Frontline Management of BIA-ALCL

Oct 05, 2021

- a rare complication of Breast Implants

There has been considerable media and regulatory attention about a rare form of non-Hodgkin’s lymphoma arising in women with textured breast implants. The World Health Organisation has classified it as a distinct entity named Breast Implant Associated Anaplastic Large Cell Lymphoma or BIA-ALCL. The risk of BIA-ALCL is 1 in 2,500 to 25,000.

Overwhelmingly, cases of BIA-ALCL seem to be associated with a history of high surface area (textured) implants and Australia accounts for 1 in 7 of the cases reported globally perhaps reflecting the high use of textured implants over the last two decades. The disease mechanism is thought to be multifactorial however the precise aetiology is still unknown. Current research suggests surgical factors such as bacterial contamination during insertion create chronic inflammation called ‘biofilm’ and through time and a genetic predisposition tissue changes occur.

BIA-ALCL has several unique features which assist in diagnosis but also treatment. It is a T-cell lymphoma, lacks anaplastic lymphoma kinase gene translocation (ALK-) and is CD30+ receptor protein positive on immunohistochemistry. Median time to disease presentation is 7-9 years from implantation.

BIA-ALCL presents typically with a periprosthetic effusion and can be associated with breast swelling, pain, erythema and can mimic infection. Patients may also report a breast lump. Rarely there may be regional lymphadenopathy at presentation. Most women with a delayed seroma (>1yr post implantation) prove to be benign. In Australia the management of BIA-ALCL is multidisciplinary. Typically, care is shared between surgeons and haematologists. Unlike most lymphomas, surgery is the mainstay with complete capsulectomy and implant removal. Haematologists will usually drive any systemic treatment of disseminated lymphoma. Thankfully, mortality rates are extremely low.

The TGA have since cancelled registration of implicated implants and Allergan announced a voluntary recall of their BIOCELL products with an established link to BIA-ALCL. There is ongoing monitoring in place of all remaining TGA listed breast implants. The recall list is freely available through the TGA website. I believe the current dilemma is what to do with patients who still have the recalled textured implants in-situ. The option of elective explantation, capsulectomy with or without reinsertion of smooth implants should be a tailored discussion with an experienced breast implant surgeon. In essence, the options that I present to women with uncomplicated textured implants is:

• Active monitoring (examinations, point of care ultrasound, education)
• Removal of textured implants and capsule as a stand alone procedure
• Exchange of textured implants for smooth implants
• Textured implant removal and referral to plastic surgeon for autologous reconstruction if a patient has previously had a mastectomy with implant reconstruction

Currently, removal of implants and capsulectomy attracts a modest Medicare rebate, however the procedure remains discretionary through the public system. I have provided a relatively simple management plan of a patient with suspected BIA-ALCL but also a guide on those patients that are asymptomatic but are known to have textured implants in situ.

ASYMPTOMATIC PATIENTS

• Encourage regular self breast checks (monthly) and include breast implant check in annual well woman examinations.
• Obtain good quality high definition ultrasound of breast tissue, implants and nodal basins annually or biennially.
• Inform patient that implant complications are more likely with age of implants and encourage specialist surgeon review for advice regarding exchange or removal.
• Encourage patients to visit the TGA website for updated information regularly.

SYMPTOMATIC PATIENTS

• Full history and examination, ask patient to locate implant details
• Routine blood work up including inflammatory markers
• Urgent breast ultrasound
  • If periprosthetic effusion present:
    • US guided aspiration of periprosthetic effusion (aim for 50cc)
• Request flow cytometry, IHC
  • If atypical cells/CD30+ve/malignant:
    • urgent surgical referral
  • If no atypical cells:
    • Consider breast MRI to assess implant integrity
• Implant rupture present: semi-urgent surgical referral
• Implants intact: treat as seroma, repeat US 3 months
  • If results non-diagnostic:
    • urgent surgical referral
  • If breast lump identified on ultrasound:
    • 3D MMG if patient over 35
    • Core biopsy of breast mass and if present abnormal lymph nodes
• Request IHC, ER/PR/Her2 of breast lump & flow cytometry and IHC of nodes
  • if malignant
    • urgent surgical referral
  • if benign
    • semi-urgent surgical referral to ensure triple assessment concordant or need for excision biopsy/further tests

Dr Tony Palasovski
Specialist Breast Clinic
30 Osborne Street
Wollongong NSW 2500
P: 02 4228 1088
F: 02 4227 3004