Association of Breast Implants with Nonspecific Symptoms, Connective Tissue Diseases, and Allergic Reactions: A Retrospective Cohort Analysis

Breast implant illness: Is it causally related to breast implants?

Once believed to be completely inert implants, Silicon Breast Implants (SBIs) have been shown to be able to induce a chronic inflammatory response in the body which can lead to a variety of possible manifestations ranging from the most common capsular contraction to rarer conditions such as malignancies and autoimmune diseases. Among the latter, new syndromes have been consistently recognized: Breast Implant Illness (BII) and autoimmunity/autoinflammatory syndrome induced by adjuvants (ASIA syndrome/Shoenfeld's Syndrome). The pathophysiological mechanisms underlying such syndromes are not yet clear and the overlap they show with other common conditions have sparked an important debate in the scientific community regarding their existence and their cause-effect relationship with SBIs. In this article Professor Cohen Tervaert and Professor Bassetto, leading experts in the field, are going to present arguments in favor and against such causal relationship according to the latest scientific evidence. Professor Cohen Tervaert is going to demonstrate how the evidence available is enough to prove a causal relationship as defined by the Bradford Hill's criteria. Professor Bassetto is going to highlight how the many biases that afflict the available evidence prevent us from drawing such conclusions. Professor Shoenfeld is going to moderate the discussion with its insightful conclusions.

The Areola study: design and rationale of a cohort study on long-term health outcomes in women with implant-based breast reconstructions

BACKGROUND

Implant-based breast reconstructions contribute considerably to the quality of life of breast cancer patients. A knowledge gap exists concerning the potential role of silicone breast implants in the development of so called 'breast implant illness' and autoimmune diseases in breast cancer survivors with implant-based reconstructions. Breast implant illness (BII) is a constellation of non-specific symptoms reported by a small group of women with silicone breast implants.

METHODS/DESIGN

The Areola study is a multi-centre retrospective cohort study with prospective follow-up aiming to assess the risk of BII and autoimmune diseases in female breast cancer survivors with and without silicone breast implants. In this report, we set out the rationale, study design and methodology of this cohort study. The cohort consists of breast cancer survivors who received surgical treatment with implant-based reconstruction in six major hospitals across the Netherlands in the period between 2000 and 2015. As comparison group, a frequency-matched sample of breast cancer survivors without breast implants will be selected. An additional group of women who received breast augmentation surgery in the same years will be selected to compare their characteristics and health outcomes with those of breast cancer patients with implants. All women still alive will be invited to complete a web-based questionnaire covering health-related topics. The entire cohort including deceased women will be linked to population-based databases of Statistics Netherlands. These include a registry of hospital diagnostic codes, a medicines prescription registry and a cause-of-death registry, through which diagnoses of autoimmune diseases will be identified. Outcomes of interest are the prevalence and incidence of BII and autoimmune diseases. In addition, risk factors for the development of BII and autoimmune disorders will be assessed among women with implants.

DISCUSSION

The Areola study will contribute to the availability of reliable information on the risks of BII and autoimmune diseases in Dutch breast cancer survivors with silicone breast implants. This will inform breast cancer survivors and aid future breast cancer patients and their treating physicians to make informed decisions about reconstructive strategies after mastectomy.

REGISTRATION

This study is registered at ClinicalTrials.gov on June 2^nd 2022 (NCT05400954).

Breast Implant Illness: Surgical, Autoimmune, and Breast Reconstruction Associations

Breast implant illness refers to a combination of different symptoms related to breast implant surgery, including fatigue, brain fog, and arthralgias. This malaise occurs after cosmetic and reconstructive breast surgeries, although it has not been proven to be a disease. Even recent studies have reported concluding statements of the etiology, diagnosis, and treatment as unclear and widely unknown. Therefore, this review aimed to determine the associations between the manifestations of breast implant illness in surgery and breast reconstruction, as well as the autoimmune responses involved. Complications associated with breast implants include breast pain, capsular contracture, infections, as well as other manifestations specific to breast reconstruction. Moreover, patients with implants may present with new-onset systemic sclerosis, Sjögren’s syndrome, and connective tissue diseases. However, the incidence of capsular contracture has steadily decreased with each generation of implants, particularly since the development of textured implants, as well as with the use of antibiotics and antiseptic pocket irrigation. However, the incidence of anaplastic large cell lymphoma has increased with the use of textured implants. Remarkably, the autoimmune response to these implants remains unclear. Therefore, close follow-up, careful observation of any symptom presentation, and evidence-based treatment decisions are necessary for patients with breast implants.

