The First Reported Case of Gluteal Implant-Associated Anaplastic Large Cell Lymphoma (ALCL)

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.

Implant replacement and anaplastic large cell lymphoma associated with breast implants: a quantitative analysis

Introduction

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma associated with breast reconstruction post-mastectomy or cosmetic-additive mammoplasty. The increasing use of implants for cosmetic purposes is expected to lead to an increase in BIA-ALCL cases. This study investigated the main characteristics of the disease and the factors predicting BIA-ALCL onset in patients with and without an implant replacement.

Methods

A quantitative analysis was performed by two independent researchers on cases extracted from 52 primary studies (case report, case series, and systematic review) published until April 2022 and searched in PubMed, Scopus, and Google-Scholar databases using "Breast-Implant" AND/OR "Associated" AND/OR "Anaplastic-Large-Cell-Lymphoma". The statistical significance was verified by Student's t-test for continuous variables, while Fisher's exact test was applied for qualitative variables. Cox model with time-dependent covariates was used to estimate BIA-ALCL's onset time. The Kaplan-Meier model allowed the estimation of the probability of survival after therapy according to breast implant exposure time.

Results

Overall, 232 patients with BIA-ALCL were extracted. The mean age at diagnosis was 55 years old, with a mean time to disease onset from the first implant of 10.3 years. The hazard of developing BIA-ALCL in a shorter time resulted significantly higher for patients not having an implant replacement (hazard ratio = 0.03; 95%CI: 0.005-0.19; p-value < 0.01). Patients with implant replacement were significantly older than patients without previous replacement at diagnosis, having a median time to diagnosis since the first implant of 13 years (7 years in patients without replacement); anyway, the median time to BIA-ALCL occurrence since the last implantation was equal to 5 years.

Discussion

Our findings suggest that, in BIA-ALCL patients, the implant substitution and/or capsulectomy may delay the disease's onset. However, the risk of reoccurrence in an earlier time should be considered in these patients. Moreover, the time to BIA-ALCL onset slightly increased with age. Selection bias, lack of awareness, misdiagnosis, and limited data availability could be identified as limits of our study. An implant replacement should be considered according to a risk stratification approach to delay the BIA-ALCL occurrence in asymptomatic patients, although a stricter follow-up after the implant substitution should be recommended.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023446726.

In vitro models of soft tissue damage by implant-associated frictional shear stresses

Silicone elastomer medical implants are ubiquitous in medicine, particularly for breast augmentation. However, when these devices are placed within the body, disruption of the natural biological interfaces occurs, which significantly changes the native energy-dissipation mechanisms of living systems. These new interfaces can introduce non-physiological contact pressures and tribological conditions that provoke inflammation and soft tissue damage. Despite their significance, the biotribological properties of implant-tissue and implant-extracellular matrix (ECM) interfaces remain poorly understood. Here, we developed an in vitro model of soft tissue damage using a custom-built in situ biotribometer mounted onto a confocal microscope. Sections of commercially-available silicone breast implants with distinct and clinically relevant surface roughness (Ra = 0.2 ± 0.03 μm, 2.7 ± 0.6 μm, and 32 ± 7.0 μm) were mounted to spherically-capped hydrogel probes and slid against collagen-coated hydrogel surfaces as well as healthy breast epithelial (MCF10A) cell monolayers to model implant-ECM and implant-tissue interfaces. In contrast to the "smooth" silicone implants (Ra < 10 μm), we demonstrate that the "microtextured" silicone implant (10 < Ra < 50 μm) induced higher frictional shear stress (τ > 100 Pa), which led to greater collagen removal and cell rupture/delamination. Our studies may provide insights into post-implantation tribological interactions between silicone breast implants and soft tissues.

