Fluid culture results were negative. Sections of the capsule and lumps of fibrinoid tissue presented large “hallmark” cells showing typical horseshoe-shaped nuclei, and the immunohistochemical tests were strongly positive for CD30 and CD4 and negative for ALK, confirming the diagnosis of ALCL on the left side. [See Figure, Supplemental Digital Content 1, which shows (left) a sample from the lumps present on the left pocket, with “hallmark” cells showing a typical horseshoe-shaped nuclei configuration (arrows), characteristic of ALCL. (Right) Cross-section of the fibrous capsule showing a rim of the same population of large pleomorphic cells (hematoxylin and eosin; original magnification, × 40), http://links.lww.com/PRS/D641. See Figure, Supplemental Digital Content 2, which shows immunohistochemical analysis of fibrous capsule sections with neoplastic cells showing (left) membrane and dot-like (arrows) CD30 positivity and (right) membrane CD4 positivity, confirming the diagnosis of ALCL (original magnification, × 40), http://links.lww.com/PRS/D642.] Complementary examinations by positron emission tomography/computed tomography and bone marrow biopsy did not show any other sites involved. No adjuvant treatment was indicated. Up to 6 months postoperatively, she presented a disease-free status, and any surgical intervention or a new implantation was formally contraindicated.
In this case, the patient presented a clinical evolution similar to BIA-ALCL, with no systemic symptoms and with clinical indolence, presenting a progressive effusion around the implant, resulting in a late seroma and leading to buttock asymmetry. In addition, the anatomopathologic cells characteristics and immunophenotyping expression were the same (i.e., CD30+, CD4+, and ALK−), evidencing that gluteal implant-associated ALCL is the same pathologic condition as the BIA-ALCL described in the literature.9
No risk factors have been clearly identified for ALCL, although many have been theorized, including the presence of a subclinical biofilm, response to particulate from textured implants, a consequence of capsular contracture or repeated capsular trauma, and genetic predisposition. However, these observations have not been confirmed in formal epidemiologic studies.10
Previous work comparing the capsules of textured and smooth implants in pigs showed that there are increased lymphocytes on textured breast implants, with a T-cell predominance, further supporting texturing as a link to chronic inflammation and T-cell response.11 If chronic trauma is an etiologic component, we should consider that, anatomically, the gluteal region naturally undergoes more stress in daily life, and this first report somehow contradicts the logic of this interpretation. In contrast, it seems that the majority of implants in gluteoplasty are smooth, but in this case the devices removed were textured, leaving open the understanding of the real role of implant surface in ALCL genesis. Assuming that the implant texturization is an etiologic factor deserves careful consideration because it will imply an obligatory exclusive use of smooth surface implants, which at this moment is not an evidence-based conclusion. Besides this, textured implants are represented by different surface technologies, defined as macrotexture,12 microtexture, and nanotexture,13,14 factors not fully understood in relation to their possible effects on the implant-tissue interface to impact outcomes. Different from the proposed augmentation operations, other implant-associated ALCL cases have been published,15–18 suggesting the presence of an underlying common etiologic factor of unknown nature in the pathogenesis of ALCL. Kadin et al. proposed that BIA-ALCL is linked to chronic bacterial antigen stimulation of Th1/Th17 antigen-driven memory T cells from capsular tissues and surrounding seromas, sustained T-cell proliferation, and subsequent genetic events in the pathogenesis of BIA-ALCL.19
The clinical evolution and pathologic and immunohistochemical analysis of this case could confirm the diagnosis of ALCL. For all purposes, this is the same disease, now in a new location, reintroducing important discussions about the understanding of this abnormality and posing certain risks and safety issues for clinical scenarios to be discussed. Thus, all recommendations regarding BIA-ALCL should also be applied to gluteal implant-associated ALCL, such as the rigorous criteria in the asepsis of implant placement and the detailed investigation of all late seroma. The role of implant surface in ALCL genesis demands further studies with regard to an evidence-based decision to adopt smooth implants to prevent the disease. For therapeutic purposes, total capsulectomy seems to be mandatory when treating this type of lymphoproliferative disorder. Regardless of whether it is a BIA-ALCL or a gluteal implant-associated ALCL, we are probably facing an implant augmentation–associated ALCL, and a new international alert should be addressed to the scientific community.
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