Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is an extremely rare and distinct oncological entity arising within or around the prosthesis previously inserted post-mastectomy,
either to treat a carcinoma or after glandular augmentation.
It is a T-cell lymphoma composed of large and pleomorphic cells which uniformly express CD30 and are negative for anaplastic lymphoma kinase (ALK) or lack genetic abnormalities involving this enzyme at chromosome 2q23.
Aetiology remains unclear.
The neoplasm begins on the luminal surface of the fibrous capsule surrounding the prosthesis and exhibiting varying degrees of infiltration of the capsule,
the adjacent soft tissue,
or the breast parenchyma.
Usually,
it presents as swelling due to effusion around the implant (seroma) or unexpected changes in breast shape; less frequently as a mass.
Axillary lymph nodes are not always enlarged.
Suspicious peri-prosthetic fluid should be sent to test CD30 immunohistochemistry,
cell block cytology,
and culture.
Although characterised by good prognosis,
this kind of lymphoma is not always promptly diagnosed.
Ultrasound plays a pivotal role in terms of screening symptomatic ladies,
demonstrating thickening or fibrous changes of the capsule surrounding the implant or deceptively normal appearances.
When present,
an adequate amount of fluid should be aspirate for testing.
Apart from being positive for CD30,
biopsy or resection specimen also express CD4 and CD43,
whilst are often negative for antigens like CD3 and CD5.
A separate staging has been proposed for this tumour,
which is displayed in table 1 and illustrated in figure 1 and 2.
A key diagnostic distinction is whether the soft tissue mass involves the implant or not. This condition has been newly recognised in clinical practice and,
according to the recently published British recommendations,
the optimal management is represented by complete surgical excision.
Retrospective data shows that women with lymphoma confined to the fibrous capsule have a better outcome compared to those in whom cancer has spread beyond the capsule.
In either case,
it is important to perform a radical surgery in the first instance,
including breast implant removal and total capsulectomy with complete excision of any associated mass and negative margins on final pathology assessment.
This approach is also recommended for patients who present only with a seroma.
An incomplete resection or inadequate local surgical may lead the individual to further unnecessary treatments,
considering that BI-ALCL is mostly localised to the breast and chest wall.
The pattern of progression of this cancer is more similar to solid tumours rather than to other non-Hodgkin’s lymphoma.
Therefore,
there does not seem to be a valid role for sentinel lymph node biopsy.
However,
if nodal dissemination occurs,
the axillary lymph nodes are the most likely to be involved; in such a case,
excisional biopsy of any suspicious nodal gland should be carried out.
In cases where the lymphoma has spread beyond the capsule,
we would generally recommend systemic chemotherapy (the most used regimen consists of cyclophosphamide,
doxorubicin,
vincristine,
and prednisolone),
the length of which would depend on the extent of the disease,
with or without additional radiotherapy.