Plastic & Reconstructive Surgery:
First Report of Nodal Marginal Zone B-Cell Lymphoma Associated with Breast Implants
Nichter, Larry S. M.D., M.S.; Mueller, Melissa A. B.A.; Burns, Robert G. M.D., Ph.D.; Stallman, Janet M. M.D.
University of Southern California,, Los Angeles, University of California, Irvine, Irvine, California, and, Plasticos Foundation, Huntington Beach, Calif. (Nichter)
Vanderbilt University School of Medicine, Nashville, Tenn., and, Plasticos Foundation, Huntington Beach, Calif. (Mueller)
Plasticos Foundation, Huntington Beach, Calif. (Burns)
Department of Pathology, Hoag Memorial Hospital, Newport Beach, Calif. (Stallman)
Correspondence to Dr. Nichter, Pacific Center for Plastic Surgery, 7677 Center Avenue, Suite 401, Huntington Beach, Calif. 92647 email@example.com
This is the first report of a nodal marginal zone B-cell lymphoma associated with breast implants and the second report of follicular lymphoma associated with breast implants. In 2010, a 58-year-old woman's magnetic resonance imaging scan diagnosed left silicone implant rupture and multiple ipsilateral abnormal axillary lymph nodes suggestive of silicone uptake fibrosis. Physical examination noted two enlarged left axillary lymph nodes and bilateral grade IV capsular contracture. Relevant history included saline implant breast augmentation in 1990, silicone implant exchange in 2001, and recent axillary discomfort. In 2003, a left upper abdominal melanoma was excised and a left axillary sentinel node biopsy was negative.
Figure. No caption a...Image Tools
Two lymph node biopsies performed in 2010 demonstrated extensive silicone granulomas comprising 30 percent of biopsied parenchyma (Fig. 1), with reactive germinal centers. One lymph node contained primary follicular lymphoma. Immunohistochemistry studies indicated the germinal center was positive for bcl-2 (Fig. 1), CD10, and CD20; partially negative for CD23 where the lymphoma obliterated the germinal center; and negative for CD5. Another lymph node contained low-grade nodal marginal zone B-cell lymphoma. The monocytoid area was positive for CD20 (Fig. 2) and bcl-2, positive for CD23 with an irregular dendritic cell pattern, partially positive for CD10, and negative for CD5. No evidence of melanoma or carcinoma was found in biopsy specimens. Capsulectomy and periprosthetic cytology revealed ruptured implant without breast malignancy.
This is the first report of implants associated nodal marginal zone B-cell lymphoma and the second report of implants associated with follicular lymphoma.1 Including this case, B-cell lymphomas have been reported in a total of four implant patients, all with silicone implants (Table 1).1–3 In three of four cases, the lymphoma arose in the context of ruptured or leaking implants and arose outside of scar capsule (Table 1).1,2 In the intact implant case, the lymphoma arose within surrounding scar capsule.3 Of three cases with compromised implants, two lymphomas arose in immediate proximity to displaced silicone. In our case, nodal marginal zone B-cell lymphoma and follicular lymphoma were found in lymph nodes that contained silicone granulomas. In another case, extranodal follicular mixed lymphoma was found next to an implant, in the same location as nonpolarized, refractile foreign material within foreign body giant cells presumed by Cook et al. to be silicone because the implant scar capsule was no longer intact.1 The close proximity of lymphoma and displaced silicone suggests that these lymphomas arising after implant rupture may not be coincidental.
A link between B-cell lymphomas and implants has previously been dismissed because of the heterogeneity and low incidence of such lymphomas.4 B-cell lymphomas are the most common primary breast lymphomas, yet anaplastic large cell lymphomas are the most common primary breast lymphomas presenting in implanted breasts.5 One explanation may be that intact silicone and saline implants increase the risk of anaplastic large cell lymphoma but only compromised silicone implants increase the risk of B-cell lymphomas. Though speculative, ruptured implants, not intact implants, may increase the risk of B-cell lymphoma. To identify such a link, surgeons should report all cases of lymphoma, both B- and T- lymphomas, in the presence of breast implants.
Larry S. Nichter, M.D., M.S.
University of Southern California,, Los Angeles, University of California, Irvine, Irvine, California, and, Plasticos Foundation, Huntington Beach, Calif.
Melissa A. Mueller, B.A.
Vanderbilt University School of Medicine, Nashville, Tenn., and, Plasticos Foundation, Huntington Beach, Calif.
Robert G. Burns, M.D., Ph.D.
Plasticos Foundation, Huntington Beach, Calif.
Janet M. Stallman, M.D.
Department of Pathology, Hoag Memorial Hospital, Newport Beach, Calif.
The authors have no financial disclosures or conflicts of interest to report.
1. Cook PD, Osborne BM, Connor RL, Strauss JF. Follicular lymphoma adjacent to foreign body granulomatous inflammation and fibrosis surrounding silicone breast prosthesis. Am J Surg Pathol. 1995;19:712–717.
2. Kraemer DM, Tony HP, Gattenlöhner S, Müller JG. Lymphoplasmacytic lymphoma in a patient with leaking silicone implant. Haematologica 2004;89:ELT01.
3. Said JW, Tasaka T, Takeuchi S, et al.. Primary effusion lymphoma in women: Report of two cases of Kaposi's sarcoma herpes virus-associated effusion-based lymphoma in human immunodeficiency virus-negative women. Blood 1996;88:3124–3128.
4. Li S, Lee AK. Silicone implant and primary breast ALK1-negative anaplastic large cell lymphoma, fact or fiction? Int J Clin Exp Pathol. 2009;3:117–127.
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
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David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, firstname.lastname@example.org
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