Nonmalignant CD30+ Cells in Contralateral Peri-Implant Capsule of Patient With BIA-ALCL: A Premalignant Step?

CD30 lymphocyte activation antigen and phosphorylated STAT3 (pSTAT3) are consistent markers of tumor cells in breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). We present a case of BIA-ALCL in a breast implant capsule containing clustered tumor cells expressing CD30, pSTAT3, pSTAT6, interleukin 9, and granzyme B tumor cell biomarkers. Remarkably, the contralateral breast contained many scattered large, atypical CD30+ cells surrounded by inflammatory cells, raising a suspicion of bilateral BIA-ALCL, known to occur in some patients. To clarify the diagnosis, immunohistochemistry and multilabel immunofluorescence were performed. Unlike the tumor cells, the atypical CD30+ cells of the contralateral breast lacked pSTAT3, pSTAT6, interleukin 9, and granzyme B, eliminating a diagnosis of bilateral BIA-ALCL. This case highlights the importance of interpreting CD30 staining in the context of other tumor cell biomarkers and histopathology to avoid an incorrect diagnosis of BIA-ALCL. We believe the findings also suggest the possibility of CD30 expression as an early event in the multistep pathogenesis of BIA-ALCL.

Short-Term Complications Associated With Acellular Dermal Matrix-Assisted Direct-to-Implant Breast Reconstruction.

BACKGROUND: Although direct-to-implant breast reconstruction is a more concise procedure than 2-stage expander/implant reconstruction, it is less frequently performed. Skeptics of direct-to-implant reconstruction cite risk of postoperative complications as a reason for its rejection. To determine whether these perceptions are valid, we evaluated our 13-year experience of acellular dermal matrix (ADM)-assisted, direct-to-implant breast reconstruction. We report complication and reoperation rates associated with this technique as well as predictors for these outcomes. METHODS: This retrospective study included all patients who underwent immediate, ADM-assisted, direct-to-implant, breast reconstruction from December 2001 to May 2014 at 2 practices. Postoperative complications, defined as those occurring within the first 12 months after reconstructive surgery, were evaluated. Univariate/multivariate analyses were performed to determine the influence of patient-, breast-, and surgery-related characteristics on the development of complications. RESULTS: A total of 1584 breast reconstructions (721 bilateral, 142 unilateral) in 863 patients were performed; 35% were oncologic, and 65% were prophylactic reconstructions. Complication rate was 8.6% and included skin necrosis (5.9%), infection (3.0%), implant loss (2.9%), seroma (1.1%), and hematoma (0.9%). Reoperative rate in breasts with complications was 3.2%. Age 50 years or older, smoking, nonnipple-sparing mastectomy, and implant size of 600 mL or greater strongly predicted the development of complications (P < 0.001). CONCLUSIONS: Our cumulative 13-year experience demonstrates that immediate, ADM-assisted, direct-to-implant breast reconstruction is safe, effective, and reliable. Complication and reoperation rates are less than 10% and are comparable to those reported for 2-stage procedures in the published literature.

The Spectrum of Non-neoplastic Changes Associated With Breast Implants: Histopathology, Imaging, and Clinical Significance.

Breast implant-associated anaplastic large cell lymphoma has been recognized as a distinct entity in the World Health Organization classification of hematolymphoid neoplasms. These neoplasms are causally related to textured implants that were used worldwide until recently. Consequently, there is an increased demand for processing periprosthetic capsules, adding new challenges for surgeons, clinicians, and pathologists. In the literature, the focus has been on breast implant-associated anaplastic large cell lymphoma; however, benign complications related to the placement of breast implants occur in up to 20% to 30% of patients. Imaging studies are helpful in assessing patients with breast implants for evidence of implant rupture, changes in tissues surrounding the implants, or regional lymphadenopathy related to breast implants, but pathologic examination is often required. In this review, we couple our experience with a review of the literature to describe a range of benign lesions associated with breast implants that can be associated with different clinical presentations or pathogenesis and that may require different diagnostic approaches. We illustrate the spectrum of the most common of these benign disorders, highlighting their clinical, imaging, gross, and microscopic features. Finally, we propose a systematic approach for the diagnosis and handling of breast implant specimens in general.

Efficacy of Vancomycin-based Continuous Triple Antibiotic Irrigation in Immediate, Implant-based Breast Reconstruction.

