All women should report any changes in their breasts. Most of the time changes are related to normal physiological changes (breast pain is often hormonal for example). If the breast is knocked, or you have a fall and hit the breast it is possible to get a swelling around the implant like the one in the photo above. However, these would go away of their own accord, usually after a few weeks of wearing a sports-bra. If something seems out of the ordinary after breast augmentation and it fails to improve after a week or two, it should be looked at by a specialist in this field.
The most common presenting symptom for BIA- ALCL is an obviously swollen breast- usually occurring for no good reason. It is caused by the formation of a delayed fluid collection (>1 year since implant placement) usually on one breast. The fluid build up is between the implant surface and the capsule. It is occasionally associated with a localised abnormal looking capsule thickening or a mass, that might be felt, or seen on USS, or only seen if the surgeon operates and looks at it directly from the inside. However more commonly the capsule may look entirely normal except for the fluid, which often contains free floating debris that is best appreciated on ultrasound or under a microscope. A number of cases have been reported in the absence of a peri-prosthetic fluid collection in association with a severe capsular contraction, a mass in the breast or under the arm, a persistent rash or intense deep itch or as a cutaneous nodule. BIA-ALCL may also occur on both sides at the same time, although this is even more rare.
The differential diagnosis of late serous fluid collection (which actually occurs with far greater frequency than ALCL being the cause), includes infection, trauma, haematoma (blood), implant rupture, double capsule, synovial metaplasia, other breast surgery being done when implants are present, breast cancer and idiopathic causes. These causes greatly outweigh the occurrence of a BIA-ALCL seroma and need to be considered and differentiated by a specialist. Patients without a clear attributable cause or who have a non-resolving peri-prosthetic fluid collection should be further evaluated-: BIA-ALCL needs to be considered.
You would normally be referred to an NHS diagnostic breast unit in a teaching hospital. You should see a consultant who has expert knowledge on breast implants and understands about ALCL. Investigation will therefore be considered with imaging such as ultrasound. Fluid can be drained off under ultrasound guidance and sent for special lymphoma cell tests if appropriate after analysis of the fluid under a microscope and by a process called flow cytometry (a test looking for characteristic CD30 positive cells). The very first time such fluid is drawn off is the best time for the test, and so ensure the person doing the procedure understands how the fluid is to be sent and too whom to check for ALCL.
A breast MRI for further evaluation might be required, and referral to a breast multidisciplinary team (MDT) with experience of this disease would be recommended. If there is a strong suspicion, or uncertainty, you may need your implant to be removed and the capsule excised for histology.
It is paramount that the cytology and pathology request forms state ‘for the exclusion of BIA-ALCL’ so that specific staining and haematopathology review is performed. If surgical exploration has been carried out, fresh seroma fluid and the capsule should be sent for cytology and histopathology to rule out BIA-ALCL. It should be remembered that the appearance of the capsule is often quite normal to the naked eye with the exception of the copious serum. So a normal appearance alone should not be a discriminator if the diagnosis is suspected.
Diagnostic evaluation of seroma fluid should also include standard culture and cytological evaluation. The pathologist must be made aware of the suspicion of BIA-ALCL so that, where appropriate, Wright Giemsa staining and cell block, with further immunohistochemistry testing for CD30 and Anaplastic Lymphoma Kinase (ALK) markers will be performed if appropriate. BIA-ALCL can only be confirmed if there are morphologically abnormal lymphocytes, and it is found in association with the implant capsule or within the effusion and is confirmed on immuno-histochemistry as being CD30 positive and ALK negative. If seroma fluid tests negative for ALCL, it might be a ‘false negative’, so if there is still a concern further testing might still be pursued.
Any abnormal breast mass associated with an implant should be biopsied and in addition to standard pathological assessment be additionally assessed for BIA-ALCL, which is now a provisional distinct entity in the World Health Organisation classification of lymphoid neoplasms.
Any patient diagnosed with BIA-ALCL should have a PET-CT to exclude regional or systemic spread. If an abnormal lymph node is found in the axilla it is recommended that it be excised whole for histology at the time of surgery, as fine needle aspiration cytology is inaccurate.
Vigilance is required especially where a late peri-prosthetic seroma occurs, as early treatment with complete capsulectomy (my preferred technique here is the total en-bloc capsulectomy) and implant removal is associated with an excellent prognosis based on follow up data we have to date. There is a need to provide patients with adequate information, and a discussion of BIA-ALCL must be included as part of the consent process and documented in the patient’s medical record where an implant is being used as part of reconstruction or cosmetic breast surgery. Implants available in the UK are still regarded as acceptably safe for use in augmentation and reconstruction operations and the MHRA does not suggest a change in practice with the current data available.