Breast Implant–Associated Anaplastic Large-Cell Lymphoma

Updated Systematic Review and Analysis of Treatment Strategies

Hani I. Naga, M.D.; Joseph A. Mellia, M.D.; Marten N. Basta, M.D.; Martin P. Morris, M.D., M.B.E.; Adrienne N. Christopher, M.D.; Frank M. Campbell, M.S.; Katie Sommers, M.P.H.; Howard Levinson, M.D.; Jonas A. Nelson, M.D., M.P.H.; John P. Fischer, M.D., M.P.H.

Disclosures

Plast Reconstr Surg. 2022;150(4):762-769. 

In This Article

Abstract and Introduction

Abstract

Background: Although guidelines have been published on treatment of breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines.

Methods: Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines.

Results: A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma (n = 114, 70.4 percent), followed by a mass (n = 14, 8.6 percent), or both (n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 (p < 0.001), whereas treatment for advanced disease remained unchanged (p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p < 0.001).

Conclusions: BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.

Introduction

Since the first reported case in 1997,[1] breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) has been a difficult entity to characterize because of its low incidence and understated clinical course, but studies have begun to shed light on its pathogenesis, diagnosis, and management. It is now understood that BIA-ALCL is a rare form of non-Hodgkin lymphoma that has been associated with textured breast implants. Textured surfaces are thought to induce a chronic inflammatory state that may induce malignant transformation of T cells in susceptible patients.[2] Most cases present as a local periprosthetic effusion and local disease is virtually curable with early treatment.[3] BIA-ALCL is thought to be an indolent disease, but it is crucial to recognize it early, because deaths have been reported in very advanced cases.[3,4] While once thought to be rare, recent studies have suggested the true incidence may be higher than early epidemiologic estimates.[5–7]

Treatment of BIA-ALCL has been highly variable, using both surgical and nonsurgical interventions.[4,8] Lack of consensus led to individualized treatment regimens based on expert opinions. In 2017, the National Cancer Center Network released landmark guidelines that provided an algorithmic approach to diagnosis and treatment of BIA-ALCL.[9] Based on these guidelines, surgical intervention with implant removal and en bloc capsulectomy ensures optimal outcomes in all patients with BIA-ALCL, whereas systemic therapy is appropriate for more advanced cases.

National and international efforts to create BIA-ALCL registries have resulted in more robust database studies,[10] but many cases are missed by these registries and are instead published as case reports. Given the improved understanding of BIA-ALCL diagnosis and management, the authors sought to provide an updated systematic review of the case literature on BIA-ALCL to help characterize treatment variation in relation to National Cancer Center Network guideline publication.

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