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.
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.
5. U.S. Food and Drug Administration: Center for Devices and Radiological Health. Anaplastic large cell lymphoma (ALCL) in women with breast implants: Preliminary FDA findings and analyses. 2011. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
- Text—maximum of 500 words (not including references)
- References—maximum of five
- Authors—no more than five
- Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.