitored, recording any implant-related complications, including BIA-ALCL. Cross-checking of clinical, pathology, and external records data identified cases. Prevalence, implant-specific prevalence (I-SP), incidence rate (IR), event-free time (EFT), and the Kaplan-Meier survival estimate were calculated.

RESULTS

All but 2 patients received macrotextured or microtextured devices bilaterally. Mean follow-up was 3.2 years (1 months to 16.4 years). Five BIA-ALCL cases were investigated. Prevalence was 1:300 patients; I-SP was 6.9 cases/1000 individuals/Allergan BIOCELL devices and 1.3 cases/1000 individuals/Mentor Siltex devices; and IR was 1.07 cases/1000 females/year. Mean (SD) EFT was 9.2 years.

CONCLUSIONS

When using a denominator based on a cohort of cosmetic patients, BIA-ALCL occurrence is higher than previously reported, particularly with macrotextured devices. Given the similar IRs in reconstructive and cosmetic cohorts, their even distribution could be consequent to underreporting due to poorer follow-up and lower awareness in the latter group. The genetic predisposition in the oncologic cohort reasonably affects the early onset more than the IR. The importance of accurate follow-up is confirmed. Stratification risks analysis can guide surgeons during patient counseling regarding the decision for prophylactic explantation.

LEVEL OF EVIDENCE: 4

Reviewing the risk of breast cancer recurrence following breast reconstruction

BACKGROUND

It is widely accepted that both autologous and alloplastic reconstruction are safe. A recent publication reported a significant association between textured implants and metastatic recurrence of breast cancer. This study aims to assess if the published results are reproducible in our cohort and to review the safety of breast reconstruction.

METHODS

This is a retrospective cohort study of adult patients undergoing mastectomy and either alloplastic or autologous breast reconstruction at a single quaternary hospital. Outcomes include disease free survival (DFS), local and recurrence free survival (LRRFS) and BIA-ALCL. For time to event endpoints, unadjusted and multivariate adjusted hazard ratios (HRs) were estimated using Cox regression, and penalized Cox regression respectively.

RESULTS

Four hundred and twenty-six patients of whom 187 underwent autologous reconstruction and 239 underwent alloplastic. There were 43 cancer recurrences (24 alloplastic and 19 autologous) and 14 local regional recurrences (8 alloplastic and 4 autologous). There were 26 deaths and no instances of BIA-ALCL. Median follow-up time was 4.7 years. No evidence of association was found between breast reconstruction method and DFS (HR 0.87 CI: 0.47-1.58). It is uncertain whether implant texture grade was associated with increased breast cancer recurrence (HR 2.17 CI: 0.65-7.52).

CONCLUSION

Both autologous and alloplastic breast reconstruction have been carried out in our cohort and reconstructive modality was not associated with either reduced DFS or LRRFS. The results in this cohort show there is uncertainty between the use of textured breast implants and either local or distant breast cancer recurrence.

Breast Implant-Associated Tumors

In addition to anaplastic large T-cell lymphomas (BIA-ALCL), other implant-related tumors have been described for some years. Squamous cell carcinoma (SSC) and B-cell lymphomas occurred in very rare cases. The unexplained pathogenesis as well as the unclear individual risk profile is an ongoing source of uncertainty for patients and physicians. The pathogenesis of the tumors is still largely not understood. While BIA-ALCL occurs more frequently with textured breast implants, other tumors were also observed with smooth implants and at other implant sites. Multiple potential mechanisms are discussed. It is suspected that the etiology of a chronic inflammatory response and subsequently immunostimulation is multifactorial and appears to play a key role in the malignant transformation. Since there are currently no sufficiently valid data for a specific risk assessment, this must be done with caution. This article presents the incidence, pathogenesis, as well as the level of evidence according to the current state of knowledge, and evaluates and discusses the current literature.

Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation

BACKGROUND

Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction.

METHODS

All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications.

RESULTS

Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive.

CONCLUSIONS

Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.

