Breast Implant Associated Anaplastic Large Cell Lymphoma Is More Frequent and Lethal Than Previously Reported
Authors: Carty Matthew , Toomey Christiana E. , Farkash Evan , May James W. , Michaelson James S. , Barnes Jeffrey A. , Abramson Jeremy S. , Hochberg Ephraim P. 
Published: October 2019

Abstract
Abstract 4760

Background:
Anaplastic large cell lymphoma (ALCL) is a rare disease, comprising 2–3% of all non-Hodgkin lymphomas. Case reports of seroma associated ALCL of the breast in association with silicone breast implants have appeared in the literature since 1997, but no data on the incidence of this complication has been reported. We use three case reports, including two previously published, in conjunction with data derived from three separate entities of Partners HealthCare (Brigham and Women's Hospital; Massachusetts General Hospital; Faulkner Hospital) to establish an incidence estimate for this rare entity.

Methods:
Individual cases were identified by pathologists, surgeons and medical oncologists. We compared a list of patients from the institutions’ Cancer Registries, with the results of a query we ran on an institution-internal query tool. For MGH patients only, we were also able to compare cancers revealed through a natural language processing search result of institutional pathology reports.
Two of the cases were in the overlap of Cancer Registry data, and query results. One case was not contained within these results as it was omitted from the Cancer Registry.

Case Presentations:
Case 1 was surgically treated for breast cancer and reconstruction at New England Medical Center. At an unknown time relative to her breast cancer and tissue expander placement, she received a McGhan 210 cc textured silicone implant to her left breast. At time of rupture this implant was replaced with a 270 cc McGhan textured silicone implant filled to 295 cc at Newton Wellesley Hospital (NWH). Her surgical course was complicated by recurrent seroma, and she was eventually switched to Mentor smooth implant, with 275 cc implant on the right and 375 filled to 425 cc on the left. However, a biopsy of tissue at the time of this implant revealed ALK-negative ALCL in the left breast. Implants were removed at NWH and she was treated at Massachusetts General Hospital (MGH). After 3 cycles of chemotherapy (CHOP plus radiation) she remains in CR now at 18 months after treatment.
Case 2 presented at Brigham and Women's Hospital (BWH) after a surgically treated right breast cancer with recurrence and reconstruction with a McGhan 270 cc textured saline implant. In 2000 the patient presented with erythema at surgical site of her cancer and a biopsy confirmed ALCL. Due to age the patient was treated with radiation alone and this induced a sustained remission of her ALCL.
Case 3 originally had bilateral augmentation mammoplasty in 1974 with bilateral McGhan 270cc textured saline implants. She presented at Northwest Medical Center in 2007 with what appeared to be an abscess at her left implant site but was positive for ALCL when biopsied. She was treated with CHOP and radiation at that institution. She recurred in 2008 in the right breast and presented to BWH for treatment. She received ESHAP, then radiation, then gemcitabine, cisplatin, and dexamethasone; despite these treatments, her disease progressed and the patient died this year.

Results:
A query of the comprehensive electronic health database of the Partners hospitals (RPDR) revealed 9,941 patients at our institutions, who had undergone full or partial reconstruction of the breast, or removal of a breast implant or tissue expander from 1992–2009. Database queries revealed 5778 patients at MGH, 4,968 at BWH, and 4780 at Faulkner Hospital (FH) with non-Hodgkin lymphoma. Cancer Registry data revealed 18 ALCL patients (4 women) at MGH, 73 ALCL patients (24 women) at BWH and 2 ALCL patients at FH (1 woman).
Of our three cases one was treated entirely within our core healthcare system, one was referred from another Partners Institution (NWH) and one was referred for tertiary care of her lymphoma. Incidence is established as 2 cases of implant-associated ALCL per 9941 patients or 0.02%. Implant-associated disease comprises 3.2% of all ALCL cases and 10% of ALCLs presenting among women.

Conclusions:
Incidence of breast implant-associated ALCL may be more common than the rare case reports suggest. Evaluation of late complications of breast implant such as chronic seroma or abscess with consideration of this disease may improve case recognition. The fatality as a result of systemic dissemination of this disease has not previously been reported.

Disclosures:
No relevant conflicts of interest to declare.