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Clemens MW, Myckatyn TM, Di Napoli A, Feldman AL, Jaffe ES, Haymaker CL, Horwitz SM, Hunt KK, Kadin ME, McCarthy CM, Miranda RN, Prince HM, Santanelli di Pompeo F, Holmes SD, Phillips LG. American Association of Plastic Surgeons Consensus on Breast Implant-Associated Anaplastic Large-Cell Lymphoma. Plast Reconstr Surg 2024; 154:473-483. [PMID: 38412359 PMCID: PMC11346714 DOI: 10.1097/prs.0000000000011370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND In the absence of high-quality evidence, there is a need for guidelines and multidisciplinary consensus recommendations on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL. METHODS A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, and supplemented by manual searches of relevant English-language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons using a Delphi consensus method. RESULTS A total of 840 articles published between January of 2011 and January of 2023 were initially identified and screened. The full text of 188 articles was assessed. An additional 43 articles were excluded for focus, and 145 articles were included in the synthesis of results, with 105 of them being case reports or case series. The analysis encompassed a comprehensive examination of the selected articles to determine the incidence, risk factors, clinical presentation, diagnostic approaches, and treatment modalities related to BIA-ALCL. CONCLUSIONS Plastic surgeons should be aware of the elevated risks by implant surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on the pathogenesis, genetic drivers, and preventative and prophylactic measures for BIA-ALCL is crucial for improving patient care. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, V.
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MESH Headings
- Humans
- Lymphoma, Large-Cell, Anaplastic/etiology
- Lymphoma, Large-Cell, Anaplastic/epidemiology
- Lymphoma, Large-Cell, Anaplastic/diagnosis
- Lymphoma, Large-Cell, Anaplastic/prevention & control
- Lymphoma, Large-Cell, Anaplastic/therapy
- Breast Implants/adverse effects
- Female
- Breast Neoplasms/etiology
- Breast Neoplasms/surgery
- Breast Neoplasms/diagnosis
- Breast Implantation/adverse effects
- Consensus
- United States/epidemiology
- Societies, Medical/standards
- Risk Factors
- Postoperative Complications/etiology
- Postoperative Complications/epidemiology
- Postoperative Complications/diagnosis
- Postoperative Complications/prevention & control
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Affiliation(s)
| | | | - Arianna Di Napoli
- Neurosciences, Mental Health, and Sense Organs Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital
| | - Andrew L. Feldman
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Mayo Clinic
| | - Elaine S. Jaffe
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute
| | | | | | - Kelly K. Hunt
- From the MD Anderson Cancer Center, University of Texas
| | - Marshall E. Kadin
- Pathology and Laboratory Medicine, Brown University Alpert School of Medicine
| | | | | | - H. Miles Prince
- Epworth Healthcare, Peter MacCallum Cancer Center, University of Melbourne
| | - Fabio Santanelli di Pompeo
- Neurosciences, Mental Health, and Sense Organs Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital
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Joks MM, Czernikiewicz K, Mazurkiewicz Ł, Joks M, Balcerzak A, Kroll-Balcerzak R, Rupa-Matysek J. Breast Implant-Associated Anaplastic Large Cell Lymphoma: Where Hematology and Plastic Surgery Meet. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e293-e300. [PMID: 38839449 DOI: 10.1016/j.clml.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
Breast implant insertion for breast reconstruction or breast augmentation is a developing procedure, with high demand worldwide-being the second most common plastic surgery in the US as of 2022. Breast-implant-associated anaplastic large cell lymphoma (BIA-ALCL) is T-cell, non-Hodgkin lymphoma, typically CD30+, ALK-, presenting with fluid collection in the inner aspect of the peri-implant capsule in most patients, with the onset exceeding 1-year after implantation. The mean time between breast implant insertion and BIA-ALCL development is 7-10 years. The main risk factor is the use of textured implants because of their susceptibility to triggering local inflammation and immune stimulation finally leading to lymphoproliferation. Genetic predispositions to hereditary breast cancer increase the risk of disease development as well. BIA-ALCL seems to be underestimated in many countries and the initial symptom-seroma might be overlooked and misdiagnosed. Despite its rarity, the awareness of the disease should be improved among patients and medical professionals. This paper summarizes epidemiology, etiopathogenesis, differential diagnosis, and treatment-both surgical and hematological approaches.
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Affiliation(s)
- Maria Magdalena Joks
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Krystian Czernikiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Łukasz Mazurkiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Joks
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Balcerzak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Renata Kroll-Balcerzak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland.
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Vittorietti M, Mazzola S, Costantino C, De Bella DD, Fruscione S, Bonaccorso N, Sciortino M, Costanza D, Belluzzo M, Savatteri A, Tramuto F, Contiero P, Tagliabue G, Immordino P, Vitale F, Di Napoli A, Mazzucco W. Implant replacement and anaplastic large cell lymphoma associated with breast implants: a quantitative analysis. Front Oncol 2023; 13:1202733. [PMID: 37927474 PMCID: PMC10622658 DOI: 10.3389/fonc.2023.1202733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma associated with breast reconstruction post-mastectomy or cosmetic-additive mammoplasty. The increasing use of implants for cosmetic purposes is expected to lead to an increase in BIA-ALCL cases. This study investigated the main characteristics of the disease and the factors predicting BIA-ALCL onset in patients with and without an implant replacement. Methods A quantitative analysis was performed by two independent researchers on cases extracted from 52 primary studies (case report, case series, and systematic review) published until April 2022 and searched in PubMed, Scopus, and Google-Scholar databases using "Breast-Implant" AND/OR "Associated" AND/OR "Anaplastic-Large-Cell-Lymphoma". The statistical significance was verified by Student's t-test for continuous variables, while Fisher's exact test was applied for qualitative variables. Cox model with time-dependent covariates was used to estimate BIA-ALCL's onset time. The Kaplan-Meier model allowed the estimation of the probability of survival after therapy according to breast implant exposure time. Results Overall, 232 patients with BIA-ALCL were extracted. The mean age at diagnosis was 55 years old, with a mean time to disease onset from the first implant of 10.3 years. The hazard of developing BIA-ALCL in a shorter time resulted significantly higher for patients not having an implant replacement (hazard ratio = 0.03; 95%CI: 0.005-0.19; p-value < 0.01). Patients with implant replacement were significantly older than patients without previous replacement at diagnosis, having a median time to diagnosis since the first implant of 13 years (7 years in patients without replacement); anyway, the median time to BIA-ALCL occurrence since the last implantation was equal to 5 years. Discussion Our findings suggest that, in BIA-ALCL patients, the implant substitution and/or capsulectomy may delay the disease's onset. However, the risk of reoccurrence in an earlier time should be considered in these patients. Moreover, the time to BIA-ALCL onset slightly increased with age. Selection bias, lack of awareness, misdiagnosis, and limited data availability could be identified as limits of our study. An implant replacement should be considered according to a risk stratification approach to delay the BIA-ALCL occurrence in asymptomatic patients, although a stricter follow-up after the implant substitution should be recommended. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023446726.
