Jamie DePolo: Hello. Thanks for listening. Our guest is Brian Wojciechowski, MD, who practices medical oncology in Delaware County, Pennsylvania, at Riddle, Taylor and Crozer hospitals, and also serves as Breastcancer.org’s medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought after speaker on the topics of medical ethics and the biology of cancer.
In September of 2022, the U.S. Food and Drug Administration put out a safety alert about reports of squamous cell carcinoma and other lymphomas developing in scar tissue that forms around breast implants. Dr. Wojciechowski joins us to explain what squamous cell carcinoma is, how it’s different from anaplastic large-cell lymphoma, which has previously been linked to implants, and what this all means for women with implants. Dr. Wojo, welcome to the podcast.
Dr. Brian Wojciechowski: Thanks, Jamie. It’s good to be back with you.
Jamie DePolo: So, first, can you tell us what squamous cell carcinoma is?
Dr. Brian Wojciechowski: Sure. Most of us know squamous carcinoma from skin, because it is the most common skin cancer, although generally not considered very dangerous. It generally has a good prognosis and is most commonly treated with surgery. Now, squamous carcinoma — what squamous means is that the cancer basically arises from squamous cells. And squamous cells cover your whole skin surface, but they’re also seen in other parts of the body, including the lining of the hollow organs of the body such as the stomach, the esophagus, the bladder, and even the lining of the genital tract. You can also see squamous cells in the respiratory epithelium and other parts of the body. So basically, they line surfaces on the inside and the outside of the body.
Jamie DePolo: So, I have to ask, then, to me like the breast area is not hollow, but is it weird that there’s — are there normally squamous cells, like, in the breast area?
Dr. Brian Wojciechowski: No, but when you put an implant in the breast, the squamous cells form a layer that surrounds the implant.
Jamie DePolo: Oh, I see, I see. Okay.
Dr. Brian Wojciechowski: So, it sort of becomes a cavity that’s not hollow.
Jamie DePolo: I see. Okay, thank you. So, how is squamous cell carcinoma different from the anaplastic large-cell lymphoma that we know has been linked to textured implants?
Dr. Brian Wojciechowski: Yeah, we’ve known about anaplastic large-cell lymphoma in textured implants for more than 10 years. And the difference between squamous and large-cell lymphoma is the cell from which the cancer originates. Because remember, every cancer starts in a normal cell, and it’s usually named for that normal cell from which it starts. So, as opposed to the cancer starting in a squamous cell, the cancer starts in a lymphocyte. So, lymphocytes are T-cells and B-cells that are involved in the immune system, and instead of lining the skin or lining the hollow organs of the body, they’re just kind of everywhere in the body in lymph nodes, in bone marrow, and other places as well. So, that’s the main difference: The cell of origin of the cancer.
Jamie DePolo: Okay, thank you for that. And then I have one more question on these different types of cancers. So, the safety alert also mentioned other lymphomas in addition to the squamous cell carcinoma. So, they’re not anaplastic large-cell lymphoma, they’re just another type of lymphoma that started in these lymphocyte cells. Is that right?
Dr. Brian Wojciechowski: That’s right. So, there’s at least 30 different kinds of lymphoma that we know of, and they’re all basically different based on where they’re located and the type of lymphocyte that they come from. So, when I looked at the literature on this, I saw cases of T-cell lymphoma, follicular lymphoma, marginal zone lymphoma, lymphoma in an effusion, which is a fluid collection in the body, and lymphoplasmacytic lymphoma. So, there could be others, the FDA didn’t really get into specifics, but yeah, apparently there’s been many different types of lymphomas found associated with the capsule of breast implants. But anaplastic large-cell, I think, remains the most common.
Jamie DePolo: Okay. We’re going to get into the rarity of this, so I don’t want people to get too concerned. But first I want to ask you about the reports about the squamous cell carcinoma. They seem to have involved both textured and smooth breast implants, which is a little bit different than the anaplastic large-cell lymphoma. And they’ve also involved both saline and silicone implants. So, what should we make of all that?