Breast Implant Safety: an Overview of Current Regulations and Screening Guidelines

Breast implant surgery for cosmetic or reconstructive purposes is becoming increasingly common. While the devices used are regulated and approved by the US Food and Drug Administration, all patients with breast implants require continued follow-up. Many patients will seek this care from their primary care providers, especially when follow-up with their plastic surgeon is difficult. It is vital that treating clinicians are knowledgeable about the history of breast implants, routine screening guidelines, and the recent breast implant "hot topics"-breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), connective tissue disease, and breast implant illness. This paper will provide the necessary information for primary care providers to appropriately counsel patients with breast implants to maintain not only their trust, but also their health.

Risk of rheumatic disease in breast implant users: a qualitative systematic review

Background

Recent studies on the risk of rheumatic disease among breast implant users have reported conflicting results. The primary objective of this study was to provide a systematic and critical review of the literature on the association between breast implants and the risk of rheumatic disease.

Methods

A qualitative systematic review was conducted in PubMed, MEDLINE, EMBASE, EBM-Reviews and CINAHL Complete from database inception to June 23rd, 2021. Eligible papers were full-length articles in English or French reporting original data on the incident risk of rheumatic disease among individuals with and without breast implants. Data were extracted from published reports and appraised using the Newcastle-Ottawa scale. The main outcome was incident risk of systemic sclerosis (SSc), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), fibromyalgia and other rheumatic disorders and symptoms.

Results

Out of 3,425 identified citations, 86 met inclusion criteria. Two cohort studies suggested a two-fold increase in risk of SSc, whereas three case-control studies showed no increase in risk. Three cohort studies did not find an increased risk of incident and confirmed SS among breast implant users, however symptoms of sicca, myalgia and fatigue were reported more frequently. A meta-analysis of heterogenous studies reported a less than two-fold increase in risk of RA. Studies did not support an association with SLE. Insufficient evidence was available for autoimmune myositis and other rheumatic diseases. Implant rupture detected on imaging was not clearly associated with incident rheumatic disease, although no studies specifically examined the risk associated with acute/traumatic rupture. Little data was available on the safety of saline breast implants. Explantation often led to temporary improvement.

Conclusions

Based on a small number of high-quality and methodologically robust studies, an association between breast implants and a small increase in risk of SSc and RA could not be excluded. Symptoms of sicca, myalgia and fatigue were reported more frequently among breast implant users. Overall, there remains much uncertainty in regard to the association between breast implants and the risk of incident rheumatic diseases. Individuals considering the placement of breast implants should be informed of this uncertainty.

Trial Registration

This study was registered in the PROSPERO database (#CRD42019133616).

Understanding Silicone Breast Implant-Associated Complications for Radiologists

미용적 성형 및 유방암 수술 후 재건의 목적으로 사용되는 실리콘 보형물의 사용이 국내외에서 크게 증가함에 따라 진료 영역에서 실리콘 보형물 삽입술을 받은 환자들을 어렵지 않게 접하게 되었다. 기존에 알려져 있던 보형물의 파열이나 구축과 같은 합병증 외에 최근에는 유방 보형물 연관 역형성 대세포 림프종과 같은 악성 종양과의 연관성도 보고되면서 보형물 관련한 영상 검사가 증가하고 있다. 이러한 상황에서 영상의학과 의사들은 보형물 삽입술을 받은 환자에 대해 어떤 검사가 필요하고 어떤 영상 소견이 보형물 관련 합병증을 시사하는지에 관한 충분한 지식을 갖추고 있어야 할 것이다. 본 종설에서는 영상의학과 의사들이 알아야 하는 실리콘 보형물의 다양한 합병증과 이들의 영상 소견에 대해 다루고자 한다.