Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Long-Term Follow-Up of 60 Patients

H. Miles Prince, Chan Cheah, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Australia
Journal of Clinical Oncology (Impact Factor: 18.43). 12/2013; 32(2). DOI: 10.1200/JCO.2013.52.7911
Source: PubMed

ABSTRACT Breast implant-associated anaplastic large-cell lymphoma (ALCL) is a recently described clinicopathologic entity that usually presents as an effusion-associated fibrous capsule surrounding an implant. Less frequently, it presents as a mass. The natural history of this disease and long-term outcomes are unknown.
We reviewed the literature for all published cases of breast implant-associated ALCL from 1997 to December 2012 and contacted corresponding authors to update clinical follow-up.
The median overall survival (OS) for 60 patients was 12 years (median follow-up, 2 years; range, 0-14 years). Therapeutic data were available for 55 patients: 39 patients (78%) received systemic chemotherapy, and of the 16 patients (28%) who did not receive chemotherapy, 12 patients opted for watchful waiting and four patients received radiation therapy alone. Thirty-nine (93%) of 42 patients with disease confined by the fibrous capsule achieved complete remission, compared with complete remission in 13 (72%) of 18 patients with a tumor mass. Patients with a breast mass had worse OS and progression-free survival (PFS; P = .052 and P = .03, respectively). The OS or PFS were similar between patients who received and did not receive chemotherapy (P = .44 and P = .28, respectively).
Most patients with breast implant-associated ALCL who had disease confined within the fibrous capsule achieved complete remission. Proper management for these patients may be limited to capsulectomy and implant removal. Patients who present with a mass have a more aggressive clinical course that may be fatal, justifying cytotoxic chemotherapy in addition to removal of implants.

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Available from: Dennis P O'Malley, Aug 16, 2014
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    • "Bone marrow involvement is uncommon, as is involvement of the central nervous system and gastrointestinal tract. In adults, breast involvement has been described, with most cases being ALK À ALCL and frequently in association with breast implants (Lechner et al, 2012; Adrada et al, 2014; Miranda et al, 2014; Reisman, 2014). Although infrequent, patients with peripheral blood involvement have a poor prognosis irrespective of ALK status (Lu et al, 2010). "
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    ABSTRACT: The currently used 2008 World Health Organization classification recognizes two types of systemic anaplastic large T cell lymphoma according to ALK protein expression in tumour cells. First, the ‘anaplastic large cell lymphoma, ALK positive’ (ALK+ ALCL) that is characterized by the presence of ALK gene rearrangements and consequent ALK protein expression, and, second, the ‘anaplastic large cell lymphoma, ALK negative’ (ALK− ALCL) that is a provisional entity lacking ALK protein expression but cannot be distinguished morphologically from ALK+ ALCL. In this review we summarize the current knowledge on the genetic lesions and biological features that underlie the pathogenesis of ALK+ and the ALK− ALCL and that can lead to the use of targeted anti-cancer agents.
    British Journal of Haematology 12/2014; 168(6). DOI:10.1111/bjh.13265 · 4.96 Impact Factor
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    • "There are two distinct clinical presentations with disparate clinical behavior: (1) the more common and indolent seroma-type in which fluid containing malignant lymphocytes accumulates between the implant and the surrounding fibrous capsule, (2) the less frequent but more aggressive mass lesion which is usually accompanied by seroma [77]. Miranda et al. recently reported the largest experience of BIA-ALCL, comprising 60 women (42 seroma-type , 18 mass-type), with median age 52 years [54]. The median time from implant insertion to diagnosis of BIA-ALCL was 9 (range 1–32) years and 93% had localized disease (83% stage I, 10% stage II). "
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    ABSTRACT: Primary breast lymphoma is a rare form of extranodal lymphoma, defined by the presence of a primary lesion within the breast with or without regional nodal involvement but no other extra-mammary sites of involvement. It comprises diverse histologic subtypes, but diffuse large B-cell lymphoma is the most common. In this review, we describe in detail the clinical features, diagnosis and staging, pathogenesis, risk factors and therapy of primary breast diffuse large B-cell lymphoma. We consider choice and number of cycles of chemotherapy, the indications for radiotherapy and discuss the need for central nervous system prophylaxis. We also provide a brief overview of the less commonly encountered histologic subtypes including marginal zone, follicular, Burkitt and breast implant associated anaplastic large cell lymphoma. We conclude with a suggested treatment approach and potential areas of future research.
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    ABSTRACT: Since 1997, reports from the scientific community have suggested a possible association, without causation, between breast implants and anaplastic large cell lymphoma (ALCL). Analysis of these patients has been challenging. Many studies have been under-reported while others have been duplicated. In 2011, a United States Food & Drug Administration (FDA) 'white paper' analyzed 34 of the 60 cases reported worldwide. All 34 patients had undergone secondary surgery for breast swelling, firmness or pain. ALCL was an incidental finding. Diagnosis of ALCL is made by hematoxylin and eosin histology and immunochemistry for the CD30 marker. ALCL occurred with all types of implants. Subsequent studies have suggested that textured implants may have a greater risk. In all cases, ALCL cells were found in the capsule, in the seroma or within a mass adjacent to the implant. There was no invasion of cells beyond the capsule into the breast parenchyma. From the FDA study, the risk of developing ALCL after receiving implants appears to be approximately one in one million per year. All cases appear to be negative for the anaplastic lymphoma kinase marker. ALCL in most of these patients may represent a new entity with less aggressive behaviour. In most patients with capsule-confined disease, proper management may prove to be implant removal and capsulectomy. Patients with a distinct mass adjacent to their implant may have a more aggressive clinical course that may become systemic. They may require chemotherapy in addition to implant removal and capsulectomy. All cases of ALCL should be referred to an appropriate specialist and reported to the FDA.
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