Breast Implant-Associated Anaplastic Large Cell Lymphoma — In the Clinic

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Patients who undergo this cosmetic procedure should be counseled on the increased risk of BIA ALCL.
Patients who undergo this cosmetic procedure should be counseled on the increased risk of BIA ALCL.

Anaplastic large cell lymphoma (ALCL) is a type of peripheral T-cell lymphoma that accounts for fewer than 2% of all lymphoma cases.1-5 ALCL consists of 4 subgroups that were recently outlined by the World Health Organization (WHO): primary systemic ALK-positive and -negative, primary cutaneous, and breast implant–associated (BIA). BIA ALCL is a rare form of ALCL with distinct clinical features that health care professionals should be aware of to avoid a delay in diagnosis.

BIA ALCL was first described in 1997, does not express ALK, and is considered less aggressive than systemic forms of ALCL.1 The underlying pathophysiology may be related to a pro-inflammatory state triggered by the implant.6 This inflammation leads to a hyperactive immune system which, in the right host, can lead to malignant transformation.

As implants are foreign, there is an expected inflammatory response to all implants, though it is unclear why some patients are more susceptible to BIA ALCL.

Patients with this disease can present with increasing seroma accumulation between the fibrous capsule and the implant that manifests as pain, asymmetry, and edema. Fluid collection with surrounding palpable lymphadenopathy may be present on physical examination. A breast ultrasound can help to identify any surrounding fluid collections and guide drainage of the fluid, which can be sent for analysis.

Yet regardless of a thorough history, physical exam, and diagnostic workup, BIA ALCL may not be diagnosed until the patient undergoes surgical revision for ostensibly non-malignant seroma accumulation.

BIA ALCL has been reported in both patients with silicone- and saline-filled implants placed for cosmetic or reconstructive purposes. The median time to disease development is 10 years from initial implant surgery, although the timeframe varies.2,3 Silicone and saline implants appear, furthermore, to carry similar risks for BIA ALCL.7 And while most BIA ALCL cases are unilateral, there are reports of bilateral diagnoses.

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