Anaplastic large cell lymphoma involving the breast: a clinicopathologic study of 6 cases and review of the literature

The Spectrum of Non-neoplastic Changes Associated With Breast Implants: Histopathology, Imaging, and Clinical Significance

Breast implant-associated anaplastic large cell lymphoma has been recognized as a distinct entity in the World Health Organization classification of hematolymphoid neoplasms. These neoplasms are causally related to textured implants that were used worldwide until recently. Consequently, there is an increased demand for processing periprosthetic capsules, adding new challenges for surgeons, clinicians, and pathologists. In the literature, the focus has been on breast implant-associated anaplastic large cell lymphoma; however, benign complications related to the placement of breast implants occur in up to 20% to 30% of patients. Imaging studies are helpful in assessing patients with breast implants for evidence of implant rupture, changes in tissues surrounding the implants, or regional lymphadenopathy related to breast implants, but pathologic examination is often required. In this review, we couple our experience with a review of the literature to describe a range of benign lesions associated with breast implants that can be associated with different clinical presentations or pathogenesis and that may require different diagnostic approaches. We illustrate the spectrum of the most common of these benign disorders, highlighting their clinical, imaging, gross, and microscopic features. Finally, we propose a systematic approach for the diagnosis and handling of breast implant specimens in general.

Implant replacement and anaplastic large cell lymphoma associated with breast implants: a quantitative analysis

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.

Anaplastic lymphoma associated with breast implants-Early diagnosis and treatment

Anaplastic large cell lymphoma associated with breast implants is a relatively new disease that deserves attention from the academic community. Brazil figures as one of the protagonists in plastic surgery, however publications are insufficient and very few cases are reported in comparison to other countries. It is a disease with excellent prognosis when diagnosed early and treated effectively, but for this to happen, it is essential that health care professionals and the patient understand its pathology. We reported two cases in a small town during a short period of time. In both cases reported by this study, the patients presented late seroma, associated with pain as a clinical presentation, at 13 and 9 years after the placement of silicone implants with textured polyurethane surfaces. After the procedure, the patients were screened for cancer. Further research with more robust samples is still needed to fully determine the risks and benefits of using textured versus smooth implants.

The plasticity of biocompatibility

Biocompatibility concerns the phenomena that occur within the interactions between biomaterials and human patients, which ultimately control the performance of many facets of medical technology. It involves aspects of materials science, many different forms of engineering and nanotechnology, chemistry, biophysics, molecular and cellular biology, immunology, pathology and a myriad of clinical applications. It is not surprising that an overarching framework of mechanisms of biocompatibility has been difficult to elucidate and validate. This essay discusses one fundamental reason for this; we have tended to consider biocompatibility pathways as essentially linear sequences of events which follow well-understood processes of materials science and biology. The reality, however, is that the pathways may involve a great deal of plasticity, in which many additional idiosyncratic factors, including those of genetic, epigenetic and viral origin, exert influence, as do complex mechanical, physical and pharmacological variables. Plasticity is an inherent core feature of the performance of synthetic materials; here we follow the more recent biological applications of plasticity concepts into the sphere of biocompatibility pathways. A straightforward linear pathway may result in successful outcomes for many patients; we may describe this in terms of classic biocompatibility pathways. In other situations, which usually command much more attention because of their unsuccessful outcomes, these plasticity-driven processes follow alternative biocompatibility pathways; often, the variability in outcomes with identical technologies is due to biological plasticity rather than material or device deficiency.

Breast Implant-Associated Anaplastic Large Cell Lymphoma

Pathologic staging including assessment of margins is essential for the proper management of patients with breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). As most patients present with effusion, cytologic examination with immunohistochemistry and/or flow cytometry immunophenotyping are essential for diagnosis. Upon a diagnosis of BIA-ALCL, en bloc resection is recommended. When a tumor mass is not identified, a systematic approach to fixation and sampling of the capsule, followed by pathologic staging and assessment of margins, is essential. Cure is likely when lymphoma is contained within the en bloc resection and margins are negative. Incomplete resection or positive margins require a multidisciplinary team assessment for adjuvant therapy.

Breast lymphomas, breast implants and capsules The timeline of BIA-ALCL with respect to surgical consent: the UK perspective

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare type of T-Cell (non-Hodgkin's) lymphoma associated with the use of silicone breast implants. Recent widespread awareness has focused not only on the management of this condition but also in regards to potential litigation of surgeons, clinics, and breast implant manufacturers. Allegations of causation and inappropriate patient consent are being raised. The purpose of this article is to establish the timeline of relevant discoveries regarding this condition and associated implications with regards to appropriate informed patient consent.

Metastatic malignant melanoma from anorectum presenting as an isolated breast tumor: A case report and literature review

RATIONALE

Anorectal malignant melanoma regularly exhibits a biological aggressive behavior which is metastasizing to lung, bone, brain or other organs and tissues early in the course of the disease. Compared with melanoma in the other parts of the body, anorectal malignant melanoma is relatively rare. Metastatic to the breast tissue from anorectal malignant melanoma or from other extra-mammary tumors are very rare.

PATIENT CONCERNS

We report the case of a 65-year-old female who suffering from anorectal malignant melanoma and implemented complete surgical resection. Two years later, a space-occupying lesion in the outer upper quadrant of the right breast was observed on a chest CT.

DIAGNOSIS

The right breast was excised, and breast metastasis of anorectal malignant melanoma was histologically confirmed.

INTERVENTIONS

Radical mastectomy of the right breast was performed, and no lymph nodes or other metastases were observed.

OUTCOMES

The patient's operative course was uneventful. The patient completely recovered and transfers to the oncology department for further treatment.

LESSON

The patient presented with an isolated breast tumor. Duo to Malignant melanoma could mimic many kind of poorly differentiated tumors, it is difficult to diagnose accurately, especially when it appears as an isolated mammary tumor. Because of the treatment measures and prognosis between malignant melanoma and breast cancer are entirely different.

Primary Lymphomas of the Breast: A Review

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.

