Anaplastic large-cell Lymphoma (ALCL) is a hot topic today as it relates to breast implant surgery. According to Wikipedia, anaplastic large-cell lymphoma (ALCL) is a type of non-Hodgkin lymphoma involving aberrant T-cells.
Recently, an association has been found between breast implants, especially textured implants in the United States, and this form of cancer. Fortunately, the incidence is very low…one paper reporting a risk of 1 in 300,000. The most typical presentation is seroma (fluid collection) forming in the breast, several years or months after breast implant surgery. The fluid must be sent for appropriate bacterial, fungal, and specific markers for this type of cancer. The cure rate for this form of cancer appears to be very high, although because of the small number of cases, more data is required. In most cases, complete removal of the implant capsule is adequate.
But is implant related ALCL truly a form of cancer?
A recent paper in the Journal of Plastic and Reconstructive Surgery (June 2016 issue, pages 1659-1669), which in my opinion, will be considered one of the landmark papers in our profession, has shown a clear association between bacterial contamination of the breast capsule and development of ALCL.
In this study, 26 breast implant associated ALCL capsule samples were collected from four centers (from the United States and Australia). In addition, three samples were collected from the same patient, but from the normal, non-involved breast. Non-tumor capsule was also collected from 62 patients who were undergoing revision surgery for significant capsular contracture.
All capsules were checked for presence of biofilm. Wikipedia describes biofilm as any group of microorganisms in which cells stick to each other and often these cells adhere to a surface. These colonies of bacteria produce a biological layer on top, in effect protecting the colony from being attacked by the body’s immune system or antibiotics. Biofilm is now believed to be involved in chronic, non-heling infections and wounds, breast implant infections or capsular contracture which may occur many years after surgery.
Both ALCL and non-tumor capsules yielded high mean number of bacteria (over 40,000,000 bacteria per milligram of tissue). However, in ALCL, there was a statistically significant presence of Ralstonia species, a Gram negative bacteria, as compared to samples from the capsular contracture group, which mainly grew Staphylococcus species, a Gram-positive bacteria.
The paper is followed by an expert commentary, which highlights several important points.
As we have believed for many years, it seems more and more apparent one, or perhaps, the main cause of clinically significant capsular contracture is biofilm formation over the implant. There appears to be a bacterial dose related response, as the normal capsule from the contralateral non ALCL involved breast had lower concentration of bacteria than the capsular contracture group. This also may be the reason textured implants have a higher association with ALCL as the texturing allows bacteria to “hide” better and form a more efficient biofilm.
Secondly, based on this paper, it appears that Gram-positive bacteria illicit a fibrotic response (capsular contracture) versus Gram-negative bacteria, which illicit a T-cell (auto-immune) response.
Given the indolent nature of implant-related ALCL, which is a term coined by oncologists and not plastic surgeons, it seems more reasonable, given the new data, that this entity is not a true form of cancer as much as it is a lymphoproliferative process. Stay tuned, as more research is in the horizon!
For now, we as plastic surgeons do our best to minimize contamination of the implant. The patient is given intravenous antibiotics before surgery, the pocket for the implant is created with as little trauma and bleeding as possible, the pocket is irrigated with triple-antibiotic solution several times, and new gloves are used for placement of the implant.
Michael A. Jazayeri, M.D. is a board certified plastic surgeon with over 16 years of experience. His office is located in Orange County, California. To schedule a complimentary consultation, please call (714) 834-0101.
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