BACKGROUND: Single irrigation of the peri-implant space with a cefazolin-based triple antibiotic solution is a routine antibiotic prophylaxis measure during implant-based breast augmentation and reconstruction. Cefazolin, however, is less efficacious against resistant Staphylococcus species, which are the predominant bacterial species isolated from the peri-implant space. Vancomycin is effective against resistant Staphylococcus species and may be a more appropriate prophylactic agent. The availability of single-injection long-acting anesthetic agents allows the novel use of the elastomeric infusion pump for continuous irrigation of antibiotic solution into the peri-implant space. The efficacy of continuous irrigation with a vancomycin-based solution is evaluated here. METHODS: Study patients (N = 163; group 1) who underwent immediate, direct-to-implant breast reconstruction received continuous infusion of a vancomycin-based triple antibiotic solution. Patients also received a single injection of liposomal bupivacaine in the pectoralis major/minor muscles for pain control. A historic control group (N = 113; group II) received ropivacaine local anesthetic via the infusion pump and a single intraoperative irrigation of the peri-implant space with the vancomycin-based triple antibiotic solution. Incidence of postsurgical infection during the 6 weeks after surgery was compared between the groups. RESULTS: Group I patients had a statistically significant lower incidence of infections (1.9%) than group II patients (6.4%) (P = 0.007). There were no vancomycin-related adverse effects. CONCLUSIONS: Continuous breast irrigation with a vancomycin-based triple antibiotic solution is a safe and effective accompaniment for immediate implant reconstruction. Use of intramuscular anesthetic injection for postoperative pain control allows the elastomeric infusion pump to be available for local tissue antibiotic irrigation.

Acellular Dermal Matrix-Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience.

BACKGROUND: Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown. METHODS: Patients undergoing acellular dermal matrix-assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture. RESULTS: A total of 1584 breast reconstructions in 863 patients were performed. Mean follow-up of patients was 4.7 years; 45 percent of patients had greater than or equal to 5 years of follow-up. The cumulative incidence of capsular contracture was 0.8 percent. Smaller implant size (<400 ml) and postoperative radiotherapy were significantly associated with an increased risk of capsular contracture, but the incidence of capsular contracture was 1.9 percent in irradiated breasts. All capsular contractures developed within the first 2 years, with no new events with longer follow-up. CONCLUSIONS: In this long-term study, the cumulative incidence of capsular contracture with acellular dermal matrix-assisted reconstruction remains low, even in irradiated breasts. Capsular contracture appears to be an early event, and longer follow-up does not appear to increase the incidence, suggesting that acellular dermal matrix may truly mitigate the development of capsular contracture as opposed to delaying its occurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The incidence of tuberous breast deformity in asymmetric and symmetric mammaplasty patients.

BACKGROUND: Breast asymmetry is commonly accompanied by tuberous deformity. To date, no study has reported the incidence of this breast deformity in the presence of asymmetry. A retrospective analysis of standard preoperative photographs was performed on 375 consecutive female patients presenting for mammaplasty over a 10-year span. METHODS: Women were examined for symmetry, asymmetry, and the presence of tuberous deformity. Patients were graded by the Grolleau Classification System. Patients having congenital anomalies, tumors, infection, radiation, chest wall deformities, previous breast surgery history, and incomplete chart data were excluded. RESULTS: Of the 375 patients studied, 81.1 percent (n = 304) presented with asymmetry. Of these asymmetric women, 88.8 percent (n = 270) were found to have tuberous deformity. Of the 71 patients who were symmetric, 7 percent (n = 5) were tuberous. Concurrent nipple-areola complex involvement in the tuberous asymmetric patient population was present in 50 percent of the women (n = 116). Of the tuberous deformities with nipple-areola complex, 87.9 percent (n = 116) were Grolleau type III. Nipple-areola complex involvement was not found in any of the symmetric patients. Of the 275 women with tuberous deformity, 531 breasts were tuberous and 60.3 percent (n = 320) were Grolleau's type III. In total, 57.1 percent of all reduction mammaplasties (n = 92) and 83.2 percent of all augmentation mammaplasties (n = 178) had asymmetry with tuberous deformity. CONCLUSIONS: This is the first published study to demonstrate that tuberous deformity is strongly associated with asymmetry in women presenting for mammaplasty. This should be evaluated in preoperative planning to ensure optimal outcome. Patients with this deformity should be educated preoperatively so their expectations of postoperative results are realistic.