Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment. METHODS: Between 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients. RESULTS: The mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free. DISCUSSION: BIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

Gastric juice ascorbic acid: effects of disease and implications for gastric carcinogenesis.

N-nitroso compounds (NOC) are strongly implicated in the causation of cancer of the stomach and it has been suggested that ascorbic acid might reduce the risk of gastric cancer by preventing their formation within gastric juice. However, until recently there have been no measurements of gastric juice ascorbic acid concentrations. We have measured both gastric juice ascorbic and total vitamin C (ascorbic acid and dehydroascorbic acid). Our findings suggest that ascorbic acid is secreted into the gastric lumen so that gastric juice concentrations are often greater than those in plasma. Gastric pathology affects this secretion, leading to values in gastric juice that are lower than plasma levels. Stimulation of gastric secretion does not raise vitamin C concentrations in individuals whose values are initially low. The role of ascorbic acid in preventing formation of NOC and protecting against gastric cancer is discussed in the light of these findings.

Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year retrospective study.

The accuracy of burn size estimation and subsequent fluid administration by referring hospitals prior to arrival at the Yorkshire Regional Burns Unit over a three-year period was assessed retrospectively. Burns around 20% body surface area were most accurately assessed, with smaller burns being overestimated and larger burns underestimated. Inaccuracies in fluid resuscitation result in, on average, patients receiving twice the appropriate volume of fluid for the burn size. The possible causes, implications and solutions to these problems are discussed.

Recurrence of subglandular breast implant capsular contracture: anterior versus total capsulectomy.

The objective of this study was to determine whether the type of capsulectomy, anterior or total, affects the recurrence of capsular contracture around subglandular silicone-gel breast implants. A retrospective analysis was performed of patients who underwent either anterior or total capsulectomy for Baker grade 3 or 4 subglandular capsular contracture in our unit. All patients were invited to a review clinic where their capsular status was assessed. There were 100 anterior- disc capsulectomies in 60 patients between 1988 and 1997 and 99 total capsulectomies in 60 patients between 1990 and 1998. The follow-up in the former group was a median of 7 years and mean 6.9 years, compared with median 2.5 and mean 3.1 years in the latter group. Eighty-six percent of the implants removed from both groups at capsulectomy were smooth-walled gel-filled implants. Sixty-nine breasts in the anterior group received textured gel implants at capsulectomy; the remaining 31 received polyurethane-coated Meme implants. In the total capsulectomy group, all but two breasts (one patient) received textured gel implants. After review, the capsular status was known in 80 percent of the anterior and 92 percent of the total capsulectomy group. The review clinic found eight new contractures in five patients to have developed in the anterior compared with none in the total group. Recurrent contractures affected 50 percent of patients (46 percent of breasts) in the anterior and 11 percent of patients (10 percent of breasts) in the total capsulectomy group. Kaplan-Meier survival analysis was applied to the data. By including only patients who received textured gel implants at capsulectomy, the Logrank found a statistical difference between the two treatment groups (0.01 < p < 0.5). We believe that this study provides some evidence that total capsulectomy for subglandular silicone breast implant capsular contracture results in a lower capsular recurrence than anterior- disc capsulectomy. The pattern and risk of recurrence after total capsulectomy and exchange for a modern textured prosthesis appear to approach those following primary augmentation.

Silicone gel-filled breast implant integrity: a retrospective review of 478 consecutively explanted implants.

Concern has been expressed over the long-term integrity of silicone gel breast implants. There are no large series representing experience with these implants outside of the United States. A retrospective case note review of explanted silicone breast implants was performed; 478 implants have been explanted during the past 11 years and relate to the use of these devices since 1971. Loss of implant integrity was not simply related to its age in vivo. Failure was more likely with implants of the late 1970s and early 1980s (second generation) and with subpectoral placement. Implant failure was independent of capsular contracture as the indication for removal (p = 0.09). There is no evidence that the currently used textured silicone gel breast implants are subject to the same loss of integrity as previous examples of these devices. The life span of these implants, the first of which are approaching 10 years in vivo, is at present unknown. Information concerning the integrity of silicone gel breast implants is essential in the current climate for counseling of both new and old implant recipients.