The plasticity of biocompatibility

Biocompatibility concerns the phenomena that occur within the interactions between biomaterials and human patients, which ultimately control the performance of many facets of medical technology. It involves aspects of materials science, many different forms of engineering and nanotechnology, chemistry, biophysics, molecular and cellular biology, immunology, pathology and a myriad of clinical applications. It is not surprising that an overarching framework of mechanisms of biocompatibility has been difficult to elucidate and validate. This essay discusses one fundamental reason for this; we have tended to consider biocompatibility pathways as essentially linear sequences of events which follow well-understood processes of materials science and biology. The reality, however, is that the pathways may involve a great deal of plasticity, in which many additional idiosyncratic factors, including those of genetic, epigenetic and viral origin, exert influence, as do complex mechanical, physical and pharmacological variables. Plasticity is an inherent core feature of the performance of synthetic materials; here we follow the more recent biological applications of plasticity concepts into the sphere of biocompatibility pathways. A straightforward linear pathway may result in successful outcomes for many patients; we may describe this in terms of classic biocompatibility pathways. In other situations, which usually command much more attention because of their unsuccessful outcomes, these plasticity-driven processes follow alternative biocompatibility pathways; often, the variability in outcomes with identical technologies is due to biological plasticity rather than material or device deficiency.

Silicone Implant Surface Roughness, Friction, and Wear

Textured silicone breast implants with high average surface roughness ("macrotextured") have been associated with a rare cancer of the immune system, Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Silicone elastomer wear debris may lead to chronic inflammation, a key step in the development of this cancer. Here, we model the generation and release of silicone wear debris in the case of a folded implant-implant ("shell-shell") sliding interface for three different types of implants, characterized by their surface roughness. The "smooth" implant shell with the lowest average surface roughness tested (Ra = 2.7 ± 0.6 μm) resulted in average friction coefficients of μavg = 0.46 ± 0.11 across 1,000 mm of sliding distance and generated 1,304 particles with an average particle diameter of Davg = 8.3 ± 13.1 μm. The "microtextured" implant shell (Ra = 32 ± 7.0 μm) exhibited μavg = 1.20 ± 0.10 and generated 2,730 particles with Davg = 4.7 ± 9.1 μm. The "macrotextured" implant shell (Ra = 80 ± 10 μm) exhibited the highest friction coefficients, μavg = 2.82 ± 0.15 and the greatest number of wear debris particles, 11,699, with an average particle size of Davg = 5.3 ± 3.3 μm. Our data may provide guidance for the design of silicone breast implants with lower surface roughness, lower friction, and smaller quantities of wear debris.

Comprehensive Evaluation of the Current Knowledge on Breast Implant Associated-Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently spotlighted T-cell origin non-Hodgkin's lymphoma with an increasing incidence of over 800 cases and 33 deaths reported worldwide. Development of BIA-ALCL is likely a complex process involving many factors, such as the textured implant surface, bacterial biofilm growth, immune response, and patient genetics. As the incidence of BIA-ALCL is expected to increase, it is important for all surgeons and physicians to be aware of this disease entity and acquire thorough knowledge of current evidence-based guidelines and recommendations. Early detection, accurate diagnosis, and appropriate treatment are the foundations of current care.

The State of the Art about Etiopathogenetic Models on Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL): A Narrative Review

BACKGROUND

Breast-implant-associated anaplastic large cell lymphoma is a rare malignancy linked to texturized breast implants. Although many researchers focus on its etiopathogenesis, this topic is affected by a lack of evidence.

MATERIALS AND METHODS

A literature review about BIA-ALCL was made.

RESULTS AND CONCLUSIONS

Although the incidence is reported between 1:355-1:30,000, there is great attention to BIA-ALCL. The incidence is uncertain due to many reasons. It may well be lower, due to inclusion in multiple databases as pointed out by the FDA and undiagnosed cases. The role of chronic inflammation, bacterial contamination, and mechanical forces was discussed. Clarification is needed to understand the mechanisms underlying the progression of alterations and mutations for BIA-ALCL; new molecular analysis and pathogenetic models should be investigated.

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.

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.

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.

Etiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Current Directions in Research

Simple Summary

The first report of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was in 1997. Although BIA-ALCL develops around breast implants, it is considered a cancer of the immune system and not a cancer of the breast ducts or lobules. Nearly all confirmed cases to date have been associated with textured surface (versus smooth surface) breast implants. As physicians have become more aware of BIA-ALCL, so has the number of reported cases, although the number of cases remains low. In most instances, patients have an excellent prognosis following removal of the breast implant and its surrounding fibrous capsule. Many theories on factors that trigger the development of BIA-ALCL, such as the presence of bacteria, have been proposed. However, the sequence(s) of events that follow the initial triggering event(s) have not been fully determined. This article summarizes the current scientific knowledge on the development of BIA-ALCL.

