Baylor University Medical Center Proceedings October 2017 - 442

Figure 2. (a) Hematoxylin and eosin stain of tumor, 20×. (b) Tumor staining positive for CD30, 20×. (c) Tumor staining for MIB-1 at approximately 80%, 20×.

performed; immunohistochemical analysis was positive for
CD4, CD30 (Figure 2b), and CD45 but negative for CD2,
CD3, CD5, CD20, TIA, CD7, PAX5, and pancytokeratin with
an MIB-1 of 80% (Figure 2c). The patient was sent to a medical oncologist for discussion of treatment options. A positron
emission tomography-computed tomography (PET/CT) scan
was ordered and was negative for metastatic disease. A follow-up
PET/CT scan for surveillance is scheduled.
DISCUSSION
In 2016, about 290,000 women in the United States had
breast augmentation using implants; 109,000 of these women
received them for reconstruction after breast cancer (3). The
Food and Drug Administration (FDA) released a statement
in early 2017 concerning a rare cancer, ALCL, that has been
linked to breast implants and is associated with nine deaths. The
FDA has received 359 reports of BIA-ALCL and only recently
released its statement because of advancements in the description of the disease and treatment recommendations as a result
of numerous case reports in the literature.
A systematic review and structured expert panel was organized by Kim et al to advise clinicians when BIA-ALCL may
be suspected. The panel agreed that there was an association
between implants and ALK-negative ALCL and that a delayed
or recurrent seroma beyond 6 months should be investigated
with aspiration and cytologic analysis or ﬂow cytometry to rule
out infection and lymphoma (4).
In general, BIA-ALCL typically manifests as a seroma or ﬂuid
collection but may present with a discrete mass originating from
the ﬁbrous capsule around the implant as opposed to the breast
parenchyma. Microscopically, the tumor cells are present in the
seroma ﬂuid or on the inner surface of the ﬁbrous capsule and
may form sheets along the capsule in mass-forming disease (5).
Seroma-forming disease usually follows an indolent clinical course

442

and has an excellent prognosis in comparison to mass-forming
disease or systemic ALK-negative ALCL, which may have more
aggressive courses and worse prognoses (5).
To date, there is no consensus on the implant substance
contributing to disease, but more cases have been reported with
textured versus smooth implants. This may indicate that the
inﬂammatory response is causative in disease formation, but
that hypothesis has not been proven.
The diﬀerential diagnosis for BIA-ALCL is broad and includes dissemination from systemic ALCL, classical Hodgkin
lymphoma, other primary breast lymphoma, misinterpretation
of triple-negative breast carcinoma, seroma formation from trauma, and double capsule formation (2, 4, 5). Treatment options
to date consist of surgical therapy including implant removal
and capsulectomy versus surgical and systemic therapy with or
without radiation, typically indicated if the patient has classic
B symptoms (2, 4, 6). The FDA recommends reporting all conﬁrmed cases to improve the understanding of this rare disease.
1.
2.

Keech JA Jr, Creech BJ. Anaplastic T-cell lymphoma in proximity to a
saline-ﬁlled breast implant. Plast Reconstr Surg 1997;100(2):554-555.
Hwang MJ, Brown H, Murrin R, Momtahan N, Sterne GD. Breast implant-associated anaplastic large cell lymphoma: a case report and literature
review. Aesthetic Plast Surg 2015;39(3):391-395.
Grady D. 9 deaths are linked to rare cancer from breast implants.
New York Times, March 24, 2017. Available at https://www.nytimes.com/2017/03/21/health/breast-implants-cancer-deaths.
html?mcubz=0&_r=1; accessed June 2, 2017.
Kim B, Roth C, Young VL, Chung KC, van Busum K, Schnyer C, Mattke S.
Anaplastic large cell lymphoma and breast implants: results from a structured
expert consultation process. Plast Reconstr Surg 2011;128(3):629-639.
Xu J, Wei S. Breast implant-associated anaplastic large cell lymphoma: review of a distinct clinicopathologic entity. Arch Pathol Lab Med
2014;138(6):842-846.
Tardío JC, Granados R. Axillary lymphadenopathy: an outstanding presentation for breast implant-associated ALK-negative anaplastic large cell
lymphoma. Int J Surg Pathol 2015;23(5):424-428.

Baylor University Medical Center Proceedings

Volume 30, Number 4

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017