Reply: Breast Implant-Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand

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I am thankful for the opportunity to respond. I am the first to acknowledge that claims of “fact” and “proof” are premature when it comes to breast implant–associated anaplastic large cell lymphoma (ALCL). Trying to elucidate the pathogenesis of this rare disease is going to be difficult because of its relative rarity and the lack of good-quality outcome data in patients with breast implants.
By contrast, we have solid evidence for the role of bacteria in the genesis of capsular contracture. This is on the back of over 10 years of clinical, laboratory, and translational research to show that bacterial mitigation results in less capsular contracture.1–6 It is this that motivated the codification and publication of the 14-point plan.7 The initiative was set up as a resource to provide up-to-date information for surgeons and patients. I thank colleagues who have read the information and taken the pledge to use evidence and their experience to guide better outcomes for their patients by incorporating some or all of these steps into their routine practice.
Brown’s critique of the article by Hu et al.8 does focus on the comparative groups that were used. We have acknowledged the limitations of this in our discussion. He has, unfortunately, misunderstood the context of the article. We sought to answer the following questions.
The answers were clear: breast implant–associated ALCL samples demonstrated a high level of bacterial contamination analogous to the levels seen in capsular contracture. A further (and unexpected) finding was that the microbiome in breast implant–associated ALCL was shifted significantly toward Gram-negative bacteria as compared with the usual Gram-positive microbiome in contracture.8
Our latest article proposes the unifying hypothesis that supports the interaction of bacterial antigens, high surface area texture, genetics, and time that pushes T lymphocytes to transform into breast implant–associated ALCL.9 The role of bacteria as one of the likely four main factors is particularly relevant, as it is something we can target right now using proven bacterial mitigation strategies. There is nothing “alarmist” about preventing contamination of breast implants—it is just good practice backed by good science.
Breast implant–associated ALCL is a hot topic. There is increasing media attention, fear of potential litigation, scrutiny of current standards, and impending decision(s) of regulators. The opportunity to do it differently this time, however, is as much up to our handling and interpretation of the science and evidence. It is fortunate that we have a strong global research collaboration led by leading institutions that are committed to tackling this disease. We have come a long way in a short time and so let us continue to do our work so that we can both cure and ultimately prevent breast implant–associated ALCL from occurring in the first place. It is time we use science and evidence to drive the right choices with respect to breast implant surgery to ensure we achieve the best outcomes for our patients.

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