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A rare type of lymphoma that forms around breast implants may be more common than recognized, but the disease does not require systemic treatment once the implants are removed, according to an expert consensus panel.
The slow-growing anaplastic large cell lymphoma (ALCL), an indolent form of non-Hodgkin's lymphoma, that is linked to breast implants has a better prognosis than systemic cases, Soeren Mattke, MD, DSc, of the RAND Corporation in Boston, and colleagues reported.
Taking out the implant and capsule of tissue around it would likely prevent recurrence without need for adjuvant radiation or chemotherapy, they recommended online in Plastic and Reconstructive Surgery.
An FDA warning was issued in January based on 34 case reports of ALCL in women with breast implants, which the agency had received since 1997. Further controversy erupted last month when the watchdog group Public Citizen notified the FDA that plastic surgery groups appeared to be advising members to downplay the risk.
The FDA urged caution in interpreting the risk, calling for a breast implant registry to monitor the situation. However, the FDA did not recommend routine removal of implants in women without symptoms or suspicious abnormalities.
Mattke's group recently reported a review of non-Hodgkin's lymphoma in women with implants, with cases most being ALCL and typically involving a seroma in the fibrous capsule around the implant.
Because so much of the information in the literature is incomplete, Mattke and colleagues convened a group of 10 experts in medical oncology, hematopathology, immunology, biomaterials, and cancer epidemiology to read the literature review, and list their level of agreement with 65 statements. The authors then combined the literature review and the consensus panel results in the current report.
One concern voiced by the experts was that ALCL around breast implants was "most likely under-identified and under-reported" since it was only classified as a distinct disease in 1994. Historically, fluid aspirated from some unexplained or recurrent seromas was discarded instead of being sent for cytology, they wrote.
This expert group strongly agreed that there was a link between breast implants and developing ALCL -- though not non-Hodgkin's lymphoma overall -- and that cases in women with implants should be attributed to the implant.
But the group wasn't sure that causality has yet been proven.
Risk factors for ALCL in association with breast implants weren't clear either.
Clinical steps garnered more certainty, with recommendation for aspiration and cytologic examination of first occurrence and especially recurrent cases of seroma around a breast implant put in place more than six months prior.
Once diagnosed, full evaluation to rule out systemic disease was strongly advocated.
The group recommended that the implant and capsule of the affected breast should always be removed, though what to do with the contralateral breast and whether immediate reimplantation in the affected breast would impact risk of progression were less clear.
"Although many women received radiation and/or chemotherapy after implant removal and capsulectomy for breast-confined ALCL, more recent reports suggest survival may be equivalent with only implant and implant capsule removal," Mattke's group wrote in the paper.
"However, this treatment question will need to be addressed with clinical registries and/or trials," they added.
The researchers cautioned that the expert panel may have expressed their own preconceptions, or relied on input from other experts, given the lack of direct evidence on many of the issues surrounding ALCL.
Moreover, plastic surgeons and implant manufacturers were present at the panel meeting and provided information when relevant. This "may have potentially influenced the panelists' final ratings," Mattke's group cautioned.
The group acknowledged other limitations including a lack of grading of evidence, as would have been done for a clinical guidelines panel, and the absence of representation of all hypotheses among the questions put before the expert panel.
The study was supported by the Plastic Surgery Educational Foundation and the Aesthetic Surgery Education and Research Foundation through unrestricted grants from Allergan, Mentor Worldwide, and Sientra.
Mattke reported having no conflicts of interest to disclose.
Primary source: Plastic and Reconstructive Surgery Source reference: Kim B, et al "Anaplastic large cell lymphoma and breast implants: Results from a structured expert consultation process" Plast Reconstr Surg 2011; DOI: 10.1097/PRS.0b013e31821f9f23.
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