Discuss with your surgeon beforehand to take pictures of the implants and capsules, what you would like to be sent to pathology, and what tests to have done. Pathology is typically concerned with the diagnosis of disease and only checks for atypical cells leading to cancer cells when examining capsule tissue. They may not check for infections from bacteria or fungus, nor do detailed descriptions unless directly requested to do so by the surgeon. Pathology reports tend to be very general unless you insist for them to be more detailed.
1. List of Potential Pathological Materials
- Swabs of Chest & Capsules
- Rarely: potential lymph node (if deemed oversize) and seroma/effusion aspirate for CD30 (if there is fluid collection).
If you have implants and develop unilateral swelling, seroma, enlarged lymph nodes, breast mass, or even capsular contracture, you should push for CD30 ALCL testing. This is especially important with textured implants (silicone and saline). There is a Facebook ALCL support group and currently there are 60+ women with the diagnosis.
Update: As of July 2017, Dr. Mark Clemens states the FDA has received 464 adverse event reports in relation to BIA-ALCL and 12 deaths. See here for this report.
As of September 2015, of the reports received by the FDA, 50 percent of BIA-ALCL cases are with textured implants, four percent are with smooth implants, one percent have a history of both and 45 percent do not specify whether they were textured or smooth implants. – FDA
Capsules & Swabs:
During surgery you can have the surgeon take swabs of your chest and capsules, and also have them take pictures of the implants and capsules. Capsules and swabs can be sent to pathology and tested for: bacteria, fungi, atypical cells, ALCL (CD30), white blood cells, and foreign materials (gel bleed: silicone, silica, talc, polyurethane). These tests are additional costs to the surgery, please inquire beforehand.
1. Bacteria – Biofilm is adherent bacteria that covers the surfaces of implants and can cause low grade chronic bacterial infections, chronic inflammation, and capsule contracture. It is very common to have biofilm/bacteria form around medical devices and it can be a good idea to test for it. In 2016 there was a research study done on the microbial epidemiology of breast implant infections where 17 species of bacteria were identified.
2. Fungi – The occurrence of fungi is rare, but has been found around saline and silicone breast implants. Saline implants that have valves are susceptible to microbial growth around them and inside the saline solution. Saline valves are permeable and allow body fluid/tissue in and allow colonization of microorganisms inside the implant. See saline implants and mold for more information. Mold can also occur around silicone implants as they disintegrate and allow body fluids to permeate the shell and implant. There have been reports of the fungus candida being found on silicone implants. Textured implants, both saline and silicone, allow body fluids to be soaked up by the textured surfaces, and therefore this also attracts fungus and provides an ideal breeding ground. Fungus thrives in warm and wet areas. Please note, fungi are slow growing and hard to detect on regular cultures, it can be a waste of money to check in most cases, especially for silicone implants.
3. Atypical Cells and ALCL (CD30) – If you have implants and develop unilateral swelling, seroma, enlarged lymph nodes, breast mass, or even capsular contracture, you should push for CD30 ALCL testing. This is especially important with textured implants.
4. White Blood Cells – Checking for lymphocyte infiltration, foreign body giant cells, and granulomas can be indicative of chronic inflammation and a foreign body reaction.
5. Foreign Materials – If you have silicone implants you can request for pathology to check for the foreign materials of silicone, silicon, and silica. If you have the earlier versions of the implants before 1991, you can request for them to check for talc, silicone, silicon, and silica in your capsules. If you have polyurethane implants, you can request for them to check for polyurethane, talc, silicone, silicon, and silica. For more info see Stanford Pathology.
Resources for capsule testing:
DNA Connexions has a Full View Test that identifies: “bacteria, viruses, fungi and parasites in removed teeth, blood, tissue, implants, bone grafts or other biological samples. It tests for 88 different pathogens, including tetanus, botulism, diphtheria, HPV 16 and HPV 18, Candida albicans and more. Using PCR, one of the most advanced tools in molecular biology today, specificity of this test is one in a trillion or greater and the sensitivity of the test is the ability to detect the DNA of between 1 and 10 microbes.”
The Carlson Company in Colorado is a toxicology lab that can do heavy metal and chemical testing of explanted capsule tissues. This test is very expensive to have done.
If you have saline implants, Mycometrics and Real Time can test saline fluid for mold and microorganisms. It costs about $180 per implant and results generally take 3-4 weeks. If you want your implants back after the testing you have to specify it with them beforehand.
Optionally as an extra measure, swabs of the implant surfaces can be taken as well if you want to check for biofilm/bacteria or fungus. Although if you do the swabs of the inner layer of the capsule that may be enough.
