INCIDENCE OF ANAPLASTIC LYMPHOMA AFTER BREAST IMPLANT

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is rare, but diagnoses seem to be increasing as both patients and clinicians become more aware of this complication, researchers in Pennsylvania say.

The exact incidence is unknown given a lack of standardized diagnostic criteria, but estimates range from one case per 30,000 to as high as one per 4,000 – even one per 1,000.

Despite disparate findings, “it is very likely that the recognized incidence of BIA-ALCL will increase significantly in coming years,” Dr. Dino Ravnic of Penn State Health in Hershey told Reuters Health.

“BIA-ALCL seems to be underreported and still unrecognized by a large segment of medical practitioners who may come in contact with breast implant patients,” he said by email.

“Furthermore, there appears to be a link between BIA-ALCL and textured breast implants, which have increased in popularity in recent years,” he observed.

In light of the evidence, he added, “the Plastic Surgery Division at Penn State College of Medicine no longer offers textured implants to any of our patients.”

Dr. Ravnic and colleagues conducted a systematic review of the literature from the first documented case of BIA-ALCL in 1997 through January 2017.

As reported online October 18 in JAMA Surgery, 30 review articles, 44 case reports or series, 15 original research articles, and 26 “other” articles (e.g., techniques, special topics, letters) were included. In all, there were 93 cases reported in the literature, plus two unreported cases from the medical center at Penn State.

Almost all cases were associated with a textured device, the team found. The underlying mechanism is believed to be chronic inflammation from indolent infections, leading to malignant transformation of T cells that are anaplastic lymphoma kinase (ALK)-negative and CD30-positive.

The mean time to presentation was 10 years after implant in patients whose mean age was 51. On presentation, 66% had an isolated late-onset seroma and 8% had an isolated new breast mass.

Ultrasound with fluid aspiration can be used to diagnose BIA-ALCL, while “treatment must include removal of the implant and surrounding capsule,” the authors state. “More advanced disease may require chemotherapy, radiotherapy, and lymph node dissection.”

Dr. Ravnic said, “The risks of BIA-ALCL may not be discussed with patients during the preoperative visit. In light of the new information, this discussion should be an important aspect of the consent process. . . . It is of utmost importance that patients have yearly follow-up with the implanting surgeon.”

Dr. Frederick Locke of Moffitt Cancer Center in Tampa, Florida told Reuters Health, “Women with breast implants, primary care physicians, plastic surgeons, and breast surgeons should have a high index of suspicion for BIA-ALCL in women who present with hardening of the implant or a fluid collection around the implant.”

He suggests referring patients to the U.S. Food and Drug Administration’s information on breast implants (http://bit.ly/2n6LpEe).

Dr. Benjamin Anderson and Dr. Shannon Colohan, both of the University of Washington in Seattle, explained in a joint email to Reuters Health, “Textured implants (as opposed to smooth-surface implants) were created to help reduce the incidence of capsular contracture. Anatomic-shaped implants are also textured, and this may help reduce rotation of the shaped implant (to avoid ‘upside-down’ implant).”

“According to the American Society of Plastic Surgeons,” they note, “women who develop BIA-ALCL may observe changes in the look or feel of the area surrounding the implant some time well after their initial surgical sites are fully healed.”

“Patients should be encouraged to seek care if they notice pain, lumps, swelling, fluid collections or unexpected changes in breast shape, including asymmetry around the implant,” they suggest. “Because the syndrome is so rare, this is not an reason to have implants exchanged in the absence of some issue or new finding.”

“However,” they advise, “women with implants should be encouraged to undergo routine mammographic screening at a center that is familiar with how to perform mammography with implants in place.”

SOURCE: http://bit.ly/2iwKyhG

JAMA Surg 2017.