Complications and satisfaction in transwomen receiving breast augmentation: short- and long-term outcomes

BACKGROUND

To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction with breast augmentation.

METHODS

This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which were operated at University Hospital Essen from 2007 to 2020.

RESULTS

99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III-IV) in this population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life owing to breast augmentation.

CONCLUSION

Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in reducing gender dysphoria.

A South African Breast Implant-Associated Anaplastic Large Cell Lymphoma: Clinical Presentation and Six-Year Follow-Up

Breast augmentation is the most common surgical procedure for women globally, with 1,795,551 cases performed in 2019. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is highly uncommon, with 733 reported cases as of January 2020. In South Africa, there are less than 4000 breast augmentation surgeries annually. This case presents the first case report documentation of a South African woman diagnosed with BIA-ALCL. The patient was a 61-year-old woman who consulted the Breast Care Centre of Excellence in Johannesburg in 2015. She had a prior history of bilateral augmentation mammoplasty with subsequent implant exchange. The patient presented with periprosthetic fluid with a mass-like enhancement on the left breast. Aspiration of the mass-like fluid was positive for CD45, CD30, and CD68 and negative for CD20 and ALK-1, indicative of BIA-ALCL. Surgical treatment included bilateral explantation, complete capsulectomies, and bilateral mastopexy. Macroscopic examination of the left breast capsulectomy demonstrated fibrous connective tissue. The histological examination of the tumor showed extensive areas of broad coagulative necrosis with foamy histiocytes. Immunohistochemistry examination of this tumor showed CD3-, CD20-, and ALK-1-negative and CD30- and CD68-positive stains. PCR analysis for T-cell clonality showed monoclonal T-cell expansion. These findings confirm the presence of BIA-ALCL. The patient recovered well after surgery and did not require adjuvant therapy. A patient with a confirmed diagnosis of BIA-ALCL was successfully treated with explantation and complete capsulectomy. She was followed up regularly for six years, and the patient remains well and in remission.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL

BACKGROUND

Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL.

OBJECTIVES

The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance.

METHODS

A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement.

RESULTS

The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria.

CONCLUSIONS

BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

LEVEL OF EVIDENCE: 4

Smooth Versus Textured Tissue Expander Breast Reconstruction: Complications and Efficacy

INTRODUCTION

Ongoing recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its link with textured devices has brought a paradigm shift in prosthetic-based breast reconstruction. Many institutions no longer offer textured expansion devices for staged reconstruction. However, there is a paucity of data regarding the efficacy of smooth tissue expanders (TE). We hypothesized that the time to final reconstruction and complication profile between smooth and textured TEs would be similar in breast reconstruction patients.

METHODS

A retrospective chart review was performed of all patients who underwent TE breast reconstruction during a 6-year period at the Penn State Hershey Medical Center. Rates of complications treated nonoperatively and those requiring reoperation were assessed. Mechanical complications, including expander malposition and rupture, were evaluated. Time to final breast reconstruction was quantified. Mixed-effects logistic regression and linear regression models, as appropriate, were used to compare textured to smooth TEs. Patient characteristics and anatomic plane placement were adjusted for in all analyses of outcomes.

RESULTS

Data were collected on 389 patients, encompassing 140 smooth and 604 textured TEs. Textured devices had an increased incidence of complications treated nonsurgically (16.7% vs 10.7%; P = 0.14). However, smooth TEs had an increased incidence of reoperation (12.1% vs 7.6%; P = 0.06). Most noteworthy was that although smooth TEs had a 40-fold increase in malposition (13.6% vs 0.3%; P < 0.001), no reoperation for this complication was warranted. Further, the time to final reconstruction was comparable between the 2 devices (textured expanders: 221 days and smooth expanders: 234 days; P = 0.15).

CONCLUSIONS

Staged, implant-based reconstruction is the most common surgical approach to recreate the breast mound following mastectomy. Textured TEs were the cornerstone to this approach. Unfortunately, the association between textured devices and BIA-ALCL now mandates an alternative. We postulated that smooth expanders would compare favorably for breast reconstruction. Although our study suggests that smooth TEs suffer more malposition, this has a negligible impact on the reconstructive timeline. Thus, smooth TEs may prove beneficial when considering the risk of BIA-ALCL associated with textured devices.