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.

Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants.

Although textured silicone breast implants have been shown to reduce the incidence of capsular contracture, there is little evidence if this effect is maintained in the long term. It has been 10 years since the double-blind randomized trial in which 53 patients received either Mentor smooth (26) or textured silicone gel implants (27). Of the 14 patients who were not known to have developed a contracture in the smooth group, 11 were reviewed. Three had bilateral contractures. In the textured group, 18 of the 24 patients not known to have contractures were reviewed. None had developed contractures. At 10 years, the incidence of capsular contracture was 65 percent of patients with smooth implants (an increase of 6 percent on the 3-year results) and 11 percent for the textured implant patients (no change on the 3-year results). A database containing the details of 1100 patients reinforces these results by examining the differences in contracture rates of textured, smooth, and polyurethane-coated implants. The effect of submuscular placement on reducing contracture rates regardless of texturing is discussed, as is the apparent increase in capsular contracture in patients who smoke.

Cellulite treatment: a myth or reality: a prospective randomized, controlled trial of two therapies, endermologie and aminophylline cream.

Cellulite is a common phenomenon that particularly affects the thighs and buttocks of women. Little scientific evidence exists to support any of the many advertised treatments for it. A total of 52 of 69 women, who were divided into three groups, completed a 12-week, randomized, controlled trial in which the effectiveness of two different treatments for cellulite was assessed. The patients acted as their own controls. The treatments investigated were twice-daily application of aminophylline cream and twice-weekly treatment with Endermologie ES1. Group 1 (double blind) received aminophylline to one thigh/buttock and a placebo cream to the other. Group 2 (singly blind) received Endermologie to one thigh/buttock. Group 3 received Endermologie to both sides and used the same cream regimen as group 1. Results were assessed subjectively by the patient and by clinical examination and photographic assessment by the surgeon (before and after the trial). Morphologic assessment included body mass index, thigh girth at two points, and thigh fat depth measurement by ultrasound. No statistical difference existed in measurements between legs for any of the treatment groups (paired t test, p > 0.4). The best subjective assessment, by the patients themselves, revealed that only 3 of 35 aminophylline-treated legs and 10 of 35 Endermologie-treated legs had their cellulite appearance improved. The authors do not believe that either of these two treatments is effective in improving the appearance of cellulite.

Anaplastic large cell lymphoma in a reconstructed breast using a silicone implant: a UK case report.

We present case of Anaplastic Large Cell Lymphoma discovered as an incidental finding whilst revising an implant based breast reconstruction in a 55 year old woman, whom previously had undergone risk reduction mastectomies and immediate reconstruction. During the procedure a presumed seroma was present but this was macroscopically atypical giving a 'milky' coloured appearance with a pink tinge to it. The atypical fluid was sent for analysis and the diagnosis of ALCL confirmed. Treatment consisted of unilateral capsulectomy on the affected side and bilateral removal of implants with staging scans suggesting the disease being confined to the capsule. She remains in remission 12 months following the original procedure.

Two-stage delayed breast reconstruction with an expander and free abdominal tissue transfer: outcomes of 65 consecutive cases by a single surgeon.

BACKGROUND: Traditional single-stage breast reconstruction with autologous tissue leaves an obvious skin island. Alternatively, a staged reconstruction with the creation of a skin envelope with a tissue expander which is then replaced with a de-epithelialised flap, leaves a breast with the original mastectomy scar and no skin island. METHODS: Consecutive patients who underwent the two-stage reconstruction between 2004 and 2010 were included in the study. Data were collected retrospectively on patient demographics, adjuvant treatments, surgical procedures and outcomes. RESULTS: A total of 65 patients who initially had a non-skin sparing mastectomy underwent two-stage breast reconstruction, of which the majority were delayed (n = 63, 95%) and unilateral (n = 64, 98.5%). Each patient was individually assessed for their suitability for the two-stage reconstruction. In 89% (n = 58) of cases, the expander was inserted in a subcutaneous pocket, while in the remaining a subpectoral pocket was elected. After the first stage, seven complications were recorded (10.7%), notably three expander extrusions, three seromas and one implant infection. Of the 65 patients, 63 proceeded to the second stage of reconstruction with 38 transverse rectus abdominis myocutaneous (TRAM) (60%), 12 superficial inferior epigastric artery (SIEA) (19%), and 13 deep inferior epigastric perforator (DIEP) (21%) flaps. Mean follow-up time since the completion of the second stage was 42 months (range 6-80 months), with complete flap loss recorded in 4.6% and minor fat necrosis in 9.5% of cases. CONCLUSIONS: The two-stage breast reconstruction using skin expansion and autologous tissue transfer eliminates the need for a visible skin paddle and produces a sensate breast with a more natural-looking breast mound.