Dr. Brian Wojciechowski: So, the risk of anaplastic large-cell lymphoma is higher for textured surface implants. We have a lot of data on this particular lymphoma, so we know a little more about that than the squamous. But it appears, at least preliminarily, that the squamous cancers can affect textured and smooth surface implants. But there’s a caveat that there’s less than 20 cases out there in the literature right now, so we don’t really know if there’s a preference for textured or smooth with squamous as yet.
Jamie DePolo: Okay. Okay. Well, I have a theory. I mean, I was wondering, given that you said the squamous cells are going to sort of surround any implant that goes in the body. As opposed to my understanding of the issue with textured implants is that it’s a little bit more irritating or perceived as something else by the body, so it sends the lymphocytes, which tend to fight infection. I’m just wondering if these squamous cells are going to be around every implant and some of them happen to turn cancerous.
Dr. Brian Wojciechowski: Yeah, I think that’s a great theory, and it does reflect the fact that cancer is a varied disease. And you know, no two cancers are the same, so every cancer has a different biology, and the risk factors are different and the behavior is different. So, yeah, I think that makes a lot of sense, Jamie.
Jamie DePolo: Okay. So, now getting to the rarity. The FDA did say these cancers were rare. I believe of as Sept. 1, 2022, the agency has received 10 reports of squamous cell carcinoma related to implants and 12 reports of all the other lymphomas related to implants. So, how are you talking to your patients? What should women look out for? How concerned should I be if I have implants?
Dr. Brian Wojciechowski: Yeah, it seems to be very uncommon. Like I said, with the anaplastic large-cell lymphoma we know that the rate of that is about one in a million patients. So, that’s, that’s considered uncommon, and most doctors would consider that a very safe ratio. Of course, we do have to make our patients aware of that because, you know, patients deserve to know all the potential side effects.
Again, with the squamous cell, we have less than 20 cases reported. But that does not necessarily tell us how rare it is. But it’s probably pretty rare. I think we need to track this and collect more cases, and then we can get a better sense of what exactly the incidence is. But you know right now, as far as we know, it’s uncommon.
Jamie DePolo: Okay. Right, and I believe that’s why the FDA put out this alert, because they want doctors to start reporting this or at least be on the lookout for it so they can actually get a good idea of how common it is.
Brian Wojciechowski: Yeah. The FDA monitors these devices and drugs and treatments, even after they’re approved. Because sometimes these side effects don’t arise in the initial studies.
Jamie DePolo: Right. Now, so what should a woman who has implants be on the lookout for? Like, do we know the symptoms of squamous cell? I know, as you said, it’s the most common type of skin cancer and usually that starts in a mole.
Dr. Brian Wojciechowski: Yeah.
Jamie DePolo: But you know you’re not going to develop moles along your breast are you? What should somebody look out for?
Dr. Brian Wojciechowski: Well, first of all you can develop moles in any part of the body. And the breast itself is not immune from skin cancer or other cancers. But this is really not a skin cancer. This is a squamous cell cancer, but not a skin cancer. It’s a cancer basically of the lining, the scar tissue that forms around the breast implant. So, I would tell my patients now the same thing I’ve always told them, which is be aware of your anatomy.
Do a self-exam from time to time so that you know when something is different, you can identify that, and you have a sense of what the baseline breast implant feels like. So, I think women should look out for swelling around the implant, pain, any new lumps or skin changes, and of course report it to the doctor when something changes.
Jamie DePolo: Okay. And I want to clarify my earlier statement and ask one more question. So, say I have implants, and I develop a mole on my breast, should I be concerned? Would that be a symptom of this squamous cell carcinoma or would that be something else?
Dr. Brian Wojciechowski: No. This type of squamous cell carcinoma is not a skin cancer and it doesn’t come from a mole. So, a mole can be of concern, and I’m not saying ignore it, but I’m saying that if it’s a mole on the breast it’s probably not what we’re talking about here.
Jamie DePolo: Okay. And would there be any sort of infection or fever or anything like that to go along with this? Or would it really just be swelling, lump, changes in how the breast feels?
Dr. Brian Wojciechowski: Yeah, fever, when you hear about a fever that’s more likely infection. I mean, cancers can cause fever, especially lymphomas, but nine times out of 10 it’s going to be infection.
Jamie DePolo: Perfect. Perfect. Thank you so much, Brian. This has been really helpful.
Dr. Brian Wojciechowski: It was my pleasure.
