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A Malignant Late Seroma 20 Years after Breast Cancer and Saline Implants

Roubaud, Margaret J. M.D.; Kulber, David A. M.D.

Plastic and Reconstructive Surgery: April 2013 - Volume 131 - Issue 4 - p 655e–657e
doi: 10.1097/PRS.0b013e3182827913
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Department of Surgery, Division of Plastic Surgery, University of Southern California, Los Angeles, Calif. (Roubaud)

University of Southern California Keck School of Medicine, and, Cedars-Sinai Medical Center, Los Angeles, Calif. (Kulber)

Correspondence to Dr. Roubaud, Department of Plastic Surgery, University of Southern California, 1500 San Pablo Street, Los Angeles, Calif. 90230 margaret.starnes@surgery.usc.edu

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Sir:

Figure

Figure

A 54-year-old woman was admitted to the hospital in March of 2012 complaining of 2 days of swelling and redness in her left breast. Her past medical history was significant for estrogen receptor/progesterone receptor–negative left breast cancer in 1991 at age 32. At that time, she underwent bilateral modified radical mastectomies and submuscular saline implants for reconstruction, with adjuvant chemotherapy. She had two subsequent recurrences in 1994 and 1997, for which she completed two additional rounds of chemoradiation.

On admission to the hospital, her left breast was tense, with overlying mild erythema. There was no adenopathy. The patient's white blood cell count was normal and she was afebrile. Radiologic imaging demonstrated a large amount of dense fluid surrounding the left implant, with distortion posteriorly. No suspicious masses or malignant characteristics were seen in either breast (Figs. 1 and 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

After imaging, she underwent aspiration of the fluid collection with both cultures and cytology. The fluid was found to be positive for malignant cells, with features consistent with poorly differentiated adenocarcinoma. The patient underwent left breast implant removal, and left breast capsule biopsy demonstrated carcinoma growing as solid sheets in scattered associated foci. It was noted, “the tumor is histologically similar to the invasive ductal carcinoma of the patient's previous left mastectomy specimen and is compatible with recurrence.”

She subsequently underwent completion radical mastectomy of the left side of chest wall. On final pathologic analysis, the carcinoma was confined to the inner surface of the fibrous implant capsule. It was estrogen receptor/progesterone receptor/Her2-neu–negative. No extension into the fibrous capsule or surrounding soft tissue was found. All axillary contents were negative.

Postoperatively, the patient has done well with no evidence of recurrence. At this time, further treatment includes 4 months of chemotherapy with Navelbine and Xeloda.

Late seroma, defined as that occurring more than 12 months postoperatively, after breast reconstruction or augmentation is a rare occurrence, with reported rates between 1 and 2 percent.1 3 Most reports in the literature attribute the occurrence to latent infection, trauma, microshear of capsule neovessels, or implant rupture.2,3 Spear et al. recently published a multicenter, retrospective, 5-year review of late seromas. In their study, they found that late seromas were more common in textured implants and 0 of 28 were due to neoplasia.2

Late seroma formation in the presence of implants has been associated with malignancy. Several reports document the infrequent occurrence of anaplastic large T-cell lymphoma, at approximately one case per 1 million women per year.4,5 To our knowledge, to date there have been no reports of late seroma as a presentation of recurrent breast cancer.

According to a consensus report by Bengston et al., late seroma in the presence of breast implants should first be managed by ruling out infection, including aspiration and subsequent initiation of microbial therapy. No cytologic tests are recommended unless the seroma is noninfectious or recurrent.3

Given our experience with our patient, any patient with late seroma should undergo fluid aspiration and cytologic evaluation, especially if the patient has a history of breast cancer. Given the aggressive nature of triple-negative breast cancer, any late seroma should be a red flag to the clinician, regardless of the number of asymptomatic years. Malignant effusions are hallmarks of many neoplastic diseases and should not be overlooked on the chest wall.

Margaret J. Roubaud, M.D.

Department of Surgery, Division of Plastic Surgery, University of Southern California, Los Angeles, Calif.

David A. Kulber, M.D.

University of Southern California Keck School of Medicine, and, Cedars-Sinai Medical Center, Los Angeles, Calif.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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REFERENCES

1. Hall-Findlay EJ. Breast implant complication review: Double capsules and late seromas. Plast Reconstr Surg. 2011;127:56–66.
2. Spear SL, Rottman SJ, Glicksman C, et al.. Late seromas after breast implants: Theory and practice. Plast Reconstr Surg. 2012;130:423–435.
3. Bengston B, Brody GS, Brown MH, et al.. Managing late periprosthetic fluid collections (seroma) in patients with breast implants: A consensus panel recommendation and review of the literature. Plast Reconstr Surg. 2011;128:1–7.
4. de Jong D, Vasmel WL, de Boer JP, et al.. Anaplastic large cell lymphoma in women with breast implants. JAMA 2008;300:2030–2035.
5. Kim B, Roth C, Chung KC, et al.. Anaplastic large cell lymphoma (ALCL) in women with breast implants. Plast Reconstr Surg. 2011;127:2141–2150.
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