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Breast implants and anaplastic large cell lymphoma

Related information

Update - sampling review commenced

3 May 2019

The TGA has commenced its review and laboratory assessment of the surface topography of samples received from the sponsors of breast implants in Australia. A team of engineers and scientists will undertake over 2,000 sets of measurements of more than 150 samples as part of the assessment.

In addition, statistical analysis of information regarding the supply of breast implants in Australia and the known cases of BIA-ALCL will occur in parallel to better estimate the risks associated for each type of implant. This includes working with the Australian Breast Device Registry (ABDR) to ensure that we are aware of as many cases of BIA-ALCL as possible.

Based on the outcomes of the testing and statistical analysis, we anticipate that a decision on whether regulatory action will be undertaken relating to specific implants will be made in mid-June.

Discussions and information sharing with other international regulatory agencies including those from the United States of America, Canada, the United Kingdom, Ireland, Japan, France and New Zealand are ongoing.

To support Australian women, information on signs and symptoms of BIA-ALCL, and a range of questions that women considering a breast implant procedure should ask their surgeon is available on our web site. In addition, we are seeking further guidance from consumer representatives on how to improve the dissemination of this information.

Consumers and health professionals are advised that since the statement on 11 January 2019, the TGA has received more confirmed cases of BIA-ALCL in Australian patients, with a total of 78 cases reported to us to date, which includes four deaths.

Consumers and health professionals are strongly encouraged to report problems with medical devices to the TGA and for breast implants also to the ABDR. Your report will contribute to the monitoring and evaluation of these products.


Breast implants and anaplastic large cell lymphoma

Update - expert working group convened

9 April 2019

The TGA convened its breast implant expert working group on 8 April. This followed decisions taken by regulators in France and Canada to remove selected textured implants from their market.

The expert working group discussed the current data on breast implant associated anaplastic large cell lymphoma (BIA-ALCL) rates and correlation with type of implant. The group identified gaps in the data currently available to inform an assessment of the true rate of BIA-ALCL in Australia particularly with different grades of texture of the implants.

The TGA takes the potential risk to women's health seriously. We have today written to all Australian suppliers of textured breast implants with a formal request for information under section 42 of the Therapeutic Goods Act 1989.

This includes the provision of data on the date when particular implants were first supplied to the Australian market and how many have been supplied so as to develop a clearer understanding of the rates of BIA-ALCL in specific types of implant. Samples of particular products have also been requested by the TGA.

Suppliers have 10 working days to responds to the request for information. After receiving information from suppliers TGA will consider whether to suspend or cancel particular products from the Australian Register of Therapeutic Goods.

Other regulators, including the US FDA and several European regulators, have also deferred making a decision until more data is available.

The expert group confirmed that the breast implant associated cancer is rare. As of 8 April 2019 the TGA has received 76 reports for BIA-ALCL in Australian women, noting that between 13,000-17,000 breast implant procedures are performed in Australia each year.

The group also discussed the benefits of textured implants, particularly for reconstructive breast surgery and the need to:

  • update the TGA website with accurate information about the benefits and risks of different types of implants
  • strongly encourage the use of the Australian Breast Device Registry, including for recording details of removal of implants and of BIA-ALCL cases
  • continue to support patients and surgeons to report all adverse events to the TGA.

Today, the TGA will also update its website with further information including information on signs and symptoms of BIA-ALCL and a range of questions that women considering a breast implant procedure should ask their surgeon.

Women with any concerns about their implants should contact their surgeon.


Breast implants and anaplastic large cell lymphoma

Update - additional confirmed cases of anaplastic large cell lymphoma

11 January 2019

Consumers and health professionals are advised that since the statement below was published, the Therapeutic Goods Administration (TGA) has confirmed more cases of anaplastic large cell lymphoma (ALCL) in Australian patients, with a total of 76 cases reported to date.

The previous advice outlined in the 'Information for consumers' and 'Information for health professionals' sections below remains current, and will be updated as new information becomes available.

Information relating to the withdrawal of Allergan textured implants from Europe is contained in the 'TGA statement' and will also be updated as new information becomes available.


Breast implants and anaplastic large cell lymphoma

Update – additional confirmed cases of anaplastic large cell lymphoma

9 May 2018

Consumers and health professionals are advised that since the statement below was published, the Therapeutic Goods Administration (TGA) has confirmed more cases of anaplastic large cell lymphoma (ALCL) in Australian patients, with a total of 72 cases reported to date.

The previous advice outlined in the 'Information for consumers' and 'Information for health professionals' sections below remains current, and will be updated as new information becomes available.


