13 minute read
Hyunjin Rheem '25 & Jean Yuan '25
Breast Reconstruction and the Risks of a Mastectomy
BY HYUNJIN RHEEM '25 & JEAN YUAN '25
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Cover Image: This specific breast implant is a saline implant. They last about 10-20 years and are usually removed due to complications or cosmetic concerns. This type of breast implant is usually safer in the case of a rupture since the saline solution can be safely absorbed by the body. (Mayo Foundation for Medical Education and Research) Image Source: Flickr - Breast Reconstruction Market by Durgesh Kumar
Process of getting a mastectomy to the process of breast reconstruction
Breast cancer is the most fatal cancer for women in the United States. It is usually caused by hereditary mutations in genes such as BRCA 1 or BRCA 2 and other external factors. Breast cancer that is not inherited through genetics has not been able to be identified (American Cancer Society of Breast Cancer). External factors such as radiation and the breathing in of certain chemicals through air pollution, such as lead, mercury, and cadmium, can also lead to abnormally rapid cell growth in the breast.
There are two types of breast cancers: carcinomas and sarcomas, divided based on the cell of the breast in which the cancer originated. Carcinomas occur when the epithelial components, such as the cells that line the lobules and milk ducts (Feng, 2018) of the breast are affected. This occurs when the DNA of a cell is damaged, the cell then grows into a malignant tumor (National Cancer Institute). Sarcomas occur when the stromal components, such as myofibroblasts and blood vessel cells, are affected (Feng, 2018). The most common type of breast cancer is Invasive Ductal Carcinoma (IDC), comprising about 80% of all breast cancer cases. A type of adenocarcinoma, IDC starts in the cells in the lining of epithelial organs, such as the lining of milk ducts. These cells secrete digestive juices that grow out of control, allowing malignant tumors to form, which are the adenocarcinomas (Cleveland Clinic). The cells then invade breast tissue and can spread further to other organs or areas through lymph nodes or the bloodstream, resulting in metastatic breast cancer.
Although the 5-year relative survival rate is high for localized and regional stage cancers, 99% and 86% respectively (American Cancer Society of Breast Cancer), part of breast cancer treatment involves surgery, specifically breast conserving surgery (BCS) and mastectomy. Breast conserving surgery removes only the part of the breast containing the cancerous tissue, allowing a patient to keep most of her breast. However, there is a high chance that patients will need radiation therapy after surgery in order to reduce the risk of a secondary cancer or of the original cancer coming back.
When women cannot receive breast-conserving surgery, a mastectomy is needed in order to remove the cancer, and sometimes a double mastectomy, which is the removal of both breasts,
in order to lower the risk of getting cancer in the second breast. A mastectomy removes the entire breast regardless of tumor size, but patients are less likely to need radiation after surgery. Both surgeries allow for the option of breast reconstruction.
There are different types of mastectomies depending on the condition of the cancer and how much tissue is needed to be removed: simple mastectomy and modified radical mastectomy. A simple mastectomy involves a surgeon removing the entire breast, including the nipple, areola, fascia, and skin. Even some of the underarm lymph nodes could possibly be removed, called a sentinel lymph node biopsy, depending on the type of procedure and the severity of the cancer. In a modified radical mastectomy, the surgeon removes the lymph nodes under the arm, which is called an axillary lymph node dissection. Sentinel lymph node biopsies are usually for “patients without axillary lymph node involvement, thereby making more extensive surgery unnecessary” (Petrelli, F. et al., 2012). Presently, sentinel lymph node biopsies are the accepted approach for women in the early stages of breast cancer, and the axillary lymph node dissection is not necessary for clinically “node-negative patients,” or patients without the axillary lymph node involvement. Other types of mastectomies include radical, skin-sparing, nipple sparing, and as previously mentioned, a double mastectomy. Radical mastectomies are very rare in present times since it requires the surgeon to remove the entire breast, axillary lymph nodes, and the pectoral muscles under the breast and has many side effects. These side effects include swelling at the surgery site, numbness in upper chest, a hematoma (buildup of blood in the wound), seroma (buildup of clear fluid in the wound), and limited arm movement (American Cancer Society). It is only done if there is cancer in the pectoral muscles. Skin-sparing mastectomies involve removing the breast tissue, nipple, and areola and leaving the skin over the breast. Nipple-sparing mastectomies follow a similar procedure to other types of mastectomies, but the nipple and areola are kept. The removal of the nipple and areola in this procedure also depends on if there is cancer found in the tissue under the nipple and areola. This procedure is usually done on women who are in the beginning stages of cancer (American Cancer Society of Breast Cancer). Lastly, a double mastectomy is when both breasts are removed in order to reduce the amount of risk of a secondary cancer; those with the BRCA gene mutation are more likely to receive a double mastectomy in order to reduce the risk of relapse.
Women have options to choose from based on aesthetics for breast reconstruction
Depending on the aesthetic that the patient desires, they primarily have two options for reconstructive breast surgery: implant reconstruction and tissue reconstruction, the latter also referred to as flap reconstruction. This article will focus on implant reconstructions.
