Cancer development years after breast implant has been a concern that is the talk of the town lately. This cancer is referred to as “Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL)”. It was first reported in 1997. After that, many other research studies had been conducted to evaluate the phenomenon. In 2017, Health Sciences Authority (HAS) of Singapore also issued a press release regarding this phenomenon. Till today, there has been on-going research on this occurrence as it is relatively recently noticed. This article will shed some light on matters relating to BIA-ALCL.
What is BIA-ALCL?
While BIA-ALCL is found in the breast, it is not exactly a type of breast cancer. Rather, it is considered a cancer of the immune system, specifically the lymphatic system and hence, it is a type of cancer known as lymphoma. It develops around the breast implants. It does not come from the breast tissue. In 2017, The World Health Organization (WHO) included BIA-ALCL as a clinical entity in the fourth edition of the Lymphoma Classification of WHO.
The symptoms of BIA-ALCL include breast enlargement, pain, asymmetry, lump in the breast or armpit, overlying skin rash, hardening of the breast, or a large fluid collection typically occurring at least more than a year after receiving an implant, and on average after 8 to 10 years.
Breast implants have either smooth or textured surfaces. Breast implants with textured surfaces are found to have higher risk for BIA-ALCL. Current lifetime risk of BIA-ALCL is estimated to be 1:2,207-1:86,029 for women with textured implants based upon current data over the past two decades. The possible association between smooth surfaces and development is BIA-ALCL is still being investigated.
BIA-ALCL can be treated well with surgery when discovered early. If the cancer has spread to other areas of the body, other treatments like radiation, chemotherapy and targeted immunotherapy may have to be used.
As of 2019, there were eight registered brands of breast implants in Singapore. Allergan Natrelle breast implant was the only textured surface breast implant registered in Singapore. As a precaution, HAS had disallowed the sale of Allergan Natrelle breast implant.
How does BIA-ALCL develop?
The exact pathogenesis of BIA-ALCL has not been well established. However, several mechanisms had been proposed. The main hypothesis involves a interplay with various factors. They include genetic predisposition, textured breast implant, bacterial biofilm as well as chronic inflammation.
Textured breast implant has foreign particles lined along the surface of the implant. These particles provide an environment whereby bacterial biofilm colonization can happen. As such, the area around the implant will be in a state of chronic inflammation. For patients who have a genetic predisposition (specifically the aberrantly oncogenic JAK/STAT3 pathway mutations and IL-6-induced overexpressed STAT3 signal pathway), it will result in over-expression of cells that produce the lymphocytes, leading to lymphoma known as BIA-ALCL.
Should one still get a breast implant then?
Breast implants are used mainly for either post-cancer reconstruction or for aesthetic purposes. Patients who wish to receive breast implants reconstruction need to discuss the benefits and risks of different types of implants with their plastic surgeons. There are several breast implants types available in the market. They can come in many different forms depending on brand. They can be smooth, textured, round, shaped, saline, liquid, and solid silicone. Each of the type has its own unique features and properties. The plastic surgeon may advise a certain implant shape, surface, and fill to achieve the optimal outcome for the patient. As BIA-ALCL is known to be associated with textured implants, it is a point of consideration for patients to think about when choosing what suits them.
While there has been growing awareness of the risk of BIA-ALCL after cosmetic breast implant surgery, there has been research done to address the risk of developing BIA-ALCL undergoing implant reconstruction after a mastectomy due to breast cancer as well. A new study, which the authors believe to be the first population-based estimate of the risk of BIA-ALCL after implant-based reconstruction, state that the risks of developing BIA-ALCL after cosmetic or reconstructive breast surgery remain roughly the same. Based on current statics, the authors estimate that about 12 cases of ALCL are expected to occur yearly per 1 million patients who receive breast reconstruction surgery. As such, the authors emphasize that the “absolute risk remains extremely low” and that women should not be discouraged from pursuing implant reconstruction after a mastectomy.
What is expected when diagnosed with BIA-ALCL?
After being diagnosis with BIA-ALCL, the patient will be referred for further scanning to determine if the disease has spread to other parts of the body. Whether or not the cancer has spread will determine the stage of the cancer, and therefore influence treatment plan. Management of BIA-ALCL will involve a multi-disciplinary team that will typically involve the oncologist, radiologist and the surgeon.
The oncologist will evaluate the staging of BIA-ALCL and advise on treatment planning. The radiologist will assess for spread of disease as. If the BIA-ALCL is only localized around the implant, the surgeon will just remove the breast implant and capsule around the implant.
The lymph node at the armpit may also be removed to determine if there has been spread of the disease. Patient with advanced diseases may require further treatment with chemotherapy and in some cases, radiation therapy and also possibly stem cell transplant therapy.
Post treatment, patients will have to be followed up accordingly with the medical team.
For early disease that is removed by surgery, recurrence of cancer is very rare.
What should I do if I think I may have BIA-ALCL?
It would be good to schedule an appointment with the plastic surgeon for a review. Sometimes, swelling in the breast may be cause by rupture of the breast implant. Therefore, an examination by the plastic surgeon would be important. At the same time, breast implants are not meant to last forever, and they may need replacement in some point in time.
Timely recognition and intervention are key to curative treatment when it comes to BIA-ALCL. A delay in diagnosis and treatment can make BIA-ALCL more dangerous and treatment more difficult.
Breast Augmentation with The Clifford Clinic
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