Breast Implant Associated with Anaplastic Large Cell Lymphoma
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of lymphoma that is most commonly associated with textured breast implants. Recently Dr Melissa Camp published a review article summarizing present knowledge regarding BIA-ALCL, including discussion of the current algorithm for diagnosis and treatment as published in the National Comprehensive Cancer Network (NCCN) Guidelines version 1.2021. The article was published in the journal Advances in Surgery.
BIA-ALCL is a rare peripheral T-cell lymphoma that most commonly arises in association with a current or prior textured breast implant and occurs with both saline and silicone implants.
Etiology:
Although the underlying mechanism of BIA-ALCL is currently unknown, Dr Melissa noted that the interaction between a bacterial biofilm and the textured implant surface may stimulate a chronic inflammatory response leading to the transformation of T cells.
Incidence:
The risk of developing BIA-ALCL is difficult to quantify. However, it is estimated to be 1 in 3000 to 1 in 30,000. The author noted that tracking of cases over time using www.thepsf.org/PROFILE will allow for a more accurate assessment of the incidence and prevalence of BIA-ALCL.
Clinical Presentation:
Dr Melissa wrote that BIA-ALCL patients present with fluid collection surrounding the breast implant or asymmetric breast swelling, occurring at least 1 year after the implant was placed and unexplained by other causes such as infection or recent trauma to the chest.
She also mentioned palpable mass, lymphadenopathy in the regional lymph node basins (axillary, supraclavicular, or internal mammary), overlying skin changes such as a rash, or capsular contracture can also occur least commonly.
Diagnosis:
For patients with breast implants presenting with a delayed fluid collection, asymmetric breast swelling, or less commonly a palpable mass, Dr Melissa noted that the initial step in the diagnostic evaluation should be an ultrasound of the breast and ipsilateral axilla. If ultrasound is inconclusive or indeterminant, she recommended breast MRI.
She suggested adding BIA-ALCL in the differential diagnosis for patients with a delayed fluid collection surrounding a breast implant. She further advises appropriate histopathologic evaluation to confirm the diagnosis.
Treatment:
Following confirmation of BIA-ALCL, the author recommended a multidisciplinary treatment approach involving plastic surgery, surgical oncology and medical oncology.
She wrote, "Most cases of BIA-ALCL are diagnosed at an early stage and have an overall good prognosis if complete surgical resection can be achieved."
She recommend systemic therapy for more advanced cases of BIA-ALCL and noted that radiation therapy may also be indicated if the residual local disease is present.
Furthermore, she recommended against the removal of breast implants in asymptomatic patients who currently have breast implants and advised to educate patients and providers on awareness of the existence of BIA-ALCL.
FDA On Implants:
The FDA released labelling guidance for all breast implants (textured and smooth) in September 2020, with recommendations for a boxed warning stating that breast implants have been associated with BIA-ALCL, that BIA-ALCL occurs more commonly in patients with textured as opposed to smooth implants, and that deaths have occurred from BIA-ALCL. Moreover, the FDA recommends that breast implant information brochures provided to patients contain a decision checklist that indicates the risk of BIA-ALC.
