In July, we reported on a rare cancer called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). It's technically not breast cancer, but a type of non-Hodgkin's lymphoma that grows in the tissue surrounding textured breast implants. In a review published yesterday in JAMA Surgery, researchers warn that this cancer might not be as rare as we thought—it's underreported, underdiagnosed, and misunderstood, they say.
For the study, professors and surgeons from Penn State College of Medicine gathered 115 research papers on BIA-ALCL. Then they analyzed the 95 patient cases in the literature to get a better idea of how the cancer develops, how and when it's diagnosed, and how it's best treated. The cancer grows an average of 10 years after implants are inserted and it's almost exclusively in women with textured implants, they found. The rough surface of these implants probably leads to chronic inflammation, a common cause of lymphomas, that turns T-cells malignant.
BIA-ALCL was first recorded in 1997, and it's been diagnosed more and more often over the last two decades. It's estimated that 1 in 30,000 women with breast implants will develop the cancer, but that rate probably doesn't reflect reality: Newer research shows it's more common, "suggesting that the incidence may actually be closer to 1 case per 4,000," the authors write.
"Our main goal of the review article was to disseminate information about this rare entity to other providers—non-plastic surgeons—who often initially see patients with a breast complaint," says Ashley Leberfinger, a general surgery resident at Penn State Health Milton S. Hershey Medical Center and one of the study's authors. "We hope that increasing awareness will help prevent a missed or delayed diagnosis."
Women usually notice something's amiss because one of their breasts is all of a sudden much larger than the other. That's because they've developed a seroma—a collection of fluid that builds up beneath the skin—around one of their implants.
"In the past, women would go to their plastic surgeons, they would switch the implant out, and no fluid would be tested," says Dino Ravnic, an assistant professor of surgery at Penn State College of Medicine and the paper's senior author. But if a patient has a seroma, the doctor should order what's known as a CD30, the only test that can detect the cancer in the fluid. When the cancer is caught early, the patient has a good chance of making a complete recovery: Of the 359 BIA-ALCL cases that have been reported to the FDA, only nine patients have died.
But doctors who don't know about this disease may treat the tumor like any other lymphoma, even though BIA-ALCL calls for a different treatment plan. It requires surgery, not chemotherapy or radiation. That means removing the implants and the tissue, or capsule, surrounding them. "When the physician doesn't realize that the lymphoma is coming from the implant, they usually just try chemotherapy and radiation therapy," says Roberto Miranda, a pathologist at MD Anderson Cancer Center, where he's helped diagnose more than 30 BIA-ALCL patients. "They don't do surgery, which is the primary therapy for BIA-ALCL."
In other lymphomas, it's no big deal if the tumor has positive margins—meaning some cancer cells are left in the body after the tumor has been removed—because chemotherapy, radiation, or immunotherapy will kill them off. But since BIA-ALCL patients normally don't receive further treatment after the implants and cancer have been removed, it's crucial that every last cancer cell comes out. "In this particular cancer, margins are essential," Miranda says. "They have to be absolutely negative, because if the surgeon leaves some of the disease behind, it's going to recur."
It's uncommon for the disease to metastasize and spread beyond the breast, but when it does, it's almost always because the doctor didn't correctly diagnose the patient, allowing the disease to progress, Miranda says. That's the mistake that Ravnic hopes becomes less and less common as more doctors become aware of this disease.
Some plastic surgeons still offer textured implants because they're less likely than smooth ones to move around or cause visible rippling beneath the skin. Ravnic, who is also a plastic surgeon at Penn State Hershey, no longer offers textured implants to his patients. In terms of BIA-ALCL, smooth implants are the safer choice: 203 of the cases reported to the FDA characterized the implants' surface. Only 28 of those patients had smooth implants, versus 175 who had textured ones.
The researchers hope that increased awareness about BIA-ALCL will spur more much-needed research on the disease and encourage better patient care overall. Doctors should brief their patients on the risks associated with breast implants and require yearly post-op follow-ups, Ravnic says. Most importantly, they hope their review leads to more swift—and accurate—diagnoses. The goal, like with so many illnesses, is a 100 percent survival rate.
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