Abstract P5-03-02: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL)– The UK experience and first reported case of neoadjuvant brentuximab
Authors: Johnson L , O'Donoghue J , Stark H , Collis N , Lennard A , Butterworth M , McLean N , Youssef M , Gui G , Lyburn I , Bristol J , Hurren J , Smith S , Jacklin R , Cunningham D , MacNeill F 
Published: March 2017

Introduction The incidence of BIA-ALCL is on the rise. It is a recognised rare risk of breast implants. It commonly presents with a sudden, dramatic seroma around an implant, or occasionally a breast mass. Diagnosis is based on cellular morphology and staining positive for CD30 and negative for anaplastic lymphoma kinase (ALK).

The aetiology and management of BIA-ALCL remains unclear. Clemens et al. suggest the conventional Ann-Arbor staging system and aggressive local and systemic treatments may not be appropriate. In the majority of cases, BIA-ALCL is confined to the seroma or the inner aspect of the capsule, so total capsulectomy alone may be sufficient. Systemic therapy may only be required in the minority where disease extends beyond the capsule. We present the UK BIA-ALCL data using the new specific staging system.

Results We report 11 cases of BIA-ALCL from seven regional centres. Treatment was multidisciplinary between breast/plastic surgery and haemato-oncology and based on best available evidence and expert opinion. Mean lead-time from implant to diagnosis was 10 years.

Using the new classification, eight Stage I cases that presented with recurrent seroma were treated successfully with implant removal and total capsulectomy. Four patients had bilateral breast augmentation (BBA); two had bilateral risk-reducing mastectomies (RRM) with implant reconstruction; two had a unilateral mastectomy and implant reconstruction for breast cancer, one of which had previously received adjuvant chemo- radio- and endocrine therapy.

All but one patient with bilateral implants had surgery to remove both implants and ipsilateral total capsulectomy. Of these, three also had contralateral capsulectomy and the pathology was benign. One patient had unilateral capsulectomy and bilateral exchange of implants.

Three patients presented with Stage IIA disease. One had previous RRM and implant reconstruction and presented with a mass. Treatment was CHOP+ (Echelon2 trial), radiotherapy and implant removal, she remains well at two years. One patient with previous BBA following a routine implant exchange developed a BIA-ALCL mass at the drain site. She was treated with local excision, adjuvant CHOP and radiotherapy. She is well at four years.

The third patient had BBA and presented with a mass adjacent to the implant and progressed rapidly through neoadjuvant CHOP to develop life threatening chest wall/thoracic cavity involvement. She achieved complete pathological response with six cycles of Brentuximab followed by bilateral total capsulectomy and implant removal. This is the first reported case of neo-adjuvant antibody therapy in BIA-ALCL.

Discussion Our data support the published literature demonstrating the majority of BIA-ALCL is stage I/II and can be safely managed with surgery alone. Chemotherapy was targeted at patients with more advanced local disease. Brentuximab, a monoclonal antibody is not licenced for BIA-ALCL but is used in refractory in ALCL. BIA-ALCL related death, although rare, is due to uncontrolled local disease progression.

Conclusion BIA-ALCL cases must be staged according to the new system to avoid overtreatment. Brentuximab should be considered first line therapy for locally advanced BIA-ALCL.

Citation Format: Johnson L, O'Donoghue J, Stark H, Collis N, Lennard A, Butterworth M, McLean N, Youssef M, Gui G, Lyburn I, Bristol J, Hurren J, Smith S, Jacklin R, Cunningham D, MacNeill F. Breast implant associated anaplastic large cell lymphoma (BIA-ALCL)– The UK experience and first reported case of neoadjuvant brentuximab [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-02.