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.
Cases have been reported as early as 1 year after surgery and as late as 37 years postaugmentation mammoplasty ref. The average time to clinical presentation is reported to be approximately 10 years post breast augmentation ref.
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.
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 formation of a biofilm. The end result is thought to be the malignant transformation of T-cells which become anaplastic lymphoma kinase negative and CD30 positive.
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.
One documented protocol for MR imaging in BIA-ALCL utilized the following sequences ref:
- 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
Lesions typically demonstrate fluorodeoxyglucose (18F) avidity on positron emission tomography and the modality may be used to assess for systemic disease.
Treatment and prognosis
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 favor a diagnosis of BIA-ALCL.
Multidisciplinary management including radiology, hematology, oncology, plastic surgery and or surgical oncology input forms the basis of management.
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.
The first case of BIA-ALCL was reported in 1997 by Keech and Creech 6.
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- 4. Pieszko K, Kuczyński M, Murawa D. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) — How to diagnose and treat? NOWOTWORY J Oncol 2018; 68, 1: 15–21 (not indexed)
- 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
- 7. Kricheldorff J, Fallenberg EM, Solbach C, Gerber-Schäfer C, Rancsó C, Fritschen UV. Breast Implant-Associated Lymphoma. (2018) Deutsches Arzteblatt international. 115 (38): 628-635. doi:10.3238/arztebl.2018.0628 - Pubmed