Breast implant-associated anaplastic large cell lymphoma: a pictorial review

Abstract

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a newly described and rare T-cell lymphoma of the breast. Since 2007, there have been 56 cases of confirmed BIA-ALCL in Australia and New Zealand. The incidence is believed to be on the rise as the prevalence of elective breast implantation increases. In 2016, the World Health Organization (WHO) classified BIA-ALCL as a recognised entity and emphasised the importance of surgical management of the disease. BIA-ALCL typically presents as a delayed, non-infective fluid collection around a textured breast implant or residual fibrous scar capsule. The mean age of presentation is 47 years, with an average time frame of 7.5 years following breast implantation. Although rare, BIA-ALCL is increasing in incidence. To avoid delays in diagnosis, radiologists should consider this form of lymphoma in the differential of any non-acute peri- or post-prosthetic effusion, and suggest cytological evaluation, so as not to miss this rare but important diagnosis. TEACHING POINTS: • BIA-ALCL is a newly described and rare T-cell lymphoma of the breast. • Since 2007, there have been 56 cases of confirmed BIA-ALCL in Australia and New Zealand. • BIA-ALCL presents as a delayed, non-infective fluid collection. • The effusion typically accumulates around a textured breast implant or residual fibrous capsule.

Keywords: Breast imaging; Lymph; Nuclear imaging; Oncologic imaging; Ultrasound.

Fig. 1

a The mammogram revealed that the implant was displaced anteriorly and inferiorly by a large, lobular, ill defined, soft tissue density mass (white arrow). The implant appears intact but compressed. b Ultrasound revealed a peri-implant effusion (white arrow), with the implant displaced and compressed by a large lobular solid heterogeneous mass (red arrow). Masses, as in this case, are unusual in breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The diagnosis was confirmed by core biopsy of the mass. c Positron emission tomography/computed tomography (PET/CT) revealed a large mixed-density mass with intense FDG activity, deep within and invading the right breast and pectoralis muscles. There was metastatic disease spread to the lung and bone

Fig. 2

a Ultrasound revealed a large effusion with no signs of infection (white arrow). Fortunately, the aspirated fluid was sent for cytology, which confirmed BIA-ALCL. b PET/CT revealed a flattened rim of soft tissue, located inferomedially in the left breast, with ill-defined margins and moderate FDG uptake (white arrow). The patient subsequently received six cycles of chemotherapy and targeted radiotherapy. Restaging PET/CT revealed complete metabolic response (red arrow)

Fig. 3

a Ultrasound revealed a large septated seroma (white arrow), which was aspirated the following day. Cytology confirmed BIA-ALCL. Ultrasound has a sensitivity of 84% and specificity of 75% for detecting an effusion. These figures are similar or better than CT or magnetic resonance imaging (MRI) in effusion detection [7]. b MRI provides characterisation of the implant’s capsule, defining enhancement and thickening [14, 15]. This makes it the modality of choice for defining the implant capsule (white arrow) [7]. BIA-ALCL typically presents as a delayed, non-infective fluid collection surrounding the implant (red arrow) or its surrounding scar capsule, with or without evidence of capsular rupture [13]. c Staging CT revealed a small to moderate effusion adjacent to both breast implants (white arrows)