Recognition of the association between breast implants and lymphomas has been notable since the 1990s, although the association has been limited to breast implant–associated anaplastic large cell lymphoma and not Epstein-Barr virus (EBV).

With a growing number of documented cases of Epstein-Barr virus–positive (EBV+) diffuse large B-cell lymphoma (DLBCL) associated with certain breast implants, researchers have detailed insights into the disease being labeled the “new face” of fibrin-associated large B-cell lymphomas (FA-LBCLs).

“BIA-ALCL has been recognized as an entity for the first time by the World Health Organization (WHO) in their 2017 classification of Tumors of Hematopoietic and Lymphoid Tissues, and it has been ratified in the new WHO and International Consensus Classification categorization of tumors,” explained the researchers in Journal of Clinical Medicine. “This lymphoma is normally detected at an early stage and has good progression-free survival and overall survival with surgery, only requiring chemotherapy in advanced stages. Until recently, there were few reports of B-cell lymphomas related to breast implants, with no clear predominance of any subtype. Since 2019, however, reports of diffuse large B-cell lymphoma (DLBCL) cases related to breast implants have clearly increased.”

Amid the increases in such cases, it’s been hypothesized that BIA EBV+ DLBCL may be the archetype of DLBCL associated with chronic inflammation (CI-DLBCL) or FA-LBCL, with the WHO classifying these cases as FA-LBCL.

In their own clinic, the researchers had a case of a middle-aged woman with diagnosed EBV+ BIA-DLBCL 7 years after undergoing breast augmentation surgery with bilateral textured breast implants, in line with the median time from implantation to diagnosis (7-10 years).

After developing pain in both breasts, examination of the left capsule revealed large, atypical and pleomorphic lymphocytes with prominent nucleoli. These cells were associated with areas of fibrin deposits and necrosis, and they tested positive for CD30, CD20, CD19, CD79a, PAX-5, BCL2 and MUM1. Other findings included a positive Ki-67 proliferation index in 50% of neoplastic cells and the presence of EBV-encoded small RNA (EBER). Based on these findings, the researchers suggest that in cases where disease affects just 1 implant capsule, testing should be done for T-cell markers, B-cell markers, and EBER to help differentiate from FA-LBCL.

A PET scan showed no pathological uptake. Management included active surveillance following surgery due to the indolent nature of the case, and, nearly 2 years later, the patient has had no evidence of recurrence.

Details of the current case study ring similar to those of 17 previously reported cases of EBV+ BIA-DLBCL. All previously documented cases have been related to textured implants, and most cases began with pain and were diagnosed at an early stage.

“The available evidence suggests a good prognosis with detection at an early stage. As in BIA-ALCL, surgical management appears to be sufficient without requiring adjuvant therapy in localized stages,” wrote the researchers. “Only 3 of the 17 cases described received adjuvant chemotherapy, not including the case with invasive disease. To our knowledge, all of them have had favorable outcomes without evidence of relapse to date. Thus, the published data support surgery as the best approach in this situation.”

From a histological perspective, capsule findings usually show large pleomorphic cells distributed in sheets, clusters, and ribbons on the luminal side of the capsule, and necrotic material with limited inflammatory infiltrate is common.

Reference

Martin de Bustamante JM, Mendoza A, López-Muñoz S, García-Fernández E, Gómez-Prieto P, Jiménez-Yuste V. A new face of fibrin-associated large B-cell lymphoma: Epstein-Barr virus-positive breast implant-associated diffuse large B-cell lymphoma. J Clin Med. 2023;12(11):3614. doi:10.3390/jcm12113614