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Affiliation(s)
| | - Sergio Mazzola
- U.O.C. of Clinical Epidemiology with Cancer Registry, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
| | - Claudio Costantino
- U.O.C. of Clinical Epidemiology with Cancer Registry, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
- PROMISE Department, University of Palermo, Palermo, Italy
| | | | | | | | | | | | | | | | - Fabio Tramuto
- U.O.C. of Clinical Epidemiology with Cancer Registry, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
- PROMISE Department, University of Palermo, Palermo, Italy
| | - Paolo Contiero
- Environmental Epidemiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanna Tagliabue
- Cancer Registry Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Francesco Vitale
- U.O.C. of Clinical Epidemiology with Cancer Registry, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
- PROMISE Department, University of Palermo, Palermo, Italy
| | - Arianna Di Napoli
- Department of Clinical and Molecular Medicine, University of Rome “Sapienza”, Rome, Italy
| | - Walter Mazzucco
- U.O.C. of Clinical Epidemiology with Cancer Registry, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
- PROMISE Department, University of Palermo, Palermo, Italy
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
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Kadin ME, Morgan J, Wei W, Song Z, Yang Y. CD30 Regulation of IL-13-STAT6 Pathway in Breast Implant-Associated Anaplastic Large Cell Lymphoma. Aesthet Surg J 2023; 43:137-146. [PMID: 35999655 PMCID: PMC10208747 DOI: 10.1093/asj/sjac234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare, usually indolent CD30+ T-cell lymphoma with tumor cells, often surrounded by eosinophils, expressing IL-13 and pSTAT6. OBJECTIVES The aim of this study was to understand the unique tumor pathology and growth regulation of BIA-ALCL, leading to potential targeted therapies. METHODS We silenced CD30 and analyzed its effect on IL-13 signaling and tumor cell viability. IL-13 signaling receptors of BIA-ALCL cell lines were evaluated by flow cytometry and pSTAT6 detected by immunohistochemistry. CD30 was deleted by CRISPR/Cas9 editing. Effects of CD30 deletion on transcription of IL-13 and IL-4, and phosphorylation of STAT6 were determined by real-time polymerase chain reaction and western blotting. The effect of CD30 deletion on p38 mitogen-activated protein kinase (MAPK) phosphorylation was determined. Suppression of IL-13 transcription by a p38 MAPK inhibitor was tested. Tumor cell viability following CD30 deletion and treatment with a pSTAT6 inhibitor were measured in cytotoxicity assays. RESULTS BIA-ALCL lines TLBR1 and TLBR2 displayed signaling receptors IL-4Rα, IL-13Rα1 and downstream pSTAT6. Deletion of CD30 by CRISPR/Cas9 editing significantly decreased transcription of IL-13, less so Th2 cytokine IL-4, and phosphorylation of STAT6. Mechanistically, we found CD30 expression is required for p38 MAPK phosphorylation and activation, and IL-13-STAT6 signaling was reduced by an inhibitor of p38 MAPK in BIA-ALCL tumor cells. Tumor cell viability was decreased by silencing of CD30, and a specific inhibitor of STAT6, indicating STAT6 inhibition is cytotoxic to BIA-ALCL tumor cells. CONCLUSIONS These findings suggest reagents targeting the IL-13 pathway, pSTAT6 and p38 MAPK, may become useful for treating BIA-ALCL patients.
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Affiliation(s)
- Marshall E Kadin
- Department of Pathology and Laboratory Medicine, Brown University Alpert
School of Medicine, Providence, RI. USA
| | | | - Wei Wei
- Fox Chase Cancer Center, Philadelphia,
PA, USA
| | - Zhihui Song
- Fox Chase Cancer Center, Philadelphia,
PA, USA
| | - Yibin Yang
- Blood Cell Development and Function Program, Fox Chase Cancer
Center, Philadelphia, PA, USA
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5
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Turner SD. Commentary on: CD30 Regulation of IL-13-STAT6 Pathway in Breast Implant-Associated Anaplastic Large Cell Lymphoma. Aesthet Surg J 2023; 43:147-149. [PMID: 36380464 DOI: 10.1093/asj/sjac297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022] Open
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6
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Naga HI, Mellia JA, Basta MN, Morris MP, Christopher AN, Campbell FM, Sommers K, Levinson H, Nelson JA, Fischer JP. Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Updated Systematic Review and Analysis of Treatment Strategies. Plast Reconstr Surg 2022; 150:762-769. [PMID: 35862104 PMCID: PMC9551598 DOI: 10.1097/prs.0000000000009538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although guidelines have been published on treatment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines. METHODS Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines. RESULTS A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma ( n = 114, 70.4 percent), followed by a mass ( n = 14, 8.6 percent), or both ( n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 ( p < 0.001), whereas treatment for advanced disease remained unchanged ( p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p < 0.001). CONCLUSIONS BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.
