Breast Implant-Associated Anaplastic Large Cell Lymphoma: Staging, Disease Progression, and Management Strategies
Mark W. Clemens, MD1, Charles E. Butler, MD1, Kelly K. Hunt, MD2, Michelle A. Fanale, MD3, Steven Horwitz, MD4, Hui Liu, MD PHD5, Jun Liu, MS1, Ken H. Young, MD PHD5, L. Jeffrey Medeiros, MD6, Roberto N. Miranda, MD6.
1Department of Plastic Surgery, M.D. Anderson Cancer Center, University of Texas, Houston, TX, USA, 2Department of Surgical Oncology, M.D. Anderson Cancer Center, University of Texas, Houston, TX, USA, 3Department of Lymphoma and Myeloma, M.D. Anderson Cancer Center, University of Texas, Houston, TX, USA, 4Department of Lymphoma, Memorial Sloane Kettering Cancer Center, New York, NY, USA, 5Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA, 6Department of Hematopathology, M.D. Anderson Cancer Center, University of Texas, Houston, TX, USA.
PURPOSE: Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a newly identified lymphoma. Patterns of disease progression and optimal treatment strategies have not been described.
Methods: The literature was reviewed for all published cases of BI-ALCL from 1997 to September 2014, contacted corresponding authors to update clinical follow up, and combined data with institutional cases. A novel clinic-pathologic TNM staging system is proposed and was compared to traditional Ann Arbor staging to determine prognostic value for overall survival (OS) and progression free survival (PFS).
Results: We identified 116 unique cases of BI-ALCL, including 91 previously reported and 25 unreported cases. Pathologic slides were available in 40 patients for pathologic staging. Average follow up was 41 months [range: 0-192 months]. The median OS was 13 years, OS rate 93% at 3-years and 89% at 5-years. 18 progression events were noted and median PFS was 13 months, with 3-year and 5-year PFS at 79.4%. Total capsulectomy with implant removal (TCIR) prolonged OS (p=0.022) and improved PFS (p=0.014), and the effect of definitive surgery was statistically significant for PFS benefit (HR=0.14, 95%, CI=0.05-0.46, p=0.001). The PFS was significantly different by Ann Arbor staging (p=0.013) and by the newly proposed clinical staging (p=0.030).
Advanced stage, presence of mass, incomplete resection, and delay in definitive surgical treatment were associated with poorer prognosis. Surgical management with definitive excision and oncologic surveillance is adequate for most patients with BI-ALCL. The role for chemotherapy, targeted immunotherapy, and/or radiation for advanced disease requires further research in larger series.
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