Breast implant-associated anaplastic large cell lymphoma: a case report with a history of spontaneously resolved late seroma

We report a case of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which had a history of spontaneous resorption of late seroma before diagnosis. A 47-year-old woman with a history of augmentation mammoplasty with round textured implants in January 2013 presented with a swelling on her right breast 6 years later, which was diagnosed as late seroma with suspected intracapsular rupture using ultrasonography (USG). Although aspiration was not done at the time of the initial USG, the seroma resolved spontaneously within weeks. A further workup proceeded with USG-guided aspiration followed by magnetic resonance imaging. Cytology of the aspirated fluid showed atypical cells. Cell block cytology and immunohistochemical staining confirmed the diagnosis of BIA-ALCL. En bloc resection with total capsulectomy and explantation was performed as curative surgery. Pathologic stage pT2N0M0 was confirmed and the patient was followed up without further treatment. Although the classic presentation of BIA-ALCL is known as late persistent seroma, an atypical manifestation such as spontaneous resorption may occur, as in the current case. A high level of suspicion and a thorough investigation with appropriate modalities will make it possible to detect this rare and potentially devastating disease.

Recurrent late seroma after immediate breast reconstruction with latissimus dorsi musculocutaneous flap

The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for breast reconstruction. However, it has the disadvantage of frequent seroma formation at the donor site, and late seroma has also been reported. The authors report histological findings after the surgical treatment of a late, repeatedly recurrent seroma at 10 years after breast reconstruction with LDMCF. In 2008, a 66-year-old female patient underwent immediate breast reconstruction with LDMCF. In 2015, a late seroma was found at the donor site. After aspiration and drainage, the seroma recurred again in 2018. Total surgical excision of the seroma was performed and bloody-appearing fluid was identified in the capsule. The excised tissue was biopsied. Histological examination revealed no evidence of blood in the fluid, and multinucleated giant cells with amorphous eosinophilic proteinaceous material were identified. The cyst was suggestive of chronic granulomatous inflammation. There was no recurrence at 8 months postoperatively. The patient described herein underwent surgical treatment of late seroma that recurred after immediate breast reconstruction with LDMCF, and histological findings were identified. These results may be helpful for other future studies regarding late seroma after breast reconstruction with LDMCF.

Incidence of Delayed Seromas and Related Risk of Bia-ALCL in a Cohort of 3521 Breast Cancer Women with Textured Implants Prospectively Followed Long Term

