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 that has primarily been associated with textured breast implants. 

Epidemiology

The entity is rare, with a reported prevalence of between 0.3 in 100,000 to 1 in 1,000 women with breast implants ^8,10. The vast majority of cases are associated with textured breast implants ^8,10.

Clinical presentation

Patients may complain of breast swelling, pain, or asymmetry. Clinical breast examination usually reveals a fluid collection (seroma) or mass. Two-thirds of patients present with a late-onset seroma (>1 year from the surgery) and one-third present with a mass ¹⁰.

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 ^8,10.

Pathology

BIA-ALCL is a T-cell non-Hodgkin lymphoma arising in a peri-implant fluid collection or in the surrounding fibrous capsule ¹⁰. 

Etiology

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 ¹⁰. The end result is thought to be the malignant transformation of T-cells, which become anaplastic lymphoma kinase (ALK) negative and CD30 positive. 

Risk factors

• textured implant surface (vs smooth implant surface) ¹⁰
• factors that have been shown not to alter risk include ¹⁰
  • indication: primary augmentation vs reconstruction
  • type: saline vs silicone
  • location: retroglandular vs retropectoral

Staging

BIA-ALCL can be staged using the TNM system ¹⁰:

• stage 1: confined to the external fibrous capsule
• stage 2: extracapsular mass (locally advanced disease)
• stage 3: regional and distant metastases

Radiographic features

Patients most commonly manifest with a peri-implant effusion (range between 50-1000 mL) only, while a minority have a breast mass +/- effusion ^8,10. Nodal disease (axillary, supraclavicular, mediastinal, and/or internal mammary groups) may rarely be involved ¹⁰.

Ultrasound

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. 

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 ^ref.

PET/CT 

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. 

Differential diagnosis

• seroma
• liquefied hematoma
• primary breast cancer

History and etymology

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