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Breast implant-associated anaplastic large cell lymphoma

Last revised by Dr Henry Knipe on 23 May 2020

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 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 1,000 women with breast implants 8,10. Less than 1000 cases have been reported (September 2019) 11. The vast majority of cases are associated with textured breast implants 8,10.

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 with two subtypes 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. 

  • 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

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 BI-ALCL 3,11. Sonography typically demonstrates a fluid collection between the breast implant and the capsule; 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-ACLC 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 MC&S 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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