An Interesting Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Case Report

Austin J Clin Case Rep. 2023; 10(1): 1273.

An Interesting Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma

Hernandez C¹*, KC B¹, Costaldi M³, and Ghimire K²

¹Department of Medicine, State University of New York Upstate Medical University, USA

²Department of Hematology and Oncology, State University of New York Upstate Medical University, USA

³Department of Pathology, State University of New York Upstate Medical University, USA

*Corresponding author: Hernandez CDepartment of Internal Medicine State University of New York Upstate Medical University 750 E Adams St Syracuse NY 13210 USA. Phone: 718-753-0358; Email: hernanca@upstate.edu

Received: January 31, 2023; Accepted: March 06, 2023; Published: March 13, 2023

Abstract

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a T-cell non-Hodgkins lymphoma that is a rare complication seen with textured breast implants. We describe the case of a 49-year-old woman with a past medical history of stage IIA infiltrating ductal carcinoma of the right breast status post bilateral mastectomy followed by chemotherapy and radiation therapy. The patient subsequently had textured implants bilaterally placed. Thirteen years later, she presented with right breast soreness with edema; pathology confirmed BIA-ALCL.

Keywords: Breast implant-associated cancer; Lymphoma; ALK-negative

Introduction

Anaplastic Large Cell Lymphoma (ALCL) is a type of T-cell non-Hodgkins lymphoma with large pleomorphic lymphoid cells with abundant cytoplasm and horseshoe-shaped nuclei positive for CD30 immunohistochemical staining [1]. The different types of ALCL are systemic and peripheral or localized. ALCL can be sub classified by the presence of the Anaplastic Lymphoma Kinase (ALK) gene or lack of the mutation designated as ALK-positive and ALK-negative, respectively. ALK-positive has the t(2;5) fusion translocation involving the ALK gene and Nucleophosmin (NPM1) gene [2].

Localized ALCL variations included Cutaneous ALCL and Breast Implant-associated Anaplastic Large Cell Lymphoma (BIA-ALCL). BIA-ALCL is very rare [3], with an incidence of 1 in 500,000 and occurring only in textured implants. BIA-ALCL is a peripheral lymphoma that typically presents in the seroma surrounding the breast implant and scar tissue. The first case of ALCL associated with textured saline breast implants was reported in 1997 [4].

In 2012, the American Society of Plastic Surgeons (ASPS), in collaboration with The Plastic Surgery Foundation (PSF) and the United States Food and Drug Administration (FDA), created The Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma etiology and Epidemiology (PROFILE) registry to gather demographic and clinical data on reported cases in the United States [3,5]. Data from the PROFILE registry shows a correlation between textured breast implants and the development of BIA-ALCL. In 2016, BIA-ALCL was recognized as a distinct sub classification of ALCL by the World Health Organization [6]. Most BIA-ALCL was encountered with the Allergan Biocell textured implants, which were recalled in 2019 [7].

The median age at diagnosis of BIA-ALCL is 52 years. The average time to onset from textured implant ranges from 7-10 years; however, cases have been reported as early as four months post-implantation [3]. Common symptoms include swelling, pain, and redness of the affected breast [8]. Rarer symptoms include lymphadenopathy, capsular contracture, and B symptoms such as fevers, night sweats, and weight loss. These symptoms are due to periprosthetic effusion in which atypical lymphoid cells are found.

Case Presentation

The patient is a 49-year-old female with a past medical history of hypertension, hyperlipidemia, anxiety, stage IIA (T1c N1 M0) ER/PR-positive, HER-2/neu negative infiltrating ductal carcinoma of the right breast diagnosed in 2009 status post bilateral with implant reconstruction. She received adjuvant Doxorubicin and Cyclophosphamide with weekly Paclitaxel and post-mastectomy radiation. She completed five years of adjuvant endocrine therapy, initially with tamoxifen for three years, followed by exemestane (6-methylenandrosta-1, 4-diene-3,17-dione) after a bilateral salpingo-oophorectomy. She completed adjuvant endocrine therapy in 2014, four months prior to the 5-year mark, due to arthralgias and weight gain.

However, eight years after completing endocrine therapy, she reported increasing swelling and fullness of her right breast, together with some discomfort. The patient had no fevers, chills, diaphoresis, or weight loss on the physical exam. There was concern that she could have capsular contracture with possible infection. Ultrasound showed a moderate to large amount of fluid with scattered thin septations, which were seen around the right breast implant. She underwent ultrasound-guided aspiration of 110 ml of fluid and was placed on antibiotics. Aspiration of the right breast demonstrated atypical cell morphology.

A subsequent MRI of the breast was notable for a moderate right-sided implant fluid collection with asymmetric mild, right capsular thickening with adjacent fat stranding and edema, possible etiology of inflammation, infection, or neoplasm. There was no enhancement in the left breast or axillary adenopathy.

The patient had a capsulectomy a month later with improvement in symptoms. The right breast periprosthetic capsule showed dense fibrous tissue, but no discrete masses were noted. The treatment was the removal of the implant. Since the disease was limited to the effusion and early capsule infiltration, it was staged IB (T2N0M0).

Cytology from the right breast seroma was positive for malignant cells. The specimen contained malignant cells with a small to moderate amount of cytoplasm and markedly atypical malignant cells with partially vacuolated cytoplasm and enlarged and irregular nuclei with prominent nucleoli along with the occasional "hallmark" cells (Figure 4).