5 Key Points
- Uncommon lymphoma linked to textured, high surface grade, implants.
- Incidence is increasing as awareness increases.
- Late-onset seromas should be urgently investigated with cytology and histology.
- Tumour Markers are CD30+ and ALK-
- Early stage disease is curable with surgery alone.
Define
Breast implant-associated Anaplastic Large Cell Lymphoma (Bi-ALCL) is a CD30+, ALK-, T-cell derived lymphoma. It fits within the non-Hodgkin lymphoma group and is linked to textured breast implants.
Pathogenesis
A unifying hypothesis of published literature suggests textured implants with a high surface grade, bacterial contamination, inflammation and patient susceptibility interact over time to produce T-cell transformation. It is multifactorial, like most carcinogenesis
More specifically:
- Textured implants creates inflammation from friction
- High surface grade acts as passive conduit for bacterial proliferation
- Bacterial contamination is a form of microbiome induction that potentiates carcinogenesis. This is suggested by cluster patterns of incidence, biofilm formation and growth of both gram-positive and negative organisms.
Incidence
Wide variations in published data from 1 in 3,000 to 1 in 3,000,000. This variation is due to geographic discrepancies in databases and the different type of textured implants available. Importantly, the incidence is increasing each year.
Clinical Picture
History and Examination
- Insidious onset
- Late onset seroma (>1 year post implant), most commonly 8 years after implants inserted.
- Firm mass and lymphadenopathy (advanced disease)
- Capsular contracture (non-specific)
Risk Factors
- Textured Implants (no reports of link to smooth implants), particularly those with high surface grade classification (large surface area and rough)
- Immunocompromised patient
![](https://www.theplasticsfella.com/content/images/2021/03/Screenshot-2021-03-20-at-14.43.37.png)
Investigations
A multi-disciplinary approach is needed between surgeon, histology, radiology and, if diagnosed, oncology teams.
Seroma
A pre-operative Ultrasound-guided seroma aspirate should be investigated for
- Cytology: large anaplastic cells
- Flow cytometry: aberrant T-Calls
- Immunohistochemistry: CD30+ and ALK- makers.
![Capsule surrounding a Textured Implant](https://www.theplasticsfella.com/content/images/2021/03/5c4efd089ebbf.jpg)
Histology
Intra-operative specimens of any residual seroma and the implant capsule should be sent at the time of capsulectomy.
The absence of tumour cells following a positive seroma aspiration does not suggestion regression or resolution, but rather a lowering of the tumour cell burden following the drainage of the malignant seroma.
![](https://www.theplasticsfella.com/content/images/2021/03/Screenshot-2021-03-20-at-14.43.47.png)
Microbiology
This does not assist in diagnosing or staging but it is interesting to note the growth of both gram-positive and negative bacteria. This is different to capsular contracture pathophysiology, which mainly grows solely gram-positive bacteria.
Staging
The aim of the investigations to diagnose and appropriately stage the patient.
Stage | Pathology | Incidence |
IA (negative) | Seroma Positive, Capsule Negative | 63% |
IA (positive) | Seroma Positive, Luminal Capsule Positive | 16% |
IC | Capsule infiltrated | 7% |
IIA | Mass extending beyond Capsule | 11% |
III | Metastatic disease with 1 axillary node | 1% |
III | Metastatic disease with multiple nodes | 1% |
Radiology
There are no standardised guidelines referencing the role of further radiology investigations. This should be considered as a case-by-case basis in addition to the ultrasound for guided seroma aspiration.
![](https://www.theplasticsfella.com/content/images/2021/03/Screenshot-2021-03-20-at-14.43.57.png)
![](https://www.theplasticsfella.com///////wp-content/uploads/2019/05/IMG_0432-1024x625.jpg)
Management
Pre-Diagnosis
Management of this condition begins in the pre-operative setting by ensuring the patient has received informed consent and they understand the risk of Bi-ALCL
Intra-operatively, efforts should be focused on disease prevention through implant choice and reducing implant contamination.
Post-Diagnosis
Early recognition is key. Following the diagnosis, staging and multi-disciplinary team input, surgery is next.
Options to consider:
- Open Capsulectomy of anterior and/or posterior wall
- Implant replacement with a smooth implant
Surgical treatment of Bi-ALCL. Courtesy of Dr Tim Papadopoulos
Stage 1A is indolent and curable through surgery alone.
Recent publications have suggested a screening programme, but this has not been formally introduced.