Breast Implant-associated Anaplastic Large Cell Lymphoma: An Evidence-based Systematic Review.

OBJECTIVE: This evidence-based systematic review synthesizes and critically appraises current clinical recommendations and advances in the diagnosis and treatment of BIA-ALCL. This review also aims to broaden physician awareness across diverse specialties, particularly among general practitioners, breast surgeons, surgical oncologists, and other clinicians who may encounter patients with breast implants in their practice. BACKGROUND: BIA-ALCL is an emerging and treatable immune cell cancer definitively linked to textured-surface breast implants. Although the National Comprehensive Cancer Network (NCCN) consensus guidelines and other clinical recommendations have been established, the evidence supporting these guidelines has not been systematically studied. The purpose of this evidence-based systematic review is to synthesize and critically appraise current clinical guidelines and recommendations while highlighting advances in diagnosis and treatment and raising awareness for this emerging disease. METHODS: This evidence-based systematic review evaluated primary research studies focusing on the diagnosis and treatment of BIA-ALCL that were published in PubMed, Google Scholar, and other scientific databases through March 2020. RESULTS AND CONCLUSIONS: The clinical knowledge of BIA-ALCL has evolved rapidly over the last several years with major advances in diagnosis and treatment, including en bloc resection as the standard of care. Despite a limited number of high-quality clinical studies comprised mainly of Level III and Level V evidence, current evidence aligns with established NCCN consensus guidelines. When diagnosed and treated in accordance with NCCN guidelines, BIA-ALCL carries an excellent prognosis.

Finding Consensus After Two Decades of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and indolent, but potentially fatal cancer of the immune system that can develop around textured-surface breast implants. The World Health Organization first recognized BIA-ALCL as a unique clinical entity in 2016. To date, over 600 confirmed cases have been reported worldwide. BIA-ALCL most commonly presents with disease confined to the capsule, as a seroma or a mass adjacent to the implant. While BIA-ALCL has a fairly indolent clinical course, with an excellent prognosis in early stage disease, disseminated cancer and death have also been reported. In this review, the authors focus on the early diagnosis and treatment, including reconstructing the breast following BIA-ALCL, and also discuss recently updated National Comprehensive Cancer Network guidelines. They also review the current epidemiology and risk factors associated with BIA-ALCL. Finally, they discuss important medicolegal considerations and the bioethics surrounding the continued use of textured-surface breast implants.

2019 NCCN Consensus Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

National Comprehensive Cancer Network (NCCN) guidelines represent the consensus standard of care for diagnosis and management of the majority of known cancers. NCCN guidelines on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) have been recognized by the US Food and Drug Administration and widely advocated by national specialty societies. Consensus guidelines have helped create a treatment standardization for BIA-ALCL at all stages of disease. NCCN guidelines are evidence-based where possible and utilize expert consensus opinion to fill in gaps that may exist. NCCN undergoes annual panel review by multidisciplinary faculty members, and this article represents the most up-to-date 2019 guidelines. Recommendations focus on parameters for achieving reliable diagnosis and disease management and emphasize the critical role for complete surgical ablation. Suggestions for adjunct treatments and chemotherapy regimens are included for advanced BIA-ALCL with lymph node involvement. BIA-ALCL recurrence and management of unresectable disease, and organ metastasis are addressed. Adherence to recognized BIA-ALCL guidelines ensures patients receive the most current efficacious treatment available.

Stepwise En Bloc Resection of Breast Implant-Associated Anaplastic Large Cell Lymphoma with Oncologic Considerations.

Guidelines published by the National Comprehensive Cancer Network state that standard of care treatment for the majority of patients with breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is surgical resection. This cancer is generally indolent, and if confined to the capsule, curative treatment is usually surgery alone. An en bloc resection involves a total capsulectomy, explantation, complete excision of associated masses, and excision of any involved lymph node(s). Patients with surgical control of disease have favorable long-term overall and event-free survival. Oncologic principles should be applied when resecting BIA-ALCL, and a complete oncologic resection is essential to cure patients of the disease. Incomplete resections, partial capsulectomies, and positive margins are all associated with high rates of disease recurrence and have potential for progression of the disease. Routine sentinel lymph node biopsy is unnecessary and full axillary lymph node dissection is rarely indicated except in cases of proven involvement of multiple nodes. Lymphoma oncology consultation and disease staging by imaging is performed prior to surgery. Importantly, en bloc resection is indicated only for an established diagnosis of BIA-ALCL, and is not recommended for merely suspicious or prophylactic surgeries. The purpose of this article was to demonstrate a stepwise approach to surgical ablation of BIA-ALCL with an emphasis on oncologic considerations critical to disease prognosis.