Epstein-Barr-virus-positive large B-cell lymphoma associated with breast implants: an analysis of eight patients suggesting a possible pathogenetic relationship

Breast implant anaplastic large cell lymphoma (ALCL) is a T-cell neoplasm arising around textured breast implants that was recognized recently as a distinct entity by the World Health Organization. Rarely, other types of lymphoma have been reported in patients with breast implants, raising the possibility of a pathogenetic relationship between breast implants and other types of lymphoma. We report eight cases of Epstein-Barr virus (EBV)-positive large B-cell lymphoma associated with breast implants. One of these cases was invasive, and the other seven neoplasms were noninvasive and showed morphologic overlap with breast implant ALCL. All eight cases expressed B-cell markers, had a non-germinal center B-cell immunophenotype, and were EBV+ with a latency type III pattern of infection. We compared the noninvasive EBV+ large B-cell lymphoma cases with a cohort of breast implant ALCL cases matched for clinical and pathologic stage. The EBV+ large B-cell lymphoma cases more frequently showed a thicker capsule, and more often were associated with calcification and prominent lymphoid aggregates outside of the capsule. The EBV+ B-cell lymphoma cells were more often arranged within necrotic fibrinoid material in a layered pattern. We believe that this case series highlights many morphologic similarities between EBV+ large B-cell lymphoma and breast implant ALCL. The data presented suggest a pathogenetic role for breast implants (as well as EBV) in the pathogenesis of EBV+ large B-cell lymphoma. We also provide some histologic findings useful for distinguishing EBV+ large B-cell lymphoma from breast implant ALCL in this clinical setting.

ALK-Negative Anaplastic Large Cell Lymphoma: Current Concepts and Molecular Pathogenesis of a Heterogeneous Group of Large T-Cell Lymphomas

Simple Summary

ALK- anaplastic large cell lymphoma (ALK- ALCL) is a rare subtype of CD30+ large T-cell lymphoma that typically affects older adults and has a poor prognosis. Recognition of its histopathologic spectrum, subtypes, and of other tumors that can resemble ALK- ALCL is crucial to avoid making a wrong diagnosis that could result in inappropriate treatment for a patient. In recent years, several important studies have identified recurrent molecular alterations that have shed light on the pathogenesis of this lymphoma. However, on the other hand, putting all this vast information together into a concise form has become challenging. In this review, we present not only a more detailed view of the histopathologic findings of ALK- ALCL but also, we attempt to provide a more simplified perspective of the relevant genetic and molecular alterations of this type of lymphoma, that in our opinion, is not available to date.

Abstract

Anaplastic large cell lymphoma (ALCL) is a subtype of CD30+ large T-cell lymphoma (TCL) that comprises ~2% of all adult non-Hodgkin lymphomas. Based on the presence/absence of the rearrangement and expression of anaplastic lymphoma kinase (ALK), ALCL is divided into ALK+ and ALK-, and both differ clinically and prognostically. This review focuses on the historical points, clinical features, histopathology, differential diagnosis, and relevant cytogenetic and molecular alterations of ALK- ALCL and its subtypes: systemic, primary cutaneous (pc-ALCL), and breast implant-associated (BIA-ALCL). Recent studies have identified recurrent genetic alterations in this TCL. In systemic ALK- ALCL, rearrangements in DUSP22 and TP63 are detected in 30% and 8% of cases, respectively, while the remaining cases are negative for these rearrangements. A similar distribution of these rearrangements is seen in pc-ALCL, whereas none have been detected in BIA-ALCL. Additionally, systemic ALK- ALCL—apart from DUSP22-rearranged cases—harbors JAK1 and/or STAT3 mutations that result in the activation of the JAK/STAT signaling pathway. The JAK1/3 and STAT3 mutations have also been identified in BIA-ALCL but not in pc-ALCL. Although the pathogenesis of these alterations is not fully understood, most of them have prognostic value and open the door to the use of potential targeted therapies for this subtype of TCL.

Breast Implant-Associated Anaplastic Large Cell lymphoma: Brief overview of current data and imaging findings

In 2016, the World Health Organization added Breast Implant-Associated Anaplastic Large Cell lymphoma as a provisionally recognized lymphoma to the family of existing Anaplastic Large Cell lymphomas. Current estimates of the lifetime risk of the disease in women with textured breast implants range from 1:1,000 to 1:30,000. The mean interval from implant placement to diagnosis is 10.7 ± 4.6 years and the most common clinical symptom at presentation is breast swelling. A high level of clinical suspicion is recommended in patients presenting with breast symptoms and/or peri-implant fluid collection occurring more than 1 year after breast implant placement. Ultrasound is the imaging modality of choice, with a high sensitivity for peri-implant fluid and a high specificity for peri-implant mass. When ultrasound is inconclusive, breast MRI is indicated. As of today, all confirmed cases have tested positive for CD30 immunohistochemistry and the disease has shown to have an excellent prognosis when it is diagnosed earlier (localized disease), and when complete surgery, consisting of explantation, capsulectomy, and removal of any associated capsule mass, is performed. This overview summarizes the available epidemiological and clinical data of Breast Implant-Associated Anaplastic Large Cell lymphoma, with an emphasis on imaging features.

Unusual Case of Anaplastic Large Cell Lymphoma Presenting as a Breast Mass in a Patient with no History of Breast Implants

Adenocarcinoma is the most common malignant neoplasm involving breast tissue. In contrast to carcinomas, the other types of malignant neoplasms involving the breast are relatively uncommon. One of the examples of this rare entity is lymphoma. Traditionally, non-Hodgkin lymphomas (NHL) involving the breast are divided into primary lymphoma of the breast and systemic lymphoma, although the distinction could be challenging. Most of NHL involving breast tissue have B cell origin; T cell NHL represents less than 20% of all lymphoma cases. Anaplastic large cell lymphomas (ALCL) involving the breast accounts for even lower percentage of cases. Similar to ALCL involving other sites, there are several main types of ALCL identified: primary cutaneous ALCL and systemic ALCL, which is subdivided into ALK positive and ALK negative subtypes. Relatively recently, an additional distinct subtype of ALK-negative ALCL was described, which is associated with textured breast implants and needs to be considered as a differential diagnosis if patient has a history of breast implants. Here, we report a case of ALCL presented as a breast mass without history of breast implant and discuss similar cases published in the literature.