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Affiliation(s)
- Hani I. Naga
- Division of Plastic Surgery, Duke University, Durham, NC
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joseph A. Mellia
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marten N. Basta
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Martin P. Morris
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Frank M. Campbell
- Biomedical Library, Perelman School of Medicine, University of Pennsylvania, PA
| | | | - Howard Levinson
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
- Plastic Surgery Foundation, Arlington Heights, IL
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John P. Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
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7
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An Unusual Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma. Case Rep Hematol 2022; 2022:4700787. [PMID: 35721802 PMCID: PMC9203203 DOI: 10.1155/2022/4700787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare disease entity associated with textured breast implants. Though the clinical course is typically indolent, BIA-ALCL can occasionally invade through the capsule into the breast parenchyma with spread to the regional lymph nodes and beyond including chest wall invasive disease. Case. We present the case of a 51-year-old female with a history of bilateral silicone breast implants placed approximately twenty years ago who presented with two months of progressively enlarging right breast mass. Ultrasound-guided biopsy of right breast mass and right axillary lymph node showed CD 30-positive ALK-negative anaplastic large cell lymphoma, and staging work up showed extension of the tumor to chest wall and ribs consistent with advanced disease. She received CHP-BV (cyclophosphamide, doxorubicin, prednisone, and brentuximab vedotin) for six cycles with complete metabolic response. This was followed by extensive surgical extirpation and reconstruction, radiation for residual disease and consolidation with autologous stem cell transplant. She is currently on maintenance brentuximab vedotin with no evidence of active disease post autologous stem cell transplant. Conclusion. Treatment guidelines for advanced chest wall invasive BIA-ALCL are not well defined. Lack of predictive factors warrants mutation analysis and genetic sequencing to identify those at highest risk of progression to chest wall invasive disease. This rare case highlights the need for definitive consensus on the optimal management of chest wall invasive BIA-ALCL.
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Schwarting R, Behling E, Allen A, Arguello-Guerra V, Budak-Alpdogan T. CD30+ Lymphoproliferative Disorders as Potential Candidates for CD30-Targeted Therapies. Arch Pathol Lab Med 2022; 146:415-432. [PMID: 35299246 DOI: 10.5858/arpa.2021-0338-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— In the early 1980s, a monoclonal antibody termed Ki-1 was developed against a cell line derived from a patient with Hodgkin lymphoma. This antibody detected a limited number of benign activated lymphocytes in lymphoid tissue, whereas in Hodgkin lymphoma it appeared to be nearly specific for Reed-Sternberg cells and their mononuclear variants. Subsequent studies showed that Ki-1 expression defined a new type of lymphoma that was later designated anaplastic large cell lymphoma with or without anaplastic large cell kinase expression/translocation. In the past 30 years, numerous new lymphoma entities have been defined, many of which are variably positive for CD30. Many virally transformed lymphoproliferative disorders are also frequently positive for CD30. OBJECTIVE.— To illustrate the broad spectrum of CD30+ hematologic malignancies and to provide an update of CD30-targeted therapies. DATA SOURCES.— Personal experiences and published works in PubMed. CONCLUSIONS.— Because of its low expression in normal tissue, CD30 was studied as a therapeutic target for many years. However, the first functional humanized antibody against CD30 was developed only about 10 years ago. Brentuximab vedotin is a humanized anti-CD30 antibody linked to a cytotoxin, and was approved by the US Food and Drug Administration in 2012 for treating refractory Hodgkin lymphoma and anaplastic large cell lymphoma. Since then, the list of Food and Drug Administration-approved CD30-targeted hematologic malignancies has grown. Recently, the therapies using tumor antigen-specific chimeric antigen receptor T cells targeting CD30 have incited a great deal of enthusiasm and are studied in clinical trials.
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Affiliation(s)
- Roland Schwarting
- From the Department of Pathology, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey (Schwarting, Behling, Allen, Arguello-Guerra)
| | - Eric Behling
- From the Department of Pathology, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey (Schwarting, Behling, Allen, Arguello-Guerra)
| | - Ashleigh Allen
- From the Department of Pathology, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey (Schwarting, Behling, Allen, Arguello-Guerra)
| | - Vivian Arguello-Guerra
- From the Department of Pathology, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey (Schwarting, Behling, Allen, Arguello-Guerra)
| | - Tulin Budak-Alpdogan
- MD Anderson Cancer Center at Cooper, Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey (Budak-Alpdogan)
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Mehta-Shah N, Ghione P. An Updated Approach and Understanding of Breast Implant-Associated Anaplastic Large Cell Lymphoma. J Natl Compr Canc Netw 2022; 20:309-315. [PMID: 35276670 DOI: 10.6004/jnccn.2022.7004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/13/2022] [Indexed: 11/17/2022]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare subtype of T-cell non-Hodgkin lymphoma that is usually localized to the fluid and capsule surrounding a breast implant. There have only been <1,000 cases and 36 deaths reported to date and the average patient presents 7 to 10 years following initial breast implant placement. Most patients present with delayed seromas, a breast mass, capsular abnormalities, lymphadenopathy, or cutaneous masses. Unlike other forms of non-Hodgkin lymphoma, most cases are cured with surgery alone. The challenge of BIA-ALCL surrounds its rarity-in regard to both its diagnosis as well as the limited available data to guide therapy for more advanced cases. Careful pathology evaluation to analyze both the fluid surrounding the capsule and the capsule itself is critical. Studies to identify which patients are at greater risk of development of this rare entity are ongoing.
