Breast implant associated - anaplastic large cell lymphoma
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of T-cell primary breast lymphoma which has primarily been associated with textured breast implants.
The entity is rare, with a prevalence of 1 in 1,000 to 1 in 10,000 women with breast implants 8. The vast majority of cases are associated with textured breast implants, regardless of the filling (saline or silicone) 8.
Patients may complain of breast swelling, pain, or asymmetry. Clinical breast examination usually reveals a fluid collection or mass.
The time of onset is at least a year following breast augmentation surgery. The average time of presentation is 8-10 years after implant placement 8.
The exact etiology remains unclear, however, it is widely thought to be multifactorial in nature, due to a combination of chronic inflammation, implant texture and a subclinical infective pathology related to the formation of a biofilm. The end result is thought to be the malignant transformation of T-cells, which become anaplastic lymphoma kinase (ALK) negative and CD30 positive.
Patients most commonly manifest with a perimplant effusion only, while a substantial minority have a breast mass, with or without an effusion 8.
Sonography typically demonstrates a fluid collection between the breast implant and the capsule; septa are often seen. 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 mass 3.
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 ref.
Lesions typically demonstrate 18F-fluorodeoxyglucose avidity on positron emission tomography. The modality may be used to assess for systemic disease.
Treatment and prognosis
On initial workup, tissue sampling should be undertaken, including aspiration of the effusion and/or fine needle aspiration or core needle biopsy of the mass if present 8.
Management typically involves a complete en-bloc capsulectomy and exploration of the prosthesis with patients subsequently receiving some form of chemotherapy and/or radiotherapy depending on the extent of disease 9.
The first case of BIA-ALCL was reported in 1997 by Keech and Creech 6.
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- 5. Di Napoli A, Pepe G, Giarnieri E, Cippitelli C, Bonifacino A, Mattei M, Martelli M, Falasca C, Cox MC, Santino I, Giovagnoli MR. Cytological diagnostic features of late breast implant seromas: From reactive to anaplastic large cell lymphoma. (2017) PloS one. 12 (7): e0181097. doi:10.1371/journal.pone.0181097 - Pubmed
- 6. Keech JA, Creech BJ. Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant. (1997) Plastic and reconstructive surgery. 100 (2): 554-5. Pubmed
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- 8. Raj SD, Shurafa M, Shah Z, Raj KM, Fishman MDC, Dialani VM. Primary and Secondary Breast Lymphoma: Clinical, Pathologic, and Multimodality Imaging Review. (2019) Radiographics : a review publication of the Radiological Society of North America, Inc. 39 (3): 610-625. doi:10.1148/rg.2019180097 - Pubmed
- 9. Kim B, Predmore ZS, Mattke S, van Busum K, Gidengil CA. Breast Implant-associated Anaplastic Large Cell Lymphoma: Updated Results from a Structured Expert Consultation Process. (2015) Plastic and reconstructive surgery. Global open. 3 (1): e296. doi:10.1097/GOX.0000000000000268 - Pubmed