Primary Squamous Cell Carcinoma Arising From a Breast Implant Capsule: A Case Report and Review of the Literature

Current Knowledge on Breast Implant-Associated Anaplastic Large Cell Lymphoma: Evidence from Italian Ministry of Health Registry Data

BACKGROUND

Accurate estimation of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) incidence is crucial for assessing breast-implant-associated risk. However, the size of the implanted population worldwide is unknown, making it challenging to appropriately estimate this figure. This study aims to provide a new reliable and reproducible method to estimate the breast-implanted-population (BIP), reporting a reliable annual BIA-ALCL incidence estimate. Moreover, we discuss all activities performed over the past decade in collecting complete histories, managing, and monitoring outcomes of each Italian case.

METHODS

Data from the National Breast Implant Registry and from manufacturers have been used to define a new formula to estimate the BIP at risk of developing a breast-implant-related event. From the BIA-ALCL registry, complete information on Italian cases has been collected and analysed. Overall survival is estimated by the Kaplan-Meier curve.

RESULTS

From 2010 to June 2024, 111 BIA-ALCL cases were recorded in Italy. The estimated incidence rate showed an upward trend, ranging from 2.68 to 6.35 cases per 100,000 patient-years. Thanks to newly promoted disease awareness, most patients had a complete response to treatment, resulting in a three-year overall survival rate estimate of 98.2%.

CONCLUSIONS

The BIP formula showed to be an innovative, effective and reproducible tool to make a reliable estimation of the implanted population, confirming that BIA-ALCL is a rare disease with an incidence rate estimate varying from 2.7 to 6.3 cases/100.000 patient-years in the last five years. Eleven-year experience in this field also confirmed that this disease has a favorable prognosis if properly treated.

LEVEL OF EVIDENCE III

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[Breast implant-associated squamous cell carcinoma: a systematic literature review]

BACKGROUND

Breast implant-associated squamous cell carcinoma (BIA-SCC) is being discussed as a distinct malignant tumour entity originating from the implant capsule. The FDA and the ASPS published a safety communication on BIA-SCC in 2022, with a first case report of BIA-SCC having been published in the 1990s. This manuscript summarises the current scientific data on this rare tumour entity.

MATERIAL AND METHODS

This systematic literature review from two independent databases includes all publications of cases with histopathologically confirmed BIA-SCC. Data extraction included study design, demographic data, implant information and details regarding diagnosis and treatment.

RESULTS

Nineteen cases of BIA-SCC with a mean age of 57±10 years were reported in 16 publications. In most cases, the indication was aesthetic augmentation (n=13). Both silicone (n=11) and saline (n=7) implants with different surfaces (smooth n=3, textured n=3, polyurethane n=1) were used. Symptoms such as unilateral swelling (n=18), pain (n=14) and erythema (n=5) occurred on an average of 23±9 years after implantation. Imaging showed fluid collection (n=8) or a tumour mass (n=4) around the breast implant. The most common surgical treatment was explantation with capsulectomy. Metastasis was described in 6 cases.

CONCLUSIONS

BIA-SCC is a malignant tumour entity associated with breast implant capsules. Based on current low-quality data (level of evidence class V), no definitive conclusion regarding correlation and causality of SCC in patients with breast implants can be drawn. There is an urgent need for national and international breast implant and breast cancer registries to obtain valid data on the incidence, pathogenesis and clinical presentation of rare tumour entities.

The evaluation of the delayed swollen breast in patients with a history of breast implants

Breast implants, whether placed for reconstructive or cosmetic purposes, are rarely lifetime devices. Rupture, resulting from compromised implant shell integrity, and capsular contracture caused by constriction of the specialized scar tissue that normally forms around breast implants, have long been recognized, and remain the leading causes of implant failure. It is apparent, however, that women with breast implants may also experience delayed breast swelling due to a range of etiologic factors. While a majority of delayed seromas associated with breast implants have a benign etiology, this presentation cannot be ignored without an adequate workup as malignancies such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL), breast implant associated diffuse large B-cell lymphoma (BIA-DLBCL), and breast implant associated squamous cell carcinoma (BIA-SCC) can have a similar clinical presentation. Since these malignancies occur with sufficient frequency, and with sometimes lethal consequences, their existence must be recognized, and an appropriate diagnostic approach implemented. A multidisciplinary team that involves a plastic surgeon, radiologist, pathologist, and, as required, surgical and medical oncologists can expedite judicious care. Herein we review and further characterize conditions that can lead to delayed swelling around breast implants.

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.

Squamous Cell Carcinoma as a Result of Likely Industrial Grade Ruptured Poly Implant Prosthèse Silicone Buttock Implants

The Poly Implant Prosthèse (PIP) implants were withdrawn from the market in 2010 due to the use of a nonmedical grade silicone filler. In 2012, the French medical authorities and the International Confederation of Societies of Plastic, Reconstructive and Aesthetic Surgery recommended the extraction of PIP implants. However, during the duration of this scandal, each country in the world did not agree with a uniform procedure, and this rule was not implemented in its entirety. Although laboratory test results on PIP implants were negative for cytotoxicity and genotoxicity, there are many reports in the literature of several complications associated with PIP implants, including high rupture rates and the fact that they are 3 to 5 times more likely to produce local tissue reactions. On the other hand, the development of more strange and worse prognosis complications, such as the development of squamous carcinoma associated with the use of silicone implants (not necessarily related to PIP implants), is less known. To date, only 6 cases have been reported, and all are related to breast augmentation. The authors made the first report of primary gluteal squamous cell cancer related to rupture and delayed removal of PIP silicone buttock implants.

