What is breast implant-associated lymphoma (BIA-ALCL)?

What is BIA-ALCL?

Lymphoma is a blood cancer that develops from lymphocytes, a type of immune cell. Anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin lymphoma, and it is described as accounting for 1% to 3% of non-Hodgkin lymphomas and about 15% of T-cell lymphomas ^[2].

In 2016, when the World Health Organization (WHO) divided anaplastic large cell lymphoma into four types, it classified the type associated with breast implants separately ^[2]. The same publication introduced BIA-ALCL as a provisional new disease entity and described it as a noninvasive disease that tends to have a favorable outcome ^[2]. However, deaths have also been reported worldwide, so it is not a disease to be taken lightly ^[1].

BIA-ALCL is also discussed as one of the CD30-positive T-cell lymphoproliferative disorders, and the literature notes that an accurate diagnosis requires careful consideration of both the clinical features and the tissue (histopathologic) findings ^[4]. A 2014 review of primary breast lymphoma also described BIA-ALCL as one of the rare subtypes encountered ^[5].

How rare is it?

According to a 2018 German review, 516 pathologically confirmed cases of BIA-ALCL had been identified worldwide as of February 2018, 7 of which were reported in Germany ^[1]. A total of 16 deaths were also reported worldwide ^[1].

The same review estimated the risk of primary anaplastic large cell lymphoma developing in women with implants at 0.35 to 1 case per million per year ^[1]. Although this is a very low rate, it considered the risk distinctly higher than that of other primary breast lymphomas ^[1].

These figures are based on data up to 2018 and on German and international reports, so they cannot be applied directly to Korean patients. A 2024 review of the epidemiology of T-cell lymphomas also summarized that the distribution and risk factors of the newly classified BIA-ALCL are only beginning to be understood, and considered that prospective registry studies based on the latest classification are needed ^[6].

Relationship to the implant surface

A 2024 consensus statement from a US plastic surgery society addressed the diagnosis and management of BIA-ALCL caused by textured implants ^[3]. This consensus screened 840 publications published from January 2011 to January 2023 and synthesized 145 of them, of which 105 were case reports or case studies ^[3].

The consensus concluded that plastic surgeons should be aware that the risk increases depending on the type of implant surface, carry out appropriate follow-up of patients, and follow the recommendations presented ^[3]. Because it is an expert consensus developed in the absence of high-level evidence, its level of evidence was rated V, and it stated that research into how the disease develops, genetic factors, and methods of prevention is still needed ^[3].

What are the symptoms?

In the 2018 review, about 80% of patients presented with a late seroma, a collection of fluid that develops around the implant long after surgery, and the rest presented with a mass, with or without a seroma ^[1]. The average time from implant placement to diagnosis ranged from 7 to 13 years ^[1].

The same review stressed that when a late seroma develops in a person with implants, BIA-ALCL should be included in the differential diagnosis (the list of possible causes to rule out) ^[1]. If, long after surgery, one breast suddenly swells or becomes larger, or you can feel a lump, it is a good idea to have an examination to find the cause. Not every symptom means lymphoma, but it is important not to ignore it without having it checked.

How is it diagnosed and treated?

In the 7 cases reported in Germany, all patients underwent surgery to remove the capsule and the implant together in one piece; 1 patient received chemotherapy, and another received chemotherapy plus adjuvant radiation therapy ^[1]. Of these 7 cases, 4 involved reconstruction with implants after breast cancer surgery, and 2 involved breast augmentation ^[1].

However, it was pointed out that because the number of cases is small, recommendations on diagnosis and treatment have not been adequately evaluated ^[1]. It has been reported that treatment with curative intent leads to a much better outlook than for systemic anaplastic large cell lymphoma, and the review stated that this diagnosis is subject to reporting ^[1].

If you have implants or are considering surgery

BIA-ALCL is rare, but it is a condition worth knowing about. The type of implant, its risks, and how it should be monitored differ from person to person, so it is a good idea to check the following with a specialist.

• The surface type of your current or planned implants
• How you will be followed up after surgery, and how often
• How swelling or a lump that appears late is examined
• Keeping a record of your implant information (product, surface, and date of surgery)
• Your doctor's view on how to manage implants when you have no symptoms