576406
research-article2015
IJSXXX10.1177/1066896915576406International Journal of Surgical PathologyHoda et al
Images in Pathology
Breast Implant–Associated Anaplastic Large Cell Lymphoma
International Journal of Surgical Pathology 2015, Vol. 23(3) 209–210 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915576406 ijs.sagepub.com
Syed Hoda, MD1, Rema Rao, MD1, and Rana S. Hoda, MD1
Figure 1. Breast implant–associated anaplastic large cell lymphoma.
A 71-year-old woman presented with a rapidly progressive and painful swelling of the left “breast.” A contralateral mastectomy had been performed 41 years previously for invasive carcinoma. Since then, there had been no evidence of recurrence or of metastases. An ipsilateral subcutaneous prophylactic mastectomy with latissimus reconstruction and placement of mammary implant had been performed 33 years ago. The left breast implant had undergone leakage over 2 decades; and the ensuing disfiguring capsular contracture had been supplanted 9 years back by a saline-filled implant.
The latter had been in place, uneventfully, until onset of the aforementioned symptoms. Mammography showed an ellipsoid cavity with smooth lining, without mural nodularity (ie, “seroma” formation) in a postmastectomy setting (Figure 1A). The implant and its 1
Weill Cornell, New York, NY, USA
Corresponding Author: Syed Hoda, Weill Cornell, 525 E 68th St, Starr 1031c, New York, NY 10065, USA. Email: [email protected]
210 capsule with the adjoining seroma cavity were excised. Grossly, the seroma lining was membranous without nodularity. Randomly taken histological sections mainly showed clusters of histiocytes amid fibrinous material (Figure 1B). Rare clusters of large pleomorphic cells with irregular (mainly reniform) nuclei and prominent nucleoli, admixed with fibrin and cellular debris, were also evident. These neoplastic cells were mostly well-preserved (Figure 1C), but were also either focally degenerated (Figure 1D) or crushed (Figure 1E). Immunohistochemically, the tumor cells were positive for CD30, CD43, CD45, and EMA and negative for various cytokeratins, CD2, CD3, CD4, and ALK1. CD30 showed positivity mainly in the membrane and golgi regions of the cells (Figure 1F). The histological and immunohistochemical findings were diagnostic of breast implant–associated anaplastic large cell lymphoma (BI-ALCL) In 2011, the US Food and Drug Administration recognized the possibility of an association between BI and ALCL.1 The disease was characterized as a rare form of non-Hodgkin, T-cell, CD30+ lymphoma that formed in or around a seroma cavity adjacent to a BI. BI-ALCL was initially thought to behave in an indolent manner2,3; however, in early 2014, Miranda et al reported on 2 distinctly different patient populations with the disease.4 Seventy-five percent of patients in the group that presented with a solid mass-forming lymphoma survived 5 years. Hundred percent of patients in the other group that presented with effusion-only without mass formation survived the same time period. In the second group of cases, BI-ALCL was generally confined to the surface of the periimplant capsule in the form of an attenuated discontinuous
International Journal of Surgical Pathology 23(3) layer (similar to the case being illustrated here). Miranda et al recommended that both groups of patients be managed by excision of BI and its capsule, and that patients with solid masses receive chemotherapy. Notably, mass-forming BI-ALCL was associated with either saline-filled or silicone gel–filled BI placed in either cosmetic or oncological reconstructive settings. Estimates of the risk of developing BI-ALCL have varied from 1:100 000 to 1:3 000 000 in women with implants.3,5 This wide variation in risk estimation is most reflective of uncertainties relating to the awareness, detection, and diagnosis of this relatively new entity. References 1. US Food and Drug Administration. Anaplastic large cell lymphoma (ALCL). http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm239995.htm. Accessed January 8, 2015. 2. Aladily TN, Medeiros LJ, Amin MB, et al. Anaplastic large cell lymphoma associated with breast implants: a report of 13 cases. Am J Surg Pathol. 2012;36:1000-1008. 3. Thompson PA, Prince HM. Breast implant-associated anaplastic large cell lymphoma: a systematic review of the literature and mini-meta analysis. Curr Hematol Malig Rep. 2013;8:196-210. 4. Miranda RN, Aladily TN, Prince HM, et al. Breast implantassociated anaplastic large-cell lymphoma: long-term follow-up of 60 patients. J Clin Oncol. 2014;32:114-120. 5. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma (ALCL) occurring in women with breast implants: analysis of 173 cases (published online December 8, 2014). Plast Reconstr Surg. doi:10.1097/PRS.0000000000001033.
