Reply to A.E. Mazzucco

VOLUME

32

䡠

NUMBER

21

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JULY

20

2014

JOURNAL OF CLINICAL ONCOLOGY

C O R R E S P O N D E N C E

Reply to A.E. Mazzucco I would like to thank Mazzucco for her letter,1 which emphasizes the need for a better definition of the clinical presentation, diagnostic approach, and treatment of patients with breast implant–associated anaplastic large-cell lymphoma (ALCL), as well as the need for increased attention of policy makers. Mazzucco notes that although the disease is rare, there is a suggestion of underdiagnosis, mainly because the disease may be still under-recognized as a complication of breast implants by physicians of different specialties. Thus, Mazzucco suggests the need for standardized criteria or when to clinically suspect the disease, the need to identify risk factors, an update on the evaluation of imaging studies to suspect this disease, and how to handle the pathologic specimens. Because most patients with breast implant–associated ALCL present with “chronic seroma”—the term given to effusion around the implants—a rare (⬍ 1%) complication among patients with breast implants, diagnosed beyond 6 months after implant placement, patients usually have the fluid drained and commonly receive antibiotic therapy.2 Although it is also recommended that fluid from chronic seromas should be sent for cultures, or for cytologic examination,2 there are no systematic studies on results of microbiologic cultures of chronic seromas, or cytologic examination of the effusion by cytopathologists. We have shown that the pathologic findings at presentation have a prognostic value, as patients who present with a tumor mass have a worse progression-free survival when compared with patients with effusion only around the breast implants.3,4 Our study revealed that patients received a wide range of therapies in various combinations, including removal of the implant, removal of capsule followed by watchful waiting, chemotherapy, radiation therapy, and stem-cell transplantation, and a standard therapy was not evident. On the basis of the clinical and pathologic presentation, we suggested that patients who present with effusion only around breast implants may benefit from removal of the implants and capsulectomy, and there may not be an additional benefit from chemotherapy, radiation therapy, or stemcell transplantation.3 The optimal treatment of patients with breast implant–associated ALCL who present with a mass needs to be defined, including the extent of surgical treatment, the possibility of reimplant, the need for radiation or chemotherapy, or the possible chemotherapeutic regimen, and the optimal follow-up after diagnosis and therapy. A partial explanation for the use of chemotherapy in some patients with breast implant–associated ALCL who present with effusion only may be that a diagnosis of ALCL usually conveys an aggressive

clinical course and poor prognosis in the mind of some oncologists. However, it is now known that ALCL comprises three well-defined groups of diseases, two of which are systemic: anaplastic lymphoma kinase (ALK) –positive ALCL, ALK-negative ALCL,5 and one that is usually confined to the skin: primary cutaneous ALCL (pcALCL). The first two are known to benefit from systemic chemotherapy, whereas pcALCL usually requires local control, but no systemic chemotherapy. We and other researchers believe that breast implant–associated ALCL constitutes a fourth group among patients with ALCL, with distinctive features that include the association with implants, the presentation with effusion, the locally aggressive behavior when implants are not removed, and the potential for fatal outcomes.3,6 Some researchers have suggested the similarity of breast implant–associated ALCL with pcALCL on the basis of the local extension of the disease; however, the main differences are, as we learn more of the disease, that more cases appear to progress locally, and as opposed to pcALCL, no cases with spontaneous regression have been described.3 Lastly, Mazzucco1 raises important issues related with policy for follow-up of patients with cosmetic breast implants, and how to better protect patients who develop a malignancy associated with a cosmetic procedure (ie, breast implants), that we believe deserve the attention of policy makers as the disease becomes better recognized and more patients with this lymphoma are diagnosed.

Roberto N. Miranda The University of Texas MD Anderson Cancer Center, Houston, TX

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest. REFERENCES 1. Mazzucco AE: Next steps for breast implant–associated anaplastic large-cell lymphoma. J Clin Oncol 32:2275-2276, 2014 2. Bengtson 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 128:1-7, 2011 3. Miranda RN, Aladily TN, Prince HM, et al: Breast implant–associated anaplastic large-cell lymphoma: Long-term follow-up of 60 patients. J Clin Oncol 32:114-120, 2014 4. Aladily TN, Medeiros LJ, Amin MB, et al: Anaplastic large cell lymphoma associated with breast implants: A report of 13 cases. Am J Surg Pathol 36:1000-1008, 2012 5. Medeiros LJ, Elenitoba-Johnson KS: Anaplastic large cell lymphoma. Am J Clin Pathol 127:707-722, 2007 6. Thompson PA, Prince HM: Breast implant-associated anaplastic large cell lymphoma: A systematic review of the literature and mini-meta analysis. Curr Hematol Malig Rep 8:196-210, 2013

DOI: 10.1200/JCO.2014.55.8205; published online ahead of print at www.jco.org on June 16, 2014

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© 2014 by American Society of Clinical Oncology

Journal of Clinical Oncology, Vol 32, No 21 (July 20), 2014: pp 2276

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