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Affiliation(s)
- Neha Mehta-Shah
- 1Division of Oncology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri; and
| | - Paola Ghione
- 2Division of Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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10
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James ER, Miranda RN, Turner SD. Primary Lymphomas of the Breast: A Review. JPRAS Open 2022; 32:127-143. [PMID: 35402679 PMCID: PMC8987598 DOI: 10.1016/j.jpra.2022.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022] Open
Abstract
Lymphomas of the breast are rare neoplasms that arise from breast lymphoid tissue and are characterised by neoplastic B or T cells. Breast lymphomas arising from B cells include, but are not limited to, diffuse large B cell lymphoma, follicular lymphoma, extra-nodal marginal zone lymphoma and Burkitt lymphoma. Anaplastic large cell lymphoma (ALCL) is of a T cell origin and both anaplastic lymphoma kinase (ALK)-positive and ALK-negative presentations have been noted in the breast. In addition, there is a more recently identified presentation of ALK-negative ALCL that arises around textured breast implants and is usually confined to a periprosthetic fibrous capsule. Here, we discuss the clinical presentations, histological and immunohistochemical features and treatment options for each type of primary breast lymphoma. We hope that this review will highlight the importance of the timely and accurate diagnosis of breast lymphoma in order to tailor the most appropriate treatment. We also wish to raise awareness of the breast implant-associated lymphomas, with the goal of stimulating work that will aid our understanding of their epidemiology and pathogenesis.
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Coombs DM, Aliotta R, Jagadeesh D, Raymond D, Isakov R. Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses. Ann Plast Surg 2021; 87:409-414. [PMID: 34176904 DOI: 10.1097/sap.0000000000002910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative. OBJECTIVES In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease. METHODS This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement. RESULTS All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up. CONCLUSIONS In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.
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Affiliation(s)
| | | | | | - Daniel Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
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12
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Abstract
ABSTRACT Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized malignancy of T-lymphocytes that is linked to certain types of textured breast implants. Although rare, the increasing awareness of the disease is resulting in more case reports and heightened anxiety in patients with textured breast implants. This review aims to summarize the available BIA-ALCL data, including the existing theories of etiopathogenesis, the diagnostic work-up for BIA-ALCL patients, BIA-ALCL treatment recommendations, the epidemiologic challenges, and the current opinions surrounding the use of textured breast implants.
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Affiliation(s)
- Alyson Skelly
- From the Tufts University School of Medicine, Boston
| | - Lifei Guo
- Division of Plastic Surgery, Lahey Hospital & Medical Center, Burlington, MA
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13
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Turton P, El‐Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma on behalf of the Medicines and Healthcare products Regulatory Agency Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group. Br J Haematol 2021; 192:444-458. [PMID: 33222158 PMCID: PMC7894347 DOI: 10.1111/bjh.17194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/13/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK)-negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimise the need for systemic treatments, reduce morbidity and the risk of poor outcomes.
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Affiliation(s)
- Philip Turton
- St James's HospitalThe Leeds Teaching Hospitals NHS TrustLeedsUK
| | | | - Iain Lyburn
- Cobalt Medical CharityCheltenhamUK
- Gloucestershire Hospitals NHS Foundation TrustGloucesterUK
| | | | | | - Suzanne D. Turner
- Division of Cellular and Molecular PathologyDepartment of PathologyUniversity of CambridgeCambridgeUK
- CEITECMasaryk UniversityBrnoCzech Republic
| | | | | | | | - Cathy Burton
- St James's HospitalThe Leeds Teaching Hospitals NHS TrustLeedsUK
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Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG). Eur J Surg Oncol 2020; 47:199-210. [PMID: 33358076 DOI: 10.1016/j.ejso.2020.07.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 01/11/2023] Open
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes.
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Affiliation(s)
- Philip Turton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Iain Lyburn
- Cobalt Medical Charity, Cheltenham, UK; Gloucestershire Hospitals NHS Foundation Trust, UK
| | | | | | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, CB20QQ, UK; CEITEC, Masaryk University, Brno, Czech Republic
| | | | | | | | - Cathy Burton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nigel Mercer
- Bristol Plastic Surgery, 58 Queen Square, Bristol, BS1 4LF, UK
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Allchin RL, Wickenden K, Pilgrim S, Wilson-Morkeh I, Miall FM. The Successful Use of Neo Adjuvant Brentuximab Vedotin in the Treatment of BIA-ALCL. Hemasphere 2020; 4:e501. [PMID: 33283170 PMCID: PMC7710186 DOI: 10.1097/hs9.0000000000000501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rebecca L Allchin
- Department of Hematology, University Hospitals, Leicester, United Kingdom
| | | | - Simon Pilgrim
- Department of Breast Surgery, University Hospitals, Leicester, United Kingdom
| | - Issac Wilson-Morkeh
- Department of Hematology, Kettering General Hospital, Kettering, United Kingdom
| | - Fiona M Miall
- Department of Hematology, University Hospitals, Leicester, United Kingdom
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16
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Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG). J Plast Reconstr Aesthet Surg 2020; 74:13-29. [PMID: 33483089 DOI: 10.1016/j.bjps.2020.10.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes. These guidelines provide an evidence-based and systematic framework for the assessment and treatment of patients with suspected or proven BIA-ALCL and are aimed at all clinicians involved in the care of people with breast implants.
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Affiliation(s)
- Philip Turton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Iain Lyburn
- Cobalt Medical Charity, Cheltenham, UK; Gloucestershire Hospitals NHS Foundation Trust, UK
| | | | | | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge CB20QQ, UK; CEITEC, Masaryk University, Brno, Czech Republic
| | | | | | | | - Cathy Burton
- St James's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nigel Mercer
- Bristol Plastic Surgery, 58 Queen Square, Bristol BS1 4LF
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Stack A, Ali N, Khan N. Breast Implant-associated Anaplastic Large Cell Lymphoma: A Review with Emphasis on the Role of Brentuximab Vedotin. JOURNAL OF CELLULAR IMMUNOLOGY 2020; 2:80-89. [PMID: 32914146 PMCID: PMC7480932 DOI: 10.33696/immunology.2.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Breast implant-associated anaplastic large cell lymphoma is a recently recognized complication of textured breast implants. It typically presents as unilateral peri-implant swelling approximately 7-10 years after implantation. While the course is usually indolent, breast implant-associated anaplastic large cell lymphoma may form a locally invasive mass and metastasize to regional lymph nodes or beyond to distant sites. Surgical excision has been well established as the standard of care for localized disease; however, guidelines directing management of advanced, recurrent or unresectable disease are based on limited and extrapolated evidence. The CD30-targeting immunoconjugate, brentuximab vedotin, has been utilized in this setting, typically in combination with chemotherapy. We recently reported a patient with unresectable breast implant-associated anaplastic large cell lymphoma who was treated with brentuximab vedotin monotherapy and has now sustained complete remission for 2.6 years. Herein, we provide an up-to-date review of the epidemiology, pathogenesis, clinical features, diagnosis and management of breast implant associated anaplastic large cell lymphoma with emphasis on the role of brentuximab vedotin.