Copyright of International Journal of Surgical Pathology is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
research-article2015
IJSXXX10.1177/1066896915576406International Journal of Surgical PathologyHoda et al
Images in Pathology
Breast Implant–Associated Anaplastic Large Cell Lymphoma
International Journal of Surgical Pathology 2015, Vol. 23(3) 209–210 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896915576406 ijs.sagepub.com
Syed Hoda, MD1, Rema Rao, MD1, and Rana S. Hoda, MD1
Figure 1. Breast implant–associated anaplastic large cell lymphoma.
A 71-year-old woman presented with a rapidly progressive and painful swelling of the left “breast.” A contralateral mastectomy had been performed 41 years previously for invasive carcinoma. Since then, there had been no evidence of recurrence or of metastases. An ipsilateral subcutaneous prophylactic mastectomy with latissimus reconstruction and placement of mammary implant had been performed 33 years ago. The left breast implant had undergone leakage over 2 decades; and the ensuing disfiguring capsular contracture had been supplanted 9 years back by a saline-filled implant.
The latter had been in place, uneventfully, until onset of the aforementioned symptoms. Mammography showed an ellipsoid cavity with smooth lining, without mural nodularity (ie, “seroma” formation) in a postmastectomy setting (Figure 1A). The implant and its 1
Weill Cornell, New York, NY, USA
Corresponding Author: Syed Hoda, Weill Cornell, 525 E 68th St, Starr 1031c, New York, NY 10065, USA. Email: [email protected]
210 capsule with the adjoining seroma cavity were excised. Grossly, the seroma lining was membranous without nodularity. Randomly taken histological sections mainly showed clusters of histiocytes amid fibrinous material (Figure 1B). Rare clusters of large pleomorphic cells with irregular (mainly reniform) nuclei and prominent nucleoli, admixed with fibrin and cellular debris, were also evident. These neoplastic cells were mostly well-preserved (Figure 1C), but were also either focally degenerated (Figure 1D) or crushed (Figure 1E). Immunohistochemically, the tumor cells were positive for CD30, CD43, CD45, and EMA and negative for various cytokeratins, CD2, CD3, CD4, and ALK1. CD30 showed positivity mainly in the membrane and golgi regions of the cells (Figure 1F). The histological and immunohistochemical findings were diagnostic of breast implant–associated anaplastic large cell lymphoma (BI-ALCL) In 2011, the US Food and Drug Administration recognized the possibility of an association between BI and ALCL.1 The disease was characterized as a rare form of non-Hodgkin, T-cell, CD30+ lymphoma that formed in or around a seroma cavity adjacent to a BI. BI-ALCL was initially thought to behave in an indolent manner2,3; however, in early 2014, Miranda et al reported on 2 distinctly different patient populations with the disease.4 Seventy-five percent of patients in the group that presented with a solid mass-forming lymphoma survived 5 years. Hundred percent of patients in the other group that presented with effusion-only without mass formation survived the same time period. In the second group of cases, BI-ALCL was generally confined to the surface of the periimplant capsule in the form of an attenuated discontinuous
International Journal of Surgical Pathology 23(3) layer (similar to the case being illustrated here). Miranda et al recommended that both groups of patients be managed by excision of BI and its capsule, and that patients with solid masses receive chemotherapy. Notably, mass-forming BI-ALCL was associated with either saline-filled or silicone gel–filled BI placed in either cosmetic or oncological reconstructive settings. Estimates of the risk of developing BI-ALCL have varied from 1:100 000 to 1:3 000 000 in women with implants.3,5 This wide variation in risk estimation is most reflective of uncertainties relating to the awareness, detection, and diagnosis of this relatively new entity. References 1. US Food and Drug Administration. Anaplastic large cell lymphoma (ALCL). http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm239995.htm. Accessed January 8, 2015. 2. Aladily TN, Medeiros LJ, Amin MB, et al. Anaplastic large cell lymphoma associated with breast implants: a report of 13 cases. Am J Surg Pathol. 2012;36:1000-1008. 3. Thompson PA, Prince HM. Breast implant-associated anaplastic large cell lymphoma: a systematic review of the literature and mini-meta analysis. Curr Hematol Malig Rep. 2013;8:196-210. 4. Miranda RN, Aladily TN, Prince HM, et al. Breast implantassociated anaplastic large-cell lymphoma: long-term follow-up of 60 patients. J Clin Oncol. 2014;32:114-120. 5. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma (ALCL) occurring in women with breast implants: analysis of 173 cases (published online December 8, 2014). Plast Reconstr Surg. doi:10.1097/PRS.0000000000001033.
Copyright of International Journal of Surgical Pathology is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