Analysis of Allergan's Biocell Implant Recall in a Major University Breast Center

Supplemental Digital Content is available in the text.

Background:

In May 2019, Health Canada released a national recall of all macrotextured breast implants that later became international in July 2019 regarding increasing accounts of suspected breast implant–associated anaplastic large cell lymphoma. In Canada, this recall targeted Allergan’s Biocell implants. This report presents the postmortem of this comprehensive single-center recall, which had to be undertaken in a limited time.

Methods:

Four months after the beginning of the recall, the authors analyzed the transcript of meetings to characterize the team assembled during the recall. Then, to reconstruct the systemic work plan as well as the crucial steps and actors of the recall process, a chronologic table of the 5 meetings held during the recall, agendas and transcripts of every meeting, electronic correspondences, and other documents created during the recall were consulted.

Results:

Between 1996 and 2018, 1260 women were affected by the recall, meaning that they received Allergan’s macrotextured implants. Ninety-two patients underwent explantation of the device or will undergo implant explantation. To this day, no patient was diagnosed with breast implant–associated anaplastic large cell lymphoma.

Conclusions:

Our center’s experience highlights the utmost importance of building a national breast implants registry. We recommend breast centers to develop preestablished crisis centers and train staff to better prepare for future device recalls and minimize waste of time. Finally, we believe that implants should be identified based on the characteristics rather than their brand name.

Breast Implant-associated Anaplastic Large Cell Lymphoma - a Systematic Review with Pooled Analysis

The association of breast implants and anaplastic large cell lymphoma (BIA-ALCL) was first described in 1997. Such an association has aroused public health concerns on breast implant safety. A systematic review was carried out with a pooled analysis of data. In total, 674 non-duplicate articles were retrieved; 77 articles were included for data extraction; 395 patients were identified for analysis. The median age at the time of diagnosis was 52 years. Implant texture was described in 201 (50.9%) patients; all 201 patients had a textured implant. The median time from the last implant insertion to diagnosis was 7.5 years. Most patients presented with seroma (67.1%, n = 265), 20.5% of patients presented with breast mass (n = 81). Patients with a breast mass at presentation, lymphadenopathy and those without seroma had more disseminated disease (P < 0.001). 73.2% of patients (n = 289) opted for primary surgery, among which 68.6% (n = 271) received removal of the implant, 61% (n = 241) received capsulectomy and 2% (n = 8) received mastectomy. Of note, 5.3% (n = 21) had reinsertion of an implant after primary surgery. Non-surgical modalities included chemotherapy, radiotherapy and haematopoietic stem cell transplant. The median follow-up interval was 2 years (range 0-14.5 years). Seventeen patients (4.3%) had recurrence of BIA-ALCL and 195 patients (49.4%) did not. The median duration to first recurrence was 1 year (range 1-3 years). Long-term clinical outcome was not reported in 183 patients. BIA-ALCL is an indolent disease that presents with seroma after implant insertion. A high index of suspicion is needed for early diagnosis and treatment.

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Current Understanding and Recommendations for Management

Worldwide, millions of women live with breast implants. Therefore, it is important that physicians be aware of an uncommon but possibly serious complication arising from breast implants: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Breast implant-associated anaplastic large-cell lymphoma most commonly presents as a delayed fluid collection around a textured breast implant or as a mass in the capsule surrounding the implant. The exact pathogenesis of the disease remains unclear. The neoplastic cells of BIA-ALCL show strong uniform staining for CD30 and are consistently negative for activin receptor-like kinase 1. Patients with confirmed cases should be referred to a lymphoma specialist or breast medical oncologist for a complete oncologic evaluation before any surgical intervention. For disease confined to the fluid accumulation or capsule, or both, surgical removal of the implant and complete capsulectomy is the preferred treatment. Postoperative chemotherapy or radiation, or both, are not considered necessary for patients with limited-stage disease and are reserved for advanced disease stages. Generally, BIA-ALCL is a local disease that follows an indolent course and has an excellent prognosis. Although complete remission of disease has occurred in patients with BIA-ALCL, median overall survival is reduced. As of March 2018, approximately 529 unique, confirmed BIA-ALCL cases had been reported in 23 countries. To date, 16 patients have died from BIA-ALCL, and all had extracapsular involvement. The aim of this article is to summarize the diagnosis, evaluation, and management of BIA-ALCL, based on established guidelines, for all practitioners who may care for patients with breast implants.

Lymphomas arising in immune-privileged sites: insights into biology, diagnosis, and pathogenesis

Session 2 of the 2018 European Association of Hematopathology/Society for Hematopathology Workshop focused on lymphomas arising in immune-privileged sites: both lymphomas arising in the traditionally described "immune sanctuary" sites of the central nervous system (CNS) and testes, as well as those arising at sites of local immune privilege. Primary CNS large B cell lymphoma and primary testicular large B cell lymphoma were discussed, and the biology of these unique tumors was highlighted by several cases showing the classic mutation profile including MYD88 L265P and CD79B. The tendency of these tumors to involve both the CNS and testis was also reinforced by several cases. Four cases of low-grade B cell lymphomas (LGBCL) of the CNS were discussed. Two were classic Bing-Neel syndrome associated with LPL, and two were LGBCL with plasmacytic differentiation and amyloid deposition without systemic disease. Rare examples of systemic T and NK cell lymphomas involving the CNS were also discussed. Several cases of breast implant-associated anaplastic large cell lymphoma (BI-ALCL) were submitted showing the typical clinicopathologic features. These cases were discussed along with a case with analogous features arising in a patient with a gastric band implant, as well as large B cell lymphomas arising alongside foreign materials. Finally, large B cell lymphomas arising in effusions or localized sites of chronic inflammation (fibrin-associated diffuse large B cell lymphoma [DLBCL] and DLBCL associated with chronic inflammation) were described. The pathogenesis of all of these lymphomas is believed to be related to decreased immune surveillance, either innate to the physiology of the organ or acquired at a local site.