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Affiliation(s)
- Anthony Stack
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA USA
| | - Nadia Ali
- Department of Medicine, section of Hematology, Temple University Hospital, Philadelphia, PA, USA
| | - Nadia Khan
- Department of Hematology and Oncology, Fox Chase Cancer Center, Philadelphia, PA USA
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Fitzal F, Turner SD, Kenner L. Is breast implant-associated anaplastic large cell lymphoma a hazard of breast implant surgery? Open Biol 2020; 9:190006. [PMID: 30939983 PMCID: PMC6501645 DOI: 10.1098/rsob.190006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) may occur after reconstructive or aesthetic breast surgery. Worldwide, approximately 1.7 million breast implant surgeries are performed each year. To date, over 500 cases of BIA-ALCL have been reported around the world, with 16 women having died. This review highlights the most important facts surrounding BIA-ALCL. There is no consensus regarding the true incidence rate of BIA-ALCL as it varies between countries, is probably significantly under-reported and is difficult to estimate due to the true number of breast prostheses used largely being unknown. BIA-ALCL develops in the breast mostly as a seroma surrounding the implant, but contained within the fibrous capsule, or more rarely as a solid mass that can become invasive infiltrating the chest wall and muscle, in some instances spreading to adjacent lymph nodes, in these cases having a far worse prognosis. The causation of BIA-ALCL remains to be established, but it has been proposed that chronic infection and/or implant toxins may be involved. What is clear is that complete capsulectomy is required for treatment of BIA-ALCL, which for early-stage disease leads to cure, whereas chemotherapy is needed for advanced-stage disease, whereby improved results have been reported with the use of brentuximab. A worldwide database for BIA-ALCL and implants should be supported by local governments.
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Affiliation(s)
- Florian Fitzal
- 1 Department of Surgery and Comprehensive Cancer Center, Medical University Vienna , Vienna , Austria
| | - Suzanne D Turner
- 2 Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge , Cambridge CB20QQ , UK.,6 Department for Experimental and Laboratory Animal Pathology, Clinical Institute of Pathology, Medical University of Vienna , 1090 Vienna , Austria
| | - Lukas Kenner
- 3 Ludwig Boltzmann Institute for Cancer Research , 1090 Vienna , Austria.,4 Unit of Laboratory Animal Pathology, University of Veterinary Medicine Vienna , 1210 Vienna , Austria.,5 Division of Experimental Pathology, Medical University of Vienna , 1090 Vienna , Austria.,6 Department for Experimental and Laboratory Animal Pathology, Clinical Institute of Pathology, Medical University of Vienna , 1090 Vienna , Austria.,7 The European Research Initiative for ALK-related Malignancies (ERIA) , Cambridge , UK
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K Groth A, Graf R. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and the Textured Breast Implant Crisis. Aesthetic Plast Surg 2020; 44:1-12. [PMID: 31624894 DOI: 10.1007/s00266-019-01521-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/05/2019] [Indexed: 12/26/2022]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell, CD-30+/ALK lymphoma. Late (9 years) periprosthetic fluid (seroma) is the most common presentation (90% of the cases). A combination of textured breast implant, bacterial contamination, and genetic predisposition seems to be necessary for BIA-ALCL to occur. There are 35 million patients with implants in the world, and at the present moment, 573 cases of BIA-ALCL have been reported. The risk of developing BIA-ALCL in Australia varies from 1:2832 to 1:86,029, with texture grades 3 and 4 seeming to pose a higher risk than grades 2 and 1. NCCN has established guidelines for diagnosis and treatment, and early diagnosis is the key to cure. At an early stage and for the vast majority of patients, the treatment consists of capsulectomy and implant removal. However, at stages II to IV, a systemic treatment is warranted, including chemotherapy, radiotherapy (residual disease), and brentuximab vedotin. The majority of patients can be cured, and complete capsular removal is the most important factor. So far, 33 patients have died from BIA-ALCL worldwide, with deaths related to delay in diagnosis and treatment. Textured implants have been in the midst of the current implant crisis, and Biocell was recalled worldwide after the latest FDA update on the disease. At the present moment, no medical society or regulatory agency has recommended implant removal. It is about time that we start robust breast implant registries to determine risks. Besides, based on scientific criteria, we must consider all the benefits and risks associated with the available breast devices.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Anne K Groth
- Brazilian Society of Plastic Surgery, Curitiba, Brazil.
- Plastic Surgery and Microsurgery Department, Erasto Gaertner Hospital, Curitiba, PR, Brazil.
- Positivo University Medical School, Curitiba, Brazil.