Level of Evidence: 5

Change of Pathological Type to Metaplastic Squamous Cell Carcinoma of the Breast During Disease Recurrence: Case Report and Literature Review

Background: Metaplastic squamous cell carcinoma (SCC) of the breast is a rare and heterogeneous group of primary breast malignancies. The etiology, pathogenesis, and proper treatment for this kind rare breast cancer are still unclear.

Case presentation: We reported a case of a 55-year-old woman with a palpable lump in the inner quadrant of the right breast. She underwent a right breast mass resection and sentinel lymph node biopsy, which revealed that the tumor was an invasive ductal carcinoma, followed by four cycles of doxorubicin plus cyclophosphamide and four cycles of docetaxel as adjuvant chemotherapy, and then simultaneous integrated boost intensity modulated radiotherapy to the whole right breast. After 2 years' follow-up, she had biopsy-proven disease recurrence in the right breast, which revealed SCC, and a mammogram showed abnormalities in the lower inner quadrant of the right breast and left axillary lymph nodes. Then we performed bilateral breast modified radical mastectomy, which confirmed that the recurrent tumors were metaplastic SCC, followed by adjuvant chemotherapy and adjuvant radiotherapy of the left supraclavicular and apical axillary regions. There has been no recurrent or metastatic evidence in the 16 months' follow-up since the second surgery.

Conclusion: This case report shows that evolution of pathology type in recurrent breast cancer after initial treatment is possible. Detailed pathologic and immunohistochemical analyses are needed for identification of this change. Surgery and adjuvant radiation and chemotherapy are appropriate treatments for recurrent primary SCC of the breast.

Case Reports on Metaplastic Squamous Cell Carcinoma of the Breast and Treatment Dilemma

Metaplastic squamous cell carcinoma of the breast is a very rare form of breast cancer that consists of both glandular and nonglandular components mixed with epithelial and mesenchymal tissues. Worldwide, the incidence of this tumor is between 0.1 and 2%. Because of the rarity of this tumor and heterogeneous behavior of the tumor cells, it is difficult to establish the standard therapeutic approach. We report 2 cases of metaplastic squamous cell carcinoma of the breast in young patients with different responses to treatment strategies. The first case is a premenopausal female with metaplastic squamous cell carcinoma treated with surgery, chemotherapy, and radiotherapy, and the second case is perimenopausal metaplastic squamous cell carcinoma with sarcomatoid subtype and osteoid matrix production which progressed on chemotherapy and was treated with surgery and radiation.

Clinicopathological features, treatment patterns, and prognosis of squamous cell carcinoma of the breast: an NCDB analysis

Background

Squamous cell carcinoma (SCC) of the breast is a rare malignancy. The clinicopathological features, treatment patterns and prognosis of SCC of the breast is still unclear.

Methods

In this study, we performed a 1:4 SCC-IDC (infiltrating ductal carcinoma) matching analysis of patients diagnosed between 2004 and 2014, using the data from the national cancer database. We used Chi-square test to compare the clinicopathological features and treatment patterns between SCC (n = 686) and IDC (n = 2744) patients. We used Kaplan-Meier analysis and Cox-regression to estimate the survival of SCC and IDC patients.

Results

We observed that SCC patients are more likely to have T3–4, grade III, and ER negative diseases, when compared to IDC patients. Breast conserving surgery (BCS) (58.3% vs 65.4%, p = 0.048), as well as radiotherapy after BCS (65.3% vs. 83.0%, p < 0.001), was less performed in SCC patients. Among low-risk patients, chemotherapy was used more often for SCC patients (42.9%) than for IDC (18.7%) patients (p = 0.002). In HR-positive patients, endocrine therapy was used less often for SCC patients (51.6%) than for IDC patients (70.5%) (p < 0.001). SCC (vs. IDC) was associated with no responses to neoadjuvant chemotherapy (20% vs. 5.05%, p = 0.019). Adjusted analysis confirmed that SCC (vs. IDC) was associated with worse OS (HR = 1.40, 95%CI 1.17–1.67, P < 0.01), after a median follow-up of 58.3 months. In SCC patients, HR status is not prognostic of OS, but endocrine therapy was significantly associated with improved OS in HR-positive SCC patients.

Conclusions

We conclude that SCC is associated with poorer clinicopathological features, no responses to neoadjuvant chemotherapy and worse clinical outcomes than IDC. The treatment patterns for SCC and IDC are different. Endocrine therapy is necessary for HR-positive SCC patients.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5212-x) contains supplementary material, which is available to authorized users.