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Cost and clinical benefit of imaging surveillance after treatment for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 48:748-751. [PMID: 34974948 DOI: 10.1016/j.ejso.2021.12.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 11/22/2022]
Abstract
Recent UK guidelines recommend that surveillance imaging should not be offered to patients who have undergone treatment for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) unless clinically indicated. The aim of this study was to explore the evolving practice at a tertiary referral unit and quantify the direct economic costs (DEC) associated with post-treatment BIA-ALCL routine radiological surveillance prior to adoption of the guidelines. Eleven patients were treated for BIA-ALCL between 2015 and 2020. At a median follow-up of 38 months (IQR 12-47) there were no local or distant relapses. Two patients did not have any radiological surveillance and 1 had follow-up elsewhere. The remaining 8 patients had a combination of positron emission tomography/computed tomography (PET/CT) (n = 10), CT (n = 2), breast ultrasound (n = 6), mammogram (n = 4) and breast magnetic resonance imaging (MRI) (n = 1) as routine imaging follow-up not guided by clinical concerns. Total cost of imaging was £10,396 (€12,257) with a median cost of £1953 (€2304) per patient [IQR £526-2029 (€621-2394)]. This cost could have been saved based on current guidelines recommending no routine surveillance for asymptomatic patients.
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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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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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Kallam A, Adusumalli J, Armitage JO. Surveillance in Patients With Diffuse Large B Cell Lymphoma. Mayo Clin Proc 2020; 95:157-163. [PMID: 31902411 DOI: 10.1016/j.mayocp.2019.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/03/2019] [Accepted: 05/14/2019] [Indexed: 01/28/2023]
Abstract
With improvement in the cure rates for diffuse large B cell lymphoma, the question of surveillance imaging in patients who achieve complete remission after the initial therapy has become relevant. Some of the clinical practice guidelines recommend surveillance scanning. However, several studies have reported no benefit in overall survival with scans. Moreover, studies have highlighted an increased risk for developing secondary malignancies because of exposure to ionizing radiation from the scans. Different international societies have contrasting guidelines for the role of surveillance computerized tomography scans in patients who achieve complete remission after first-line therapy. Any benefit of surveillance imaging must be balanced by the costs, risk of radiation exposure, and lack of survival benefit. The PubMed platform was searched using relevant keywords for English-language articles with no date restrictions. Search terms were cross-referenced with review articles, and additional articles were identified by manually searching reference lists. Results were reviewed by the authors and selected for inclusion based on relevance. We present a review of this current data available for surveillance imaging in patients with diffuse large B cell lymphoma.
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Affiliation(s)
- Avyakta Kallam
- Division of Oncology/Hematology, University of Nebraska Medical Center, Omaha.
| | | | - James O Armitage
- Division of Oncology/Hematology, University of Nebraska Medical Center, Omaha
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Adams HJA, Kwee TC. Systematic review on the value of end-of-treatment FDG-PET in improving overall survival of lymphoma patients. Ann Hematol 2019; 99:1-5. [PMID: 31811361 PMCID: PMC6944673 DOI: 10.1007/s00277-019-03881-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/26/2019] [Indexed: 01/01/2023]
Abstract
This study aimed to systematically review the value of end-of-treatment 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in improving overall survival (OS) of lymphoma patients. Medline was systematically searched for (1) randomized trials comparing the OS of patients who underwent end-of-treatment FDG-PET to those without and FDG-PET-based end-of-treatment evaluation and for (2) non-randomized studies comparing the OS of patients who underwent end-of-treatment FDG-PET to a (historical) cohort of patients without an FDG-PET-based end-of-treatment evaluation. The Medline search revealed 6284 articles. However, none of these reported data on the value of end-of-treatment FDG-PET in improving OS of lymphoma patients. In conclusion, the present systematic review reveals that there is currently no study at all that evaluates the value of end-of-treatment FDG-PET in improving OS of lymphoma patients. As a result, it remains unknown whether end-of-treatment FDG-PET increases OS and in which lymphoma subtype these examinations are of particular value. Future studies are required to demonstrate its value in this setting before it can be recommended as an evidence-based diagnostic tool by guidelines on the use of imaging in lymphoma.
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Affiliation(s)
- Hugo J A Adams
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands.
| | - Thomas C Kwee
- Department of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Kang KW, Lee SR, Kim DS, Yu ES, Sung HJ, Kim SJ, Choi CW, Park Y, Kim BS. Lack of usefulness of computed tomography for surveillance in patients with aggressive non-Hodgkin lymphoma. PLoS One 2018; 13:e0192656. [PMID: 29444176 PMCID: PMC5812643 DOI: 10.1371/journal.pone.0192656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/26/2018] [Indexed: 11/23/2022] Open
Abstract
Surveillance computed tomography (CT) is usual practice for patients with aggressive non-Hodgkin lymphoma (aNHL) in complete remission (CR). However, evidence to support this strategy is lacking. We retrospectively analyzed our institutional lymphoma registry, including patients with lymphoma consecutively enrolled from June 1995 to October 2016. Of 1,385 patients with aNHL, 664 achieved CR and were followed up with or without surveillance CT. Surveillance CT was performed for 609 patients every 3 or 6 months for the first 2 years, then every 6 or 12 months thereafter. Relapse was detected in 171 patients, of whom 152 underwent surveillance CT during follow-up. Of these 152 patients, asymptomatic relapse was detected in 67 (44%) using surveillance CT, and symptomatic relapse outside the surveillance interval was detected in the remaining 85 (56%). Detection of asymptomatic relapse using surveillance CT did not improve the overall or post-relapse survival in patients with relapsed aNHL. Surveillance CT interval (3 or 6 months) did not affect survival. No subgroups were identified that favored the use of surveillance CT to detect relapse. The results of this study suggest that routine surveillance CT in patients with aNHL to detect asymptomatic relapse might have a limited role in improving survival. CT is recommended when a relapse is clinically suspected.
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Affiliation(s)
- Ka-Won Kang
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Se Ryeon Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Dae Sik Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Eun Sang Yu
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Hwa Jung Sung
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chul Won Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Yong Park
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Byung Soo Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
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Cederleuf H, Hjort Jakobsen L, Ellin F, de Nully Brown P, Stauffer Larsen T, Bøgsted M, Relander T, Jerkeman M, El-Galaly TC. Outcome of peripheral T-cell lymphoma in first complete remission: a Danish-Swedish population-based study. Leuk Lymphoma 2017; 58:2815-2823. [DOI: 10.1080/10428194.2017.1300888] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Henrik Cederleuf
- Department of Clinical Sciences, Oncology and Pathology, Lund University, Lund, Sweden
| | - Lasse Hjort Jakobsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Fredrik Ellin
- Department of Clinical Sciences, Oncology and Pathology, Lund University, Lund, Sweden
- Department of Internal Medicine, Kalmar County Hospital, Kalmar, Sweden
| | - Peter de Nully Brown
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Martin Bøgsted
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas Relander
- Department of Clinical Sciences, Oncology and Pathology, Lund University, Lund, Sweden
| | - Mats Jerkeman
- Department of Clinical Sciences, Oncology and Pathology, Lund University, Lund, Sweden
| | - Tarec Christoffer El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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