Breast Implant-Associated Bilateral B-Cell Lymphoma

An Update on Implant-Associated Malignancies and Their Biocompatibility

Implanted medical devices are widely used across various medical specialties for numerous applications, ranging from cardiovascular supports to orthopedic prostheses and cosmetic enhancements. However, recent observations have raised concerns about the potential of these implants to induce malignancies in the tissues surrounding them. There have been several case reports documenting the occurrence of cancers adjacent to these devices, prompting a closer examination of their safety. This review delves into the epidemiology, clinical presentations, pathological findings, and hypothesized mechanisms of carcinogenesis related to implanted devices. It also explores how the surgical domain and the intrinsic properties and biocompatibility of the implants might influence the development of these rare but serious malignancies. Understanding these associations is crucial for assessing the risks associated with the use of medical implants, and for developing strategies to mitigate potential adverse outcomes.

Breast silicone implants' pericapsular impairment: current underdiagnosed status

Many complications related to silicone implants have been reported recently, from clinical symptoms manifestations to association with some specific types of cancer. During the early 2010s, it was believed that implants were biocompatible and inert to the human body and that gel bleeding/leakage events were rare and without repercussions for the human body. However, at the end of 2010s, several studies pointed out that gel bleeding was more frequent than previously believed, and the pathogenic potential of free silicone should not be ignored. The Food and Drug Administration recommends performing magnetic resonance imaging in asymptomatic patients 5-6 years after implant placement. The descriptors in the Breast Imaging and Reporting Data System lexicon seem outdated for classifying the new generations of implants with cohesive gel, which hinders the diagnosis of device complications. In this review, supported by our research data publications related to silicone implants for 6 years on a prospective study protocol, most of them being original articles, we summarized the main complications observed in clinical practice and discuss the impact of these changes on patients' outcomes focusing on the pericapsular space.

[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.

Clinical Implications and Management of Non-BIA-ALCL Breast Implant Capsular Pathology

SUMMARY

The breast implant capsule is a dynamic structure that forms following the implantation of a device. Although normally benign, increased awareness of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) highlights that disease may arise from the capsule. BIA-ALCL presents as a late seroma or mass but explains few of the late seromas found in breast implant patients. To date, many of these seromas lack a clear cause and are often described as "idiopathic." Several benign and malignant breast implant capsular diseases can cause a late seroma or mass, including breast implant-associated squamous cell carcinoma. Similar to early reports of BIA-ALCL, these conditions are rare and largely limited to case reports or series. The purpose of this special topic is to present a narrative review highlighting capsular abnormalities that contribute to the formation of late seroma or mass in an attempt to broaden the differential diagnosis and help plastic surgeons identify the cause. Specifically, we review the presentation and management of BIA-ALCL, synovial metaplasia, capsular epithelialization, late hematoma, double capsule, breast cancer, squamous cell carcinoma, mesenchymal tumor, and B-cell lymphoma. Although rare, plastic surgeons should consider these capsular conditions as causes of late seromas and masses. Usually, these conditions may be diagnosed by following the National Comprehensive Cancer Network screening guidelines for BIA-ALCL. Thorough evaluation and workup of late seromas and masses may lead to improved characterization of these rare breast implant capsular conditions and improve our understanding of their pathophysiology and management.

Interleukin 17 and senescent cells regulate the foreign body response to synthetic material implants in mice and humans

Medical devices and implants made of synthetic materials can induce an immune-mediated process when implanted in the body called the foreign body response, which results in formation of a fibrous capsule around the implant. To explore the immune and stromal connections underpinning the foreign body response, we analyzed fibrotic capsules surrounding surgically excised human breast implants from 12 individuals. We found increased numbers of interleukin 17 (IL17)-producing γδ⁺ T cells and CD4⁺ T helper 17 (T_H17) cells as well as senescent stromal cells in the fibrotic capsules. Further analysis in a murine model demonstrated an early innate IL17 response to implanted synthetic material (polycaprolactone) particles that was mediated by innate lymphoid cells and γδ⁺ T cells. This was followed by a chronic adaptive CD4⁺ T_H17 cell response that was antigen dependent. Synthetic materials with varying chemical and physical properties implanted either in injured muscle or subcutaneously induced similar IL17 responses in mice. Mice deficient in IL17 signaling established that IL17 was required for the fibrotic response to implanted synthetic materials and the development of p16^INK4a senescent cells. IL6 produced by senescent cells was sufficient for the induction of IL17 expression in T cells. Treatment with a senolytic agent (navitoclax) that killed senescent cells reduced IL17 expression and fibrosis in the mouse implant model. Discovery of a feed-forward loop between the T_H17 immune response and the senescence response to implanted synthetic materials introduces new targets for therapeutic intervention in the foreign body response.

