COMMENTARY

Breast Implants and Lymphoma: Is There a Link?

Bruce D. Cheson, MD

Disclosures

March 18, 2011

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Hello. I'm Bruce Cheson from Georgetown University Hospital and the Lombardi Comprehensive Cancer Center, with Medscape Hematology. Today, we're going to talk about what causes lymphoma and what we think might cause lymphoma. Most of the time, we don't have a clue as to what causes lymphoma in our patients. A number of unusual associations have appeared over the years. We know that chronic immunosuppression can cause lymphoma, and several infections are associated with it, such as Helicobacter pylori, Chlamydia psittaci (for orbital adnexal lymphomas), Campylobacter jejuni, and of course HIV, adult T-cell leukemia, Epstein-Barr virus, and hepatitis C.

The epidemiologic studies looking at causative agents in lymphoma have really not been terribly consistent or revealing. A trend for hair dye and toxins of various types has been found, but nothing that we could really put our hands around. Recently, a somewhat scary association between breast implants and anaplastic large cell lymphoma (ALCL) has been discovered. ALCL is, most of the time, a T-cell lymphoma, and it accounts for 15% of T-cell lymphomas. T-cell lymphomas account for approximately 10%-15% of non-Hodgkin lymphomas, so these are very unusual lymphomas. They occur in about 1 in 500,000 women.

The story with breast implants goes back to the 1960s when they first started performing breast augmentation. Since that time, between 5 and 10 million implants [have been done]. The number of women is not certain because we know more accurately how many implants are sold, and how many are put in, but some women have 1, and some have 2. However, some women have their breast implants taken out and replaced, so the total number isn't known.

What we do know is that breast implants were initially a grade-2 device with the US Food and Drug Administration (FDA) because the FDA thought silicone was inert. What has happened is that [ALCL has developed in] at least 60 women with breast implants. Why do we think these are related? ALCL occurs uniformly near the breast in a seroma or adjacent to the breast tissue. They are always symptomatic, with pain or evidence of capsular contraction or a progressive seroma. Unusually, they have almost all been anaplastic lymphoma kinase negative, whereas typically, this is a 50/50 split. There's something unusual going on here.

ALCL occurs anywhere from 1 year to 23 years after the implants have been put in place, and the women's ages have ranged from 20 to more than 80 years. On the basis of this information, the FDA has upgraded implants to a grade 3, meaning that [an implant] is a somewhat dangerous device. We are not supposed to have silicone in our bodies, and therefore one could say that ALCL occurs because of the silicone. Two thirds of the cases have been in silicone implants and one third have been in saline implants. It's really very unusual.

Another interesting observation that I've made in my clinic is that I am starting to see (perhaps because of heightened awareness) more women with breast implants and other kinds of lymphomas. Today, I saw a woman with Hodgkin lymphoma that developed after she received breast implants. I have a patient on the inpatient service now with a primary central nervous system lymphoma and breast implants that were initially silicone but were then replaced with saline. I have another patient with Hodgkin lymphoma. When this was discussed at a T-cell meeting in January, one of my colleagues reported that she had seen a half dozen [cases of] mycosis fungoides in women with breast implants.

It's really kind of worrisome. Women who have implants are asking, "What's the likelihood of lymphoma developing?" We can't give them that information. "Is it better to have my implants taken out?" We can't give them that information either because we don't have enough data.

The FDA has a phone number (1-800-332-4088) for reporting additional cases to them, or you can go to their Medwatch Website and report cases of breast implants and lymphoma. The FDA wants to know about more than just Hodgkin lymphoma. If we can get more cases, we can get a better idea of the association between these 2 and how best to manage ALCL. ALCL tends to run a fairly indolent course and morphologically has a more indolent picture, but it is still an aggressive T-cell lymphoma. We also don't have much information on the outcome of these patients following therapy.

More information is needed. It is a worrisome situation, but it is also an opportunity to get together, give some more data to the FDA, and hopefully help our patients who have breast implants. As you know, most implants are cosmetic, but a lot of them are for postmastectomy augmentation. We can really provide a meaningful service with these additional data.

I'm Bruce Cheson signing off from Georgetown University Hospital for Medscape Hematology. I hope you found this information of interest and I look forward to speaking with you again in the future. Have a good day.

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