Breast implants and anaplastic large cell lymphoma

Update - additional confirmed cases of anaplastic large cell lymphoma

13 September 2017

Consumers and health professionals are advised that since the statement below was published, the TGA has confirmed more cases of anaplastic large cell lymphoma (ALCL) in Australian patients, with a total of 56 cases reported to date.

The Medical Journal of Australia last month published an article discussing anaplastic large cell lymphoma (ALCL) in the context of the Australian Breast Device Registry and advocating strategies to strengthen the registry.

The Plastic and Reconstructive Surgery Journal in May published an epidemiological study of patients in Australia and New Zealand.

The US Food and Drug Administration also published an update regarding this issue on 23 March 2017.

Accordingly in the 'How can the risk be reduced?' section of 'Information for health professionals' contained within our original statement below, our advice regarding pocket irrigation has been updated slightly.


Breast implants and anaplastic large cell lymphoma

Expert advisory panel advice on association with anaplastic large cell lymphoma

20 December 2016

As part of the TGA's ongoing monitoring of the association between breast implants and anaplastic large cell lymphoma (ALCL), consumers and health professionals are advised that an expert advisory panel was convened to discuss the issue on 16 November 2016 and has been providing ongoing advice.

The expert advisory panel included representation from plastic surgeons, cosmetic surgeons, breast-cancer surgeons, cancer epidemiologists, data analysts and public-health practitioners. The panel's advice is outlined in the 'Information for consumers' and 'Information for health professionals' sections below.

Breast implant-associated ALCL is a rare type of lymphoma that develops near breast implants. The TGA published safety communications regarding this issue on 27 January 2011 and 27 September 2016.

Since our last safety communication, the TGA has been provided with additional data and is advising that 46 cases of breast implant-associated ALCL have now been confirmed in Australia, including three that resulted in death. These cases have all occurred since 2007. Most cases of breast implant-associated ALCL are cured by removal of the implant and the capsule surrounding the implant, however a small number are more aggressive.

The TGA is also aware of a small number of unconfirmed cases. These are being investigated. Consumers and health professionals are asked to report any suspected cases to the TGA.

Future TGA actions

  • The TGA will work with research groups to obtain better estimates of the risk of breast implant-associated ALCL.[1]
  • The TGA will work with manufacturers, Australian experts on breast implant-associated ALCL, and Australian experts on breast augmentation and reconstructive surgery to evaluate the benefit-risk balance of the various types of breast implants.
  • The TGA will continue to liaise with its major overseas regulatory partners and collaborate in international working groups.

Information for consumers

The expert advisory panel has provided the following 'Q&A':

Breast implant-associated ALCL is a rare type of cancer.

It usually involves a swelling of the breast, typically 3 to 14 years after the operation to insert the breast implant. This swelling is due to an accumulation of fluid. Breast implant-associated ALCL has been known to occur as soon as 1 year after the operation and as late as 37 years after the operation.

Less commonly, breast implant-associated ALCL can take the form of a lump in the breast or a lump in the armpit.

If you notice any of these problems (swelling or a lump), or have any other concerns with your implants, you should seek medical attention.

Most cases of breast implant-associated ALCL are cured by removal of the implant and the capsule surrounding the implant.

Based on the currently available data, it is not possible to provide an accurate estimate of risk. Current expert opinion puts the risk of ALCL at between 1-in-1,000 and 1-in-10,000. Based on currently available data, most (95%) of cases of breast implant-associated ALCL occur between 3 and 14 years after the implant (median: 8 years; range: 1-37 years).

It can be difficult to express this risk in a concrete way, such that you can make a fully informed decision about whether or not to have a breast implant. Some different ways of expressing the risk are given below:

  • One woman will be diagnosed with breast implant-associated ALCL for every 1000 to 10,000 women with breast implants.
  • Suppose we took 1-in-5000 women, the middle of the experts' range, as the best estimate of risk of ALCL in women who have breast implants. This would mean that, of 5000 women with implants, one woman will develop ALCL over a period of about 3-14 years following an implant; the other 4999 women will not develop ALCL.

Because breast implant-associated ALCL is rare, experts do not recommend removal of breast implants for women who have no problems with the implant. If you are concerned you should discuss your options with your doctor.

Generally, breast implants are not lifetime devices regardless of breast implant-associated ALCL. Typically they are removed after 10-15 years. The longer you have the implant, the more likely it will need to be removed. Common reasons for removal are contracture (hard or painful implants) or movement of the implant.

If you develop swelling of an implanted breast your doctor will send you for an ultrasound scan to see if this is due to a fluid collection. If fluid is present it will be removed and sent to the laboratory for analysis. Most fluid collections are not ALCL, but the laboratory test will be able to tell for sure. Mammograms are not helpful for diagnosing ALCL.

