Breast implant-associated anaplastic large cell lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of T-cell lymphoma which has primarily been associated with textured breast implants.  

Clinical presentation

Patients typically present with development of a late onset fluid collection surrounding the implant or less commonly after identification of a breast or axillary mass. Cases have been reported as early as 1 year after surgery and as late as 37 years post augmentation mammoplasty. The average time to clinical presentation is reported to be approximately 10 years post breast augmentation. 

Pathology

The exact causative aetiology has not been confirmed, however it is widely postulated that it is likely multifactorial in nature and due to a combination of factors including chronic inflammation, implant texturing and a subclinical infective pathology related to biofilm. The end result of the multiple insults is thought to cause malignant transformation of T-cells which are anaplastic lymphoma kinase negative and CD30 positive. 

Radiographic features

Ultrasound

Sonography typically demonstrates a fluid collection between the breast implant and the capsule. Septa are often appreciated during the study. Ultrasound is reported to have a sensitivity of 84% and specificity of 75% for detecting effusions and a sensitivity of 46% and specificity of 100% for detecting a BIA-ALCL mass³. 

MRI

BIA-ALCL related effusions and masses may be appreciated on MRI. Capsular enhancement has also been reported in a small number of cases as has evidence of implant rupture.

One documented protocol for MR imaging in BIA-ALCL utilised the following sequences³: 

• T1-weighted spin echo 
• T2-weighted fat suppressed fast spin echo 
• Dynamic contrast enhanced T1-weighted 3D fat surpassed fast spoiled gradient echo at 2 minute intervals pre and post administration of intravenous gadopentetate dimeglumine. 
• Delayed contrasted enhanced T1-weighted 3D fat-suppressed fast spoiled gradient echo

PET/CT 

Lesions typically demonstrate fludeoxyglucose (¹⁸F) avidity on positron emission tomography and the modality may be utilised to assess for systemic disease. 

Treatment

In the initial setting, ultrasound guided fine needle aspiration of the effusion surrounding the breast implant is undertaken. Cytology is subsequently used to assist with confirming the diagnosis. A finding of atypical cells with ≥10% expressing CD30 is said to favour a diagnosis of BIA-ALCL.

Multidisciplinary management including radiology, haematology, oncology, plastic surgery and or surgical oncology input forms the basis of management. 

Management typically involves a complete en-bloc capsulectomy and explantation fo the prosthesis with patients subsequently receiving some form of chemotherapy and or radiotherapy depending on the extent of disease. 

Differential diagnosis

• seroma
• liquified haematoma
• primary breast cancer

History

The first case of BIA-ALCL was reported in 1997 by Keech and Creech ⁶.