Drainage in breast reduction surgery: a prospective randomised intra-patient trail.

One hundred and fifty bilateral breast reductions were prospectively randomised intra-operatively to receive a unilateral wound drain. Seven patients required post-operative evacuation of haematoma, three on the drained and four on the undrained sides. There was no statistical difference in haematoma formation between drained and undrained sides (p = 1), or the incidence of wound healing or other complications. We believe that routine wound drainage in breast reduction surgery is an unnecessary intervention.

Breast reconstruction by tissue expansion. A retrospective technical review of 197 two-stage delayed reconstructions following mastectomy for malignant breast disease in 189 patients.

Despite the advent of free tissue transfer, breast reconstruction by tissue expansion is an important technique in the armamentarium of the reconstructive breast surgeon. The concept is deceptively simple and yet in reality can produce difficult complications and poor results. A database was compiled of all the patients receiving tissue expanders and/or implants for cosmetic, congenital and reconstructive purposes between 1986 and 1998. 189 patients had 197 delayed two-stage tissue expansion breast reconstructions following mastectomies for malignant breast disease between 1986 and 1997. 103 breasts (52%) had two uncomplicated stages. The remainder had one or more complications, revisional procedures for complications or alterations to the reconstruction for size, position or shape. Overall each breast reconstruction required 2.9 procedures (range 2-9). The complications and additional procedures are discussed. In particular, capsular contracture of the definitive implant (12%) was related to implant type and not to the speed of tissue expansion or the degree or duration of over-expansion. Although 17% of patients received radiotherapy, none of those who developed contracture around the definitive implant had this adjuvant therapy, P< 0.05. Twelve reconstructions (6%) totally failed due to complications of which six underwent secondary flap reconstruction. Twenty-one patients have subsequently developed metastatic disease of which 15 have died to date. Breast reconstruction by tissue expansion is still an important technique. It should be used carefully and thoughtfully by surgeons trained to deal with any complications. Patients need to be carefully selected and counselled prior to undertaking this process.

Breast implants: a survey of cosmetic clinics.

The quality of information available to prospective cosmetic breast implant recipients in the private sector was assessed. Sixteen women telephoned 14 clinics requesting written information about breast implants and their safety. The information received varied enormously in quality. Of the purely cosmetic clinics offering information, it was generally of better quality and more consistent than private hospitals where accredited plastic surgeons operate. In the current climate of consumer choice and negative attention given to silicone breast implants by the media, more comprehensive information should be readily available to guide potential patients.

Reduction of potential contamination of breast implants by the use of 'nipple shields'.

Forty-three breast implant operations in 25 patients were studied prospectively to determine the effectiveness of covering the nipple-areolar complex with an adhesive film dressing in preventing perioperative expression of bacteria from nipple ducts contaminating the operative field. One swab from the nipple after skin preparation and none of the swabs taken from the outer surface of the film dressing postoperatively yielded any bacterial growth. Fourteen breasts (33%) in 11 patients (44%) yielded bacterial growth from swabs under the film postoperatively. Six of 9 breasts (67%) in 5 patients who had capsulectomies had bacteria isolated from under the film postoperatively. Ten of 14 (71%) control breasts (no shields) in 6 of 7 patients (86%) had positive postoperative swabs. This study confirms the potential risk of bacterial contamination arising from nipple duct flora during intra-operative breast manipulation, and the effectiveness of a perioperative adhesive film placed over the nipple-areolar complex in preventing subclinical bacterial contamination of implanted breast prostheses.