A 45-year-old female patient presented with swelling and redness of the left breast. 15 years ago, she underwent cosmetic bilateral breast augmentation. There was no significant medical history. After clinical examination which revealed fluid collection and axillary lymphadenopathy, diagnostic imaging work-up was performed.
Figure 1. Ultrasound shows fluid collection with hypoechoic content
Figure 2. Ultrasound image of clearly visible irregularly shaped solid parts in fluid collection
Figure 3. Sonographically visible enlarged axillary lymph nodes with irregular and thickened cortex
Figure 4. Breast MRI post-contrast subtracted T1 image shows contracted implant and consequently smaller left breast, peri-implant mass type lesions and thickened fibrous capsule
Figure 5. Breast MRI T2-weighted image with fat suppression shows fluid collection with surrounding hypointense lesions
Background Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a very rare subtype of T-cell non-Hodgkin lymphoma with an incidence of 0.3% per 100 000 women per year. Occurs most often in patients who have breast implants with textured surface. Aetiology is still unclear, widely thought to be multifactorial. Only known risk factor is textured implant surface, while indication for implant insertion, implant content and location have not been proven as risk factors. This lymphoma type arises in fluid collection surrounding implant or in the fibrous capsule. [1,2]
Clinical Perspective The average time of presentation is between 8-10 years after implant insertion.  Patients mostly complain about swelling, redness, pain, rash and asymmetry of the breast because of capsule retraction. Clinical breast examination reveals mass or more often fluid collection.
Imaging Perspective In general, BIA-ALCL is usually presented with only peri-implant effusion (seroma), rarely there is a discreet breast mass with or without effusion, originating from the fibrous capsule. Mass forming disease may have more aggressive courses and worse prognosis. Spreading of disease in regional lymph nodes rarely occurs.  Diagnostic mammography shows asymmetry around implant in comparison with contralateral breast, not adequately distinguishing between the effusion and a solid mass. Ultrasound typically shows a complex fluid collection with often seen septa and echogenic content. Sensitivity for detecting discreet mass in effusion is 46%. MRI also detects fluid, seroma collection with higher sensitivity for mass recognition, capsular thickening and chest wall invasion. The final diagnosis is set on the basis of fine needle aspiration of fluid collection and tissue biopsy if mass lesion is suspected. Specimens should be undertaken for cytological and histopathological analysis. In case of lymphadenopathy on clinical examination and based on sonographic findings of regional lymph nodes, specimens should also be taken if morphology is suspicious. [4-6]
Teaching Points Establishing the diagnosis of BIA-ALCL can be challenging. Imaging modalities appear suboptimal in detection of BIA-ALCL. Underdiagnosing reflects a lack of awareness of this rare entity, suggesting the importance of better understanding of the imaging findings associated with this lymphoma type. Multidisciplinary approach is essential for the diagnosis and therapy management.
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