Sir:
A 44-year-old woman was referred to our clinic for evaluation of an enlarged right breast 6 years after bilateral augmentation with subpectoral textured saline implants (Fig. 1). She sustained a minor trauma, and her chest swelling was treated with antibiotics, aspiration, and implant exchange. Asymmetry persisted for 2 years before her visit to our clinic. A capsulectomy with implant exchange was performed. The implant was not ruptured; however, there was a 10-cm mass associated with the capsule consistent with T-cell lymphoma of anaplastic large cell lymphoma morphology (Fig. 2). The patient underwent multimodality treatment, including irradiation, with no evidence of recurrent disease. She returned to our clinic for reconstruction. Given her recent chest wall irradiation and refusal of transverse rectus abdominis musculocutaneous flap surgery, she underwent latissimus dorsi flap surgery over a tissue expander to provide symmetry with the contralateral augmented breast. Expansion was performed without difficulty and the expander was exchanged with a saline implant.
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Fig. 1.:
Preoperative view showing gross enlargement of the right breast 6 years after subpectoral saline implant placement.
Fig. 2.:
Intraoperative views of the complex mass measuring 12 × 10 × 4.5 cm (left), the capsulectomy specimen (center), and the intact saline implant (right).
It is estimated that over 300,000 cosmetic breast augmentation procedures are performed annually in the United States. This figure continues to rise despite debate regarding the safety of saline and silicone implants. Epidemiologic studies have found no causative relationship between implants and malignancies or connective tissue diseases1,2; however, there have been reports of a rare subtype of non-Hodgkin lymphoma of the breast observed in patients with breast implants.3,4 Primary breast lymphoma is an unusual subset of cancer that constitutes less than 0.5 percent of malignant neoplasms of the breast.
Registry-linked studies of patients with cosmetic breast implants have shown no increase in malignancy compared with the general population. A recent review from The Netherlands showed an 18-fold increase in the odds of developing anaplastic large cell lymphoma in the setting of silicone implants5; however, it is imperative to note that the absolute risk remains exceedingly low because of the low prevalence of breast lymphomas. A literature search revealed few cases of breast lymphoma in the setting of breast implants, with the large majority being anaplastic large cell lymphoma. All cases of primary breast lymphoma arising in proximity to implants have a common presentation of swelling or asymmetry around the implant, generally outside the perioperative period, and diagnosis was made by means of cytology or histology.4
Although the retrospective data reject a causal link between breast implants and malignancy, the cases reviewed discuss an unusual morphology of primary breast lymphoma, including this case, presenting as asymmetry after augmentation. Asymmetric enlargement after augmentation may be attributable to many causes, including hematoma, seroma or infection, capsular contracture, or implant failure, and can often be diagnosed by physical examination or imaging. Alternatively, there are rare reports of autoinflation or tumor coincident with augmentation. Although the relationship is speculative, further study is warranted. Our experience and literature review indicate the benefit of imaging, aspiration with cytology and culture, and histologic analysis of the capsulectomy specimen. In particular, it is important to be aware of potential malignancy in those patients who experience breast enlargement outside of the immediate perioperative period. Reconstruction is possible after aggressive, multimodality treatment of primary breast lymphoma.
DISCLOSURE
Neither of the authors has a financial interest in the content of this article.
Summer E. Hanson, M.D.
Division of Plastic Surgery
Department of Surgery
University of Wisconsin-Madison
Madison, Wis.
Karol A. Gutowski, M.D.
Division of Plastic Surgery
Northshore University Health System
University of Chicago
Chicago, Ill.
REFERENCES
1. Friis S, Holmich LR, McLaughlin JK, et al. Cancer risk among Danish women with cosmetic breast implants.
Int J Cancer 2006;118:998–1003.
2. McLaughlin JK, Lipworth L, Fryzek JP, Ye W, Tarone RE, Nyren O. Long-term cancer risk among Swedish women with cosmetic breast implants: An update of a nationwide study.
J Natl Cancer Inst. 2006;98:557–560.
3. Sahoo S, Rosen PP, Feddersen RM, Viswanatha DS, Clark DA, Chadburn A. Anaplastic large cell lymphoma arising in a silicone breast implant capsule: A case report and review of the literature.
Arch Pathol Lab Med. 2003;127:e115–e118.
4. Wong AK, Lopategui J, Clancy S, Kulber D, Bose S. Anaplastic large cell lymphoma associated with a breast implant capsule: A case report and review of the literature.
Am J Surg Pathol. 2008;32:1265–1268.
5. de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic large-cell lymphoma in women with breast implants.
JAMA. 2008;300:2030–2035.
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