Characteristics and Treatment of Advanced Breast Implant-Associated Anaplastic Large Cell Lymphoma

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) most commonly follows an indolent course; however, a subset of patients display more advanced disease marked by recurrent and disseminated growth refractory to treatment. This study evaluated outcomes of advanced disease, specifically bilateral disease, lymph node involvement, organ metastasis, and/or disease-related death.

METHODS

Published cases of BIA-ALCL from 1997 to 2018 and unpublished cases at the authors' institution were retrospectively reviewed, and patients with advanced disease were selected. Treatment and outcomes were compared against a control of BIA-ALCL subjects without advanced disease.

RESULTS

Thirty-nine patients with advanced BIA-ALCL were identified who had bilateral disease (n = 7), lymph node and organ metastasis (stage IIB-IV, n = 24), and disease-related death (n = 8). Sixty-five patients were included in a comparison control group (stage 1A-1C). Treatment types for advanced disease patients were complete surgery, n = 16 (55.2%); limited surgery, n = 19 (65.5%); chemotherapy, n = 26 (89.7%); salvage chemotherapy, n = 11 (37.9%); radiation, n = 15 (51.7%); and autologous stem cell transplant, n = 6 (20.7%). The rates of complete remission for the bilateral and lymphadenopathy groups were 4 of 7 (57%, P < 0.001) and 16 of 24 (67%, P = 0.128), respectively. Compared with the control group, advanced disease patients had significantly longer time from diagnosis to definitive surgery (21 versus 8 months, P = 0.039) and a lower rate of complete surgery (59% versus 88%, P = 0.004).

CONCLUSIONS

Advanced disease BIA-ALCL may be a consequence of a delay or suboptimal treatment of BIA-ALCL. Optimal adjuvant chemotherapy and indications for radiation for BIA-ALCL patients with advanced features are not yet clearly defined. Advanced disease is the end of the spectrum of cancer stages, and these patients substantiate the World Health Organization classification of BIA-ALCL as a lymphoma rather than benign or lymphoproliferative.

Clinicopathologic Features and Prognostic Impact of Lymph Node Involvement in Patients With Breast Implant-associated Anaplastic Large Cell Lymphoma

Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a rare T-cell lymphoma that arises around breast implants. Most patients manifest with periprosthetic effusion, whereas a subset of patients develops a tumor mass or lymph node involvement (LNI). The aim of this study is to describe the pathologic features of lymph nodes from patients with BI-ALCL and assess the prognostic impact of LNI. Clinical findings and histopathologic features of lymph nodes were assessed in 70 patients with BI-ALCL. LNI was defined by the histologic demonstration of ALCL in lymph nodes. Fourteen (20%) patients with BI-ALCL had LNI, all lymph nodes involved were regional, the most frequent were axillary (93%). The pattern of involvement was sinusoidal in 13 (92.9%) cases, often associated with perifollicular, interfollicular, and diffuse patterns. Two cases had Hodgkin-like patterns. The 5-year overall survival was 75% for patients with LNI and 97.9% for patients without LNI at presentation (P=0.003). Six of 49 (12.2%) of patients with tumor confined by the capsule had LNI, compared with LNI in 8/21 (38%) patients with tumor beyond the capsule. Most patients with LNI achieved complete remission after various therapeutic approaches. Two of 14 (14.3%) patients with LNI died of disease compared with 0/56 (0%) patients without LNI. Twenty percent of patients with BI-ALCL had LNI by lymphoma, most often in a sinusoidal pattern. We conclude that BI-ALCL beyond capsule is associated with a higher risk of LNI. Involvement of lymph nodes was associated with decreased overall survival. Misdiagnosis as Hodgkin lymphoma is a pitfall.

Pioneers of Breast Implant-Associated Anaplastic Large Cell Lymphoma: History from Case Report to Global Recognition

The first case of breast implant-associated anaplastic large cell lymphoma (breast implant ALCL) was described by John Keech and the late Brevator Creech in 1997. In the following 2 decades, much research has led to acceptance of breast implant ALCL as a specific clinicopathologic entity, a process that we bring up to life through the memories of 6 persons who were involved in this progress, although we acknowledge that many others also have contributed to the current state of the art of this disease. Dr. Keech recalls the events that led him and Creech to first report the disease. Ahmet Dogan and colleagues at the Mayo Clinic described a series of 4 patients with breast implant ALCL, and led to increased awareness of breast implant ALCL in the pathology community. Daphne de Jong and colleagues in the Netherlands were the first to provide epidemiologic evidence to support the association between breast implants and ALCL. Garry Brody was one of the first investigators to collect a large number of patients with the disease, present the spectrum of clinical findings, and alert the community of plastic surgeons. Roberto Miranda and L. Jeffrey Medeiros and colleagues studied the pathologic findings of a large number of cases of breast implant ALCL, and published the findings in 2 impactful studies in the medical oncology literature. The recognition and acceptance of this disease by surgeons, epidemiologists, and medical oncologists, working together, has led to subsequent studies on the pathogenesis and optimal therapy of this disease.