Splenic marginal zone B-cell lymphoma associated with ruptured breast implants: case report and review of the literature

We describe splenomegaly and bilateral grade 2 Baker breast capsular contracture in a woman who had undergone augmentation mammoplasty. This case represents the first documented instance of splenic marginal zone lymphoma, and is among the rare reports of B-cell lymphoma, arising in a patient with breast implants.

Bilateral breast implant associated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): A case report

INTRODUCTION

An estimated 30.000 breast implants are placed in the Netherlands annually. An increasing amount of reports have linked implants to the rare anaplastic large cell lymphoma (ALCL). Other implant-related lymphomas, such as those of B-cell lineage, are much rarer.

PRESENTATION OF CASE

A 62-year-old female presented with pain and Baker grade III capsular contraction of the right breast. Subpectorally placed textured anatomical implants had been in situ for 26 years after cosmetic augmentation. Magnetic Resonance Imaging (MRI) showed bilateral implant leakage. Explantation of both implants confirmed bilateral leakage after which symptoms went into remission. Three months later our patient noticed an erythematous area, scar swelling and serous fluid leakage on the lateral side of the inframammary fold of the right breast. Siliconomas were excised bilaterally together with a partial capsulectomy on the left. Histopathology and immunohistochemical analysis showed monotonous small cell B-lymphocytic infiltration (CD20+, CD5+, CD23+, ALK-) in both capsules, highly suggestive for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL).

DISCUSSION

CLL/SLL are classified as nearly the same disease. The primary difference is the localization; CLL is found the bone marrow and blood whereas SLL is predominantly in the lymph nodes and spleen. There are no previous descriptions of bilateral CLL/SLL found in periprosthetic capsules.

CONCLUSION

Breast implants are increasingly linked to various malignancies. In most cases, including our patient, implant explantation together with long-term follow-up suffices. MRI yields additional value in early stage diagnosis. More research is required to further optimize multidisciplinary care and improve patient outcomes.

Is breast implant-associated anaplastic large cell lymphoma a hazard of breast implant surgery?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) may occur after reconstructive or aesthetic breast surgery. Worldwide, approximately 1.7 million breast implant surgeries are performed each year. To date, over 500 cases of BIA-ALCL have been reported around the world, with 16 women having died. This review highlights the most important facts surrounding BIA-ALCL. There is no consensus regarding the true incidence rate of BIA-ALCL as it varies between countries, is probably significantly under-reported and is difficult to estimate due to the true number of breast prostheses used largely being unknown. BIA-ALCL develops in the breast mostly as a seroma surrounding the implant, but contained within the fibrous capsule, or more rarely as a solid mass that can become invasive infiltrating the chest wall and muscle, in some instances spreading to adjacent lymph nodes, in these cases having a far worse prognosis. The causation of BIA-ALCL remains to be established, but it has been proposed that chronic infection and/or implant toxins may be involved. What is clear is that complete capsulectomy is required for treatment of BIA-ALCL, which for early-stage disease leads to cure, whereas chemotherapy is needed for advanced-stage disease, whereby improved results have been reported with the use of brentuximab. A worldwide database for BIA-ALCL and implants should be supported by local governments.

A Case Report of a Breast Implant-Associated Plasmacytoma and Literature Review of Non-ALCL Breast Implant-Associated Neoplasms

Lymphomas associated with breast implants are rare, with the most common being anaplastic large cell lymphoma (ALCL). Non-ALCL breast implant-associated lymphomas are even more rare, with only a small handful of such neoplasms reported to date. Given the need to better understand these pathologies as well as the increasing clinical and media attention being paid to these diseases, we review the available literature of hematolymphoid neoplasms other than ALCL associated with breast implants and describe the first case of a patient diagnosed with a primary breast implant-associated plasmacytoma.

LEVEL OF EVIDENCE: 5