Breast implant-associated anaplastic large cell lymphoma

Last revised by Frank Gaillard on 12 Mar 2023

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

In BIA-ALCL, the peri-implant fluid is referred to as an effusion rather than a seroma, as the latter is acellular 11.  

The entity is rare, with a reported prevalence of between 0.3 in 100,000 to 1 in 1000 women with breast implants 8,10. Less than 1000 cases have been reported (c. 2019) 11. The vast majority of cases are associated with textured breast implants 8,10.

  • 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

Patients may complain of breast swelling, pain, or asymmetry. Clinical breast examination usually reveals a fluid collection (effusion) or mass. Two-thirds of patients present with a late onset effusion (>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.

BIA-ALCL is a T-cell non-Hodgkin lymphoma grouped with other anaplastic large cell lymphomas in the WHO classification of haematolymphoid tumors (5th edition) 12.

Two subtypes are recognized based on morphology 10,11:

  • peri-implant effusion

  • peri-implant 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 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. 

It 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

The Lugano classification and Deauville scale have not been validated for BIA-ALCL 11.

Patients most commonly manifest with a peri-implant effusion (range between 50-1000 mL) only, while less commonly they present with a breast mass +/- effusion 8,10. Nodal disease (axillary, supraclavicular, mediastinal, and/or internal mammary groups) may rarely be involved 10. Ultrasound is the first-line modality followed by MRI. Mammography demonstrates non-specific findings 11.

Ultrasound has high sensitivity (84%) for BIA-ALCL 3,11. It typically demonstrates a fluid collection between the breast implant and the capsule, and septa are often seen. If a mass is present it is typically solid, hypoechoic, and well-circumscribed but without hypervascularity. Complex cystic masses have also been reported 11. Peri-implant breast parenchymal inflammation may also be seen 11.

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 is not able to distinguish between benign and malignant peri-implant effusions due to the low cellularity of BIA-ALCL 11.

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. At least 50 mL of fluid should be aspirated for microbiology and cytology 11.

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. Patients with the peri-implant effusion subtype have a better prognosis than those with peri-implant mass subtype or advanced disease 11.

The first case of BIA-ALCL was reported in 1997 by Keech and Creech 6. The association with breast implants was suggested in 2008 by de Jong et al. and Roden et al 11.

  • 5-10 mL of peri-implant fluid can be considered normal in an asymptomatic patient 11

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Cases and figures

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