medwireNews: US researchers have detailed the pathophysiology, clinical presentation, and management of breast implant-associated anaplastic large cell lymphoma (ALCL) in a move to educate healthcare professionals dealing with this rare but increasingly common diagnosis.
“It is important for all physicians involved in the care of patients with breast implants to be aware of this entity and be able to recognize initial symptoms,” they write in JAMA Surgery.
The team identified 93 cases from a systematic review of the literature published between the first documented case in August 1997 and January 2017, and added two previously unreported cases diagnosed at their institution, finding that “almost all” cases were associated with a textured implant.
Women receiving silicone implants were enriched in their sample relative to those with saline implants, at 61% and 39%, respectively, which the authors say “may be related to the greater use of textured anatomic silicone implants more recently.”
Patients presented with implant-associated ALCL at an average of around 10 years after implant placement, with an average time of 8.6 years for the 54% of women undergoing reconstruction surgery and 9.9 years for the 46% having cosmetic surgery.
The majority (66%) presented with an isolated late-onset seroma, 8% with an isolated new breast mass, and 7% with both, while the remaining 18% presented with other features, such as capsular contracture, axillary lymphadenopathy, skin lesions, or type B symptoms (eg, fever, night sweats).
The investigators from the Penn State Health Milton S Hershey Medical Center in the USA in Hershey, say that ultrasound with fine-needle fluid aspiration is generally the first step for evaluating women who report breast swelling, but they note that magnetic resonance imaging is also sometimes used. The diagnosis is confirmed by immunohistochemistry, with CD30 and epithelial membrane antigen positivity alongside ALK negativity signaling the presence of breast implant-associated ALCL.
Dino Ravnic and fellow authors note that expert consensus-based treatment guidelines are available, which state that for women with localized disease (seroma or stage I) it is enough to perform complete capsulectomy and implant removal, but that those with more advanced disease (stage II–IV) should be referred to a medical oncologist for additional treatment, including chemotherapy, radiotherapy, or both.
And indeed among the cases included in their systematic review, the majority (84%) of the 74 patients for whom treatment information was available underwent at least a complete capsulectomy and removal of the implant. Nearly two-thirds (61%) received chemotherapy, most commonly the combination of cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone (CHOP), and just under a third (30%) received adjuvant radiotherapy. Six patients were given neoadjuvant chemotherapy and one woman required capsulectomy after the lymphoma recurred following chemotherapy.
In view of the rising rates of breast augmentation and implant-based breast reconstruction, they expect to see an associated increase in the incidence of implant-associated ALCL, making it “critical that physicians treating patients with breast cancer be educated about […] this rare form of ALCL, which is often curable when diagnosed early.”
Furthermore, “[b]efore breast augmentation or reconstruction, surgeons need to convey the risk of breast implant-associated anaplastic large cell lymphoma to patients, with particular emphasis on the established linkage to textured implants; patients must be educated on the importance of routine surveillance after implantation, and it is likely that increased follow-up will lead to a further rise in this diagnosis,” Ravnic et al conclude.
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