Breast implant-associated anaplastic large cell lymphoma: a review

Breast implant-associated anaplastic large cell lymphoma is a newly recognized provisional entity in the 2017 revision of the World Health Organization Classification of Tumors of Hematopoietic and Lymphoid Tissues. It is an uncommon, slow growing T-cell lymphoma with morphology and immunophenotype similar to anaplastic lymphoma kinase-negative anaplastic large cell lymphoma. However, the presentation and treatment are unique. Breast implant-associated anaplastic large cell lymphoma often presents as a unilateral effusion confined to the capsule of a textured-surface breast implant, a median time of 9 years after the initial implants have been placed. Although it follows an indolent clinical course, breast implant-associated anaplastic large cell lymphoma has the potential to form a mass, to invade locally through the capsule into breast parenchyma or soft tissue and/or to spread to regional lymph nodes. In most cases, an explantation with a complete capsulectomy removing all disease, without chemotherapy is considered to be curative and confers an excellent event free and overall survival. Here we provide a comprehensive review of breast implant-associated anaplastic large cell lymphoma, including history, epidemiology, clinical features, imaging and pathology findings, pathologic handling, pathogenic mechanisms, model for progression, therapy and outcomes as well as an analysis of causality between breast implants and anaplastic large cell lymphoma.

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

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 .

How to Diagnose and Treat Breast Implant-Associated Anaplastic Large Cell Lymphoma

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease.

SUMMARY

The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant-associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant-associated anaplastic large cell lymphoma are discussed.

The Pathological Spectrum of Systemic Anaplastic Large Cell Lymphoma (ALCL)

Anaplastic large cell lymphoma (ALCL) represents a group of malignant T-cell lymphoproliferations that share morphological and immunophenotypical features, namely strong CD30 expression and variable loss of T-cell markers, but differ in clinical presentation and prognosis. The recognition of anaplastic lymphoma kinase (ALK) fusion proteins as a result of chromosomal translocations or inversions was the starting point for the distinction of different subgroups of ALCL. According to their distinct clinical settings and molecular findings, the 2016 revised World Health Organization (WHO) classification recognizes four different entities: systemic ALK-positive ALCL (ALK+ ALCL), systemic ALK-negative ALCL (ALK− ALCL), primary cutaneous ALCL (pC-ALCL), and breast implant-associated ALCL (BI-ALCL), the latter included as a provisional entity. ALK is rearranged in approximately 80% of systemic ALCL cases with one of its partner genes, most commonly NPM1, and is associated with favorable prognosis, whereas systemic ALK− ALCL shows heterogeneous clinical, phenotypical, and genetic features, underlining the different oncogenesis between these two entities. Recognition of the pathological spectrum of ALCL is crucial to understand its pathogenesis and its boundaries with other entities. In this review, we will focus on the morphological, immunophenotypical, and molecular features of systemic ALK+ and ALK− ALCL. In addition, BI-ALCL will be discussed.

MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference Report

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon neoplasia occurring in women with either cosmetic or reconstructive breast implants. The actual knowledge about BIA-ALCL deriving from the literature presents several limits, and it remains difficult to make inferences about BIA-ALCL epidemiology, cause, and pathogenesis. This is the reason why the authors decided to organize an evidence-based consensus conference during the Maurizio Bruno Nava (MBN 2016) Aesthetic Breast Meeting held in Milan in December of 2016. Twenty key opinion leaders in the field of plastic surgery from all over the world have been invited to express and discuss their opinion about some key questions on BIA-ALCL, trying to reach a consensus about BIA-ALCL cause, pathogenesis, diagnosis, and treatment in light of the actual best evidence.

Understanding rare adverse sequelae of breast implants: anaplastic large-cell lymphoma, late seromas, and double capsules

Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a distinct type of T-cell lymphoma arising around breast implants. The United States FDA recently updated the 2011 safety communication, warning that women with breast implants may have a very low risk of developing ALCL adjacent to a breast implant. According to the World Health Organization, BI-LCL is not a breast cancer or cancer of the breast tissue; it is a lymphoma, a cancer of immune cells. BI-ALCL is highly curable in the majority of patients. Informed consent should include the risk of BI-ALCL with breast implant patients. Women with breast implants are encouraged to contact their plastic surgeon if they notice swelling, fluid collections, or unexpected changes in breast shape. Physicians are encouraged to send suspicious peri-prosthetic fluid for CD30 immunohistochemistry, cell block cytology, and culture in symptomatic patients. An observation from reported cases indicates a predominance of textured device involvement. More information is needed to fully understand risk factors and etiology. The association of bacteria and biofilm with ALCL is currently being investigated and one theory is that biofilm may play a role in this disease process stressing the importance of best practice techniques intraoperatively. Recent studies have reported clinical presentation, prognosis, and treatment outcomes with long term followup demonstrating the critical role for surgical management.

Silicone-induced granuloma of breast implant capsule (SIGBIC): similarities and differences with anaplastic large cell lymphoma (ALCL) and their differential diagnosis

Primary breast lymphoma is a rare disease and accounts for 0.5% of cases of breast cancer. Most primary breast lymphomas develop from B cells, and the involvement of T cells is rare. Anaplastic large cell lymphoma (ALCL) is a recently discovered T-cell lymphoma associated with breast implants. Only a few cases have been reported to date. It is believed that the incidence of ALCL is increasing because of the increasing number of breast implants. The clinical presentation is variable and can manifest as a palpable mass in the breast or armpit, breast pain, or capsular contracture. Because of the rarity of the disease and the lack of knowledge to date, clinical diagnosis is often delayed, with consequent delays in treatment. The cause and pathogenesis have not been fully elucidated, and there are no evidence-based guidelines for diagnosis, treatment, or follow-up of this disease. We present a review of cases of patients with silicone breast implants, including ALCL, a rare type of breast cancer that is still under study, and silicone-induced granuloma of breast implant capsule and its differential diagnosis, and discuss if a silicone-induced granuloma of breast implant capsule could be the precursor of the disease.