Abstract

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoma. Where implant history is known, all confirmed cases to date have occurred in patients with exposure to textured implants. There is a spectrum of disease presentation, with the most common occurring as a seroma with an indolent course. A less common presentation occurs as locally advanced or, rarely, as metastatic disease. Here we review the immunological characteristics of BIA-ALCL and potential triggers leading to its development. BIA-ALCL occurs in an inflammatory microenvironment with significant lymphocyte and plasma cell infiltration and a prominent Th1/Th17 phenotype in advanced disease. Genetic lesions affecting the JAK/STAT signaling pathway are commonly present. Proposed triggers for the development of malignancy include mechanical friction, silicone implant shell particulates, silicone leachables, and bacteria. Of these, the bacterial hypothesis has received significant attention, supported by a plausible biologic model. In this model, bacteria form an adherent biofilm in the favorable environment of the textured implant surface, producing a bacterial load that elicits a chronic inflammatory response. Bacterial antigens, primarily of Gram-negative origin, may trigger innate immunity and induce T-cell proliferation with subsequent malignant transformation in genetically susceptible individuals. Although much remains to be elucidated regarding the multifactorial origins of BIA-ALCL, future research should focus on prevention and treatment strategies, recognizing susceptible populations, and whether decreasing the risk of BIA-ALCL is possible.

The Crucial Role of Surgical Treatment in BIA-ALCL Prognosis in Early- and Advanced-Stage Patients

BACKGROUND

Studies on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are trying to optimize medical and surgical treatments for early and advanced stages of this disease. The aim of this article is to share the experience gathered on the authors' prospectively collected 46 well-documented cases.

METHODS

Italian physicians are obliged to report BIA-ALCL cases to the Italian Ministry of Health. Because of this cooperation with health care professionals, the competent authority has coordinated and centralized the collection of information for each patient in 46 cases of BIA-ALCL. Statistical analyses with cumulative incidence and corresponding 95 percent confidence interval are provided for each year, dividing the number of new cases that occurred in a defined year and the population at risk of experiencing BIA-ALCL during the same year.

RESULTS

The mean time to the onset of symptoms is reduced to 6.4 ± 3.77 years (range, 1 to 22 years). Increased knowledge has also shortened the average time to diagnosis, at 7.2 ± 3.71 years (range, 2 to 22 years). A late seroma appears in 91 percent of cases. The patient who died underwent limited surgery. The Italian incidence has been estimated as 2.8 per 100,000 patients receiving implants (95 percent CI, 0.88 to 4.84) in 2015; 2.1 (95 percent CI, 0.43 to 3.86) in 2016; 3.2 (95 percent CI, 1.11 to 5.31) in 2017; and 3.5 (95 percent CI, 1.36 to 5.78) in 2018.

CONCLUSION

Although the number of cases has risen slightly, BIA-ALCL is still a rare disease with a stable incidence, easily recognized and with a favorable prognosis also in advanced stages if complete surgical excision is performed.

Breast Prosthesis Syndrome: Pathophysiology and Management Algorithm

The cosmetic use of devices like prostheses to increase breast volume is nothing new. It is calculated that millions of people have been exposed to silicone in several ways, including breast implants, and since 1964 there has been uncertainty regarding their safety. We did not find in the literature any studies that reported the appearance of a specific immunological disease in patients with silicone breast implants. Furthermore, there are also neither case-control studies nor reports of patients proving that symptoms of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) occurred after the placement of silicone implants nor that the patients had pre-existing symptoms. Several studies link silicone to allergic reactions and the development of systemic autoimmune diseases; however, other studies deny this association. There are currently several theories about the effect of silicone on the body. One theory with greater acceptance proposes an adjuvant effect of silicone on the development of autoimmune diseases in genetically predisposed patients. However, the variety of symptoms occurring in patients who develop these pathologies leads to doubts about the relationship between the adjuvant effects of a silicone prosthesis may have with a specific autoimmune disease or a mix of these diseases. The lack of consensus on this topic obliges a full review of what has already been reported in the literature to integrate the knowledge and propose a focus for new research on this matter. LEVEL OF EVIDENCE IV: 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 Review with Emphasis on the Role of Brentuximab Vedotin