Implant reconstruction options include saline and silicone breast implants, both made of a silicone outer layer and a saline or silicone gel on the inside. The surgical procedure for implant reconstruction is much quicker than that for tissue reconstruction and leads to fewer postoperative complications. There are multiple types of implants, the major types being round or shaped. Round implants come in textured and smooth options, whereas shaped implants are always textured. Although smooth implants are preferred by patients, studies on these two implant types have presented conflicting information, some studies showing the potential for capsular contracture with smooth implants. Capsular contracture, one of the major risks of breast implants, is an immune system response to the presence of a foreign object, in this case, the implant. The immune system separates the implant from the rest of the body by creating a layer of scar tissue around the implant. Capsular capture leads to a hardening of the area of the tissue surrounding the implant, leading to possible pain in the breast area and aesthetic irregularity. Studies published in 1993 and 1996 demonstrated that patients with textured breast implants had fewer occurrences of capsular contractures compared to those with smooth implants (Asplund, 1996). However, a study in 1997 showed no significant difference in rate
Image 1: This is a tumor shown on a diagnostic mammogram. In this case, a sentinel lymph node biopsy was needed Image Source: Flickr-Diagnostic Mammogram by Elissa Malcohn
Image 2: This is a T cell/ histiocyte rich diffuse large B cell lymphoma. Breast implantassociated anaplastic large cell lymphoma, a rare form of T-cell lymphoma, can develop following breast implantation. Source: Flickr-Pathology Outlines contributed by Drs. Asmaa Gaber Abdou and Nancy Youssef Assad of capsular contracture between patients who received textured or smooth implants (Tarpila, 1997). Even so, textured and shaped implants are still popular, as they adhere to the surrounding tissue better than smooth implants, are firmer to the touch, and hold the teardrop shape better.
Risks with Breast Implants
The primary risks associated with breast implants include rupture of the implant, capsular contracture, and certain kinds of implants can cause breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Breast implantassociated anaplastic large cell lymphoma is a form of T-cell lymphoma in the scar tissue around the implant. A T-cell lymphoma (or Cutaneous T-cell lymphoma) is a “rare type of cancer that begins in white blood cells called T cells,” and these T cells develop abnormalities causing them to attack the skin. Usually these cells aid the “germ-fighting immune system,” but a cutaneous T-cell lymphoma can cause rashes on the skin and, sometimes, skin tumors (Mayo Foundation for Medical Education and Research). Although very rare – the risk of developing BIA-ALCL estimated at 0.35 to 1 case per million people per year – BIA-ALCL occurs more frequently in people who have had textured implants than in those with smooth implants (Kricheldorff, 2018). The most common indicators of BIA-ALCL include fluid collection or an unusual mass near the implant, associated with 70% and 30% of recorded cases, respectively (Mitry, 2020).
Although a clear cause behind BIA-ALCL is unknown, there are several theories. Some previous studies suggest that chronic inflammation surrounding the breast can cause BIA-ALCL. Tissue inflammation around the implant occurs when rougher surfaced implants stimulate higher macrophage activity, scar tissue formation, and T-cell responses by rubbing against the tissue surrounding the implant (Doloff, 2021). It is theorized that the textured surface on the implant would be rubbed off, with the rubbed off surfaces (silicone) ending up trapped in the surrounding tissue. This would stimulate chronic inflammation that could eventually lead to lymphomas (Doloff, 2021). Chronic inflammation can lead to leukocytes such as neutrophils, monocytes, macrophages, and eosinophils contributing to development of cancer. Additionally, inflammatory mediators, which promote inflammatory response, such as cytokines, chemokines, and free radicals, lead to increased cell growth and a development of mutations within the cell. One T-cell associated cytokine that promotes the inflammatory response, IL-6, is identified as a tumor growth stimulating cytokine (Sansone, 2012), which would lead to growth of breast carcinomas (Lajevardi, 2021), contributing to BIA-ALCL.
Another theory is that biofilm growth might play a role. Biofilm is comprised of structures of cells that stick to each other and adhere to the surface of objects – in this case, the surface of the breast implant. Textured implants have increased surface area and therefore greater ability for biofilm growth and bacterial buildup. Biofilm tends to buildup in the implant surface texture as well as the spaces where the tissue and implant meet. Previous studies have shown a positive correlation between implant surface area and bacterial growth as well as increased T-cell response to biofilm infection (Hu, 2015). A high amount of bacteria can lead to immunostimulation, more specifically, the stimulation of lymphocytes, leading to lymphoma growth (Loch-Wilkinson, 2017). Additionally, the greater bacterial growth eventually leads to transformation of cell genes and the development
of CD30-positive ALK-negative T cells (Kao, 2021). These are cells lacking the expression of a protein, anaplastic lymphoma kinase, which plays a role in brain development. However, the mutated form of this gene can lead to the genesis of ALK-negative anaplastic large cell lymphomas.
Conclusion: Breast reconstruction after a mastectomy is a common procedure for many breast cancer patients, with options that allow for comfort and aesthetic satisfaction. However, there are risks to certain options, such as textured implants, which can lead to the genesis of a new cancer, breast implant-associated large cell lymphomas (BIA-ALCL). Despite the presence of this risk, the FDA has found that the quantified risk rate of this lymphoma, depending on the specific manufacturing of a textured versus a non-textured implant, has gone from 1 in 3,000 patients down to 1 to 30,000 patients. The development of biocompatible prosthetics works to decrease the risk of breast implant associated problems while still creating an implant that addresses both the structural and aesthetic needs of the patient.
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