Complete Surgical Excision Is Essential for the Management of Patients With Breast Implant-Associated Anaplastic Large-Cell Lymphoma

Abstract

Purpose: Breast implant-associated anaplastic large-cell lymphoma (BI-ALCL) is a rare type of T-cell lymphoma that arises around breast implants. The optimal management of this disease has not been established. The goal of this study is to evaluate the efficacy of different therapies used in patients with BI-ALCL to determine an optimal treatment approach.

Patients and methods: In this study, we applied strict criteria to pathologic findings, assessed therapies used, and conducted a clinical follow-up of 87 patients with BI-ALCL, including 50 previously reported in the literature and 37 unreported. A Prentice, Williams, and Peterson model was used to assess the rate of events for each therapeutic intervention.

Results: The median and mean follow-up times were 45 and 30 months, respectively (range, 3 to 217 months). The median overall survival (OS) time after diagnosis of BI-ALCL was 13 years, and the OS rate was 93% and 89% at 3 and 5 years, respectively. Patients with lymphoma confined by the fibrous capsule surrounding the implant had better event-free survival (EFS) and OS than did patients with lymphoma that had spread beyond the capsule (P = .03). Patients who underwent a complete surgical excision that consisted of total capsulectomy with breast implant removal had better OS (P = .022) and EFS (P = .014) than did patients who received partial capsulectomy, systemic chemotherapy, or radiation therapy.

Conclusion: Surgical management with complete surgical excision is essential to achieve optimal EFS in patients with BI-ALCL.

Fig 1.

Pathologic T staging. (A and B) T1: lymphoma cells confined to the effusion or a layer on the luminal side of the capsule; (C and D) T2: lymphoma cells superficially infiltrate the luminal side of the capsule. Arrows indicate the areas of invasion; (E and F) T3: clusters or sheets of lymphoma cells infiltrate into the thickness of the capsule; and (G and H) T4: lymphoma cells infiltrating beyond the capsule, into the adjacent soft tissue or breast parenchyma. Left column, hematoxylin and eosin stain; right column, CD30 immunohistochemistry; magnification, ×100.

Fig 2.

This TNM system was modeled after the American Joint Committee on Cancer TNM staging system for solid tumors.

Fig 3.

Survival curves according to treatment approaches: event-free survival (A), overall survival (B). Survival curves according to Ann Arbor stage: event-free survival (C), overall survival (D). Survival curves according to proposed TNM staging: event-free survival (E), overall survival (F).

Fig 4.

Patient example and surgical treatment. This woman presented 7 years after bilateral cosmetic breast augmentation with swelling of the left breast and palpable lymphadenopathy (A). She underwent an incisional biopsy of the capsule, drainage of the effusion, and subsequent complete surgical excision that included implant removal and total capsulectomy with lymph node excisional biopsy by ultrasound guidance (B and C). Effusion demonstrated large cells (D: Wright Giemsa, ×1000; E: Anti CD30 immunocytochemistry, ×1000) capsule and excised lymph nodes were negative for lymphoma. The diagnosis rendered was breast implant–associated anaplastic large-cell lymphoma, Ann Arbor stage IE, MD Anderson Cancer Center stage 1A. Scanning electron microscopy demonstrates the textured surface of the involved breast implant with attached cells. (F; magnification, ×1,000) The patient did not receive radiation or chemotherapy and underwent surveillance by positron emission tomography–computed tomography scan every 3 months the first year and every 6 months after the first year. Patient is disease free after 2 years of follow-up.