Unfortunately, case reports about implant-associated malignancies frequently lack details about implant or foreign body model or design, manufacturer, or even specific implant material alloys or types. Case studies tend to focus on patient risk factors and clinical details rather than precise descriptions of implanted devices or materials. For example, rotator cuff suture anchors can be made of titanium, thermoplastics, or biodegradable materials, but the case study implicating suture anchors did not specify a material type.
The first-reported gluteal implant-associated ALK-negative ALCL case was diagnosed after lymphoma had already fatally disseminated to the patient’s lungs – an unusual situation for implant-associated ALCLs, which can usually be cured by removing the implant and capsule before dissemination occurs, Dr Gould noted.
“That case is a little different from the usual cases of breast implant-associated lymphomas in that it was fairly advanced by the time the patient presented to medical attention and only 1 year had elapsed between placement of the implants and development of the lymphoma,” Dr Popplewell agreed. “The breast implant-associated cases typically develop an average of 10 years after placement of the implants. The gluteal implants had been placed at a private medical center and the implant manufacturer and texturization was not disclosed by that private medical center.”
According to the International Society of Aesthetic Plastic Surgery, more than 36,000 gluteal implant surgeries were performed internationally in 2017.
Any silicone-containing implant, “particularly if texturized,” should be viewed with suspicion when fluid has collected around it, Dr Popplewell said. Fluid collections should be aspirated and tested “even if a particular implant type has not previously been reported as associated with ALCL,” she advised.
“As the USC gluteal implant case report points out, cases could potentially go undiagnosed,” she said. “The same is the case with breast implant lymphoma – if a patient presents with a fluid collection around the implant and the implant is removed but the fluid is not tested, then the case may go unnoticed and the important staging workup to confirm that there is no distant spread might not be ordered.”
Because causality and molecular mechanisms have not yet been established, it is not clear what implant materials or anatomic locations might be associated with the highest risk of implant-associated malignancies. Fluids should be tested in any patient with peri-implant fluid accumulations, for any implant type, Dr Gould recommended.
ALK-negative ALCL has also been reported in association with a metallic orthopedic implant, for example, although metallic orthopedic implants have more frequently been reported to be associated with sarcomas across existing case studies and retrospective cohort analyses.11-14 A recent case report detailed bilateral osteosarcomas that were found to be associated with metallic implants in 2 pet dogs.15
Orthopedic implant-associated tumors in humans are typically sarcomas rather than carcinomas, noted Frederick J. Schoen, MD, PhD, a materials scientist and senior pathologist at Harvard Medical School and Brigham and Women’s Hospital in Boston, Massachusetts.
“But implant-associated cancers in general are very rare,” Dr Schoen emphasized. “Except in very specific cases, it’s virtually impossible to ascertain cause and effect. BIA-ALCLs occur in a very specific location relative to the implant and involve a tumor that is not usually associated with implants. That combination is very unusual and I might say it is the first situation where I’ve been relatively persuaded that this is something specifically related to a category of breast implants.”