Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a new provisional category in the 2016 World Health Organization (WHO) classification of lymphoid neoplasms, and its incidence is rising owing to increasing recognition of this complication of breast implant insertion. At a median of 10 years after implant insertion, the typical presenting features are sudden-onset breast swelling secondary to peri-implant effusion and less frequently mass-forming disease. Histologic features comprise pleomorphic cells expressing CD30 and negative anaplastic lymphoma kinase (ALK) receptor, similar to systemic and cutaneous ALKnegative anaplastic large cell lymphoma (ALCL). The effusion-only subtype is generally indolent and curable with surgery, unlike the more aggressive mass-forming disease, for which systemic therapy is advocated. High clinical suspicion and pertinent use of radiologic and pathology modalities are essential for timely and accurate diagnosis of BIA-ALCL. Contemporary imaging techniques including US, mammography, breast MRI, CT, and PET/CT are routinely used in breast disease and lymphomas; however, the unique behavior of BIA-ALCL pre sents significant diagnostic and radiologic interpretative challenges, with numerous nuanced imaging features being pertinent, and current lymphoma staging and response guidelines are not easily applicable to BIA-ALCL. The authors evaluate available evidence in this evolving field; detail key indications, strengths, and limitations of the panoply of radiologic techniques for BIA-ALCL; and propose multiparametric imaging paradigms for management of the peri-implant effusion and massforming or advanced disease subtypes, with the goal of accurate optimal patient care. The authors also predict a future model of multimodal assessment using novel imaging and molecular techniques and define key research directions. © RSNA, 2020 • radiographics.rsna.org
Allogeneic stem cell transplantation (allo-SCT) has been extensively investigated as a potentially curative treatment strategy for myeloma. Early studies using myeloablative conditioning showed an unacceptable transplant-related mortality (TRM) of 53%, despite long-term remission rates (39%). 1 Recent improvements in transplant conditioning, graft-versus-host disease (GvHD) prophylaxis and treatment, and supportive care have seen allo-SCT for myeloma re-emerge as a viable option, in particular for young patients with high-risk disease, in whom the prognosis remains poor. 2 Despite this, newer therapeutic strategies have raised the bar for what allo-SCT would need to achieve to be seen as a useful option. 3 At our institution, we use a low-intensity fludarabine/cyclophosphamide conditioning regimen without pre-emptive T-cell depletion. This has been shown to be safe and effective in acute myeloid leukemia, 4 acute lymphoblastic leukaemia 5 and lymphoid malignancies 6 for patients over a wide age range (the latter report included 11 of the current cohort).For this study, we retrospectively collected data from myeloma patients who underwent allo-SCT. Patients received reduced intensity conditioning with fludarabine 25 mg/ m 2 /day for 5 days and cyclophosphamide 1 g/m 2 /day for 2 days, followed by infusion of stem cells from human leukocyte antigen (HLA)-matched donors. GvHD prophylaxis consisted of short-course methotrexate (5 mg/m 2 on days +3, +6 and +11), and cyclosporin (5 mg/kg on day À2 and 3 mg/kg per day thereafter, adjusted according to blood levels). Standard supportive therapy and antimicrobial prophylaxis were employed. Full details of the protocol are as previously described. 4 Myeloma was monitored with serum and urine protein electrophoresis, and latterly serum-free light chain assay. From 2007 onwards, patients received their conditioning in an ambulatory setting, with admission to the hospital ward only if medical complications arose. Details of the statistical methods are given in Supplementary Materials.All 37 patients with myeloma undergoing allo-SCT between 2000 and 2018 were included in the analysis. The majority were male (76%) with a median age at transplant of 52 years (range 31-63). International Staging System (ISS) values were recorded for 32 patients as follows: I 21Á9%, II 40Á6% and III 38Á0%. At least one high-risk cytogenetic feature (t(4:14), t(14:16),17pÀ or 1q+) was present for 57% of the cohort who had available cytogenetic analysis, consistent with a high-risk population.
e19574 Background: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was recognised by the WHO in 2016 as a rare sub-type of peripheral T-cell, non-Hodgkin lymphoma (NHL), characterized by an indolent clinical course and excellent prognosis. Little evidence exists on the role of post-treatment imaging surveillance with variable practices across the world. Recent UK guidelines recommend that routine surveillance imaging should not be offered to BIA-ALCL patients, in line with national/international recommendations for other NHLs. The aim of this study was to quantify the direct economic costs (DEC) of post-treatment BIA-ALCL routine radiological surveillance at our institution compared to the DEC if UK guidelines were followed. Methods: Following IRB approval a retrospective analysis of a prospectively maintained database of BIA-ALCL patients at The Royal Marsden Hospital was performed. DECs were estimated using current (2020) NHS tariffs for radiological investigations. Imaging undertaken for symptomatic problems/non-BIA-ALCL related concerns was excluded. Results: Eleven patients [median age: 49 years (IQR 45-52)] were treated for BIA-ALCL between 2015-2020 following cosmetic augmentation (n = 6) or breast reconstruction (n = 5). Median time from first implant surgery to BIA-ALCL diagnosis was 11 years (IQR 8-12). Patients presented with effusion (n = 7), mass (n = 2) or effusion and mass (n = 2). One patient had neoadjuvant CHOP/brentuximab, all 11 had explantation with en bloc total capsulectomy, 1 had adjuvant CHOP. Median follow-up was 38 months (IQR 12-47) with no local or distant relapses. Two patients did not have any radiological surveillance and 1 had follow-up elsewhere. The remaining 8 patients had a combination of PET/CT (n = 10), CT (n = 2), breast ultrasound (n = 6), mammogram (n = 4) and breast MRI (n = 1) as routine imaging follow-up not guided by clinical concerns. This represents evolving practice at our institution as the UK guidelines were published in 2021. Total cost of routine imaging surveillance was £10,396 ($14,396) with median cost of £1,953 ($2,705) per patient [IQR £526-2029 ($728-2,810)]. This cost could have been saved based on current guidelines recommending no routine surveillance for patients with no symptoms or clinical concerns. Conclusions: This data demonstrates that omission of routine post-treatment imaging surveillance, as per the recent UK guidelines, would result in a median DEC saving of £1,953 ($2,705) per patient at our institution. No local or distant relapses where identified within the follow-up period, in line with the existing literature suggesting BIA-ALCL has a very low risk of relapse and excellent prognosis. These findings provide a value-based analysis to further support the recommendation not to perform routine post-treatment imaging surveillance in patients with BIA-ALCL.
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