It is key for oncologists and surgeons to be aware of the symptoms of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and how this disease should be treated, according to Valerie Lemaine, MD, MPH, FRCSC.
At the 37thAnnual Miami Breast Cancer Conference, Lemain, of Plastic Surgery Consultants at Minnesota Oncology, discussed the signs and symptoms of BIA-ALCL, as well as how the disease is diagnosed and treated.
BIA-ALCL is an extranodal T-cell lymphoma that develops in the fluid and the capsule tissue adjacent to breast implants. As of July 2019, the FDA had received 573 unique, confirmed cases, including 481 that were linked to textured implants, that led to 33 deaths. While many cases of BIA-ALCL are likely still underreported, according to Lemaine, what health care specialists do know is that 481 of these cases are linked to the Allergan BioCell textured implants. To date, there have been no confirmed cases of BIA-ALCL associated with smooth implants alone, but in those who have a complex history and had several breast implants over that time.
BIA-ALCL presents clinically as a seroma, which occurs on average 8-10 years after the initial placement of the textured implant. Other symptoms include a palpable mass, palpable lymphadenooathy, skin rash, fevers, or capsular contracture.
If BIA-ALCL is suspected, the first step is to undergo a breast ultrasound. “If the ultrasound is indeterminate, the next step is to do a breast MRI. And it's important to know that the mammogram itself is not the greatest imaging modality for BIA-ALCL. The next step, especially knowing that patients present with a seroma fluid collection is to do a fine needle aspiration.
At times, if this suspicion occurs on an emergency room visit, fluid will be collected and the capsule will be sent to pathology. “Another thing that's important to know is that it is normal to have a small amount of fluid around breast implants,” Lemaine added.
“The ALCL cells will be floating in the seroma fluid and there will be no capsule involvement,” she explained. “As the disease progresses, there will be accumulation of tumor cells on the luminal side of the capsule and eventually this will progress to full capsular invasion. In the later stages, the invasion of the breast and surrounding soft tissue as well as axillary lymph node will be found.”
Upon diagnosis, BIA-ALCL is a B-cell lymphoma, most commonly diffuse large B-cell lymphoma (50%) or marginal zone lymphoma (18.3%). Fibrin-associated large B-cell lymphoma associated with Epstein Barr virus infection; extranodal natural killer/T-cell lymphoma, nasal type; or plasmablastic lymphoma are also types of the disease, but are less common. Disease stages include Ia (35%-70%), Ib (3%-11%), Ic (8%-13%), IIa (8%-25%), IIb (3%-5%), III (3%-9%), and IV (1%-2%).
Surgical treatment for BIA-ALCL includes surgical excision if the disease is noninvasive. Moreover, the implants are removed as well. Chemotherapy is administered in the adjuvant setting if the disease is stage 2 and higher, and radiation is given if margins are positive and/or there is chest wall involvement.
A 2016 study showed that overall survival rates at three and five years were 94% and 91%, respectively.
After treatment, a physical exam will be done every 3-6 months for 2 years, as well as a PET/CT scan every 6 months for 2 years.
“At this time, the FDA does not recommend removal of these or other types of breast implants in patients who have no symptoms due to the low risk of developing BIA-ALCLC,” Lemaine said. “(Health care providers) should inform you patients about the risk of developing BIA-ALCL and what to look for.”
Lemaine V. Surgical Considerations in Breast Implant-Associated Anaplastic Large Cell Lymphoma. Presented at: 37thAnnual Miami Breast Cancer Conference; Miami, Florida; March 5-8, 2020.