Breast implant-associated anaplastic large cell lymphoma is a recently recognized complication of textured breast implants. It typically presents as unilateral peri-implant swelling approximately 7-10 years after implantation. While the course is usually indolent, breast implant-associated anaplastic large cell lymphoma may form a locally invasive mass and metastasize to regional lymph nodes or beyond to distant sites. Surgical excision has been well established as the standard of care for localized disease; however, guidelines directing management of advanced, recurrent or unresectable disease are based on limited and extrapolated evidence. The CD30-targeting immunoconjugate, brentuximab vedotin, has been utilized in this setting, typically in combination with chemotherapy. We recently reported a patient with unresectable breast implant-associated anaplastic large cell lymphoma who was treated with brentuximab vedotin monotherapy and has now sustained complete remission for 2.6 years. Herein, we provide an up-to-date review of the epidemiology, pathogenesis, clinical features, diagnosis and management of breast implant associated anaplastic large cell lymphoma with emphasis on the role of brentuximab vedotin.

What is the Evidence of Lymphoma in Patients with Prostheses Other Than Breast Implants?

INTRODUCTION

Medical devices such as hip, knee, breast, vascular prostheses, among others, are very useful in different pathologies. We cannot doubt that their use is a great tool, besides being an advance in medicine; they provide a change in the quality of life of many patients; however, they are not exempt from adverse reactions and events.

METHODS

We conduct a systematic review about lymphoma in the presences of prostheses other than breast implants.

RESULTS

We selected 21 publications with a total of 24 patients. The largest number of prostheses was related to long bones in a total of 13 prostheses. The most frequent symptoms were: pain (52%), inflammation (24%), visible or palpable mass 20%. The most frequent type of lymphoma was non-Hodgkin B cell lymphoma in 14 cases.

DISCUSSION

The presence of microparticles make biological degradation and wear of the implants, with macrophage and lymphocyte activation and the consequent production of proinflammatory cytokines such as tumor necrosis factor α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2).

CONCLUSION

Lymphoma is not a common disease in patients with prostheses, and more data are needed to identify risk factors and make proper diagnoses.

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.

Invited Discussion on: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and the Textured Implant Crisis

The author discusses some important points about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and adds new and updated information about the disease (ALCL). 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.

Death by Implants: Critical Analysis of the FDA-MAUDE Database on Breast Implant-related Mortality

Since the 1992 moratorium by the Food and Drug Administration (FDA), the debate on the association of breast implants with systemic illnesses has been ongoing. Breast implant-associated anaplastic large cell lymphoma has also raised significant safety concerns in recent years.

Methods

A systematic search of the Manufacturer and User Facility Device Experience (MAUDE) database was performed to identify all cases of breast implant-associated deaths reported to the FDA.

Results

The search identified 50 reported cases of apparent implant-related mortality; breast implant-associated anaplastic large cell lymphoma comprised the majority of fatal outcomes (n = 21, 42%), followed by lymphoma (n = 4, 8%), breast cancer (n = 3, 6%), pancreatic cancer (n = 2, 4%), implant rupture (n = 2, 4%), and postoperative infections (n = 2, 4%). Single cases (n = 1, 2% each) of leukemia, small bowel cancer, lung disease, pneumonia, autoimmune and joint disease, amyotrophic lateral sclerosis, liver failure, and sudden death, and 2 cases (4%) of newborn deaths, to mothers with breast implants, were also identified. A literature review demonstrated that 54% of alleged implant-related deaths were not truly associated with breast implant use: the majority of these reports (82%) originated from the public and third-party sources, rather than evidence-based reports by health-care professionals and journal articles.

Conclusions

Although there exists a need for more comprehensive reporting in federal databases, the information available should be considered for a more complete understanding of implant-associated adverse outcomes. With only 46% of FDA-reported implant-related deaths demonstrated to be truly associated with breast implant use, there exists a need for public awareness and education on breast implant safety.