- , Curitiba, Brazil.
| | - Ruth Graf
- Brazilian Society of Plastic Surgery, Curitiba, Brazil
- Federal University of Parana, Curitiba, Brazil
- Pieta Medical Center, Rua Solimões 1175, Curitiba, PR, Brazil
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20
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Turner SD, Wright P. Commentary on: Validation of a CD30 Enzyme-Linked Immunosorbant Assay for the Rapid Detection of Breast Implant-Associated Anaplastic Large Cell Lymphoma. Aesthet Surg J 2020; 40:154-155. [PMID: 30789658 DOI: 10.1093/asj/sjz025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Suzanne D Turner
- Department of Pathology, University of Cambridge, and the Department of Histopathology, Addenbrooke’s Hospital, Cambridge, UK
| | - Penny Wright
- Department of Pathology, University of Cambridge, and the Department of Histopathology, Addenbrooke’s Hospital, Cambridge, UK
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21
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Breast implant-associated anaplastic large cell lymphoma: A comprehensive review. Cancer Treat Rev 2020; 84:101963. [PMID: 31958739 DOI: 10.1016/j.ctrv.2020.101963] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/28/2019] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized non-Hodgkin lymphoma of T-cell origin. Despite the low incidence of this new disease, the increasing use of breast implants for cosmetic or post-mastectomy reconstruction purposes places BIA-ALC as an emerging and compelling medical challenge. The real BIA-ALCL pathogenesis has not been fully uncovered so far, while different putative causal factors have been proposed. Breast implants with textured surfaces seem to be associated with nearly all cases of BIA-ALCL, while the real the risk of disease development has not been well estimated so far. Late onset, persistent seroma around breast implant represents the classical clinical presentation. Most of the BIA-ALCL patients presents with localized disease, which confers an excellent prognosis. Unlike other non-Hodgkin lymphomas, surgical excision of the mass has a key role in the treatment. For patients with advanced and disseminated diseases, the treatment did not differ from other types of T-cell lymphoma. For these reasons, BIA-ALCL represents an emerging disease which requires multidisciplinary team approach to well define diagnostic workup and treatment for each patient. This review article aims to summarize available data on BIA-ALCL. First, we will outline available data on BIA-ALCL epidemiology, pathogenesis, diagnostic work-up, and treatment. Second, we will point out the potential psychological implications as well as the risk of perception distortion for women with breast implants, especially for those with previous breast cancer. Lastly, we will summarize the current national recommendations regarding textured breast implants and discuss the diagnostic-therapeutic algorithm for BIA-ALCL management.
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Choi KJ, Brown AM, Pham CH, Patel SV, Patel KM, Carey J. Current Considerations of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Breast Surgery: a Systematic Review. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-00342-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Cell of Origin and Immunologic Events in the Pathogenesis of Breast Implant-Associated Anaplastic Large-Cell Lymphoma. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 190:2-10. [PMID: 31610171 PMCID: PMC7298558 DOI: 10.1016/j.ajpath.2019.09.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
Abstract
Breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase–negative T-cell lymphoma. Nearly all cases have been associated with textured implants. Most cases are of effusion-limited, indolent disease, with an excellent prognosis after implant and capsule removal. However, capsular invasion and tumor mass have a more aggressive course and a fatal outcome risk. This review summarizes the current knowledge on BIA-ALCL cell of origin and immunologic factors underlying its pathogenesis. Cytokine expression profiling of BIA-ALCL cell lines and clinical specimens reveals a predominantly type 17 helper T-cell (Th17)/Th1 signature, implicating this as its cell of origin. However, a Th2 allergic inflammatory response is suggested by the presence of IL-13, with infiltration of eosinophils and IgE-coated mast cells in clinical specimens of BIA-ALCL. The microenvironment-induced T-cell plasticity, a factor increasingly appreciated, may partially explain these divergent results. Mutations resulting in constitutive Janus kinase (JAK)–STAT activation have been detected and associated with BIA-ALCL pathogenesis in a small number of cases. One possible scenario is that an inflammatory microenvironment stimulates an immune response, followed by polyclonal expansion of Th17/Th1 cell subsets with release of inflammatory cytokines and chemokines and accumulation of seroma. JAK-STAT3 gain-of-function mutations within this pathway and others may subsequently lead to monoclonal T-cell proliferation and clinical BIA-ALCL. Current research suggests that therapies targeting JAK proteins warrant investigation in BIA-ALCL.
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Jones JL, Hanby AM, Wells C, Calaminici M, Johnson L, Turton P, Deb R, Provenzano E, Shaaban A, Ellis IO, Pinder SE. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): an overview of presentation and pathogenesis and guidelines for pathological diagnosis and management. Histopathology 2019; 75:787-796. [PMID: 31166611 DOI: 10.1111/his.13932] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/29/2022]
Abstract
AIMS Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon complication associated largely with textured implants. It is important that the symptoms associated with BIA-ALCL are recognised and that robust pathways are in place to establish the diagnosis. The aim of this paper is to review what is known of the incidence of the disease, current thoughts on pathogenesis, patterns of presentation and pathological features to provide standard guidelines for its diagnosis. METHODS AND RESULTS Systematic review of the literature via PubMed covering cases series, modes of presentation, cytological, histological and immunohistochemical features and disease outcome. Since 1997, 518 cases throughout 25 countries have been registered on the American Society of Plastic Surgeons PROFILE registry, with an estimated risk for women with an implant of one to three per million per year. It most frequently presents as a late-onset accumulation of seroma fluid, sometimes as a mass lesion. The neoplastic cells are highly atypical, consistently strongly positive for CD30, with 43-90% also positive for EMA, and all are ALK-negative. Behaviour is best predicted using a staging system for solid tumours. CONCLUSION BIA-ALCL is a rare but important complication of breast implants. While characterised by CD30-positive neoplastic cells this must be interpreted with care, and we provide pathological guidelines for the robust diagnosis of this lesion as well as the most appropriate staging system and management strategies. Finally, in order to generate more accurate data on incidence, we recommend mechanisms for the routine central reporting of all cases.
