American Society of Plastic Surgeons
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ASPS statement on Breast Implant Associated-Squamous Cell Carcinoma (BIA-SCC)

On Sept. 8, 2022, the Food and Drug Administration (FDA) released a new safety communication about squamous cell carcinoma (SCC) and various lymphomas in the capsule around breast implants. This document is now available to healthcare providers, patients and caregivers on the FDA's Medical Device Safety webpage.

The American Society of Plastic Surgeons (ASPS)/The Plastic Surgery Foundation (PSF) has been in communication with the Food and Drug Administration (FDA) regarding this emerging issue. Data on this topic are limited and evolving; however, the Society would like to provide ASPS members with additional information specifically about Breast Implant-Associated Squamous Cell Carcinoma (BIA-SCC) to support increased clinical awareness and enhanced clinical decision-making as more evidence becomes available.

BIA-SCC is a very rare but potentially aggressive epithelial-based tumor that appears to be associated with breast implants and emanates from the breast implant capsule. At this time, ASPS/PSF is aware of so few reported cases of BIA-SCC that it is not possible to determine what factors increase patient risk.

ASPS/PSF is committed to driving patient safety and informed decision making through research and the ongoing and persistent surveillance of breast implants. Information for your patients may be found on the ASPS webpage (Breast Implant Safety: What Patients Need to Know).

Overview

The following overview is presented to help plastic surgeons recognize Breast Implant-Associated Squamous Cell Carcinoma (BIA-SCC) as a distinct disease entity and long-term complication of breast implants. In light of broad specialty-wide awareness concerning Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), information regarding BIA-SCC is presented in a comparative format below. A reference list of all available published case reports is included at the end of this statement, and The PSF is finalizing a manuscript summarizing the current state of knowledge for Plastic and Reconstructive Surgery.

  BIA-SCC BIA-ALCL
What is it? Breast implant-associated squamous cell carcinoma (BIA-SCC) is a very rare but potentially aggressive, epithelial-based tumor that appears to emanate from the breast implant capsule. Pathology shows sheets of squamous cells lining the capsule in nests and bundles. BIA-SCC can exhibit highly invasive properties including spread to lymph nodes, local tissues and distant sites, such as muscle and bone.
BIA-SCC is not a cancer of the breast tissue itself.
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and treatable type of T-cell lymphoma that can develop around breast implants. BIA-ALCL can exhibit highly invasive properties, including spread to lymph nodes, local tissues and distant sites.
BIA-ALCL is not a cancer of the breast tissue itself.
Number of Known Cases To the best of our knowledge, there are 16 cases reported in the literature; 2 additional cases have been reported to The PSF from individual surgeons and are under review. ASPS recognizes approximately 400 both suspected and confirmed cases in the United States and a total of 1,227 worldwide as of August 2022.
Lifetime Risk Unknown Current lifetime risk of BIA-ALCL varies widely (e.g., estimates of 1:2,207-1:86,029 based upon variable risk with different manufacturer types of textured implants. More recently, cumulative risk over 20 years in breast reconstruction patients implanted with Biocell devices was estimated at 1:100 (Cordeiro et al, 2020).
Age at presentation 55.8 years (range 40-81) 55.3 years (range 28-84)
Average length since initial implantation 22.74 years (range 11-40 years) 10.32 years (range 0.08-41 years)
Implant Surface In case reports, BIA-SCC has been reported in patients who have had smooth and/or textured implants. No cases of BIA-ALCL have been confirmed in patients who have only had smooth implants in case series, case reports or registries. However, it is not possible to exclude the appearance of BIA-ALCL in association with smooth implants at this time. The FDA states that all confirmed cases worldwide either have a history of a textured device or an incomplete clinical history available for review.
Implant Type BIA-SCC has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients. BIA-ALCL has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients.
Presentation    
• Delayed seroma Yes Yes
• Unilateral swelling Yes Yes
• Pain, erythema Yes Yes
• Capsular contracture Often Sometimes
Extracapsular spread at presentation 80% at presentation 28% at presentation
Typical Pathology Squamous cells in sheets with varying degrees of atypia and metaplasia and at least one focus of SCC. Lymphoma with mass confined to single area on capsule.
Diagnostic Assessment CK 5/6+; p63+; Flow cytometry + for squamous cells and keratin CD30+; ALK-; Flow cytometry + for T-cells
Imaging Ultrasound to evaluate for peri-prosthetic fluid +/- aspiration; MRI with and without contrast to evaluate capsule to rule out mass; PET-CT for extent of disease, if present. Ultrasound to evaluate for peri-prosthetic fluid +/- aspiration; PET‐CT is performed following a positive diagnosis. Mammograms are not helpful for evaluating lymphoma but are important for the evaluation of breast cancer.
Treatment Official treatment recommendations will need to be based on emerging data. At present, it appears that explantation with complete (en bloc) capsulectomy will provide the best outcomes.
Based on existing case reports, it appears that incomplete resection of BIA-SCC can result in early and/or aggressive recurrence.
In the majority of cases, explantation with complete (en bloc) capsulectomy is curative. Incomplete capsular resection has been associated with both recurrence and significantly lower survival. Rare patients will present with more advanced disease and may require radiotherapy and chemotherapy. Treatment approach should follow international guidelines established by the National Comprehensive Cancer Network (NCCN) for BIA-ALCL. Current treatment recommendation is for bilateral complete capsulectomy and implant removal, as a small number of women have had contralateral disease found incidentally.
Chemotherapy / Radiation Therapy Patients treated within these cases did not appear to respond. Responds to Brentuximab plus CT.
Mortality 43.8% at six months. 2.8% at one year.
Reporting The FDA recommends that any suspected or confirmed cases of SCC, lymphomas, or any other cancers around the breast implant be reported to the FDA's Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov.
Pending IRB approval, The PSF will soon enable plastic surgeons to report confirmed or suspected breast implant-associated capsular pathologies, including BIA-SCC cases, to PROFILE (ThePSF.org/PROFILE)
The FDA recommends that any suspected or confirmed cases of BIA‐ALCL be reported to the PROFILE registry, the FDA's Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov.
To report a case to PROFILE, go to ThePSF.org/PROFILE.
Patient Counseling and Informed Consent BIA‐SCC should be discussed with any patient considering breast implants as part of the informed-consent process. BIA‐ALCL should continue to be discussed with any patient considering breast implants as part of the informed-consent process.