Introduction:Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is an indolent subtype of ALCL, arising in the space between the implant and the capsule. BIA-ALCL seems to be directly related to the exposure to breast implants, and usually happens more than 7 years from implant placement. In 2011 the Food and Drug administration released the first safety communication on the risk of BIA-ALCL for women with breast implants, raising awareness of the disease. In 60-70% of the cases BIA-ALCL presents as a delayed seroma, a non-resolving fluid collection around breast implants arising after at least 1 year from implant placement. In previous studies, the risk of developing a late seroma ranged between 0.05% to 0.1% for people with textured surface breast implants. Among those with delayed seromas, the risk of BIA-ALCL has been estimated from retrospective cohorts to be 10%. (McGuire 2017, Clemens 2017, Maxwell 2015, Di Napoli 2017). Methods:A prospective cohort study was conducted in the population that underwent breast reconstruction with textured breast implants after mastectomy for breast cancer by a single surgeon at Memorial Sloan Kettering Cancer Center (MSKCC). Patients were enrolled from December 1992 to December 2017 at the time of tissue expander insertion, underwent long-term follow up and major events related to implants were prospectively recorded. We actively started looking for BIA-ALCL in late seromas in early 2011. All cases of BIA-ALCL were analyzed by our hematopathology service at MSKCC. We identified all late seromas sent to hematopathology to exclude BIA-ALCL by cross checking all the pathology reports containing the words "lymphoma" or "anaplastic" or "ALCL" in this population. We calculated the cumulative incidence of clinically relevant late seromas, considering death as a competing risk with the statistical program R version 3.5.1. Results:Between 1992 and 2017, 3521 women underwent breast reconstruction with textured surface expanders followed by permanent textured breast implants. Median age at surgery was 48 years (range 18-88), 1056 (30.0%) underwent unilateral reconstruction and 2464 (70.0%) bilateral reconstruction. Reason for mastectomy was lobular carcinoma in 675 (19.1%), 116 in situ, ductal carcinoma in 2529 (71.8%), 591 in situ, other histology in 59 (1.7%), unknown in 257 (7.3%). Besides surgery, additional treatments for breast cancer were: chemotherapy in 1015 (28.8%), radiotherapy in 285 (8.1%), chemo and radiotherapy in 706 (20.0%), none in 1514 (43.0%). Median follow up of the cohort was 8.2 years (range 3.4 months - 26.4 years). After a median exposure of 9 years (range 1.8 - 15.8 years), 28 women developed a clinically relevant delayed seroma, and 8 were diagnosed with BIA-ALCL (28.5% of the late seromas). The first late seroma was analyzed with flow cytometry in February 2011. All seromas sent to pathology were clinically relevant (main symptom was swelling of the breast - in 15 patients, tenderness/fullness of the breast - in 5 patients, asymmetry - in 3 patients, capsule contracture - in 5 patients). Three patients had previous drainage of peri-implant fluid that was not analyzed in pathology. 2 additional cases of BIA-ALCL were diagnosed in this population, one on an internal mammary chain lymph node biopsy, without fluid collection, and another with a capsular mass and lymph node involvement. Rate of late seroma accounting for the varying follow-up and death as a competing event was 1.6% at 15 years. Rough percentage getting a seroma was 0.79%, 1/126 women exposed. All the 28 samples were analyzed with cytology, and 22/28 with flow cytometry including CD30. 14/28 (50%) of these women removed the implants for several reasons, 3/28 (10.7%) immediately exchanged the implants with another textured surface device. Conclusions:in this population of breast cancer patients receiving textured breast implant reconstructions, the incidence of clinically relevant seromas and BIA-ALCL seems higher than previously reported. Similarly, the ratio of patients testing positive for BIA-ALCL on the total number of seromas analyzed higher than previously estimated. We believe these results will be informative for people with breast reconstructions after breast cancer and their surgeons, to better estimate the risk of seroma and BIA-ALCL with textured implants. Disclosures Cordeiro: Inamed: Research Funding; Acelity: Research Funding; Allergan: Research Funding. Dogan:Takeda: Consultancy; Novartis: Consultancy; Celgene: Consultancy; Seattle Genetics: Consultancy; Corvus Pharmaceuticals: Consultancy; Roche: Consultancy, Research Funding. Horwitz:Seattle Genetics: Consultancy, Research Funding; Millennium/Takeda: Consultancy, Research Funding; Trillium: Research Funding; Kyowa Hakko Kirin: Consultancy; Millennium/Takeda: Consultancy, Research Funding; Kyowa Hakko Kirin: Consultancy; Astex: Consultancy; Portola: Consultancy; Affimed: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Kyowa Hakko Kirin: Consultancy; Kura: Consultancy; Celgene: Consultancy, Research Funding; Affimed: Consultancy; Trillium: Research Funding; Forty-Seven: Research Funding; Miragen: Consultancy; Mundipharma: Consultancy; Aileron: Research Funding; Affimed: Consultancy; ADCT Therapeutics: Research Funding; Trillium: Research Funding; ADCT Therapeutics: Research Funding; Innate Pharma: Consultancy; Affimed: Consultancy; Forty-Seven: Research Funding; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Portola: Consultancy; Portola: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding; Kyowa Hakko Kirin: Consultancy; Mundipharma: Consultancy; Mundipharma: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Innate Pharma: Consultancy; Aileron: Research Funding; Innate Pharma: Consultancy; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Seattle Genetics: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Miragen: Consultancy; Miragen: Consultancy; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Mundipharma: Consultancy; Kura: Consultancy; Kura: Consultancy; Aileron: Research Funding; ADCT Therapeutics: Research Funding; Innate Pharma: Consultancy; Astex: Consultancy; ADCT Therapeutics: Research Funding; Astex: Consultancy; Millennium/Takeda: Consultancy, Research Funding; Miragen: Consultancy; Astex: Consultancy; Millennium/Takeda: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding; Forty-Seven: Research Funding; Infinity/Verastem: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Aileron: Research Funding; Kura: Consultancy; Trillium: Research Funding; Portola: Consultancy; Forty-Seven: Research Funding.