LITERATURE UPDATE
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant-associated squamous cell carcinoma (BIA-SCC) are emerging neoplastic complications related to breast implants. While BIA-ALCL is often linked to macrotextured implants, current evidence does not suggest an implant-type association for BIA-SCC. Chronic inflammation and genetics have been hypothesized as key pathogenetic players, although for both conditions, the exact mechanisms and specific risks related to breast implants are yet to be established.
While the genetic alterations in BIA-SCC are still unknown, JAK-STAT pathway activation has been outlined as a dominant signature of BIA-ALCL. Recent genetic investigation has uncovered various molecular players, including MEK-ERK, PI3K/AKT, CDK4- 6, and PDL1. The clinical presentation of BIA-ALCL and BIA-SCC overlaps, including most commonly late seroma and breast swelling, warranting ultrasound and cytological examinations, which are the first recommended steps as part of the diagnostic work-up. While the role of mammography is still limited, MRI and CT-PET are recommended according to the clinical presentation and for disease staging. To date, the mainstay of treatment for BIA-ALCL and BIA-SCC is implant removal with en-bloc capsulectomy. Chemotherapy and radiation therapy have also been used for advanced-stage BIA-ALCL and BIA-SCC. In-depth characterisation of the tumour genetics is key for the development of novel therapeutic strategies, especially for advanced stage BIA-ALCL and BIA-SCC, which show a more aggressive course and poor prognosis.
Preventing Bacterial Contamination of Breast Implants Using Infection Mitigation Techniques: An In Vitro Study Chow O, Hu H, Lajevardi SS, Deva AK, Atkinson RL. Aesthet Surg J. 2024 May 15; 44 (6): 605–11. doi: 10.1093/asj/ sjae013.
Bacterial contamination of implants has been linked to biofilm formation and subsequent infection, capsular contracture, and breast implant- associated anaplastic large cell lymphoma. Reducing contamination during implant insertion should therefore reduce biofilm formation disease sequelae. The aim of this study was to compare levels of contamination between preventative techniques.
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A model to simulate the passage of implants through a skin incision was designed that utilised a sterile textured polyvinyl plastic sheet contaminated with Staphylococcus epidermidis. In the first stage of the polyvinyl contamination model, implants were subject to infection-mitigation techniques and passed through the incision, then placed onto horse blood agar plates and incubated for 24 hours. In the second stage of the study the same contamination was applied to human abdominal wall specimens. A 5-cm incision was made through skin and fat, then implants were passed through and levels of contamination were measured as described.
Smooth implants grew a mean of 95 colony-forming units (CFUs; approximately 1 CFU/cm2
) and
textured implants grew 86 CFUs (also approximately 1 CFU/cm2
). CFU counts
were analysed by the Mann-Whitney U-test which showed no significant difference between implant types (P<0.05); independent-sample t-tests showed a significant difference. The dependent-variable techniques were then compared as groups by one-way analysis of variance, which also showed a significant reduction compared with the control group (P<0.01). This in vitro study has shown the
effectiveness of antiseptic rinse and skin/ implant barrier techniques for reducing bacterial contamination of breast implants at the time of insertion.
A case of BIA-ALCL in which postoperative chest wall recurrence was highly suspected: the third reported case of BIA-ALCL in Japan Tajiri W, Shimamoto R, Koga Y et al. Surg Case Rep. 2024 Aug 23; 10 (1): 196. doi: 10.1186/s40792-024-01996-6.
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare malignancy. Many cases of BIA-ALCL are identified based on the presence of late-onset effusion and/or masses. Importantly, the United States Food and Drug Administration noted that in all cases diagnosed in patients with textured implants, the patients either had a history of mixed implantation of smooth and textured devices or no clinical history was supplied for review.
In Japan, the first case of BIA-ALCL
was reported in 2019, with a third was encountered in December 2021. There have been a total of five cases of BIA- ALCL previously reported at Japanese academic conferences (Japan Oncoplastic Breast Surgery Society. http://jopbs.umin. jp/medical/
index.html), of which only
the first case has been published. Unlike the first case, this patient had clinical features that were highly suggestive of the postoperative chest wall recurrence of breast cancer, with a mass and rash on the skin.
The patient in this case was a 45-year- old woman who had undergone breast reconstruction after breast cancer surgery of the right breast eight years previously. The patient presented with a mass and skin rash inside the inframammary area, and the authors suspected a damaged silicone breast implant (SBI) or chest wall recurrence. They examined the mass by a core needle biopsy and made a pathological diagnosis of BIA-ALCL. Imaging findings suggested internal thoracic lymph node swelling and lymphoma infiltration beyond the capsule but no metastatic lesions (cStage III). After en bloc resection of the SBI and lymphoma, adjuvant systemic therapy was performed.
The authors encountered the third case of BIA-ALCL in Japan. This was a case with clinically advanced stage of disease; however, the BIA-ALCL was found to be in remission.
Undifferentiated Pleomorphic Sarcoma Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma Chandrasiri N, Taiwo O, Ahmed M, Malhotra A, El-Sheikh S. J Breast Cancer. 2024 Jun; 27 (3): 215–22. doi: 10.4048/ jbc.2024.0054.
Breast implant augmentation is a low- risk procedure with few life-threatening complications, most commonly rupture or leakage and contraction of the capsule. Breast implant-associated (BIA) malignancies are rare. Anaplastic large cell lymphoma (ALCL) is the most well-known neoplastic condition associated with breast augmentation. Carcinomas arising in association with implants have been reported but are rarer than ALCL. BIA- mesenchymal tumours are extremely rare and most are locally aggressive fibromatosis. To date, only eight cases of BIA sarcomas have been reported. Herein, the authors describe a case of silicone BIA-undifferentiated pleomorphic sarcoma (UPS) that was initially mistaken for ALCL because of a significant clinical and radiological overlap in presentation and imaging. Here, they present the morphological and molecular features of this rare neoplasm, and review the existing literature related to BIA sarcomas to highlight the importance of considering this diagnosis in cases of recurrent ALCL- negative BIA effusions.
OCTOBER 2024
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