Monday, October 8, 2018

Efficient Scanning of BIA-ALCL (Implant related cancer)- part 1

An interview with Dr. Robert Bard, digital breast imaging specialist

My understanding of Breast implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is that it's a cancer caused by long standing breast implants.  It seems to be more common in the textured breast implants as opposed to the smooth breast implants but it does happens in both. So this has recently been highlighted because the more we're doing screening with ultrasound and with MRI we're finding more of these cases that are early and thus asymptomatic. 

The seroma or fluid collection around the implant is best identified by ultrasound.   All the imaging like CT, MRI, and Ultrasound can detect fluid, it just depends how fine a resolution or how small a fluid that you want. The beauty of the Ultrasound is, not only does it detect the fluid, but since the implant is near the skin, we can see if the fluid and associated tumor are breaking through the skin surface.  Sometimes the fluid causes inflammation of the skin, because it's on top of the implant, and we can measure the thickness of the skin, which MRI and CT cannot do.

A textured implant acts like a foreign body. Imagine getting a splinter under the skin; first it hurts, then the pain goes away but it starts to swell and become infected with pus and may even burst out through the skin. The same way the textured implant causes the inflammation. And we know chronic inflammation is associated with cancer. This is a reason to have textured implants scanned periodically with the simple safe sonogram to make sure there's nothing developing. The textured implant is 90% more likely to cause a reaction and the ALCL cancer than the smooth implant.

All late onset fluid collections should be aspirated and tested regardless of how small because you don't want to miss a potentially curable early cancer, if you don't catch it early, and it spreads, then the treatment is much more radical.

Imaging through ultrasound technology can accurately access fluid amount, even if the fluid is behind the implant. In fact, fluid detection from anywhere in the body, is most easily detected by ultrasound.  We have different probes so if the fluid is deep, we use a probe that focuses more deeply like behind the implant. But, It takes a few seconds with a regular probe to find the fluid especially since the patient is vertical (sitting up) during the exam which makes the fluid completely dependent.

There's two types of fluids; there's very clear fluid which registers in the monitor as looking completely black.  But cancerous fluid appears if you have a negative fluid aspiration report. You have to go back to the breast and scan and look for either solid tumors or fluid in other areas. Because the cancer fluid tends to be "laculated", cloudy, sticky or compartmentalized.  Hence, sonography can really find more-- it can be more accurate if you look harder and have the right equipment.   

The investigation of this unusual disease is so early that in the case of preventing false negatives, there are new optical technologies that I work with, that come from Israel, and the Boston Medical Centers, that may be able to do this in the very near future.  For women with negative fluid tests, you can have an MRI, which covers a broader area, however, make sure that the person who did the Ultrasound is skilled and has looked all over the breast, both on top and behind, and also looked for the solid cancers that can be anywhere surrounding the implant.

A year ago an allergist sent me a patient with a red breast. The skin was discolored and red and painful. He thought it was an allergy. Since she had a breast implant, we scanned it and we found out, not only was the skin thickened but also, there was fluid surrounding the breast implant. Once you see fluid around a textured breast implant, you are automatically alluded to the possibility of the ALCL disorder. And if you do see fluid, we next scan the entire breast for solid tumors that may be in the area of the fluid or distant around the implant from the fluid. And then we check for metastatic disease to the lymph nodes. So we look at the breast and then we see the lymph nodes that actually are between the ribs by the breast bone. And we also look at the more common spread areas of the lymph nodes under the arm.  

Scar tissue is generally benign but the tumor can be adjacent to the scar tissue. Fortunately when we use our very high resolution machines, we can differentiate between scar tissue and tumor. More importantly we can use the doppler flow capacity which shows vessels in the tumor because scar tissue does not have any blood vessel flow, it's dead essentially. And tumors need blood vessels to grow. So with a push a button we can put on the power doppler and many other blood imaging technologies we have and see that there are tumor vessels that are next to the scar in the tumor. So yes we can differentiate the two. 

A smart protocol is to test all masses and areas of increased density near a breast implant to rule out BIA ALCL. A simple ultrasound scan is the quickest and most cost effective (and frankly most accurate) way to find this.  Make sure your technician is trained in breast imaging and in ultrasound to specifically do imaging of the breast. There's special certifications for mammography and breast ultrasound and you need the 3D and 4D high resolution equipment to show small fluid collections in and behind the skin. 

Sometimes, a woman is told that a mass should not and cannot be biopsied because it could rupture the implant.  For this, we conduct an FNA (Fine Needle Aspiration) using needles to extract fluid or cells similar to taking a blood sample.  These needles are so fine you can barely fell them break the skin to do these fine needle aspirations.  It's a relatively small needle to take out the fluid. Or if it's a larger needle for a bigger biopsy, since we do it under image guidance, you can avoid the breast implant. 

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Robert L. Bard, MD, PC, DABR, FASLMS is internationally known and recognized as a leader in the field of 21st Century 3-D ULTRASONOGRAPHIC VOLUMETRIC DOPPLER IMAGING. Dr. Bard specializes in advanced 3-D sonography to detect cancers in numerous organs including the breast, prostate, skin, thyroid, melanoma and other areas. Dr. Bard’s images are used to accurately guide biopsies, target therapy and provide focused follow-up after treatment.  Dr. Bard is currently in consulting practice in New York. He appears frequently on regional television, national radio and is a consultant to major healthcare organizations. He is committed to improving non-invasive cancer testing and developing minimally invasive image guided technologies to prevent cancer spread through his foundation, The Biofoundation for Angiogenesis Research and Development. In his role as director of BARD CANCER DIAGNOSTICS, he lectures at Mt. Sinai Medical Center, NYU Medical Center and leading international hospitals in England, France, Spain and the Netherlands.

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