Commentary on: Lymphomas Associated With Breast Implants: A Review of the Literature.

Epidemiological studies and previous meta-analyses have shown that breast implant–associated anaplastic large cell lymphoma (BI-ALCL) is a distinct type of T-cell lymphoma involving the capsule or effusion surrounding a breast implant. A United States Food and Drug Administration safety communication in 2011 prompted the American Society of Plastic Surgeons (ASPS) to initiate a patient registry, include BI-ALCL language in patient consent forms warning of this potential malignancy, as well as pressured implant manufacturers to include the same in package inserts. Despite being first described 18 years ago, little progress has been made to understand the etiology or molecular pathogenesis of this lymphoma. In addition, BI-ALCL remains unfamiliar or misunderstood by many oncologists, surgeons, radiologists, pathologists, and patients. In many ways, the authors present a timely and much needed literature review on previous case reports of lymphoma and breast implants. The manuscript supports several pertinent findings, including that the presentation of ALCL is a spectrum with occasional disease-related death, that the presence of mass portends a worse prognosis, that cases are not isolated to a particular type of implant, and that improved global awareness is needed. The authors are to be commended for trying to make further sense of a very rare disease that has been sporadically reported over the last two decades. More diseasefocused manuscripts are needed on BI-ALCL as diagnosis and treatment of these patients is commonly delayed months and, in some cases, years. However, with so little known on this disease, it is absolutely critical that more recent reports should accurately report details of the circumstances of the disease, the pathologic findings, and detailed therapeutic approaches, to avoid misdiagnosis and misinformation. Therefore, a meta-analysis needs to be as accurate as possible, be a synthesis of previous findings, and offer physicians guidance for moving forward. Accuracy in patient details is critical and requires constant revision and dogged persistence. There is a consistent phenotype reported in most cases of BI-ALCL, with strong expression of CD30 and almost all cases reported as anaplastic lymphoma kinase negative. The criteria used to identify cases at our institution are listed in Table 1 and have been previously reported. The accurate diagnosis of BI-ALCL requires that the lymphoma cells are found within an effusion or lining the capsule that surrounds an implant. Some of the reported lymphomas were not found attached with the implant or capsule, and their inclusion is misleading, since these cases may represent a different disease that happens to occur in patients with implants. For instance, in Kraemer et al the patient had device explantation nearly a decade before symptoms of a systemic B cell lymphoma developed. The lymphoma was never found in the breast or the axilla, just in the bone marrow. When determining if a patient has BI-ALCL, it must be differentiated from either systemic ALCL, primary cutaneous ALCL, or from primary breast lymphoma (PBL). BI-ALCL is distinct from PBL, which is a disease of the breast parenchyma, representing 0.04-0.5% of breast cancers and 1-2% of all lymphomas.