Mucosal CD30-Positive T-Cell Lymphoproliferative Disorder Arising in the Oral Cavity Following Dental Implants: Report of the First Case

Intraoral CD30+ T-Cell Lymphoproliferative Disorder with Lymphomatoid Papulosis Type C Features Mimics Lymphoma Histopathologically and Immunohistochemically

BACKGROUND

Previous studies have shown that at least a of intraoral eosinophilic ulcer is best classified as a CD30 + T-cell lymphoproliferative disorder (LPD), with histopathology reminiscent of lymphomatoid papulosis (LyP) of the skin. Microscopically, a mixed population of inflammatory cells, often including eosinophils and varying numbers of atypical lymphoid cells, frequently expressing CD30, is typical for LyP, whose clinicopathological spectrum includes type A, B, C, D, E, and LyP with DUSP22/IRF4 rearrangement. To date, about 27 intraoral LyP cases have been reported. Of them, 7 cases were diagnosed as LyP type C, which is frequently confused with anaplastic large cell lymphoma (ALCL) on histopathology.

METHODS

A 60-year-old male was referred for a one-month history of a tongue ulcer.

RESULTS

Microscopy showed numerous subepithelial atypical large lymphoid cells, which expressed CD4 (with partial loss of CD3, CD5, and CD7), CD8 (few cells), CD30 (about 50%, in non-diffuse pattern with size variability), TIA-1, and Ki-67 (85%), without staining for CD56, ALK, LMP1, and EBER1/2, concerning for a diagnosis of ALCL. However, after three weeks, the lesion completely healed.

CONCLUSION

We present here a rare case of intraoral CD30+ T-cell LPD that we believe is the oral counterpart of cutaneous LyP type C.

Breast implant illness: Is it causally related to breast implants?

Once believed to be completely inert implants, Silicon Breast Implants (SBIs) have been shown to be able to induce a chronic inflammatory response in the body which can lead to a variety of possible manifestations ranging from the most common capsular contraction to rarer conditions such as malignancies and autoimmune diseases. Among the latter, new syndromes have been consistently recognized: Breast Implant Illness (BII) and autoimmunity/autoinflammatory syndrome induced by adjuvants (ASIA syndrome/Shoenfeld's Syndrome). The pathophysiological mechanisms underlying such syndromes are not yet clear and the overlap they show with other common conditions have sparked an important debate in the scientific community regarding their existence and their cause-effect relationship with SBIs. In this article Professor Cohen Tervaert and Professor Bassetto, leading experts in the field, are going to present arguments in favor and against such causal relationship according to the latest scientific evidence. Professor Cohen Tervaert is going to demonstrate how the evidence available is enough to prove a causal relationship as defined by the Bradford Hill's criteria. Professor Bassetto is going to highlight how the many biases that afflict the available evidence prevent us from drawing such conclusions. Professor Shoenfeld is going to moderate the discussion with its insightful conclusions.

Metallic implant-associated lymphoma: ALK-negative anaplastic large cell lymphoma associated with total knee replacement arthroplasty

Metallic implant-associated lymphomas are extremely rare. Only seven cases have been reported in association with knee joint arthroplasty, and all tumors were large B-cell lymphomas. This report is the first case of anaplastic large cell lymphoma occurring after total knee replacement arthroplasty. An 80‑year‑old female patient was admitted because of right knee pain for 2 years. She had undergone total knee replacement arthroplasty 10 years prior. Computed tomography showed an irregular osteolytic lesion in the right lateral femoral condyle, adjacent to the metallic prosthesis. Histologic findings reveal sheets of anaplastic tumor cells that were positive for CD2, CD4, CD5, CD43, and CD30 but negative for CD3, CD20, CD15, and anaplastic lymphoma kinase. Epstein-Barr encoding region in situ hybridization was negative. Analysis of T-cell receptor γ gene rearrangement studies using BIOMED-2-based multiplex polymerase chain reaction confirmed monoclonal T cell proliferation. The woman was finally diagnosed with ALK-negative anaplastic large cell lymphoma.

Comprehensive Evaluation of the Current Knowledge on Breast Implant Associated-Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently spotlighted T-cell origin non-Hodgkin's lymphoma with an increasing incidence of over 800 cases and 33 deaths reported worldwide. Development of BIA-ALCL is likely a complex process involving many factors, such as the textured implant surface, bacterial biofilm growth, immune response, and patient genetics. As the incidence of BIA-ALCL is expected to increase, it is important for all surgeons and physicians to be aware of this disease entity and acquire thorough knowledge of current evidence-based guidelines and recommendations. Early detection, accurate diagnosis, and appropriate treatment are the foundations of current care.