Other investigations such as MRI and CT-scans would typically be done if the laboratory analysis of the fluid confirms a diagnosis of ALCL.

Based on external expert clinical advice received by the TGA, regular screening is not recommended at this time.

If you notice enlargement or swelling of one or both breasts, or a lump, you should seek medical advice as soon as possible.

Breast implant-associated ALCL can develop regardless of whether the implant is inserted for cosmetic reasons or for reconstruction of the breast following breast cancer.

It can occur with both saline and silicone gel filled implants.

To date:

  • No Australian cases have been reported in women who have only had smooth implants.
  • All Australian cases have occurred in women who have had textured or polyurethane implants.

Based on the currently available data:

  • It is uncertain whether textured (either micro or macro) and polyurethane implants carry different risks.
  • It is uncertain whether different brands of textured and polyurethane implants carry different risks.
  • It is not possible to predict which women with textured or polyurethane implants will develop breast implant-associated ALCL.

Most cases are cured by removal of the implant and capsule surrounding the implant. Usually your doctor will remove both implants, even if breast implant-associated ALCL has only occurred in one breast. This is because there is a small but real risk that breast implant-associated ALCL can develop in the opposite breast. Sometimes there is a solid lump (not just fluid). In these cases, chemotherapy or radiotherapy may be required.

Over the last 10 years, three Australian women have died from breast implant-associated ALCL.

The management of breast implant-associated-ALCL is multidisciplinary with all patients requiring a referral to a surgeon experienced with breast implants and the involvement of a haematologist who specialises in lymphoma, for initial and ongoing investigations and management.

The TGA has been monitoring BIA-ALCL since 2011 after receiving the first adverse event report in 2009. It established an expert working group in 2016 to seek advice on BIA-ALCL. The working group includes plastic surgeons, cosmetic surgeons, breast-cancer surgeons, cancer epidemiologists, data analysts, public -health practitioners and consumers.

The TGA has worked with this group to develop targeted information for consumers and health professionals.

The introduction of a new requirement for Patient Information Leaflets for implantable devices commencing in 2018 enhances patient access to information.

There are a range of types of textured breast implants supplied in Australian. By compelling suppliers to provide additional information specific to the Australian market, the TGA can make well informed decisions about safety of particular types of implants. Suppliers have 10 working days to respond to the request for information. After receiving this information the TGA will consider action to suspend or cancel particular products.

The decision by the French regulator appears to be based on events described to them from patients and doctors as well as data published about three implants, which has been extrapolated to other products. Other regulators, including those in the US, Germany and the UK are also seeking additional evidence on the risk of BIA-ALCL, and we are working closely with these regulators.

Patients who have breast implants should expect that the regulator makes decisions based on sound scientific and medical evidence.

Textured implants of varying roughness are used in 82% of operations in Australia. They play an important role in reconstructive surgery. Smooth implants are an alternative but they may require a higher rate of replacement reoperation due to greater rates of contracture of these implant.

The international consensus is that there is no evidence supporting the removal of breast implants in the absence of properly diagnosed BIA-ALCL.

Information for health professionals

Based on advice from Australian experts in cosmetic and reconstructive breast surgery, cancer epidemiology, and lymphoma (i.e., the expert advisory panel), the TGA is providing the following information to health professionals. Because breast implant-associated ALCL (BIA-ALCL) is rare, various aspects of this disease are not fully characterised. A more complete picture is expected over coming years. Health professionals should keep themselves apprised of the latest evidence.

The expert advisory panel has provided the following 'Q&A':

This is a rare form of non-Hodgkin lymphoma. In 2016, the WHO classified breast implant-associated ALCL as a distinct clinical entity, separate from other categories of ALCL.[2]

Unique characteristics include:

  • being purely T-cell
  • having no anaplastic lymphoma kinase gene translocation (ALK-)
  • being CD30 receptor protein positive on immunohistochemistry
  • being in close anatomical association with a breast implant.

The possibility of breast implant-associated ALCL should be included in informed consent. The disease is rare. A one-number estimate of the risk is not possible with the currently available data. Current expert opinion is that the risk is between 1-in-1000 and 1-in-10,000 women with implants. Most cases occur between 3 and 14 years after insertion of the implant (median: 8 years; range: 1-37 years).

Based on the currently available data, breast implant-associated ALCL does not seem to occur when only smooth implants are used. All Australian cases to date have occurred in women with textured or polyurethane implants.

Women with implants should be made aware of the common presenting symptoms: delayed effusion/seroma or, less commonly, a mass or lymphadenopathy.