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Affiliation(s)
- J Louise Jones
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Andrew M Hanby
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Clive Wells
- Department of Histopathology, Rockefeller Building, University College Hospital London NHS Foundation Trust, London, UK
| | - Marie Calaminici
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Laura Johnson
- St Bartholomew's Hospital, West Smithfield, London, UK
| | - Philip Turton
- Breast Unit, St James's Hospital, The Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Rahul Deb
- Department of Histopathology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Elena Provenzano
- Department of Histopathology, Addenbrookes Hospital, Cambridge, UK
| | - Abeer Shaaban
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian O Ellis
- Department of Histopathology, City Hospital Campus, Nottingham University Hospitals, Nottingham, UK
| | - Sarah E Pinder
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Stack A, Levy I. Brentuximab vedotin as monotherapy for unresectable breast implant-associated anaplastic large cell lymphoma. Clin Case Rep 2019; 7:1003-1006. [PMID: 31110735 PMCID: PMC6510013 DOI: 10.1002/ccr3.2142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/21/2019] [Accepted: 03/14/2019] [Indexed: 11/24/2022] Open
Abstract
BI-ALCL is a rare CD30+ T-cell malignancy, which is known to complicate textured breast implants. The CD30-targeting immunoconjugate, brentuximab vedotin, has been suggested for invasive BI-ALCL; however, its efficacy for unresectable BI-ALCL has not been demonstrated. We present a case of unresectable BI-ALCL, which was successfully treated with brentuximab vedotin.
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Affiliation(s)
- Anthony Stack
- Department of Internal MedicineTemple University HospitalPhiladelphiaPennsylvania
| | - Isaac Levy
- Millennium OncologyPembroke PinesFlorida
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Mukhtar RA, Holland M, Sieber DA, Wen KW, Rugo HS, Kadin ME, Bean GR. Synchronous Breast Implant-associated Anaplastic Large Cell Lymphoma and Invasive Carcinoma: Genomic Profiling and Management Implications. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2188. [PMID: 31321184 PMCID: PMC6554181 DOI: 10.1097/gox.0000000000002188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 01/17/2023]
Abstract
A 59-year-old woman with a history of cosmetic implants developed ipsilateral synchronous breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and invasive ductal carcinoma in the left breast. Each tumor was subjected to next-generation sequencing, and separate analyses revealed mutually exclusive aberrations: an activating STAT3 mutation in the lymphoma and a PIK3CA in-frame deletion in the carcinoma. The patient was treated with removal of implants, capsulectomy, partial mastectomy, sentinel node biopsy, radiotherapy, and endocrine therapy with no evidence of recurrence for 1 year. This case illustrates the importance of obtaining thorough evaluation for concomitant malignancies in the breast at the time of diagnosis of BIA-ALCL. Herein, we review the current recommendations for evaluation and management of BIA-ALCL.
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Affiliation(s)
- Rita A Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco, Calif
| | - Michael Holland
- Department of Surgery, University of California San Francisco, San Francisco, Calif
| | | | - Kwun Wah Wen
- Department of Pathology, University of California San Francisco, San Francisco, Calif
| | - Hope S Rugo
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco; San Francisco, Calif
| | - Marshall E Kadin
- Department of Dermatology and Skin Surgery, Boston University School of Medicine; Boston, Mass
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, R.I
| | - Gregory R Bean
- Department of Pathology, Stanford University School of Medicine, Stanford, Calif
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27
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Turner SD. The Cellular Origins of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Implications for Immunogenesis. Aesthet Surg J 2019; 39:S21-S27. [PMID: 30715172 PMCID: PMC6355097 DOI: 10.1093/asj/sjy229] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The exact cellular origins of most malignancies are unknown, largely because of the complex nature of malignancies, and because the potential vast number of pathways towards transformation are difficult to discern from established growths. This is compounded by the fact that cancer cells have evolved rather than being the consequence of a design process, with most data collected from (sometimes epidemiological) studies of large numbers of related malignancies. In the case of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), the relative rarity of this disease, coupled with limited insight into its biological basis, have hampered progress. The known facts that are holding up as our knowledge increases with rising incidences are that most cases have been reported in the context of textured breast implants, although not all women with these implants develop BIA-ALCL, and cure for early-stage disease (accounting for the majority of patients) can be achieved via complete capsulectomy and implant removal. However, some theories can be gleaned from the limited biological studies conducted to date whereby a T-helper cell derivation is implicated, with its specific and apparent subset of origin dependent on, and shaped by, a number of factors, including the inflammatory microenvironment (the presence of other inflammatory cell types), the driving antigen (bacterial and/or synthetic), the acquisition of driving oncogenic events, and the inherent genetics/health status of the patient.
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Affiliation(s)
- Suzanne Dawn Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
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28
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Sandoval-Sus JD, Brahim A, Khan A, Raphael B, Ansari-Lari A, Ruiz M. Brentuximab vedotin as frontline treatment for HIV-related extracavitary primary effusion lymphoma. Int J Hematol 2019; 109:622-626. [PMID: 30671911 DOI: 10.1007/s12185-019-02592-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/26/2018] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Primary effusion lymphoma (PEL) is a rare and aggressive herpesvirus-8 (HHV-8) driven B cell non-Hodgkin's lymphoma (NHL) that is usually associated with human immunodeficiency virus (HIV) infection, and has a poor prognosis. PEL is comprised of two clinically distinct but pathologically similar variants: classic and extracavitary PEL. Based on retrospective series, treatment options include combined antiretroviral therapy (cART) in conjunction with chemotherapy regimens used in other forms of NHLs. Treatment outcomes with this approach are usually dismal and there is no standard of care. We present a case of a patient with HIV associated CD30+ extracavitary PEL unfit for multi-agent chemotherapy, who achieved a durable complete response with single agent brentuximab-vedotin and cART.