An unusual case of cluster of differentiation 30-positive T-cell lymphoproliferative disorder manifesting as mandibular gingival ulceration: A case report

BACKGROUND

Primary cutaneous cluster of differentiation 30-positive (CD30+) T-cell lymphoproliferative disorders are the second most common type of skin T-cell lymphoma. The lesions exhibit an indolent course, with a morphology resembling high-grade T-cell lymphoma.

CASE DESCRIPTION

A 67-year-old healthy man sought treatment for a large nonhealing ulcer on the buccal gingiva of the mandibular right premolars. He reported a history of recurrent cutaneous lesions, for which he was seen 1 year earlier at a hospital. Results of incisional biopsy showed a dense lymphoid cell infiltrate composed of atypical CD30+ T-cells intermixed with eosinophils. The diagnosis was updated to CD30+ T-cell lymphoproliferative disorder, which was similar to the cutaneous lesion diagnosis. The lesion area healed completely, and there were no signs of recurrence at 18-month follow-up.

PRACTICAL IMPLICATIONS

Oral CD30+ T-cell lymphoproliferative disorder has a favorable outcome, but it is commonly misdiagnosed. Biopsy is crucial and should be combined with clinical examination to avoid chemotherapeutic treatments intended for high-grade lymphoma.

The State of the Art about Etiopathogenetic Models on Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL): A Narrative Review

BACKGROUND

Breast-implant-associated anaplastic large cell lymphoma is a rare malignancy linked to texturized breast implants. Although many researchers focus on its etiopathogenesis, this topic is affected by a lack of evidence.

MATERIALS AND METHODS

A literature review about BIA-ALCL was made.

RESULTS AND CONCLUSIONS

Although the incidence is reported between 1:355-1:30,000, there is great attention to BIA-ALCL. The incidence is uncertain due to many reasons. It may well be lower, due to inclusion in multiple databases as pointed out by the FDA and undiagnosed cases. The role of chronic inflammation, bacterial contamination, and mechanical forces was discussed. Clarification is needed to understand the mechanisms underlying the progression of alterations and mutations for BIA-ALCL; new molecular analysis and pathogenetic models should be investigated.

Etiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Current Directions in Research

Simple Summary

The first report of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was in 1997. Although BIA-ALCL develops around breast implants, it is considered a cancer of the immune system and not a cancer of the breast ducts or lobules. Nearly all confirmed cases to date have been associated with textured surface (versus smooth surface) breast implants. As physicians have become more aware of BIA-ALCL, so has the number of reported cases, although the number of cases remains low. In most instances, patients have an excellent prognosis following removal of the breast implant and its surrounding fibrous capsule. Many theories on factors that trigger the development of BIA-ALCL, such as the presence of bacteria, have been proposed. However, the sequence(s) of events that follow the initial triggering event(s) have not been fully determined. This article summarizes the current scientific knowledge on the development of BIA-ALCL.

Abstract

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoma. Where implant history is known, all confirmed cases to date have occurred in patients with exposure to textured implants. There is a spectrum of disease presentation, with the most common occurring as a seroma with an indolent course. A less common presentation occurs as locally advanced or, rarely, as metastatic disease. Here we review the immunological characteristics of BIA-ALCL and potential triggers leading to its development. BIA-ALCL occurs in an inflammatory microenvironment with significant lymphocyte and plasma cell infiltration and a prominent Th1/Th17 phenotype in advanced disease. Genetic lesions affecting the JAK/STAT signaling pathway are commonly present. Proposed triggers for the development of malignancy include mechanical friction, silicone implant shell particulates, silicone leachables, and bacteria. Of these, the bacterial hypothesis has received significant attention, supported by a plausible biologic model. In this model, bacteria form an adherent biofilm in the favorable environment of the textured implant surface, producing a bacterial load that elicits a chronic inflammatory response. Bacterial antigens, primarily of Gram-negative origin, may trigger innate immunity and induce T-cell proliferation with subsequent malignant transformation in genetically susceptible individuals. Although much remains to be elucidated regarding the multifactorial origins of BIA-ALCL, future research should focus on prevention and treatment strategies, recognizing susceptible populations, and whether decreasing the risk of BIA-ALCL is possible.

