Flow cytometry (FC) can efficiently diagnose breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL), and may differentiate it from other CD30-positive lymphomas, according to a letter to the editor of the Journal of Clinical Oncology.1

The letter was written in response to the guideline recommendations for the work-up in diagnosing BIA-ALCL.2 The guideline recommends the work-up to include air-dried smears of periprosthetic fluid, analysis of a cell block by hematoxylin and eosin staining and immunohistochemistry, and evaluation of the capsulectomy specimen.

In the letter, the authors indicated that FC should also be considered part of the initial work-up for BIA-ALCL.1 “FC, because of its sensitivity and specificity, is necessary as a first-line tool in the diagnosis of lymphoma, including BIA-ALCL,” the authors wrote.

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The authors of the letter analyzed 39 samples of periprosthetic fluid from women with breast implants (and 1 gluteal implant) by flow cytometry. Of these patients, BIA-ALCL was identified in 11.11% (4 individuals). There were 3 cases of T1 stage and 1 case of T2 stage, according to analysis of the capsulectomy specimens. The authors also conducted the work-up as recommended by the clinical practice guideline.

One of the patients with BIA-ALCL also had chronic lymphocytic leukemia cells in their periprosthetic fluid, which had been diagnosed 8 months prior to their BIA-ALCL.

Flow cytometry demonstrated at least 2 tumor cell subpopulations in 3 of 4 cases, and all tumor cells were positive for CD30, CD4, and CD45. The number of CD30 positive cells was significantly greater in BIA-ALCL compared with cases negative for BIA-ALCL (P =.03).

The authors stated that an integral analysis is necessary, but also recommend that “immunophenotype by FC must also be considered a first line of study.” They note that FC is widely available and can allow for an early diagnosis and identification of heterogenous cell populations.

In reply to the letter, the authors of the clinical practice guideline acknowledged that FC is an important tool. They highlighted that “our goal was to provide diverse health care providers with practical guidelines that could most easily and accurately answer a critical diagnostic question for patient care.”3

CD30 detection by FC may not always be available and practice patterns of FC vary widely across geographic regions. Moreover, a cell block can provide more information than FC, including the identification of Epstein-Barr virus and can allow for molecular analysis.


  1. Romero M, Melo A, Bedoya N, et al. Should flow cytometry be considered a first line of study in the diagnosis of breast implant–associated anaplastic large-cell lymphoma? [published online June 17, 2020]. J Clin Oncol. doi: 10.1200/JCO.20.00712
  2. Jaffe ES, Ashar BS, Clemens MW, et al. Best practices guideline for the pathologic diagnosis of breast implant–associated anaplastic large-cell lymphoma. J Clin Oncol. 2020;38:1102-1111.
  3. Jaffe ES, Feldman AL, Gaulard P, et al. Reply to M. Romero et al [published online June 17, 2020]. J Clin Oncol. doi: 10.1200/JCO.20.00712