What is a Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has recently been classified as a distinct disease by the World Health Organization (WHO), and various countries have published guidelines for its management. This rare cancer, characterized by malignant T cells, has been associated with textured breast implants; the FDA has confirmed 359 cases and 9 reported deaths. In the United States, the lifetime prevalence (probability to have it) of BIA-ALCL is 33 cases per million among individuals with textured implants, while Lebanon does not yet have a registry for the condition

Four main hypotheses about BIA-ALCL development include:

1. Genetic predisposition: Specific gene mutations might increase risk. This may also explain the large variability in incidence that has been seen in different parts of the world, such as the high frequency in Australia.

2. Chronic inflammation triggered by mechanical stress: Textured implants may cause long-term inflammation due to their surface. Current data suggest that more coarsely textured surfaces pose a higher risk.

3. Bacterial biofilm: Textured surfaces might promote bacterial growth leading to long-standing inflammation.

4. Duration: BIA-ALCL often develops 8 years after surgery; textured implants might be a factor in T-cell transformation. There is no correlation between BIA-ALCL and implant content.

BIA-ALCL commonly presents as breast swelling due to a late seroma formation (fluid buildup), often years after implant surgery. It can also cause skin reddening, capsular contracture, or a palpable mass.

Late seromas should be investigated with high-resolution ultrasound and seroma fluid analysis to rule out BIA-ALCL.

A sample of at least 20 mL of fluid should be sent for flow cytometry and immunohistochemistry testing, including tests for CD30 and ALK markers; BIA-ALCL is CD30 positive and ALK-negative. Preoperative PET/CT scans are often recommended to assess for possible disseminated disease.

Surgical treatment typically suffices for localized BIA-ALCL, with postoperative follow-up for at least 2 years, it involves removing the implant and capsule, with follow-up care.

For advanced cases, additional chemotherapy or targeted treatments may be necessary.