All about BIA-ALCL (breast implant-associated large-cell lymphoma)

The topic of ALCL and breast implants has become inherently linked in recent years, given the discovery of a rare type of lymphoma associated with textured-surface breast implants. Over the past decade, there have been a number of reported cases of ALCL in women with textured breast implants. There are important facts and statistics to consider when reviewing the topic, and we’ll try to get through the most important of them in this blog post.

What is ALCL? 

The Leukaemia Foundation provides us with an apt definition of Anaplastic Large Cell Lymphoma (ALCL), describing it as a rare type of non-Hodgkin lymphoma made up of either malignant T-cells (the cells in the immune system) or “Null-lymphocytes”. It occurs in two forms: one which is systemic and aggressive, affecting all organs in the body, or one which is cutaneous, slow-growing and confined to the skin. It is a rare disease of which the cause is unknown. The Macmillan Cancer Foundation present a definition in lay terms, stating that ALCL develops when white blood cells called T-cells become abnormal, generally building up in. The lymph nodes and potentially affecting other areas of the body. This article also states that the condition is more common in children and young adults. The facts are slightly different however when it comes to breast implant-associated ALCL (BIA-ALCL).

What is BIA-ALCL? 

The TGA defines BIA-ALCL as a rare cancer of the immune system which is not breast cancer (which forms in the cells of the breast) but rather a cancer that grows in the fluid and scar tissue which has formed around a breast implant. There is an important distinction between BIA-ALCL and breast cancer. It is extremely important to note that this rare disease has historically only been associated with textured-surface implants. There are no cited cases of BIA-ALCL in patients with smooth implants.

The Australian Society of Plastic Surgeons states that it takes on average 7-10 years before the disease develops in a woman who has had breast implants. They state that early stage disease is curable with surgery alone, while if the disease has spread through the capsule to local lymph glands, the prognosis is less favourable. As such, it is important to recognise the symptoms.

Why have this disease been associated with breast implants?

There have been a number of articles considering the possible role of textured breast implants in causing BIA-ALCL. There are several unifying factors that have been posited to cause the condition.

  1. Textured breast implants create high surface area textures that increase the risk of bacterial contamination
  2. Bacterial contamination at the time of surgery can reach a threshold that causes inflammation
  3. The patient has a genetic predisposition to ALCL

ASPS considers that bacteria has been identified as a causation factor of ALCL, and textured implants increase the risk of bacterial contamination due to their high surface area texture.

What is the likelihood of getting BIA-ALCL? 

The current literature provides a variety of statistics regarding BIA-ALCL risk, dependant on the type of implant. In Australia, the risk of BIA-ALCL in patients with implants that have a high surface area texture is 1 in 4000 to 1 in 7000. These implants include Biocell, Allergan, Polyurethane, and Silimed. In contrast, the risk of patients that have implants with a lower surface area texture is much less, 1 in 60,000. These implants include Siltex and Mentor. There is currently no cited risk of  BIA-ALCL in patients that have smooth surface implants, and it is proposed that this is due to the reduced risk of bacterial contamination. An example of a smooth implant is the Motiva implant. En masse, the risk of BIA-ALCL remains extremely low, particularly for implants with a lower surface area.

What are the symptoms of BIA-ALCL?

In order to ensure early detection and successful treatment, patients should remain vigilant in their monitoring of changes in the breast. The most common symptom is significant and late onset swelling in one or both breasts caused by fluid build-up. This can also present itself as a lump in either the breast or armpit. A degree of swelling post-surgery is certainly normal, however all concerns should be raised with a qualified healthcare practitioner, particularly if you see a dramatic change in the volume or size of the breast.

Once swelling has been assessed by your surgeon, they may refer you for an ultrasound. BIA-ALCL cannot be detected through mammogram, and an ultrasound is necessary to diagnose the swelling. In the instance of fluid being the cause of the swelling, a fine needle aspiration will be performed to take a sample for analysis. The majority of fluid build-ups are not associated with BIA-ALCL, however it is always best to be vigilant and address these concerns.

What are the treatment options for ALCL? 

The treatment plan for BIA-ALCL is subject to the stage of the disease. According to the American Academy of Family Physicians, the majority of the information about treatment describes removal of the implant as well as the capsule surrounding the implant, and for some patients treatment with chemotherapy and radiation is required. Treatment plans are determined by the practitioner, and for most cases that are detected early when patients experience onset swelling or unusual lumps when they appear, removal of the implant and the capsule is sufficient to treat the disease, as it has not yet spread beyond the capsule.

What if I have textured breast implants?

The TGA suggests that BIA-ALCL is extremely rare, and as such, it is not recommended to remove your implants if you are a healthy person with no symptoms. The risk of this disease is as rare as 1 in 40,000 compared to the 1 in 8 who are at risk of breast cancer (regardless of whether they have implants). As such, the most important thing to consider if you do have any type of breast implant is to remain vigilant with your breast checks and appointments. Dr. Philip Richardson from Brisbane Plastic & Cosmetic Surgery in a recent article suggests that patients should be contacted by their operating surgeon every two years to receive an ultrasound and have a review appointment to ensure that patients are staying on top of their health and possible symptoms. Yet plastic surgeon consultation can be hefty, and patients may be reluctant to fork out any money when they believe there are no issues. BRAS Clinic aims to provide review services and ultrasound referrals to patients with no out-of-pocket costs, and no obligations. The goal is to ensure optimal safety and long-term maintenance for all patients. If you think you may be due for a breast implant review, please contact us. 

What if I am considering getting breast implants?

For those considering breast implants, we encourage you to continue your research and to preferably choose a smooth surface implant to mitigate the potential risk associated with textured surfaces. It is important to ensure you are always choosing a fully qualified plastic surgeon who follows the 14-point plan to minimise bacterial contamination. There are a number of considerations that need to be made when choosing a surgeon including their safety measures, the type of implant they use, the hospitals they operate in, and the number of years’ experience they possess. Always do your research, and if you would like more information on how to choose a plastic surgeon, do not hesitate to contact us. 

What next? 

Research surrounding the causes and treatment of BIA-ALCL continues to this day, and measures to ban textured implants are currently being placed under an industry spotlight. To stay up to date with the latest news and policies surrounding BIA-ALCL, make sure to follow us on Instagram @brasbrisbane