The authors have declared that no competing interests exist.
Breast implant-associated anaplastic large cell lymphoma (ALCL) is a recently recognized type of T-cell lymphoma that can develop following breast implants, with morphologic and immunophenotypic features indistinguishable from those of ALK-negative ALCL. Here we report a case of a 58-year-old woman with a history of subglandular silicone implants placed for bilateral breast augmentation 25 years ago, who presented with bilateral breast pain and was found to have bilateral Baker Grade III capsular contracture, and heterogenous fluid collection centered near the left third costochondral articulation, a suspicious left chest wall lesion, and left axillary lymphadenopathy on imaging. A left axillary lymph node core biopsy and an aspiration of the fluid were performed, and no malignant cells were identified. The patient underwent bilateral removal of breast implants and total capsulectomies. Microscopic examination of the capsule surrounding the left breast implant revealed large pleomorphic tumor cells in a fibrinous exudate. By immunohistochemistry, the tumor cells were found to be positive for CD3 (subset), CD4, CD7, CD30 (strong and uniform), and CD43, and negative for CD2, CD5, CD8, and ALK1, supporting the diagnosis of breast implant-associated ALCL. No lymphoma cells were identified in the right breast capsule, confirmed by CD30 stain. Breast implant-associated ALCL is a very rare disease that can develop many years after breast implant placement. Proper evaluation with breast imaging and pathologic workup is essential to confirm the diagnosis in suspected cases. Our case highlights that adequate sampling is important in the investigation of patients with suspected breast implant-associated ALCL.
In 2016, about 290,000 women in the United States had breast augmentation with implants; about a third of these women received them for reconstruction after breast cancer.
Here, we describe the case of a 58-year-old female with a history of subglandular silicone implants presenting with bilateral breast pain, in whom bilateral removal of breast implants and total capsulectomies were performed, and the subsequent histologic diagnosis of breast implant-associated ALCL was unexpected.
A 58-year-old woman with no history of cancer presented to Harbor-UCLA Medical Center for pain in her bilateral breast radiating to her left arm for 3 months. The patient had a history of bilateral subglandular silicone implants placed for breast augmentation 25 years ago. She was on conservative management for her recently diagnosed meningioma. On examination, both of her breasts were firm and distorted cosmetically, consistent with Baker Grade III capsular contracture. However, there was no palpable mass, nipple retraction, or skin changes. A magnetic resonance imaging (MRI) of the bilateral breasts showed asymmetric thickening of the medial aspect of the left implant capsule, diffuse edematous appearance of the left breast extending to the chest wall and pectoralis musculature, left axillary lymphadenopathy, and an approximately 5.5 x 3.3 cm mass centered along a left anterior rib near the costochondral junction; there was no evidence of intra- or extracapsular rupture of the subglandular silicone implants. A chest computed tomography (CT) scan with contrast demonstrated a 3.7 cm anterior left para-sternal inflammatory lesion with enlarged left axillary lymph nodes, favoring infectious etiology. A mammogram of the left breast demonstrated a distorted implant in the left breast at 8 o’clock, 9 o’clock and 10 o’clock at a posterior depth. A high-resolution real-time ultrasound scanning of the left breast showed a 3.6 x 0.8 cm oval, parallel-hypoechoic area adjacent to the implant, most likely inflammatory in origin, involving 8 o'clock, 9 o'clock and 10 o'clock position. The area was located 13 centimeters from the nipple and showed indistinct margins. Additionally, multiple enlarged left axillary lymph nodes measuring up to 1.7 x 1.5 cm were detected. A chest MRI with and without contrast revealed a rim enhancing heterogenous fluid collection centered near the left third costochondral articulation most suggestive of an abscess. An ultrasound-guided aspiration of the left parasternal fluid was performed, and 0.5 mL hazy pink aspirated fluid was submitted for cytologic evaluation which revealed mainly blood without malignant cells. A left axillary lymph node 18-gauge core biopsy (2 cores) showed no evidence of lymphoma or carcinoma. Due to the uncertain etiology of the patient’s symptoms and given the long history of the implants, the patient underwent bilateral capsulectomy and implant removal. Gross examination of specimens showed both implants were textured and appeared intact, and the capsules were extensively covered with thick, chalky-white deposits. The manufacturer’s imprint was not legible.
The capsules were extensively sampled and submitted for microscopic examination. The H&E stained sections of the capsule surrounding the left breast implant showed a fibrinous exudate containing tumor cells (
The pathogenesis of breast implant-associated ALCL is poorly understood. Available evidence suggests that it develops in the setting of implant-induced chronic inflammation.
Breast implant-associated-ALCL typically manifests as a seroma or fluid collection but may present with a discrete mass originating from the fibrous capsule around the implant.
Morphologically, the tumor is comprised of large, pleomorphic cells with abundant cytoplasm, sometimes horseshoe-shaped nuclei, and prominent nucleoli.
Breast implant-associated ALCL is histologically similar to but clinically distinct from other CD30-positive anaplastic T-cell lymphomas such as primary cutaneous ALCL, ALK-negative ALCL, and ALK-positive ALCL. The latter three rarely involve breast in patients with implants, usually presenting as late dissemination.
Classic Hodgkin lymphoma (CHL) has been rarely reported to arise adjacent to a breast implant.
In the present case, the bilateral capsulectomy and implant removal provided both the diagnosis and the primary treatment for the lymphoma. Given advanced disease, our patient opted for additional chemotherapy.
In conclusion, breast implant-associated ALCL is a very rare peripheral T-cell lymphoma arising around breast implants. Appropriate evaluation with breast imaging and pathologic workup is essential to confirm the diagnosis in suspected cases. Peri-prosthetic effusions occurring more than one year following breast implant placement should be aspirated, and a large volume of the aspirated fluid should be submitted to cytology for examination of lymphoma. The FDA recommends reporting all confirmed cases to improve the understanding of this rare disease. Complete surgical removal of the entire capsule and implant lead to optimal outcomes. Adjuvant radiotherapy and anthracycline-based chemotherapy are warranted for locally advanced and advanced cases. When caught early, breast implant-associated ALCL is curable in most patients. However, due to the rarity of this newly recognized disease, a diagnosis of breast implant-associated ALCL can be delayed. Clinicians and pathologists need to be aware of this entity.
KV and XQ identified the case and conceived of the presented idea. KV performed the literature search and wrote the first draft of the article. JC prepared the figures/figure legends and helped shape the manuscript. RRB, PJ, and RV provided critical feedbacks. XQ supervised this work, performed additional literature search, and wrote the final version of the article.