Breast Implant Associated Anaplastic Large Cell Lymphoma

Recently, there has been media attention regarding Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).  Because I do a significant amount of breast augmentation as well as breast reconstruction for patients who have undergone mastectomies for breast cancer, I have a lot of patients with breast implants.  I therefore decided to write a short list of frequently ask questions regarding this disease.

Q: What is Breast Implant Associated Anaplastic Large Cell Lymthoma (BIA-ALCL)?

A: Breast implant associated anaplastic large cell lymphoma is an uncommon lymphoma that has only been reported in patients with a history of a textured breast implant.  It is not a cancer of the breast tissue itself, but of the scar envelope (called the capsule) that the body naturally forms around a breast implant.  Oncology organizations currently classify BIA-ALCL as a lymphoma.  It is a spectrum of disease that ranges from a fluid collection within the capsule to a rare lymphoma.  Because this is such a rare disease, there is currently ongoing research that is being done to better understand and define BIA-ALCL.

Q: What are the symptoms of Breast Implant Associated Anaplastic Large Cell Lymthoma (BIA-ALCL)?

A: The first symptom of BIA-ALCL is usually a swelling of the breast between 2 and 28 years after the insertion of breast implants.  The average presentation is 8 years after implantation of the breast implant.  The swelling is due to a collection of fluid surrounding the implant.  This causes the breast to enlarge significantly over a period of days or weeks.  It can also present as a lump in the breast or arm pit.  It is usually completely curable if diagnosed early.

Q: What are the risks of developing BIA-ALCL?

A: Current conservative estimates suggest that greater than 35 million women worldwide have textured breast implants, with 1.5 million breast implants inserted in 2016 alone.  It is estimated that there are approximately 3 million women with textured breast implants in the current US population.  As of December 2018, the American Society of plastic surgeons has received reports of approximately 656 confirmed or suspected cases of BIA-ALCL worldwide and 257 reported cases in the United States.  Therefore, it is felt to be an uncommon disease.

An analysis of global BIA-ALCL cases has revealed a substantial variation in the incidence around the world with the lowest incidence in Europe, China in Brazil and the highest incidence in Australia and New Zealand.  Scandinavian countries, which have excellent implant registries, have had almost no reported cases.  It is therefore felt that genetic predisposition and ethnicity may play an important role.

There seems to be a significant difference in the risk of developing BIA-ALCL depending upon the type of implant that is used.  The outer shell of a breast implant can be either smooth or textured.  As of this writing, there have been no cases of BIA-ALCL reported in women exposed to smooth implants only.  Furthermore, no reports of the disease had been identified before the introduction of surface textured implants.  When looking at textured implants, there are several different types of surface texturing depending and how rough the surface is.  There are micro-textured, macro textured and polyurethane surfaces that have increasing amount of texturing.  It is currently felt that the more textured implants seem to have a higher risk.  The risk can be explained by the textured grade of the implants as follows:

Grade 1 (smooth surface only) - The current risk is felt to be ZERO

Grade 2 (micro-textured implants) - The current risk is felt to be 1 in 60,631

Grade 3 (macro textured implants) - The current risk is felt to be 1 in 3,817

Grade 4 (polyurethane surface) – The current risk is felt to be 1 in 2,832

Q: Is it a problem with silicone or saline implants?

A:  BIA-ALCL appears to purely be related to the surface of the implant and not with the implant is filled with.

Q: If it is a problem with textured implants, why would a physician use textured implants?

A: There are 2 primary reasons that a surgeon may recommend a textured surface implant.  First, some data has shown a lower rate of capsular contracture (which is when firm scar tissue forms around an implant) with use of textured implants.  Second, all tear drop or anatomic-shaped implants have a textured surface to help hold them in place.

Q: Should patients have their textured implants removed because of the risk of BIA-ALCL?

A: Neither the FDA nor any plastic surgery society currently recommends that women should preventatively remove textured breast implants to prevent BIA-ALCL.

Q: Should women with breast implants be screened for BIA-ALCL?

A: There is no blood test to specifically screen for BIA-ALCL.  The expert opinion is that asymptomatic women without breast changes do not require more than routine mammograms and breast exams.  But, if the patient experiences a change in the breast implants, especially if there is a swelling or a lump, she should undergo examination, imaging and consultation with a plastic surgeon.  If there is fluid around the implant, the fluid should be aspirated under ultrasound guidance and sent for analysis.