What is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), how common is it and how is it treated?

The majority of women with breast implants won’t experience any issues after having breast augmentation surgery. However, women with textured implants are at a tiny risk of contracting breast implant-associated anaplastic large cell lymphoma (also known as BIA-ALCL or ALCL), a very rare sub-type of T-cell non-Hodgkin lymphoma (NHL).

Below Consultant Plastic, Reconstructive and Aesthetic Surgeon Stephen McCulley answers some of the most frequently asked questions on this disease.

What is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?

BIA-ALCL is a very rare type of lymphoma (a type of cancer of the blood cells) that occurs in the capsule around textured breast implants (implants with a rough surface instead of a smooth surface).

Although this cancer forms in the breasts, it isn’t breast cancer, it’s a rare sub-type of T-cell non-Hodgkin lymphoma (NHL).

The diagnosis and treatment of BIA-ALCL is often straightforward and treatment usually involves surgery to remove the implant and capsule, and chemotherapy in some cases.

Earlier in the year, the Food and Drug Administration (FDA) issued a letter to health care providers outlining their background research and recommendations for the disease.

What are the symptoms of BIA-ALCL?

A patient presenting with BIA-ALCL will usually have experienced a new swelling of the breast on one side due to an unexplained persistent seroma (fluid collection around the implant). Most patients with seroma fluid collections do not have ALCL but symptoms like this should be investigated.

As well as swelling, other symptoms of breast implant associated anaplastic large cell lymphoma include:

• Breast asymmetry—one breast looks larger or is a different shape to the other
• Breast lumps
• Rarely pain associated with changes in breast
• Redness

Symptoms can start to develop a year after the surgical site has fully healed but on average it occurs seven to eight years after breast implant surgery.

As well as assessing the above symptoms, your health care provider will review your medical history and assess your general health. Once they have an overall picture of your health you’ll have a series of tests to diagnose whether you have BIA-ALCL.

If you’re experiencing any symptoms related to BIA-ALCL it’s important you speak to your doctor or the surgeon who performed your breast augmentation immediately.

How is BIA-ALCL diagnosed?

Unlike breast cancer, BIA-ALCL won’t show up on a mammogram. It’s diagnosed using ultrasound or an MRI (magnetic resonance imaging) scan to detect seroma fluid accumulation, breast lumps or swollen lymph nodes in the surrounding area.

If these tests indicate there’s excess fluid or a lump then your doctor will perform a biopsy by using a fine needle to extract fluid from the capsule (scar tissue around an implant) for testing.

You’ll also likely have a complete blood count test to determine your overall health and whether there are any abnormal cells which would indicate lymphoma.

If these test are positive then the next step is usually further tests to determine the nature of the cancer and if it’s spread.

Once the results of these tests have been reviewed, most patients will then be scheduled for surgery to remove the implant and capsule.

What treatment is available for BIA-ALCL?

The treatment for the majority of cases is surgery to remove the implant and capsule. Occasionally, if there’s suspected lymph node involvement (this is when cancer is suspected or has been detected in the lymph nodes), some lymph nodes will also need to be removed. In rare cases, patients may need chemotherapy as part of their treatment if the cancer is more advanced.

What causes BIA-ALCL?

The cause of breast implant-associated anaplastic large cell lymphoma is unknown but may be related to a very low-grade long-term infection around the implant.

Research has shown that women with textured breast implants are at a greater risk of contracting this type of cancer than women with smooth breast implants. This is thought to be because the surface area of textured implants is larger than smooth implants and therefore they’re susceptible to a greater load of bacteria attachment and biofilm. Bacterial biofilm has been implicated in cases of ALCL.

What are the risk factors associated with BIA-ALCL?

The exact cause of this disease is unknown, however, there are some factors that are believed to increase the risk of contracting the disease:

• The vast majority of women with a BIA-ALCL diagnosis have textured implants.
• On average it occurs when the implant has been in situ for seven to eight years.

According to the FDA, “patients with breast implants have an increased risk of developing this disease within the scar capsule adjacent to the implant”. So although there’s an increased risk for women with implants that are textured, the disease can potentially occur in the scar tissue adjacent to any type of implant. Therefore it’s important that all women are aware of the risks, no matter what type of breast implants they have.

Whether you have textured or smooth, or saline or silicone implants, it’s important to be aware of the risks of BIA-ALCL, whether you’re planning to have a breast augmentation or already have breast implants.

How can I reduce the risk of contracting BIA-ALCL?

As this type of cancer is so new and so rare, its cause is currently unknown. It’s strongly associated with textured breast implants, so the best way to reduce the risk of contracting BIA-ALCL is to opt for smooth implants.

Using smooth breast implants probably removes the risk of ALCL but may have a higher risk of capsular contracture or hardening around the implants. The majority of tear-drop (anatomical) implants are textured implants as this reduces the risk of rotation of the implant.

Newer style implants now have ‘micro-texturing’ which may be protective against ALCL. Speak to your surgeon about your implant options during your consultation.

How common is BIA-ALCL?

The incidence of this cancer is not accurately known but a recent estimation in the UK suggests it may affect 1 in 28,000 implants. In the UK there are 45 confirmed reported cases. I have not so far seen a case in my private or NHS patients in my practice of 20 years.

Implants with rougher types of texturing design may be at a greater risk. However, it is extremely rare in all types of implant design.

The condition has only been recognised worldwide in the last few years due to its rarity.

Should I have my textured breast implants removed?

Internationally there is no evidence or recommendation that you need to get textured implants removed or changed. There is also no recommendation that any scans are required if you have no signs or symptoms.

If you have had breast implant surgery under my care you will likely have textured breast implants. However, I do not believe there is any significant risk to you.

What’s the survival rate of BIA-ALCL?

According to the Association of Breast Surgery, “the overall survival rate for patients diagnosed with BIA-ALCL is 89% at five years. This rate is significantly higher for patients with Stage I disease who undergo complete capsulectomy and implant removal”.

Once the implants and capsule have been removed there is very little chance of the disease reoccurring and further treatment being required.

According to the American Society of Plastic Surgeons, the disease is highly treatable and to date, there have only been nine reported cases of women dying as a result of BIA-ALCL.

Do breast implants increase cancer risk?

Women with breast implants are at no greater risk of contracting breast cancer than women without implants. Women with breast implants that are textured are at risk of contracting breast implant-associated anaplastic large cell lymphoma, but this is extremely rare.

What if I’ve had breast implants due to reconstructive surgery—am I more at risk from BIA-ALCL?

No, breast implant-associated anaplastic large cell lymphoma is a cancer of the blood cells so is a different type of cancer to breast cancer. If you’ve had implants as part of your breast reconstruction surgery you are at no greater risk from contracting BIA-ALCL than women who’ve had a breast augmentation for aesthetic reasons.

As part of your breast cancer treatment, you will be monitored closely for any issues with your breast implants.

Further resources

If you’re a patient of Stephen McCulley’s and want to find out more about BIA-ALCL or if you’re considering having breast implant surgery contact Stephen today on 0115 962 4535.

If you’re concerned about the risks and complications associated with breast implant surgery then read our FAQs on the potential complications after breast augmentation here.

If you’re considering having breast augmentation surgery then read our guide to how to pick a trusted plastic surgeon to help you make the right choice.