Breast Implant Associated – Anaplastic Large Cell Lymphoma - PowerPoint Presentation

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Breast Implant Associated – Anaplastic Large Cell Lymphoma BIA - ALCL

Drs. Hofer and

Zhong

University Health Network

Toronto

May 2019

ACKNOWLEDGEMENTDr. Peter Lennox from UBC

Dr. Mark Clemens from MD Anderson

Dr. Robert

Strazar

(UHN clinical fellow)

What is it?Breast Implant Associated Anaplastic Large Cell Lymphoma

(BIA-ALCL) is a novel and rare lymphoma

Recently recognized by the

World Health Organization

Acts differently than other lymphomas

BIA-ALCL is generally an indolent and localized disease with excellent prognosis when treated early

What implants are involved?

Has been associated only with textured devices

What is the cause?

Chronic inflammation because of bacteria/biofilm

Immune reaction to this biofilm

Textured contour may have facilitated bacterial adherence

Probably also in a

genetically susceptible

individual

What about smooth implants?No definitively confirmed cases with only smooth implants

Smooth implants have been around 20 years longer and no confirmed cases

Smooth implants should be safe

Who is monitoring this?The plastic surgery societies are working closely with:

National Comprehensive Cancer Network

(NCCN)

lymphoma oncologists, plastic surgeons, radiation oncologists, and surgical oncologists

Health Canada

FDA

Plastic Surgery Societies

BIA-ALCL Global

Network

Roundtable

Consistent messaging on diagnosis and treatment across international societies

Global prospective registry with standardised data

Cross-country data exchange

Network for disbursement of disease updates

Localised access to medical care

Centralised tissue repositories

24 countries represented

Australia:

Anand

Deva, MD

Belgium:

Ivar

van

Heijningen

, MD

Brazil:

Alexandre

Passos

, MD

Canada: Peter Lennox, MD

Finland:

Catarina

Svarvar

, MD

France: Michael

Atlan

, MD

Germany:

Raymund

Horch

, MD

Japan: Toshiharu

Minabe

, MD

Ireland:

Catriona

Lawlor

, MD

Israel:

Yoav

Barnea

, MD

Netherlands:

Hinne

Rakhorst

, MD

New Zealand: Julian Lofts, MD

South Africa: Chris

Snijman

, MD

South Korea: Roe, Tae Suk MD

Spain: Antonio Diaz Gutierrez, MD

Sweden: Per

Heden

, MD

Taiwan:

Nai

-Chen Cheng, MD

United Kingdom: Joe

O’Donoghue

, MD

How common is this?

ALCL

is RARE

Odds

for textured implants only

are variable around the world1 in 3,817 (US data from FDA)

1 in 4, 835 (Canadian data from 2018)

Only

700

cases around the world

Out of millions of people with breast implants

The most common implant is textured

28

in Canada

To put it into perspectiveOdds of being struck by lightening in your lifetime

1 in 3000

Odds of being born with 11 fingers or toes

1 in 500

Risk of breast cancer

1 in 8 in the average population1 in 2 in BRCA gene carrier

How do we look for it?

A large spontaneous fluid collection (78% of patients)

Average of 7 to 10  years after textured device

Sometimes associated palpable mass or lymph nodes

But don’t I have fluid around my implant?

Every implant will likely have a scant or minimal amount (5-10 mL) of surrounding fluid

This is normal

What do I do if I have a seroma?

See your surgeon

Ultrasound and fluid sampling will diagnose ALCL

How do we treat it?

The vast majority BIA-ALCL patients have

early stage

disease (when the disease is still contained in the capsule)

Treated with:

Complete surgical excision

Remove the implant with the surrounding fibrous capsule

Immune therapy or chemotherapy is

rarely

required (10% when lymphoma cells are outside the capsule)

Has anyone died?3 reports of BIA-ALCL associated death in Australia (FDA)

No deaths reported from BIA-ALCL in Canada

Delay in seeking treatment related to events

Summary

When diagnosed early, BIA-ALCL is commonly indolent and slow growing with an excellent prognosis, particularly when treated with surgery

Should I just remove my implant now?Removal of implants and total excision of capsule and replacement with a smooth device is associated with a

10-15% risk of complications

Implant infection

Seromas

and hematomas

Implant malpositionImplant loss

The risk of complications is significantly higher than the risk of ALCL

What to do about it?

Currently Health-CAN and FDA

DOES NOT recommend

explanation without symptoms

Risks of surgery outweigh benefits

See your surgeon for an exam

Follow up with your surgeon annual or semi-annual basis

Unless there are symptoms, risks of surgery outweigh the risks of ALCL

Conduct regular breast self-exams and see your healthcare professional for periodic follow-up.

If you experience unusual changes to your breasts, including breast pain, sudden swelling, or a lump, consult a healthcare professional.

Removing your breast implants is not recommended if you do not have any signs or symptoms suggesting BIA-ALCL. Patients should discuss the risks and benefits of removal with their healthcare professional.

Conclusion Health Canada has banned the use of textured implants from Allergan to avoid the development of this rare lymphoma, textured implants are still available by other manufacturers

Breast implant ALCL is a rare cancer but can cause a great deal of anxiety in breast cancer patients reconstructed with implants.

At UHN, we will see and examine all of our patients with concerns about their implants

Currently there is no recommendation to remove textured implants by ANY health authority

We need to approach this with each patient on a individual basis