Generally implants are sent to pathology more for the purpose of having their appearance and labeling recorded with any identifying marks, characters or numbers. This may be useful for those interested in legal proceedings. Plastic surgeons may be able to do this too. See the article, “The Importance of Documenting the Appearance and Status of Breast Implants at Time of Explantation.” If you do send your implants to pathology, ensure that they are not destroyed and will be returned back to you.
You can also request for your breast implants to be weighed.
Removing lymph nodes is a controversial topic. Foreign substances in the breast have the potential to migrate to local and occasionally distant lymph nodes. Silicone from ruptured or intact implants can be found in lymph nodes. Textured implants can have shell fragments flake off and those may also be found in the lymph nodes and be associated with ALCL.
Normally lymph nodes are no larger than 0.5 in (1.3 cm) in diameter and are difficult to feel. They can enlarge to greater than 2.5 in (6 cm). It is not recommended for lymph nodes less than 0.5 cm to be removed. Lymph nodes are an important part of the immune system and they help the body recognize and fight off infections. Silicone and shell fragments are very difficult to break down and therefore removal of large silicone-filled lymph nodes may be appropriate in some cases. See here for more information on lymph node pathology.
“Dr. Lu-Jean Feng has performed extensive research on silicone lymphadenopathy over the last 20 years as a result of breast augmentation. As a result of this research, she has published a peer-reviewed paper [Pathology of Lymph Nodes From Patients With Breast Implants] with scientists from the Armed Forces Institute of Pathology in Washington, D.C. as well as from Case Western Reserve University in Cleveland.
The study concluded that silicone in the lymph nodes can be diagnosed by ultrasound and localized by needle localization for precise removal. The polyurethane covered gel filled breast implants are associated with extensive silicone lymphadenopathy in the axilla, retropectoral, internal mammary, and sometimes neck nodes, but never in nodes below the diaphragm. The saline implants are never associated with silicone lymphadenopathy. Ruptured gel implants are only sometimes associated with silicone lymphadenopathy.”
Dr. Lu-Jean Feng’s Webinar Transcript, pg. 9:
“The silicone in the lymph nodes first has to be detected by ultrasound, which is probably the best way because it has a very specific signal. But to remove it you really have to have it needle localize, meaning that particular node has to be specified through needle localization and that can only be done by a radiologist. You can’t tell which [lymph nodes] have silicone and which [lymph nodes] do not if you just blindly go into the axillary space. They really have to be localized. Most of the silicone that I see in the lymph nodes are incredibly small and not alway accessible.
Some of this silicone lymph nodes are actually behind the ribs. They are very close to the lung, and the only way to remove these lymph nodes is to take out a rib to remove them. Some silicone in the lymph nodes are very high up in the chest near the axillary vessels. They are very hard to be localized. So, yes, you can approach it in those areas but which ones are you going to take? Are you going to take it all or are you going to take a few? So, unless the lymph node can be localized I wouldn’t take them out because you could take out normal lymph nodes and that certainly wouldn’t be good.
So if the lymph node is enlarged, if the lymph node is painful, if the lymph nodes can be localized, then these are all the conditions in which you could take our the lymph node. Otherwise if it too small, too inaccessible, you can’t get to it. The most important thing is how did it get there? So it is more important to remove the implant and capsules that really remove the secondary effect of implantation.”
If fluid collection is found, request for it to be sent to pathology and do the CD30 test for ALCL. Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a cancer of the immune system. One of the presenting signs of lymphoma is seroma and it is highly recommended for it to be analyzed for the possibility of ALCL. There is a Facebook ALCL support group and currently there are 60+ women with the diagnosis. It is more commonly found in textured implants. Don’t assume the doctor will test for fluid collection or send capsules off for testing, these can easily be discarded unless requested by the patient before the surgery.
2. Request Detailed Pathology Report
You can request for a very detailed pathology report, noting the following:
Pathological lesions, if there is any foreign material (such as silicone), lymphocyte infiltration, chronic inflammation, and histologic features.
Note: Nearly every patient receives “synovial metalplasia” in their capsule pathology reports.
Please note that pathology will apply a fixative of formalin or formaldehyde to the capsules and will generally make slides of some of the capsule tissue. Fixatives permanently tamper the capsules and prevent any future form of testing on them. The lab will either hold the capsules for a certain amount of time or destroy them after analysis unless you would like them returned to you, which would need to be prearranged. The capsules tell the story of your body’s reaction to the implant. There is an expert, Dr. Pierre Blais, who examines breast implants and capsules but he is currently back logged. You may wish to have the capsule returned to you or ensure it is kept by the lab so that Dr. Blais may one day analyze them.