Breast Implant-associated Double Capsules: What Do We Know So Far? A Systematic Review of the Literature

INTRODUCTION

A double capsule is a recently described rare occurrence following breast implant placement in which an inner capsule envelope totally or partially adheres to the implant surface while a distinct outer capsule adheres to surrounding tissues, with an intercapsular space developing between the two. The objective of this study is to review all available literature related to formation of double capsules and propose a treatment algorithm.

METHODS AND MATERIALS

A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. Articles reporting management of breast implant-associated double capsules were included in this review.

RESULTS

A total of 9 studies (68 implants) were included in the review. 94.1% of double capsules occurred with textured Biocell shaped and round implants independently from implant pocket (p value=0.64). In all cases, double capsules were diagnosed fortuitously intra-operatively for another surgical indication. Capsular contracture was present in 50% of double capsules patients and was the most common indication for secondary breast surgery, 81.5% of which being clinically evident (p value<0.001). Treatment consisted in 84.4% in an inner capsulectomy with smooth implants exchange, and management of the outer capsule as per the capsular contracture algorithm.

CONCLUSION

Double capsule formation is caused by delamination of a tight adhering capsule to a textured implant surface into two layers and continuous micro-shearing forces, and the probable contribution of bacterial biofilm. The only treatment reported so far includes inner with or without outer capsulectomy with smooth implant exchange.

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 .

Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value

BACKGROUND

Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs.

METHODS

The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs.

RESULTS

The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates.

CONCLUSION

The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Breast Implant-associated Anaplastic Large Cell Lymphoma Diagnosis 6 Years After Implant Removal: A Case Report

ABSTRACT

We present a case report of a 48-year-old woman with a late-onset seroma of her left breast, 6 years after removal of her textured breast implants. At that time, she also had a late-onset seroma of her left breast, and capsulectomy was performed along with removal of the implants. The current late seroma presentation, which followed 6 years of uneventful healing, was treated with en bloc excision of the encapsulated seroma. Pathology results were concordant with locally invasive anaplastic large cell lymphoma (ALCL). Review of her previous seroma cytology from 6 years ago was performed given the current updated guideline standards on breast implant-associated ALCL (BIA-ALCL). Evidence of BIA-ALCL confirmed the patient had the diagnosis 6 years ago. The disease persisted and remained indolent for 6 years and manifested clinically as a late seroma of the left breast. This case report emphasizes the high degree of suspicion that is required in late seroma cases involving textured breast implants or a history of textured breast implants, along with the need for en bloc capsulectomy as a primary treatment for diagnosed BIA-ALCL to avoid incomplete capsulectomy and recurrence of the disease.

Sarcoidosis Presenting as Late Seroma Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma

ABSTRACT

Late seroma related to breast silicone implants is a rare complication. Interest for its characterization has grown after its association with the recently described breast implant-associated anaplastic large cell lymphoma. The differential diagnosis includes infectious diseases, mechanical and traumatic causes, tumors, postpartum seroma, and inflammatory, allergic, or idiopathic causes.Sarcoidosis has been associated with breast silicone implants over the last decades, but it has never been reported as a cause of breast effusion. We describe a rare presentation of sarcoidosis as a late breast implant seroma simulating the clinical features and radiologic findings of breast implant-associated anaplastic large cell lymphoma and highlight that sarcoidosis can be suspected by the presence of nonnecrotizing epithelioid granulomas in the cytology, with a characteristic inverted ratio of CD4/CD8 T cells.The aims of this article are to review the current evidence about sarcoidosis related to silicone implants and breast cancer, provide a new alternative in the differential diagnosis of late seroma, and advise the scientific community how early implant removal can improve the disease.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Review of Epidemiology and Prevalence Assessment in Europe

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) epidemiologic studies focus on incidence and risk estimates.

