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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance image of a retroprosthetic lobulated mass measuring 14&#8239;&#215;&#8239;10&#8239;&#215;&#8239;7&#8239;cm with irregular margins in addition to peripheral enhancement and central necrosis and invasion of the chest wall through to the mediastinum&#46;</p>"
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She had been diagnosed with right breast carcinoma 5 years earlier and had undergone mastectomy and prosthetic breast reconstruction&#46; She was receiving hormone therapy&#46; No signs of recurrence had been detected in a follow-up mammogram 4 months earlier&#46; The ultrasound examination had shown waves indicating possible periprosthetic fluid collection but no findings suggestive of malignancy&#46; The patient reported asthenia and considerable weight loss in recent months&#46; Skin biopsy showed spongiotic dermatitis with a superficial and deep perivascular lymphohistiocytic infiltrate&#46; No tumor cells were observed and immunohistochemical staining was negative for cytokeratin 19 and CD30&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging was ordered to assess the possibility of a cutaneous metastasis from breast cancer or a prosthetic complication&#46; The findings showed a retroprosthetic mass invading the chest wall and extending into the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Aspiration of the periprosthetic fluid showed large CD30<span class="elsevierStyleSup">&#43;</span>&#44; CD3<span class="elsevierStyleSup">&#43;</span>&#44; and ALK- tumor cells&#44; confirming the diagnosis of BIA-ALCL &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Given the presence of extramammary disease&#44; the patient was treated with systemic chemotherapy &#40;cyclophosphamide&#44; hydroxydaunorubicin&#44; and prednisone&#41; and brentuximab before surgical explantation of the implant and capsulectomy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">BIA-ALCL is a lymphoproliferative disorder caused by tumor cells invading the capsule or periprosthetic fluid&#46; The mean age at diagnosis is 52&#46;5 years and the mean time from breast implantation to diagnosis is 9 years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> BIA-ALCL presents as periprosthetic seroma in 86&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> although it can also manifest as a mass&#44; nodule&#44; or lymph node enlargement&#46; Skin lesions are very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Just 2 cases of BIA-ALCL with skin lesions as the presenting manifestation have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a>Elswick and Nguyen<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described the case of a woman who presented with a breast mass&#44; erythema&#44; and breast swelling in addition to elevated acute phase reactants in the blood work-up&#46; The skin biopsy was negative for malignancy&#44; suggesting to the authors that the skin lesions were due to a periprosthetic infection concurrent with the lymphoma&#46; In the case published by Alcal&#225; et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> however&#44; the detection of CD30<span class="elsevierStyleSup">&#43;</span> tumor cells during histologic examination of the skin nodules was key to establishing a diagnosis of BIA-ALCL rather than breast cancer recurrence&#46; Nineteen of the 186 patients in the PROFILE &#40;Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41; registry developed skin lesions in addition to other systemic manifestations&#44; and 12 of these lesions were described as redness on the skin&#46; Type of skin lesion was not specified in the other cases&#44; and none of the lesions were analyzed histologically&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Neither our case nor the cases in the literature &#40;with the exception of that described by Alcal&#225; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41; exhibited specific clinical or microscopic changes&#46; BIA-ALCL should be suspected in patients with breast implants who develop skin lesions&#44; in particular erythema&#44; and breast swelling&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It has been hypothesized that the etiology of BIA-ALCL is multifactorial and is influenced by type of implant&#44; genetic predisposition&#44; and possible chronic periprosthetic superinfection associated with a bacterial biofilm&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The Spanish Ministry of Health recently published a clinical protocol for the detection of BIA-ALCL that recommends an initial ultrasound assessment with aspiration and cytologic and microbiologic analysis of periprosthetic fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> BIA-ALCL is histologically characterized by a proliferation of highly pleomorphic lymphoid cells with abundant cytoplasm and an irregular nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Diagnosis must be confirmed by immunohistochemistry&#44; which characteristically shows CD30 positivity and ALK negativity in all tumor cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">BIA-ALCL is generally localized at diagnosis and the prognosis is excellent following surgical excision&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Extracapsular spread is very uncommon&#46; In their review of 173 cases of BIA-ALCL&#44; Brody et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reported just 18 cases of extracapsular spread and 9 of these had a fatal outcome&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have described a new case of advanced-stage BIA-ALCL in a woman who&#44; in addition to increased breast volume&#44; presented with skin lesions and constitutional syndrome&#46; She required chemotherapy prior to surgery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although BIA-ALCL is rare&#44; the number of cases in recent years has increased exponentially&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is crucial thus to be familiar with this condition&#44; as early diagnosis together with detection of localized disease is associated with a favorable prognosis following surgical explantation and capsulectomy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Breast Implant–Associated Anaplastic Large Cell Lymphoma
Linfoma anaplásico de células grandes asociado a implantes mamarios
I. Gracia-Darder
Autor para correspondencia
ines.gracia@ssib.es

Corresponding author.
