Breast Implant Associated – Anaplastic Large Cell Lymphoma (BIA-ALCL) has become a hot and controversial topic in plastic surgery. ALCL has been demonstrated to occur following reconstruction as well as augmentation and can occur in the setting of saline filled or silicone gel implants. The common denominator based on current evidence is the association with the use of textured surface breast implants. The risk of developing BIA-ALCL has been in flux with the original estimates being that it would affect 1 in 300,000 women; however, current estimates are that the risk is now between 1 in 1,000 to 1 in 10,000 women. The most common presentation is a late seroma that typically occurs 1 or more years following implantation.

Over the past several years, important information about BIA-ALCL has been learned. Theories regarding the etiology include bacteria induced inflammation (biofilm theory), particulate matter, and genetic predisposition. Textured surface devices are implicated because they may provide a greater surface area for these inflammatory processes to occur. Macro-textured devices have been implicated in the majority of cases to date; however, it is important to appreciate that 55% of cases have no information regarding the implant type. To date there have been no reported cases with the use of a smooth surface only device. Common symptoms include breast enlargement due to fluid collection, pain, asymmetry, breast mass, overlying skin rash, or hardening of the breast. The average interval from implantation to the development of ALCL is 8 to 10 years. Patients presenting with ALCL may manifest initially with a periprosthetic effusion (80%), breast mass (40%) or lymphadenopathy (17%). Optimal screening includes ultrasound for suspicious cases or a PET-CT scan for confirmed cases. There is no role for mammography in screening for cases of suspected BIA-ALCL. Diagnosis is through aspiration for cytology (anaplastic cells), immunohistochemistry (CD-30 cells), and flow cytometry (T-cell clones).

Current treatment recommendations for disease confined to the capsule include total capsulectomy and removal of the breast implants. The insertion of new implants immediately following the capsulectomy can be considered if desired and has been demonstrated to be safe. In women with bilateral breast implants, consideration for removal of the contralateral implant is important, as approximately 4.6% of cases have demonstrated incidental lymphoma in the contralateral breast. Sentinel lymph node biopsy is not recommended because the implant capsule may drain to multiple regional lymph node basins. In the setting of advanced disease, defined as disease outside the capsule, unresectable or with lymph node involvement, chemotherapy and/ or radiation therapy may be indicated.

One of the controversies surrounding BIA-ALCL is whether this is a lymphoproliferative disorder or true malignancy at every stage of the disease process. The World Health Organization has classified BIA-ALCL as a cancer and specific disease entity in 2016. BIA-ALCL has been classified as an uncommon variant of lymphoma that is easily treated when diagnosed and treated early. Some have opined that when ALCL is in the effusion stage only, it may actually represent a lymphoproliferative disorder and that it does not become a malignancy until there is a solid mass. Others however, have opined that the BIA-ALCL is progressive and without proper treatment, will progress beyond the effusion stage to a solid stage and spread to regional lymph nodes before metastasizing through out the body. To date there have been 16 deaths reported and attributed to BIA-ALCL. A common denominator in these deaths was the incomplete removal of the breast capsule that harbors the malignant cells. Adding to the controversy surrounding ALCL is a recent report of spontaneous regression of documented BIA-ALCL in two patients. In the first patient, aspiration of a late seroma demonstrated atypical T cells that were positive for CD30. In the second patient, cytology and immunohistochemistry demonstrated atypical T cells that were CD30 positive. Repeat cytology performed 8-10 weeks later in both patients demonstrated no evidence of ALCL suggestive of a lymphoproliferative component to this disease.

In summary, BIA-ALCL is an uncommon entity that is successfully treated when diagnosed early. Suspicion is based on physical examination and aspiration of seroma fluid. Diagnosis is based on cytology for anaplastic cells that are CD30 positive. Management includes total capsulectomy and explantation. Further research as to the exact etiology and pathophysiology is ongoing. All patients diagnosed with BIA-ALCL should be reported to the appropriate agencies to track the incidence and prevalence.

References
1. Nava M. MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference Report. Plast. Reconstr. Surg. 141: 40, 2018
2. Clemens MW et al. NCCN Consensus Guidelines for the Diagnosis and Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma. ASJ. 2017, Vol 37(3) 285–289
3. Clemens MW et al. Complete Surgical Excision Is Essential for the Management of Patients With Breast Implant–Associated Anaplastic Large-Cell Lymphoma. J Clin Oncol 34:160-168. 2015.
4. U.S. Food & Drug Administration. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). U.S. Food & Drug Administration Website. . Accessed May 1, 2018.
5. Fleming D, Stone J, Tansley P. Spontaneous Regression and Resolution of Breast Implant-Associated Anaplastic Large Cell Lymphoma: Implications for Research, Diagnosis and Clinical Management. Aesthetic Plast Surg. 2018 Feb 14. doi: 10.1007/s00266-017-1064-z. [Epub ahead of print]