OBJECTIVES

The aim of this study was to perform a thorough literature review, and to provide an accurate estimate of BIA-ALCL prevalence in Europe.

METHODS

We searched PubMed, Web of Science, SCOPUS, and Google Scholar databases to identify publications reporting BIA-ALCL epidemiology. Research was conducted between November 2019 and August 2020. European prevalence was assessed as the ratio between pathology-confirmed cases and breast implant-bearing individuals. The Committee on Device Safety and Development (CDSD) collected data from national plastic surgery societies, health authorities, and disease-specific registries to calculate the numerator. The denominator was estimated by combining European demographic data with scientific reports.

RESULTS

Our research identified 507 articles: 106 were excluded for not being relevant to BIA-ALCL. From the remaining 401 articles, we selected 35 that discussed epidemiology and 12 reviews. The CDSD reported 420 cases in Europe, with an overall prevalence of 1:13,745 cases in the 28 member states of the European Union (EU-28). Countries where specific measures have been implemented to tackle BIA-ALCL account for 61% of the EU-28 population and actively reported 382 cases with an overall prevalence of 1:9121.

CONCLUSION

Countries where specific measures have been implemented show a higher prevalence of BIA-ALCL compared with the European mean, suggesting that these countries have improved the detection of the condition and reduced underreporting, which affects the numerator value. Other nations should adopt projections based on these measures to avoid underestimating how widespread BIA-ALCL is.

LEVEL OF EVIDENCE: 4

Cellular and Molecular Mechanisms of Breast Implant-Associated Anaplastic Large Cell Lymphoma

SUMMARY

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and highly treatable cancer of the immune system that can form around textured-surface breast implants. Although the underlying cause has yet to be elucidated, an emerging theme-linking pathogenesis to a chronic inflammatory state-continues to dominate the current literature. Specifically, the combination of increasing mutation burden and chronic inflammation leads to aberrant T-cell clonal expansion. However, the impetus remains largely unknown. Proposed mechanisms include a lipopolysaccharide endotoxin response, oncogenic transformation related to viral infection, associated trauma to the breast pocket, particulate matter digestion by capsular macrophages, chronic allergic inflammation, and genetic susceptibility. The Janus kinase-signal transducer and activator of transcription 3 (JAK-STAT3) pathway is a major signaling pathway that regulates a variety of intracellular growth and survival processes. Constitutive activation of JAK-STAT3 has been implicated in several malignancies, including lymphomas, and has recently been identified as a potential key mediator in BIA-ALCL. The purpose of this article is to review the cellular and molecular mechanisms of BIA-ALCL with a focus on the role of oncogenic JAK-STAT3 signaling in BIA-ALCL tumorigenesis and progression. Selected experimental work from the authors' group on aberrant JAK-STAT3 signaling in BIA-ALCL is also included. The authors discuss how an inflammatory microenvironment may facilitate malignant transformation through the JAK-STAT3 pathway-highlighting its potential mechanistic role. The authors' hope is that further investigation of this signaling pathway will reveal avenues for using JAK-STAT3 signaling as a prognostic indicator and novel therapeutic target in the case of advanced disease.

Breast Implant-associated Anaplastic Large Cell Lymphoma: An Evidence-based Systematic Review

OBJECTIVE

This evidence-based systematic review synthesizes and critically appraises current clinical recommendations and advances in the diagnosis and treatment of BIA-ALCL. This review also aims to broaden physician awareness across diverse specialties, particularly among general practitioners, breast surgeons, surgical oncologists, and other clinicians who may encounter patients with breast implants in their practice.

BACKGROUND

BIA-ALCL is an emerging and treatable immune cell cancer definitively linked to textured-surface breast implants. Although the National Comprehensive Cancer Network (NCCN) consensus guidelines and other clinical recommendations have been established, the evidence supporting these guidelines has not been systematically studied. The purpose of this evidence-based systematic review is to synthesize and critically appraise current clinical guidelines and recommendations while highlighting advances in diagnosis and treatment and raising awareness for this emerging disease.