[Breast implant-associated anaplastic large cell lymphoma. Case report of an undiagnosed form, management and reconstruction (ALCL)]

Breast implant-associated anaplastic large cell lymphoma (ALCL) is an extremely rare disease. Is a new nosologic entity with a multifactorial origin and a wide occurrence delay after breast implantation. This article reports the case of a 60 years old patient with a progressive swelling of the right breast after aesthetic breast implants. Diagnostic was delayed because first surgeon was not familiar with the disease. Patient was then referred to us for management. We performed an implant removal and a complete capsulectomy. Pathologic report confirms the diagnostic. After one year and normal ultrasound evaluation, we reconstructed the breast with lipomodeling and mastopexy. Contralateral implant was also removed at time of reconstruction. Vast majority of breast implant-associated ALCL occurs at a time lapse of 11 to 15 years after implant augmentation, with a mean age of 63 years. Among the worldwide 173 cases reported in March 2015, smooth implants seem not to be at risk but 80% of cases were associated with macrotexturized implants. Clinical presentation and diagnostic tools are more and more published but there is to date no recommendation concerning reconstruction delay after implant removal for this pathology. We advise the realization of a breast ultrasound every three months during the first year and wait for a one-year period before reconstruction. In case of aesthetic surgery, mastopexia can be done to allow for glandular shaping. Lipomodeling is an excellent technique to correct the lack of volume due to implant removal. In case of reconstructive setting, implant can be replaced by flap procedure with lipomodeling if needed or lipomodeling alone if recipient site is favorable and patient has enough fat tissue. Contralateral implant should be removed during reconstruction time.

Complete Surgical Excision Is Essential for the Management of Patients With Breast Implant-Associated Anaplastic Large-Cell Lymphoma

PURPOSE

Breast implant-associated anaplastic large-cell lymphoma (BI-ALCL) is a rare type of T-cell lymphoma that arises around breast implants. The optimal management of this disease has not been established. The goal of this study is to evaluate the efficacy of different therapies used in patients with BI-ALCL to determine an optimal treatment approach.

PATIENTS AND METHODS

In this study, we applied strict criteria to pathologic findings, assessed therapies used, and conducted a clinical follow-up of 87 patients with BI-ALCL, including 50 previously reported in the literature and 37 unreported. A Prentice, Williams, and Peterson model was used to assess the rate of events for each therapeutic intervention.

RESULTS

The median and mean follow-up times were 45 and 30 months, respectively (range, 3 to 217 months). The median overall survival (OS) time after diagnosis of BI-ALCL was 13 years, and the OS rate was 93% and 89% at 3 and 5 years, respectively. Patients with lymphoma confined by the fibrous capsule surrounding the implant had better event-free survival (EFS) and OS than did patients with lymphoma that had spread beyond the capsule (P = .03). Patients who underwent a complete surgical excision that consisted of total capsulectomy with breast implant removal had better OS (P = .022) and EFS (P = .014) than did patients who received partial capsulectomy, systemic chemotherapy, or radiation therapy.

CONCLUSION

Surgical management with complete surgical excision is essential to achieve optimal EFS in patients with BI-ALCL.

Silicone implants and lymphoma: The role of inflammation

The risk of hematological malignancies is mainly determined by genetic background, age, sex, race and ethnicity, geographic location, exposure to certain chemicals and radiation; along with the more recently proposed immune factors such as chronic inflammation, immunodeficiencies, autoimmunity, and infections. Paradigmatic examples include the development of lymphoma in Sjögren's syndrome and Hashimoto thyroiditis, gastric MALT lymphoma in Helicobacter pylori infection, or lymphomas associated with infections by Epstein-Barr virus, human herpes virus 8 (HHV 8) and leukemia/lymphoma virus 1 (HTLV-1). A growing number of reports indicates an increased risk of lymphoma, particularly of the anaplastic large cell (ALCL) type. The implants, specifically those used in the past, elicit chronic stimulation of the immune system against the prosthetic material. This is particularly the case in genetically susceptible hosts. We suggest that polyclonal activation may result in monoclonality in those at risk hosts, ultimately leading to lymphoma. We suggest that patients with an inflammatory response against silicone implants be monitored carefully.

Coming of Age: Breast Implant-Associated Anaplastic Large Cell Lymphoma After 18 Years of Investigation

Breast implant associated anaplastic large cell lymphoma (BIALCL) is a distinct clinical entity that can present in patients receiving either reconstructive or cosmetic breast implants. Presenting symptoms include onset of a delayed (>1 year after implantation) fluid collection, mass of the capsule, or lymphadenopathy. Treatment has progressed in recent years and most commonly includes implant removal and total resection of the tumor, including capsule, mass, and involved lymph nodes. Further research is warranted to determine potential malignant drivers, disease progression, and optimal treatment strategies in advanced disease.

Lymphomas Associated with Breast Implants: A Review of the Literature

BACKGROUND

Recently there have been concerns raised about anaplastic large cell lymphoma (ALCL) associated with breast implants.

OBJECTIVES

The main aim of this article was to review and analyze the published literature specifically for hematopoietic malignancies associated with breast implants and postulate a hypothesis for their etiology and pathogenesis.

METHODS

The PubMed database was searched using key words "lymphoma" and "breast implants" for published papers and abstracts on implant-associated hematopoietic malignancies.

RESULTS

The authors found 83 published cases reported of lymphomas associated with breast implants in the medical literature. The reported cases involved various subtypes of lymphomas and the majority were ALCL, of which 66 were confirmed as ALK negative; however there was no association with any particular type of implant. The more aggressive cases and reported low death rate appeared to be related to the presence of breast masses at the time of presentation rather than effusion. The remaining reports were occasional case reports of T-cell lymphoma, follicular lymphoma, marginal zone B-cell lymphoma, primary effusion lymphoma and lymphoplasmacytic lymphoma.

CONCLUSIONS

Considering the many thousands of women that have breast implants every year; the compiled data show that there is a very small risk of developing lymphoma. Increased awareness of association between implants and ALCL is needed globally and prospective patients considering breast implants should be fully informed of the risk. As the behavior of ALCL in these cases was indolent as compared with other primary breast lymphomas, it could suggest an abnormal reactive process.