The Crucial Role of Surgical Treatment in BIA-ALCL Prognosis in Early- and Advanced-Stage Patients

BACKGROUND

Studies on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are trying to optimize medical and surgical treatments for early and advanced stages of this disease. The aim of this article is to share the experience gathered on the authors' prospectively collected 46 well-documented cases.

METHODS

Italian physicians are obliged to report BIA-ALCL cases to the Italian Ministry of Health. Because of this cooperation with health care professionals, the competent authority has coordinated and centralized the collection of information for each patient in 46 cases of BIA-ALCL. Statistical analyses with cumulative incidence and corresponding 95 percent confidence interval are provided for each year, dividing the number of new cases that occurred in a defined year and the population at risk of experiencing BIA-ALCL during the same year.

RESULTS

The mean time to the onset of symptoms is reduced to 6.4 ± 3.77 years (range, 1 to 22 years). Increased knowledge has also shortened the average time to diagnosis, at 7.2 ± 3.71 years (range, 2 to 22 years). A late seroma appears in 91 percent of cases. The patient who died underwent limited surgery. The Italian incidence has been estimated as 2.8 per 100,000 patients receiving implants (95 percent CI, 0.88 to 4.84) in 2015; 2.1 (95 percent CI, 0.43 to 3.86) in 2016; 3.2 (95 percent CI, 1.11 to 5.31) in 2017; and 3.5 (95 percent CI, 1.36 to 5.78) in 2018.

CONCLUSION

Although the number of cases has risen slightly, BIA-ALCL is still a rare disease with a stable incidence, easily recognized and with a favorable prognosis also in advanced stages if complete surgical excision is performed.

What is the Evidence of Lymphoma in Patients with Prostheses Other Than Breast Implants?

INTRODUCTION

Medical devices such as hip, knee, breast, vascular prostheses, among others, are very useful in different pathologies. We cannot doubt that their use is a great tool, besides being an advance in medicine; they provide a change in the quality of life of many patients; however, they are not exempt from adverse reactions and events.

METHODS

We conduct a systematic review about lymphoma in the presences of prostheses other than breast implants.

RESULTS

We selected 21 publications with a total of 24 patients. The largest number of prostheses was related to long bones in a total of 13 prostheses. The most frequent symptoms were: pain (52%), inflammation (24%), visible or palpable mass 20%. The most frequent type of lymphoma was non-Hodgkin B cell lymphoma in 14 cases.

DISCUSSION

The presence of microparticles make biological degradation and wear of the implants, with macrophage and lymphocyte activation and the consequent production of proinflammatory cytokines such as tumor necrosis factor α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2).

CONCLUSION

Lymphoma is not a common disease in patients with prostheses, and more data are needed to identify risk factors and make proper diagnoses.

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.

Gluteal Implant-Associated Anaplastic Large Cell Lymphoma

The association of anaplastic large cell lymphoma (ALCL) to breast implants (breast implant-associated ALCL) has brought back the discussion on the clinical safety of the use of silicone implants. A 63-year-old woman came to our institution in early 2015, reporting a gluteal augmentation with silicone implants in 2006 and a recent increasing volume and distortion of the left buttock. Radiologic imaging showed a large amount of fluid collection around the implant. The left side implant was removed and the capsule was left intact, presupposing a future reimplantation. The fluid collected was positive for Staphylococcus aureus. Three years later, she presented again with a new seroma on the explanted side and was submitted to total capsulectomy and fluid drainage, and the material was submitted to laboratory examination. Culture results were negative. Pathologic preparation and sections of the capsule and lumps showed large cells characterized by horseshoe-shaped nuclei. Immunohistochemistry was positive for CD30/CD4 and negative for anaplastic lymphoma kinase, confirming the presence of ALCL, then associated with gluteal implant, an event not described in literature. Positron emission tomography/computed tomography and bone marrow biopsy were performed, and neither showed any other sites involved. The same disease in a new location introduces important discussions about the understanding of this abnormality and poses certain risks and safety issues to clinical scenarios to be discussed. Regardless of whether it is a breast implant-associated ALCL or a gluteal implant-associated ALCL, now we are probably facing an implant augmentation-associated disease and a new international alert should be addressed to the scientific community. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Finding Consensus After Two Decades of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and indolent, but potentially fatal cancer of the immune system that can develop around textured-surface breast implants. The World Health Organization first recognized BIA-ALCL as a unique clinical entity in 2016. To date, over 600 confirmed cases have been reported worldwide. BIA-ALCL most commonly presents with disease confined to the capsule, as a seroma or a mass adjacent to the implant. While BIA-ALCL has a fairly indolent clinical course, with an excellent prognosis in early stage disease, disseminated cancer and death have also been reported. In this review, the authors focus on the early diagnosis and treatment, including reconstructing the breast following BIA-ALCL, and also discuss recently updated National Comprehensive Cancer Network guidelines. They also review the current epidemiology and risk factors associated with BIA-ALCL. Finally, they discuss important medicolegal considerations and the bioethics surrounding the continued use of textured-surface breast implants.

