What is BIA-ALCL?
BIA-ALCL is a form of malignancy of the T-cells, which are involved in the immune system. It is a type of Non-Hodgkins lymphoma. Whilst other forms of ALCL are often aggressive and metastasise (or spread through the blood to other areas of the body) early, BIA-ALCL is typically very slow growing, can be diagnosed early in the disease and has an excellent prognosis when treated promptly. It also has a unique antigenic profile, with all reported cases found to be ALK negative and CD30 positive. The current theory is that BIA-ALCL is the end pathway of a sub-clinical infection of the breast prosthesis at the time of insertion. Biofilm formation on the textured implant leads to chronic inflammation and increased T cell response. These T-cells then mutate and multiply to cause a tumour mass.
What should I look out for?
Due to the increased surface area and ability to capture bacteria during implantation and protect biofilm populations in the body, textured implants have been heavily implicated in BIA-ALCL. Indeed, there have been no reported cases of BIA-ALCL in patients with only smooth implants to date. Because of this, macrotextured implants have recently been banned in France, Canada and the Netherlands.
There are four factors required to cause ALCL: Patient genetic predisposition to the disease, textured implants, bacterial colonization, and time. Patients with ALCL most commonly present with a late seroma (fluid on the implant), approximately 10 years after augmentation, or a mass adjacent to a textured implant. In the recorded literature, only 7 patients have presented with bilateral disease, and 24 with lymph node or organ metastases. If you have any new collections of fluid around your implant or a mass, you should have an ultrasound guided aspiration, the fluid sent for FLO cytometry, and tested for CD30 and ALK antigens. For most patients with diagnosed BIA-ALCL, a total capsulectomy, explantation and washout of the surgical pocket will be curative.
What is Breast Implant Illness (BII)?
Firstly, it should be noted that Breast Implant Illness and ALCL are separate disease entities. A study recently published in the American journal Plastic and Reconstructive Surgery (PRS) has shown that since the FDA warnings were released regarding textured implants and ALCL, there have been growing number of Google searches and Twitter hashtags linking Breast Implant Illness with ALCL and breast cancer. Unlike ALCL, BII is currently still relatively poorly understood and lacking in quality scientific research or evidence. Whilst public awareness of BII has grown exponentially due to social media and internet chat rooms dedicated to it, quality scientific research is a slow process, and has not yet been able to answer the many questions asked by patients with concerns. The term BII has been applied to a number of symptoms including but not limited to:
Central Nervous System – Memory loss, headaches, migraines, tinnitus, vertigo
Musculoskeletal – Muscle/Joint pain, numbness, tingling in limbs, neuralgia, slow muscle recovery after exercise
Immune/Inflammatory – Raynaud’s, Hashimoto’s, RA, scleroderma, SLE, MCTD, Sjogren’s, MS, recurrent infections, toxic shock, chronic fatigue, night sweats, slow healing, food intolerances, lymphadenitis
Gastrointestinal and genitourinary – Polyuria, liver and kidney disease, decreased libido, UTI, reflux, gastritis, weight loss/gain, dehydration, IBS, metallic taste, globus, dysphagia, pancreatitis, cholecystitis
Integument – Alopecia, dermatitis, rashes
Psychological – Anxiety, depression, panic attacks,
Cardiovascular – SOB, palpitations, arrhythmia, cardiac pain, cough.
Whilst the exact mechanism of BII is not yet understood, one theory is that silicone or one of its breakdown products may behave as adjuvants, increasing the response of either the cellular or humoral immune systems to the presence of other antigens. Known adjuvants in humans include Paraffin, petroleum jelly, silicon dioxide, beryllium, aluminium, and bacteria such as Staphylococcus, Nocardia, Salmonella, and Mycobacterium. It is possible, but not yet proven, that bacterial contamination of the implant may contribute to symptoms of BII. At a recent Plastic Surgery Convention in Australia, a retrospective analysis of implants removed by one surgeon for patients with symptoms of BII showed significantly higher rates of bacterial colonisation than those removed for non-BII related issues.
A rise in patient advocacy groups and increased access to information through social media has seen an increase in the number of patients presenting to GP’s and their surgeons concerned about BII. It would be wrong to be dismissive of these concerns. The current lack of scientific evidence of the cause of BII does not mean there is no association, particularly given what we know from the cause of ALCL and the potential effects of implants and biofilm and on the immune system.
If you have concerns about BII, it is important that you rule out other causes of these symptoms by first seeing your GP. As part of their work-up, they may order some or all of the following as preliminary blood work:
Serum IgG, IgM
Autoimmune disease markers (ANA/ANCA’s etc)
In the absence of any other medical cause for your symptoms, you may decide to consult your Plastic Surgeon for consideration of explantation. In a recent study, symptomatic patients that did not have serological evidence of any autoimmune disease after implantation had an 80% improvement in physical symptoms and a 93% improvement in psychological well-being after their implants were removed. What this shows is that even though we cannot yet test for BII or fully understand the underlying mechanisms, surgical explantation can potentially treat both the physical and psychological symptoms of patients concerned about BII. – Dr Drew Cronin