Today we are discussing the association between certain kinds of breast implants and an increased risk of a rare type of non-Hodgkin T-cell lymphoma known as anaplastic large-cell lymphoma (ALCL), with Scott Chapin, MD, head of Chapin Aesthetics in Doylestown, Pennsylvania, who is a consultant to Sientra, a maker of breast implants, as well as with Francisco Hernandez-Ilizaliturri, MD, chief of lymphoma and myeloma at the Roswell Park Cancer Institute in Buffalo, New York.
In 2011, the US Food and Drug Administration (FDA) issued a statement regarding a possible link between certain breast implants and the development of ALCL. In 2016, the World Health Organization recognized breast implant–associated ALCL as a lymphoma that can develop following implantation of breast implants. This March, the FDA issued an additional statement saying that the agency has received 359 cases of breast implant–associated ALCL. According to the FDA, the data so far suggest that this type of lymphoma occurs more frequently after implantation of textured-surface breast implants vs smooth-surface implants.
—Interviewed by Anna Azvolinsky
Cancer Network: Dr. Chapin, let’s start with you. Could you talk about the different breast implant options available and what factors you and your patients take into account when making the choice of which implant to pick in the context of this new data?
Dr. Chapin: The patients basically have two different choices for the kind of outer shell they can use with their implants—a smooth variety and a textured variety. On the inside, we have the saline implants and the silicone gel implants. The issue we are discussing today concerns the external shell of the implant. The smooth variety is a bit less stiff and has less rippling when it is in situ or in the patient. It is, however, somewhat slippery due to the smooth surface; it has what is known as a jackhammer effect, which will cause it to expand the pocket and make it slightly larger than the original pocket that we made for that implant. What can happen is that these implants can sometimes slide out of position, even if the patient had perfect surgery. This can happen 1 year, 2 years, or 5 years later.
The textured implants have fallen into favor throughout the world, and they were beginning to catch on here in the United States because they integrate with the surrounding tissue and, most importantly, they provide control to the surgeon. The outside of a textured implant has a little bit more surface area to integrate with the tissue; it’s sort of a Velcro effect that occurs, so that when you come back 1 year, 2 years, or 5 years later, the implants are still predictably in the same position that you placed them originally. There is less capsular contracture based on whatever study you read with these implants, meaning that the scar tissue becomes more inflamed less often than with the smooth type.
Cancer Network: Dr. Hernandez-Ilizaliturri, you’ve published a case report of a patient diagnosed with ALCL who had bilateral silicone breast implants. Could you talk about that case and what we know so far about the link between implants and an ALCL diagnosis?
Dr. Hernandez-Ilizaliturri: One thing to acknowledge is that breast implants associated with ALCL are rare. We reported a case in the literature of a patient who was referred to us for evaluation and treatment. This particular patient had breast implants that were silicone-based 8 years prior to the diagnosis of ALCL. The patient had started to complain about the asymmetry in size of her breasts, which led to an evaluation by her physicians and plastic surgeons. Imaging demonstrated the presence of an abnormality in the breast around the capsule and she underwent further surgical exploration. The patient was referred to our institution after she was suspected to have ALCL, and we conducted several imaging and laboratory studies to determine if the lymphoma had spread outside the breast tissue or outside of the implant area.
In this particular case, there was no evidence of systemic dissemination, which is rare, and the patient was treated with a multidisciplinary approach, which normally involves surgeons, a radiation oncologist, and a medical oncologist. She underwent resection of the breast implants, and the surgical margins were negative upon pathology review. After surgery, the patient did very well and didn’t require any further therapy. This is often the case for the majority of patients who undergo surgical resection, when the implants are removed and there is no evidence of dissemination of the lymphoma either locally or systemically; there is really no evidence that adding further therapy provides clinical benefit. The patient has been free of cancer for about 1 year, and we examine her periodically for recurrence.
Again, these are rare malignancies. In the medical literature, there are reports that suggest that the incidence of ALCL associated with breast implants is around 1 case for every 300,000 women who undergo breast implant surgical procedures. There is not a higher association with saline or silicone implants, but some physicians report that implants that have textured surfaces are associated with a higher incidence. Usually the typical symptoms that patients complain of is enlargement of the breast that is affected by the lymphoma, which leads to medical attention and evaluation. In general, clinical outcomes are excellent and overall survival is more than 10 years. It’s important to highlight that there is a time gap between the surgical implantation and the development of the lymphoma; on average, it happens about 8 years post-implantation. Since this clinical entity is rare and the outcome is good, we have to be careful not to produce some kind of panic in the community, while still remaining aware of these rare situations and monitoring the breasts of patients who undergo breast implant procedures.