LEVEL OF EVIDENCE

3

Breast implant-associated anaplastic large cell lymphoma: a case report and literature review

Breast implant-associated anaplastic large cell lymphoma (ALCL) is a rare new clinical entity. The incidence is 0.3 % per 100,000 women per year. Patients present with non-specific implant-related complications resulting in delayed diagnosis. We present such a case to raise awareness and discuss management. A 48-year-old female presented with a 3-month history of left breast pain and swelling. She had undergone multiple bilateral augmentations 8 years previously. Triple assessment revealed a seroma, and a magnetic resonance imaging scan excluded implant rupture. Cytology showed a typical cells with mitotic activity which lead to removal of implants and a left capsulectomy. Final histology revealed an anaplastic lymphoma kinase (ALK) negative ALCL confined to the capsule. A computerised tomography scan and bone marrow biopsy excluded systemic disease, but due to later identified B symptoms, she received CHOP chemotherapy under the care of the haematologists. ALK-negative ALCL is associated with breast implants, and any persistent late onset seroma or breast symptoms should raise the suspicion of ALK-negative ALCL as a differential diagnosis. The recommended treatment is surgical removal of the implant including a full capsulectomy, highlighting the suspicion of ALCL to the pathologist. Exclusion of systematic disease is also recommended in all patients, and the need for adjuvant therapy should be addressed on an individual case basis. For disease confined to the capsule, adjuvant chemoradiotherapy is not needed.

LEVEL OF EVIDENCE V

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 http://www.springer.com/00266 .

Anaplastic lymphoma kinase (ALK) positive anaplastic large cell lymphoma (ALCL) of breast in a patient without a breast implant

Non-Hodgkin lymphoma of the breast is an uncommon entity accounting for approximately 0.5% of malignant breast neoplasms and around 3% of extranodal lymphomas. Most cases of anaplastic large cell lymphoma (ALCL) of the breast have been associated with breast implants, and a few ALCL aris.ing de novo in patients without breast implants have been reported. We report a case of a 19-year-old female who presented with a lump in the right breast of 3 months' duration. Examination revealed an Eastern Cooperative Oncology Group performance status of 2 and a 6.5 cm2 lump in the right breast. Lumpectomy revealed large neoplastic cells positive for CD30, EMA, CD5, and anaplastic lymphoma kinase (ALK), suggestive of anaplastic large cell lymphoma. The patient underwent lumpectomy followed by 6 cycles of anthracycline-based chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone 3 weekly. On follow up, this patient had an event-free survival of 23 months. We are reporting this case of ALCL (ALK positive) in a patient with no breast implant previously, and hence, it is of clinical importance.

Anaplastic large cell lymphoma (ALCL) and breast implants: breaking down the evidence

Systemic anaplastic large cell lymphoma (ALCL) is a distinct disease classification provisionally sub-divided into ALCL, Anaplastic Lymphoma Kinase (ALK)(+) and ALCL, ALK(-) entities. More recently, another category of ALCL has been increasingly reported in the literature and is associated with the presence of breast implants. A comprehensive review of the 71 reported cases of breast implant associated ALCL (iALCL) is presented indicating the apparent risk factors and main characteristics of this rare cancer. The average patient is 50 years of age and most cases present in the capsule surrounding the implant as part of the periprosthetic fluid or the capsule itself on average at 10 years post-surgery suggesting that iALCL is a late complication. The absolute risk is low ranging from 1:500,000 to 1:3,000,000 patients with breast implants per year. The majority of cases are ALK-negative, yet are associated with silicone-coated implants suggestive of the mechanism of tumorigenesis which is discussed in relation to chronic inflammation, immunogenicity of the implants and sub-clinical infection. In particular, capsulotomy alone seems to be sufficient for the treatment of many cases suggesting the implants provide the biological stimulus whereas others require further treatment including chemo- and radiotherapy although reported cases remain too low to recommend a therapeutic approach. However, CD30-based therapeutics might be a future option.

Breast implant-associated anaplastic large cell lymphoma: review of a distinct clinicopathologic entity

Primary breast anaplastic large cell lymphoma (ALCL) is rare but is more commonly seen in patients with implants; fewer than 50 cases of breast implant-associated ALCL have been reported in the English language literature. Breast implant-associated ALCL is not a disease of the breast parenchyma, but instead is a disease of the fibrous capsule surrounding the implant. The patients usually present with an effusion around the implant and, rarely, with a solid mass. Morphologically, the neoplastic cells are large, epithelioid, and pleomorphic, with abundant cytoplasm, vesicular irregular nuclei, and frequent mitoses. Occasional "hallmark" cells may be present. The lesional cells typically show strong and diffuse immunoreactivity for CD30 and often express T-cell markers, cytotoxic-associated antigens, and epithelial membrane antigen. Almost all reported cases are negative for anaplastic lymphoma kinase. Molecular genetic analyses have demonstrated T-cell receptor gene rearrangements. The differential diagnosis essentially includes poorly differentiated carcinoma, other lymphomas, and chronic inflammation. Once a diagnosis of lymphoma is established, it is important to exclude systemic anaplastic lymphoma kinase-negative ALCL involving the breast, primary cutaneous ALCL, and other CD30(+) lymphoproliferative disorders. The patients with effusion-associated ALCL often have an indolent course and excellent prognosis, responding well to excision of the fibrous capsule around the implant (capsulectomy) and implant removal. In contrast, patients who present with a distinct mass may have a more aggressive course and poor prognosis, requiring chemotherapy and/or radiation therapy.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Report of 2 Cases and Review of the Literature

Although primary breast lymphomas are exceedingly rare, cases of breast implant-associated anaplastic large cell lymphoma (iALCL) continue to be reported. The authors describe their experience with 2 patients and review the literature. Both patients presented with periprosthetic fluid collection. Neither had evidence of systemic disease nor received systemic therapy. Both were disease free after bilateral capsulectomies and implant removal without implant replacement, and disease did not recur. During the literature review, 63 cases of iALCL (including our 2 patients) were identified. The median time from implant placement to diagnosis was 9 years. Both saline and silicone implants were associated with iALCL. Of the 26 cases for which implant surface was reported, the surface was textured in 24. Of the 58 patients with an identifiable presentation, 39 had periprosthetic fluid collection, including 7 with an associated mass; 13 had an isolated mass at presentation, including 1 with axillary adenopathy. Forty patients had capsulectomy, 7 of whom underwent implant replacement. Of the 44 patients with known treatment, 33 received chemotherapy and 23 received radiation. Of the 49 patients with known anaplastic large cell lymphoma, 15 had disease recurrence, and 4 patient deaths were reported. Of the 18 patients presenting with a mass, 11 had disease recurrence, including all 4 patients who died. This study represents the largest review of patients with iALCL described to date. Although most cases have an indolent clinical course, the variety of presentations defined as "seroma" vs "capsular involvement" emphasizes the importance of investigating a definitive method of diagnosis, management, and treatment of this disease. LEVEL OF EVIDENCE 5.

Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients

Breast implant-associated anaplastic large cell lymphoma (BIA ALCL) is a newly described clinicopathologic entity. The purpose of this study is to describe the imaging findings of patients with BIA ALCL and determine their sensitivity and specificity in the detection of the presence of an effusion or a mass related to BIA ALCL. A retrospective search was performed of our files as well as of the world literature for patients with pathologically proven BIA ALCL who had been assessed by any imaging study including ultrasound (US), computerized tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT, as well as mammography. The sensitivity and specificity of each imaging modality in the detection of an effusion or a mass around breast implants was determined. We identified 44 patients who had BIA ALCL and imaging studies performed between 1997 and 2013. The sensitivity for detecting an effusion was 84, 55, 82, and 38 %, and for detecting a mass was 46, 50, 50, and 64 %, by US, CT, MRI, and PET, respectively. The sensitivity of mammography in the detection of an abnormality without distinction of effusion or mass was 73 %, and specificity 50 %. Progression-free survival was worse in patients with an implant-associated mass (p = 0.001).

CONCLUSIONS

Current imaging with US, CT, MR, and PET appears suboptimal in the detection of an imaging abnormality associated with BIA ALCL. This under diagnosis may reflect a lack of awareness of this rare entity suggesting the need for better understanding of the spectrum of imaging findings associated with BIA ALCL by breast imagers.

Implant-associated anaplastic large cell lymphoma of the breast: Insight into a poorly understood disease

Implant-associated anaplastic large cell lymphoma (ALCL) is the subject of much debate in the field of plastic surgery. Only a few published cases have been reported and the rarity of the disease may make proving causality exceedingly difficult. Despite this, it is of utmost importance that full attention be devoted to this subject to ensure the safety and well-being of patients. The authors report one new case of implant-associated ALCL that recently presented to their institution. Implant-associated ALCL is a poorly understood disease. It should likely be considered its own clinical entity and categorized into two subtypes: one presenting as a seroma and the other as a distinct mass or masses. When reported, only textured implants have been associated with ALCL. The United States Food and Drug Administration and American Society of Plastic Surgeons have initiated a registry and have collected critical data to gain further understanding of this disease.

Breast implant-associated anaplastic large-cell lymphoma: long-term follow-up of 60 patients

PURPOSE

Breast implant-associated anaplastic large-cell lymphoma (ALCL) is a recently described clinicopathologic entity that usually presents as an effusion-associated fibrous capsule surrounding an implant. Less frequently, it presents as a mass. The natural history of this disease and long-term outcomes are unknown.

PATIENTS AND METHODS

We reviewed the literature for all published cases of breast implant-associated ALCL from 1997 to December 2012 and contacted corresponding authors to update clinical follow-up.

RESULTS

The median overall survival (OS) for 60 patients was 12 years (median follow-up, 2 years; range, 0-14 years). Capsulectomy and implant removal was performed on 56 of 60 patients (93%). Therapeutic data were available for 55 patients: 39 patients (78%) received systemic chemotherapy, and of the 16 patients (28%) who did not receive chemotherapy, 12 patients opted for watchful waiting and four patients received radiation therapy alone. Thirty-nine (93%) of 42 patients with disease confined by the fibrous capsule achieved complete remission, compared with complete remission in 13 (72%) of 18 patients with a tumor mass. Patients with a breast mass had worse OS and progression-free survival (PFS; P = .052 and P = .03, respectively). The OS or PFS were similar between patients who received and did not receive chemotherapy (P = .44 and P = .28, respectively).

CONCLUSION

Most patients with breast implant-associated ALCL who had disease confined within the fibrous capsule achieved complete remission. Proper management for these patients may be limited to capsulectomy and implant removal. Patients who present with a mass have a more aggressive clinical course that may be fatal, justifying cytotoxic chemotherapy in addition to removal of implants.

Anaplastic large cell lymphoma of the breast arising around mammary implant capsule: an Italian report

Anaplastic large cell lymphoma (ALCL) of the breast is a very rare nonepithelial neoplasm. In the literature, this tumor has sometimes been described in proximity of breast implants (60 implant-related ALCL reported). In 2010, a patient who had undergone a right mastectomy and tissue expander/implant reconstruction for a "ductal" carcinoma 10 years before was referred to our unit for evaluation. On examination, an enlarged reconstructed right breast was found. The reconstructed breast did not show tenderness or signs of infection, ulceration, or breakdown. Mammograms and ultrasound scan did not suggest the presence of recurrent cancer, infection, deflation of the implant, or severe capsule contracture. The patient underwent mammary implant replacement. About 3 weeks after surgery, the patient came back to our unit for a new mild enlargement of the operated breast and the implant was removed. Three months later, the patient returned with a skin lesion in the right parasternal region. A radical excisional biopsy was performed under local anesthesia and the diagnosis of ALK-1-negative ALCL was finally made. The clinical and histological diagnosis of this disease is difficult as it can often be mistaken for a simple seroma (breast enlargement), an infection, or an unspecific reaction to silicone (redness and/or tension of the skin, itching, and fever). We strongly suggest considering ALCL in any patient with a spontaneous breast seroma lasting more than 6 months after mammary prosthesis implantation. The suspicion of ALCL must be suggested to the pathologist immediately.

LEVEL OF EVIDENCE V

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 .