Teaching Case

A 59-year-old woman with breast implants for augmentation mammoplasty since 2007 came to the Emergency Department with an increase in the size and hardening of her right breast for the last 2 months. No heat, erythema or other signs of local infection in the physical examination. No fever. 

Bilateral breast and axillary ultrasound were performed: Bilateral subpectoral implants. Findings were compatible with probable bilateral intracapsular implant rupture (increased intercapsular space, capsule folds and heterogeneous echogenic images). Furthermore, in the right breast, abundant anechoic peri-implant fluid was observed with heterogeneous images (may be debris or capsular components of the prosthesis). No breast mass or axillary lymphadenopathy were associated. Fine-needle aspiration of this liquid was performed, obtaining 40 ccs that we sent to pathological study.   

Pathological report: Cytology and immunohistochemical profile (CD30 positive; cytokeratins, CD20, CD3 and ALK-negative) concordant with implant-associated anaplastic large cell lymphoma (BIA-ALCL). Category C5. Radiology-pathology correlation: Appropriate. 

The diagnosis was confirmed after implant removal. 

MRI was not performed. The expected MRI findings in BIA-ALCL are peri-implant effusions (frequent finding) and/or associated mass (depending on the  BIA-ALCL form). Signs of implant rupture with thickening and irregularity are also frequent. Capsular enhancement is occasionally seen. We will also identify suspicious regional lymphadenopathies if they exist.

Body F18-FDG PET-CT didn’t show suspicious findings.

BIA-ALCL is a rare peripheral T-cell lymphoma, classified by WHO as a separate subtype of non-Hodgkin lymphoma. It is a disease of the breast implant capsule [1]. Annual incidence is estimated at 0.1 to 0.3 per 100,000 women with implants [2] and its exact pathology is not well understood yet.

It carries a good prognosis with a median overall survival rate up to 93% at 3 years and 89% at 5 years [3] and can arise in two different forms of presentation: In situ (more frequent) or infiltrative disease (palpable mass or lymph nodes involvement). Almost all documented cases of BIA-ALCL have been associated with a textured device, especially those with a higher surface area [4, 5, 6, 7, 8, 9]. No increased risk of lymphoma has been identified in patients with implants after cancer surgery compared to patients with cosmetic implants [4].

There exist two forms of BIA-ALCL: peri-implant effusion-type and peri-implant mass-type. In the majority of patients (60-90%), it usually presents with unilateral breast swelling caused by a rapid onset of spontaneous fluid collection (seroma). The average onset is 8 -10 years after implantation [1, 3, 5, 10, 11]. Palpable breast mass is less frequent (10-40%) [3, 4, 10]. Lymphadenopathy (20%), skin manifestations and B symptoms (fever, chills, weight loss, etc) can also be present. [1].              

Imaging diagnostic should start with an ultrasound evaluation to identify the presence of seroma, capsular masses or regional lymphadenopathy. Fine-needle aspiration of peri-implant fluid collections should be performed and in case of solid mass, a histologic sample is recommended. To evaluate collections, masses and lymph nodes MRI can be helpful, especially in mass-type lymphomas [4]. Mammography is not considered an acceptable imaging modality [1]. PET is also used to evaluating associated capsular masses, chest wall involvement and systemic spread (lymph nodes) [4]. 

The diagnosis requires CD30+ immunohistochemistry, large anaplastic cells on cytology and local expansion on flow cytometry [1].

A standard of care for the treatment doesn’t exist. For localized disease, in most cases, surgery can be sufficient, (total capsulectomy and removal of the implant in addition to the capsule with negative margins). In cases of advanced disease combinations of chemotherapy are being used [3]. Radiation therapy may be used for local residual or unresectable disease.

For post-treatment surveillance, CT or PET imaging at a maximum of every 6 months for the first 2 years is recommended by NCCN Guidelines [3].

Written informed patient consent for publication has been obtained.