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Affiliation(s)
- Jose D Sandoval-Sus
- Department of Malignant Hematology and Cellular Therapy at Memorial Healthcare System, H. Lee Moffitt Cancer Center, 801 N Flamingo Road, Pembroke Pines, 33028, FL, USA.
| | - Amanda Brahim
- Department of Pharmacy, Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Alina Khan
- Department of Pharmacy, Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Barbara Raphael
- Department of Diagnostic Radiology, Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Ali Ansari-Lari
- Division of Hematopathology, Department of Anatomic and Clinical Pathology, Memorial Healthcare System, Hollywood, FL, USA
| | - Marco Ruiz
- Department of Malignant Hematology and Cellular Therapy at Memorial Healthcare System, H. Lee Moffitt Cancer Center, 801 N Flamingo Road, Pembroke Pines, 33028, FL, USA
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Mehta-Shah N, Clemens MW, Horwitz SM. How I treat breast implant-associated anaplastic large cell lymphoma. Blood 2018; 132:1889-1898. [PMID: 30209119 PMCID: PMC6536699 DOI: 10.1182/blood-2018-03-785972] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/22/2018] [Indexed: 11/20/2022] Open
Abstract
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently described form of T-cell non-Hodgkin lymphoma now formally recognized by the World Health Organization classification of lymphoid neoplasms. The disease most often presents with a delayed seroma around the breast implant, almost exclusively with a textured surface, and manifests with breast pain, swelling or asymmetry, capsular contracture, but can also present with a breast mass, and lymph node involvement. The prognosis of BIA-ALCL is favorable compared with many other subtypes of systemic T-cell lymphoma; however, unlike other non-Hodgkin lymphomas, complete surgical excision for localized disease is an important part of the management of these patients. In this paper, we share our recommendations for a multidisciplinary team approach to the diagnosis, workup, and treatment of BIA-ALCL in line with consensus guidelines by the National Comprehensive Cancer Network.
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Affiliation(s)
- Neha Mehta-Shah
- Division of Oncology, Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Mark W Clemens
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX; and
| | - Steven M Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
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Ramos-Gallardo G, Cuenca-Pardo J, Cardenas-Camarena L, Duran-Vega H, Rodríguez-Olivares E, Bayter-Marin JE, Levelier De Doig Alvear G, Vazquez G, Fontbona-Torres M, Galán-Suárez R, Guzman-Stein G, Guzmán-Padilla S, Echeverría-Roldán G, Silva-Gavarrete JF, Vallarta-Rodríguez A, Contreras-Bulnes L, Oaxaca-Escobar CG, Caravantes-Cortes I, Flores ME, Cowes-McGowen J, Maciel-Sosa ML, Delgado-Binasco R, Rincón-Rubio L. Is Latin America Ready to Identify Anaplastic Large Cell Lymphoma in Breast Implants Patients? Regional Encounter During the National Plastic Surgery Meeting in Cancun, Mexico. Aesthetic Plast Surg 2018; 42:1421-1428. [PMID: 29770862 DOI: 10.1007/s00266-018-1148-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/28/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Anaplastic large cell lymphoma associated with breast implants is receiving increased attention. Most cases have been reported in Europe, North America (USA and Canada), Australia and New Zealand. Fewer cases have been reported in Latin America (including Mexico), Africa and Asia. METHODS This report was delivered during our national plastic surgery meeting in Cancun in May 2017. Before the meeting, two participants reviewed the literature. The review was performed using the following information sources: PubMed, Embase, Cochrane, Fisterra, Google Scholar and LILACS, with entries from 1980 to August 2015 in several languages (English, Spanish, French and Portuguese). The results were revealed during the meeting to the other participants. The consensus was divided into two parts. The first part included an open-ended question regarding the incidence and prevalence of the problem. The second part included clinical scenarios with different items that were rated by the participants. After this activity, accordance among the responses was evaluated. RESULTS Seven cases were reported during the meeting (3 from Mexico, 3 from Chile and 1 from Argentina). Fifty percent of the participants reported consulting with guidelines and clinical centers to help with potential cases. Most agreed that further studies must be done in cases of chronic seroma where the capsule plays an important role. DISCUSSION A current debate exists about the incidence of this problem in Latin America because we did not report the same number of cases as Europe, Australia or North America. More studies are required to determine the differences among reports in Latin America. CONCLUSION Most representatives agreed that further studies must be done. Concern is increasing, and the problem is known. Other factors involved may be considered, and the problem must not be ignored. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Guillermo Ramos-Gallardo
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico.
| | - Jesus Cuenca-Pardo
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Lazaro Cardenas-Camarena
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Hector Duran-Vega
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Eugenio Rodríguez-Olivares
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Jorge Enrique Bayter-Marin
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Gerardo Levelier De Doig Alvear
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Guillermo Vazquez
- Sociedad Argentina de Cirugía Plástica Estética y Reconstructiva, Federación Iberolatinoamericana de Cirugía Plástica, Buenos Aires, Argentina
| | | | - Ricardo Galán-Suárez
- Sociedad Colombiana de Cirugía Plástica Estética y Reconstructiva, Cartagena, Colombia
| | - Gabriela Guzman-Stein
- Asociación Costarricense de Cirugía Plástica Estética y Reconstructiva, San José, Costa Rica
| | - Sergio Guzmán-Padilla
- Sociedad Dominicana de Cirugía Plástica Reconstructiva y Estética, Punta Cana, Dominican Republic
| | | | | | - Alfonso Vallarta-Rodríguez
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Livia Contreras-Bulnes
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Carlos Guillemro Oaxaca-Escobar
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | - Isabel Caravantes-Cortes
- Asociación Mexicana de Cirugía Plástica Estética y Reconstructiva, Flamencos No. 74 esquina con Félix Parra Col. San José Insurgentes Delegación, 03900, Benito Juárez Distrito Federal, Mexico
| | | | - Jorge Cowes-McGowen
- Asociación Panameña de Cirugía Plástica Estética y Reconstructiva, Panama City, Panama
| | - María Liz Maciel-Sosa
- Sociedad Paraguaya de Cirugía Plástica Estética y Reconstructiva, Asunción, Paraguay
| | | | - Linda Rincón-Rubio
- Sociedad Venezolana de Cirugía Plástica Estética, Reconstructiva y Maxilofacial, Caracas, Venezuela
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