How I treat breast implant-associated anaplastic large cell lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently described form of T-cell non-Hodgkin lymphoma now formally recognized by the World Health Organization classification of lymphoid neoplasms. The disease most often presents with a delayed seroma around the breast implant, almost exclusively with a textured surface, and manifests with breast pain, swelling or asymmetry, capsular contracture, but can also present with a breast mass, and lymph node involvement. The prognosis of BIA-ALCL is favorable compared with many other subtypes of systemic T-cell lymphoma; however, unlike other non-Hodgkin lymphomas, complete surgical excision for localized disease is an important part of the management of these patients. In this paper, we share our recommendations for a multidisciplinary team approach to the diagnosis, workup, and treatment of BIA-ALCL in line with consensus guidelines by the National Comprehensive Cancer Network.

NCCN Consensus Guidelines for the Diagnosis and Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Published case series demonstrate a lack of treatment standardization for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with a wide variety of therapeutic strategies being employed at all stages of disease. The National Comprehensive Cancer Network (NCCN) annually publishes Clinical Practice Guidelines for Non-Hodgkin Lymphomas. For the first time, BIA-ALCL management will be included which signifies an important and needed guideline addition. The new BIA-ALCL guideline was achieved by a consensus of lymphoma oncologists, plastic surgeons, radiation oncologists, and surgical oncologists. NCCN guidelines focus on the diagnosis and management throughout the stages of many lymphoma subtypes based upon the most current data available. This article summarizes the essential recommendations and optimal therapeutic strategies of the NCCN guidelines critical to the plastic surgery community. We encourage international adoption of these BIA-ALCL treatment standards by our specialty societies across the oncology and surgery disciplines.

Innovation and management of diabetic foot wounds.

Recent innovations in the field of wound healing have created numerous advanced therapies from which clinicians may now choose. The challenge for the reconstructive surgeon is to ensure that these adjunct technologies are used according to an evidence-based protocol to ensure optimal healing. Critical to successful outcomes is that new modes of therapy do not supplant, but are used in tandem with, core principles of wound management: establishing a correct diagnosis, ensuring a good local blood supply, debriding the wound to a clean base, correcting the biomechanical abnormality, and nurturing the wound until it shows signs of healing. Debridement should be performed as often as necessary until the wound is deemed clean and ready for reconstruction. Useful adjuncts in debridement include hydrotherapy and ultrasonic therapy. The majority of reconstructions are accomplished through simple techniques. If a wound is not meeting the expected healing trajectory, management adjuncts such as negative pressure wound therapy, growth factor, cultured skin, and hyperbaric oxygen can then reactivate or expedite the process toward achieving a healed wound.

Use of a collagen-glycosaminoglycan copolymer (Integra) in combination with adjuvant treatments for reconstruction of severe chest keloids.

BACKGROUND: Keloids occurring on the chest can be deforming with significant painful sequelae for patients. These lesions can pose a therapeutic dilemma for the dermatologic surgeon as certain excision defects may be too large to close primarily and recurrences tend to be high (40-100%). A collagen-glycosaminoglycan copolymer (Integra) has been found to be useful in the surgical treatment of scar excisions as the bovine collagen and glycosaminoglycans provide a template for neocollagenesis. Additionally, this dermal regeneration template concomitantly reduces tensile forces on the wound. METHODS: The authors' group has followed five patients with chronic chest keloids refractory to myriad of interventions and treated these patients with surgical excision followed by Integra placement into the wound bed on the chest. Split-thickness grafts were applied shortly thereafter. Patients were followed at regular intervals and all patients received adjuvant therapy with single-dose radiation and intralesional chemotherapy (triamcinolone and/or 5 fluorouracil). RESULTS: This treatment protocol has provided a cure rate of 100% over an average of 43 months follow-up. The symptoms often accompanied by these chest keloids also appear to improve. CONCLUSION: The authors believe that this study provides the groundwork for further investigation of Integra for surgical management of keloids. A placebo-controlled study should be performed to adequately determine if this data holds true.

Biological basis of diabetic foot wounds.

The steps to achieving a healthy healing wound include a correct diagnosis, ensuring a good local blood supply, debriding the wound to reveal a clean base, correcting the biomechanical abnormality, and nurturing the wound until it shows signs of healing. Debridement should be performed as often as necessary until the wound is deemed clean and ready for reconstruction. The repair is then dictated by how much of the foot remains post-debridement and how the foot can be closed in the most biomechanically stable construct possible. The subsequent reconstruction can then usually be accomplished by simple techniques most of the time, and with complex flap reconstruction in about 10% of cases. Wound healing adjuncts such as growth factor, cultured skin, and hyperbaric oxygen can be helpful adjuncts.