, N. Izquierdo, J. Boix-Vilanova, D. Ramos
Departamento de Dermatología, Hospital Universitario Son Espases, Palma de Mallorca, Baleares, Spain
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance image of a retroprosthetic lobulated mass measuring 14&#8239;&#215;&#8239;10&#8239;&#215;&#8239;7&#8239;cm with irregular margins in addition to peripheral enhancement and central necrosis and invasion of the chest wall through to the mediastinum&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Breast implant&#8211;associated anaplastic large cell lymphoma &#40;BIA-ALCL&#41; is a very rare form of T-cell lymphoma and its incidence has grown in recent decades&#46; The most common presentation is breast swelling due to periprosthetic seroma&#46; In this article&#44; we describe a case of BIA-ALCL whose first clinical manifestation was skin lesions in the intermammary area&#46; There have very few reports of this presentation in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 70-year-old woman was referred to our department for evaluation of an erythematous&#44; indurated plaque with slight superficial scaling in the intermammary area and increased right breast volume &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; She had been diagnosed with right breast carcinoma 5 years earlier and had undergone mastectomy and prosthetic breast reconstruction&#46; She was receiving hormone therapy&#46; No signs of recurrence had been detected in a follow-up mammogram 4 months earlier&#46; The ultrasound examination had shown waves indicating possible periprosthetic fluid collection but no findings suggestive of malignancy&#46; The patient reported asthenia and considerable weight loss in recent months&#46; Skin biopsy showed spongiotic dermatitis with a superficial and deep perivascular lymphohistiocytic infiltrate&#46; No tumor cells were observed and immunohistochemical staining was negative for cytokeratin 19 and CD30&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging was ordered to assess the possibility of a cutaneous metastasis from breast cancer or a prosthetic complication&#46; The findings showed a retroprosthetic mass invading the chest wall and extending into the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Aspiration of the periprosthetic fluid showed large CD30<span class="elsevierStyleSup">&#43;</span>&#44; CD3<span class="elsevierStyleSup">&#43;</span>&#44; and ALK- tumor cells&#44; confirming the diagnosis of BIA-ALCL &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Given the presence of extramammary disease&#44; the patient was treated with systemic chemotherapy &#40;cyclophosphamide&#44; hydroxydaunorubicin&#44; and prednisone&#41; and brentuximab before surgical explantation of the implant and capsulectomy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">BIA-ALCL is a lymphoproliferative disorder caused by tumor cells invading the capsule or periprosthetic fluid&#46; The mean age at diagnosis is 52&#46;5 years and the mean time from breast implantation to diagnosis is 9 years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> BIA-ALCL presents as periprosthetic seroma in 86&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> although it can also manifest as a mass&#44; nodule&#44; or lymph node enlargement&#46; Skin lesions are very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Just 2 cases of BIA-ALCL with skin lesions as the presenting manifestation have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a>Elswick and Nguyen<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described the case of a woman who presented with a breast mass&#44; erythema&#44; and breast swelling in addition to elevated acute phase reactants in the blood work-up&#46; The skin biopsy was negative for malignancy&#44; suggesting to the authors that the skin lesions were due to a periprosthetic infection concurrent with the lymphoma&#46; In the case published by Alcal&#225; et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> however&#44; the detection of CD30<span class="elsevierStyleSup">&#43;</span> tumor cells during histologic examination of the skin nodules was key to establishing a diagnosis of BIA-ALCL rather than breast cancer recurrence&#46; Nineteen of the 186 patients in the PROFILE &#40;Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41; registry developed skin lesions in addition to other systemic manifestations&#44; and 12 of these lesions were described as redness on the skin&#46; Type of skin lesion was not specified in the other cases&#44; and none of the lesions were analyzed histologically&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Neither our case nor the cases in the literature &#40;with the exception of that described by Alcal&#225; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41; exhibited specific clinical or microscopic changes&#46; BIA-ALCL should be suspected in patients with breast implants who develop skin lesions&#44; in particular erythema&#44; and breast swelling&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It has been hypothesized that the etiology of BIA-ALCL is multifactorial and is influenced by type of implant&#44; genetic predisposition&#44; and possible chronic periprosthetic superinfection associated with a bacterial biofilm&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The Spanish Ministry of Health recently published a clinical protocol for the detection of BIA-ALCL that recommends an initial ultrasound assessment with aspiration and cytologic and microbiologic analysis of periprosthetic fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> BIA-ALCL is histologically characterized by a proliferation of highly pleomorphic lymphoid cells with abundant cytoplasm and an irregular nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Diagnosis must be confirmed by immunohistochemistry&#44; which characteristically shows CD30 positivity and ALK negativity in all tumor cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">BIA-ALCL is generally localized at diagnosis and the prognosis is excellent following surgical excision&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Extracapsular spread is very uncommon&#46; In their review of 173 cases of BIA-ALCL&#44; Brody et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reported just 18 cases of extracapsular spread and 9 of these had a fatal outcome&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have described a new case of advanced-stage BIA-ALCL in a woman who&#44; in addition to increased breast volume&#44; presented with skin lesions and constitutional syndrome&#46; She required chemotherapy prior to surgery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although BIA-ALCL is rare&#44; the number of cases in recent years has increased exponentially&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is crucial thus to be familiar with this condition&#44; as early diagnosis together with detection of localized disease is associated with a favorable prognosis following surgical explantation and capsulectomy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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ISSN: 15782190
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