Breast Implant-Associated Lymphoma

BACKGROUND

There has been increasing evidence in recent years that breast implants can, in rare cases, be associated with the development of an anaplastic large-cell lymphoma (ALCL).

METHODS

This review is based on relevant publications retrieved by a selective search in PubMed for articles that appeared from the time of the initial description of breast-implant-associated ALCL onward (1997 to January 2018), and by a further search in German nationwide databases.

RESULTS

516 pathologically confirmed cases of breast-implant-associated (BIA) ALCL were documented around the world until February 2018; seven of these arose in Germany and were reported to the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM). In approximately 80% of the affected women, the BIA-ALCL manifested itself as a late-developing seroma at the implant site; in the rest, as a solid tumor with or without an accompanying seroma. The mean implant exposure time ranged from 7 to 13 years on average. 16 fatalities have been reported worldwide. Among the 7 cases reported in Germany, four women had undergone breast reconstruction with implants after breast cancer surgery, and two had undergone breast augmentation surgery. In all patients, the entire capsule-and-implant unit was resected. One patient underwent chemotherapy and one further patient underwent chemotherapy and adjuvant radiotherapy.

CONCLUSION

The risk that a woman with breast implants will develop a primary anaplastic large-cell lymphoma is estimated at 0.35 to 1 case per million persons per year. The incidence of implant-associated ALCL is thus very low, yet nevertheless markedly higher than that of other primary lymphomas of the breast. Because of the low case numbers, recommendations for the diagnostic evaluation and treatment of this entity have not been adequately evaluated. Treatment with primary curative intent for BIA-ALCL confers a much better prognosis than when performed for a systemic ALCL. Whenever a patient with a breast implant presents with a late-developing seroma, BIA-ALCL should be included in the differential diagnosis. This diagnosis is reportable.

The Inflammatory Effects of Breast Implant Particulate Shedding: Comparison With Orthopedic Implants

Currently, there is a dearth of information regarding the degree of particle shedding from breast implants (BIs) and what are the general biological consequences of BI debris. Thus, it is unclear to what degree BI debris compromises the long-term biological performance of BIs. For orthopedic implants, it is well established that the severity of biological reactivity to implant debris governs long-term clinical performance. Orthopedic implant particulate debris is generally in the range of 0.01 to 100 μm in diameter. Implant debris-induced bioreactivity/inflammation is mostly a peri-implant phenomenon caused by local innate immune cells (eg, macrophages) that produce proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2). In orthopedics, there have been few systemic concerns associated with polymeric implant debris (like silicone) other than documented dissemination to remote organs (eg, liver, spleen, etc.) with no known associated pathogenicity. This is not true of metal implant debris where normal (well-functioning) implants can induce systemic reactions such as delayed type hypersensitivity. Diagnostic analysis of orthopedic tissues has focused on innate (macrophage mediated) and adaptive (lymphocyte-mediated hypersensitivity) immune responses. Orthopedic implant debris-associated lymphocyte cancers have not been reported in over 40 years of orthopedic literature. Adaptive immune responses such as hypersensitivity reactions to orthopedic implant debris have been dominated by certain implant types that produce specific kinds of debris (eg, metal-on-metal total joint prostheses). Orthopedic hypersensitivity responses and atypical BI bioreactivity such as BI-associated anaplastic large cell lymphoma share crossover markers for diagnosis. Differentiating normal innate immune reactivity to particles from anaplastic large cell lymphoma reactions from delayed type hypersensitivity reactions to BI-associated implant debris remains unclear but vital to patients and surgeons.

Nanotechnology, nanosurfaces and silicone gel breast implants: current aspects

Nanotechnology is defined as the design of products that interact with biological systems on the nanoscopic scale. Creating a controlled nanotexture and understanding the ways in which surface properties impact inflammatory response is of the utmost significance in designing implants that can provide satisfactory outcomes.