ASPS/PSF Recommendations

  • Prior to implantation of any breast implant, plastic surgeons should provide patients with the manufacturer's patient labeling, the FDA-required patient decision checklist and any other educational material to best discuss the benefits and risks of breast implants.
  • Preoperative workup is essential. All patients presenting with a late seroma should have fine needle aspiration (FNA) and cytology testing. Specimens should be sent for immunohistochemistry including CD30, ALK, CK 5/6, p63 and flow cytometry to look for T-cells, squamous cells and keratin.
  • All patients presenting with a late seroma should undergo a breast ultrasound and MRI with and without contrast. If disease is confirmed, a PET-CT should be considered prior to surgical intervention. A thorough preoperative work-up allows for potentially the most appropriately planned, single-stage surgery with the greatest chance of success for cure.
  • Consider the possibility of BIA-ALCL, BIA-SCC and other lymphomas when treating a patient with late onset, peri-implant changes. If you have a patient with suspected BIA-ALCL or BIA-SCC, refer them to experts familiar with the diagnosis and treatment of BIA-ALCL and BIA-SCC.
  • At surgery, collect fresh seroma fluid, representative portions of the capsule, and specific pathology requests to rule out both BIA-ALCL and BIA-SCC.
    • Diagnostic evaluation should include cytological evaluation of seroma fluid or mass with Wright Giemsa stained smears and cell block immunohistochemistry/flow cytometry testing for cluster of differentiation (CD30) and Anaplastic Lymphoma Kinase (ALK) markers, as well as Cytokeratin 5/6 (CK 5/6) and p63.
      • Flow cytometry should include instructions to look for T cells, squamous cells, and keratin.
  • All confirmed or suspected BIA-SCC data should be entered into the PROFILE Registry (Data entry mechanism forthcoming).
  • Data for all patients with seroma should be entered into the National Breast Implant Registry (NBIR).

ASPS/PSF is committed to patient safety, advancing quality of care and practicing medicine based upon the best available scientific evidence. We will continue to monitor and review all new information as it becomes available to keep the plastic surgery community informed. If you have any further Questions, please do not hesitate to contact Amy Hughes at ahughes@plasticsurgery.org.

References

Buchanan PJ, Chopra VK, Walker KL, Rudolph R, Greco RJ. Primary Squamous Cell Carcinoma Arising From a Breast Implant Capsule: A Case Report and Review of the Literature. Aesthet Surg J. 2018 Jun 13;38(7). doi: 10.1093/asj/sjy092. PMID: 29659713.

Cordeiro PG, Ghione P, Ni A, et al. Risk of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) in a cohort of 3546 women prospectively followed long term after reconstruction with textured breast implants. J Plast Reconstr Aesthet Surg. 2020;73:841–846.

Goldberg MT, Llaneras J, Willson TD, Boyd JB, Venegas RJ, Dauphine C, Kalantari BN. Squamous Cell Carcinoma Arising in Breast Implant Capsules. Ann Plast Surg. 2021 Mar 1;86(3):268-272. doi: 10.1097/SAP.0000000000002524. PMID: 32804719.

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Alikhan MB, Nassar A, Mansoor I. Squamous metaplasia on the breast implant capsule. Int J Surg Pathol. 2010 Dec;18(6):570-4. doi: 10.1177/1066896908329587. Epub 2009 Jan 14. PMID: 19147510.

Soni SE, Laun JC, Beard AS, Kuykendall LV. "Breast Implant Capsule-Associated Squamous Cell Carcinoma During Pregnancy: A Mimicker of Breast Implant-Associated Anaplastic Large Cell Lymphoma". Plast Reconstr Surg. 2022 Aug 12. doi: 10.1097/PRS.0000000000009506. Epub ahead of print. PMID: 35960919.

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Zhou YM, Chaudhry HE, Shah A, Andrews J. Breast Squamous Cell Carcinoma Following Breast Augmentation. Cureus. 2018 Oct 3;10(10):e3405. doi: 10.7759/cureus.3405. PMID: 30533339; PMCID: PMC6278994.

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