METHODS

This evidence-based systematic review evaluated primary research studies focusing on the diagnosis and treatment of BIA-ALCL that were published in PubMed, Google Scholar, and other scientific databases through March 2020.

RESULTS AND CONCLUSIONS

The clinical knowledge of BIA-ALCL has evolved rapidly over the last several years with major advances in diagnosis and treatment, including en bloc resection as the standard of care. Despite a limited number of high-quality clinical studies comprised mainly of Level III and Level V evidence, current evidence aligns with established NCCN consensus guidelines. When diagnosed and treated in accordance with NCCN guidelines, BIA-ALCL carries an excellent prognosis.

What is the Process for Breast Implant Manufacturing? Inside Eight Breast Implant Factories

BACKGROUND

With the recent association between breast implants and anaplastic large cell lymphoma, breast implants have become the focus of many warnings. Surgeons and health professionals are not involved in all the processes of the manufacturing and distribution of this product. Not all countries have breast implant factories that are easy for surgeons to visit and better understand the manufacturing process.

METHODS

A questionnaire about breast implant manufacturing and distribution was validated in consensus and form. Two plastic surgeons visited eight factories and administered the questionnaire in the presence of a photographer, who documented that the questionnaire was answered in the same way for all visits. Once the visitors finished obtaining the information (questionnaire responses and video recording), this information was validated by a different member of a safety committee in Mexico. For the observations to be considered valid, the information from the questionnaire and the video must be presented.

RESULTS

We visited eight factories: three in France (Sebbin, Arion and Eurosilicone), two in Costa Rica (Allergan and Motiva), one in Scotland (Nagor), one in Germany (Polytech) and one in Korea (Bellagel). In four factories (Eurosilicone, Motiva, Nagor and Sebbin), the information on the process for manufacturing an implant was observed and recorded (validated). The quality laboratory was visited, and video recording was performed in six factories (Bellagel, Eurosilicone, Motiva, Nagor, Polytech and Sebbin).

CONCLUSION

It was possible to observe and verify that most of the companies that distribute breast implants in Mexico perform their manufacturing processes according to ISO standards. A breast implant registry can help people further understand how BIA-ALCL will behave in the future and allow more tests to better understand this pathology.

LEVEL OF EVIDENCE V

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 .

Breast Implant-associated Anaplastic Large Cell Lymphoma: A Canadian Surgical Oncology Survey

Background

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) awareness has increased, resulting in concerns regarding the safety of implant-based reconstruction. Breast cancer patients are first seen by surgical oncologists, who are therefore potentially the first health-care professionals to encounter concerns regarding BIA-ALCL. We therefore surveyed surgical oncologists on their understanding of BIA-ALCL to better assess potential effects on plastic surgery practice.

Methods

An anonymous web-based survey consisting of 9 multiple-choice questions was sent to breast surgical oncologists that are members of the Canadian Society of Surgical Oncology (n = 135).

Results

Forty-two members responded (n = 42/135, 31%) and all participants were aware of BIA-ALCL. All participants reported that BIA-ALCL has not deterred them from referring patients for implant-based reconstruction. Twenty-two respondents (52%) discuss BIA-ALCL with their patients and 21% (n = 9) believe that BIA-ALCL typically follows a metastatic course. Eight respondents (19%) reported having a poor understanding of BIA-ALCL, while 14% (n = 6) were unable to identify the link to textured implants. There were no statistical differences based on case-load volume.

Conclusions

Approximately half of the respondent Canadian breast surgical oncologists discuss BIA-ALCL with their patients, yet there is a knowledge gap in terms of the epidemiology and clinical-pathological course of BIA-ALCL. It is of utmost importance to ensure that the plastic surgery community aims at including surgical oncologist colleagues in educational platforms regarding BIA-ALCL to ensure collaboration and unity in an effort to offer the most accurate information to patients, and prevent misinformation that may deter patients from seeking implant-based reconstruction.