Based on the current epidemiological evidence, the expert panel advised the TGA that breast implants were likely to be a necessary, but not sufficient, cause of breast implant-associated ALCL. The expert panel's reasoning included:

  • the ALCL cells occur in close proximity to the implant
  • breast implant-associated ALCL is a distinct clinical entity, separate from other categories of ALCL2
  • ALCL, with the distinct features of breast implant-associated-ALCL (e.g., ALK-negative, CD30-positive, typical clinical course), has not been reported in the absence of an implant.

The expert panel emphasised that, as with other cancers, the complete set of causal factors is unknown.[3] To date, no patient-specific susceptibility factors, which might help predict risk, have been identified.

The currently available data suggest that the risk might be reduced by using smooth implants.

In addition, a hypothesis currently in favour, but not proven, is that T-cell stimulation due to a chronic bacterial biofilm infection increases the risk of ALCL developing. Therefore, standard-of-care precautions, such as antibiotic prophylaxis, pocket irrigation, sterility, and skin preparation should be maintained when placing an implant. It is also hypothesised that such precautions would have the additional benefit of reducing the risk of contracture.

A group of Australian breast implant researchers have made the following recommendations:[4]

  1. Use intravenous antibiotic prophylaxis at the time of anaesthetic induction.
  2. Avoid periareolar incisions; these have been shown in both laboratory and clinical studies to lead to a higher rate of contracture as the pocket dissection is contaminated directly by bacteria within the breast tissue.
  3. Use nipple shields to prevent spillage of bacteria into the pocket.
  4. Perform careful atraumatic dissection to minimise devascularised tissue.
  5. Perform careful haemostasis.
  6. Avoid dissection into the breast parenchyma. The use of a dual-plane, subfascial pocket has anatomic advantages.
  7. Perform pocket irrigation (refer to hospital or health department guidelines).
  8. Use an introduction sleeve. We have recommended the use of a cut-off surgical glove to minimise skin contact.
  9. Use new instruments and drapes, and change surgical gloves prior to handling the implant.
  10. Minimise the time of implant opening.
  11. Minimise repositioning and replacement of the implant.
  12. Use a layered closure.
  13. Avoid using a drainage tube, which can be a potential site of entry for bacteria.
  14. Use antibiotic prophylaxis to cover subsequent procedures that breach skin or mucosa.

For women who already have implants, the current consensus of expert opinion is that screening or prophylactic removal in asymptomatic patients is not recommended.

The main method of investigation is ultrasound evaluation to confirm the presence and extent of an effusion, determine if there is presence of a mass, and evaluate regional lymph node basins for lymphadenopathy. Fine needle aspiration (+/- or core biopsy) of an effusion (mass) is performed and the aspirate (tissue) sent, for cytology (histology) and flow cytometry +/- molecular studies, for confirmation of the diagnosis of breast implant-associated ALCL. PET/CT and MRI are reserved for confirmed cases. There does not appear to be a role for mammography.[5]

The management of this condition is multidisciplinary and all patients require a referral to a surgeon experienced with breast implants and the involvement of a haematologist who specialises in lymphoma, for initial and ongoing investigations and management.

Curative treatment for most women is removal of the implant and oncological capsulectomy, which includes complete resection of any mass associated with the capsule. Contralateral breast implants should be removed with complete capsulectomy because several bilateral cases have been detected incidentally. Both the capsule and fluid should be sent for pathology.[5]

Most diagnosed cases are adequately treated with complete capsulectomy and implant removal. However, aggressive variants have been reported. To date, three deaths have occurred in Australia.

References

  1. Knight R et al. Epidemiology and risk factors for Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in Australia & New Zealand. Plastic & Reconstructive Surgery Global Open 2016;4(9S):82-83.
  2. Swerdlow SH, Campo E, Pileri SA et al. The 2016 revision of the World Health Organisation classification of lymphoid neoplasms. Blood 2016; 127(2):2375-2390
  3. Rothman KJ, Greenland S. Causation and causal inference in epidemiology. Am J Public Health. 2005;95(Suppl 1):S144-S151.
  4. Deva AK, Adams WP, Jr., Vickery K. The role of bacterial biofilms in device-associated infection. Plast Reconstr Surg 2013;132(5):1319-1328.
  5. American Society of Plastic Surgeons FAQ. www.thepsf.org/Documents/Clinical/PROFILE/profile-faq.pdf (pdf,2.46Mb).

Reporting problems

Consumers and health professionals are encouraged to report problems with medical devices. Your report will contribute to the TGA's monitoring of these products. For more information see the TGA Incident Reporting and Investigation Scheme (IRIS).

The TGA cannot give advice about an individual's medical condition. You are strongly encouraged to talk with a health professional if you are concerned about a possible adverse event associated with a medical device