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How I treat breast implant–associated anaplastic large cell lymphoma

Neha Mehta-Shah, Mark W. Clemens and Steven M. Horwitz

Article Figures & Data

Figures

  • Figure 1.

    Clinical example of BIA-ALCL. Patient is a 42-year-old woman who presented with a late periprosthetic seroma of the left breast capsule (A) ∼7 years following cosmetic augmentation-mastopexy with bilateral textured breast implants. A fine needle aspirate (FNA) of the periprosthetic effusion demonstrated clonal expansion of CD30+ large anaplastic T cells. (B) A preoperative PET/CT scan demonstrated a posterior capsule wall mass invading the chest wall. (C) Specimen from a bilateral explantation; total capsulectomy with excision of the skin involvement demonstrated a posterior mass on the capsule. Complete surgical excision is essential as residual disease is associated with disease progression.

  • Figure 2.

    BIA-ALCL schematic and TNM staging. (A) The schematic demonstrates that BIA-ALCL typically presents in the seroma surrounding the breast implant. The lymphoma is usually contained within the fibrous capsule and distinct from breast parenchyma. BIA-ALCL typically is isolated to within the fluid and/or inner wall of the capsule, although invasion into or beyond the capsule is less commonly seen and associated with a worse prognosis. (B) This can be seen histologically or on gross review of the pathology at the time of surgery. (C) Clinical and pathologic staging of BIA-ALCL follows the MD Anderson Solid Tumor Staging System modeled after the American Joint Committee on Cancer TNM stages. Using this system, BIA-ALCL patients have a spectrum of disease from IA (35.6%, effusion only), IB (11.5%), IC (13.8%), IIA (25.3%), IIB (4.6%), III (9.2%), to stage IV (0%). Adapted from Clemens et al7 with permission.

  • Figure 3.

    Pathology. (A) Cytological appearances of BIA-ALCL cells on cytopsin preparation from an effusion (original magnification ×600; Giemsa stain). (B) Histological appearances of BIA-ALCL in capsulectomy specimen (original magnification ×400; hematoxylin and eosin stain). (C) CD30 expression by the neoplastic cells of BIA-ALCL (original magnification ×400; immunoperoxidase stain). (D) Foreign body giant cells reaction against silicone particulate shed from textured implant in the capsule. (original magnification ×400; hematoxylin and eosin stain) (E) Flow cytometric immunophenotyping of effusion from a case of BIA-ALCL. The neoplastic cells, shown with purple dots, express CD4 and CD2 (dim) (E) but not CD3 (F). They are brightly positive for CD30. Normal CD4 and CD8-positive T cells are shown in red and green, respectively. Small numbers of NK cells, shown by dark blue dots, are present. The remaining mononuclear cells, shown in gray dots, are mostly macrophages. All panels are gated on mononuclear cells. (G) The flow cytometric gate for CD30.

  • Figure 4.

    BIA-ALCL treatment algorithm. Diagnosis and treatment follow NCCN guidelines. The essential elements are summarized in the algorithm in the artwork. US, ultrasound.

  • Figure 5.

    Survival curves according to treatment approaches and TNM tumor staging. (A-B) treatment approaches and (C-D) TNM tumor staging; (A,C) EFS, (B,D) overall survival. CS, complete surgery; LS, limited surgery; XRT, external beam radiation. Reprinted from Clemens et al7 with permission.