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乳房假体植入相关间变大细胞淋巴瘤（BIA-ALCL）是一种罕见的外周T细胞淋巴瘤，发病率呈上升趋势。不过，许多治疗乳腺癌患者的临床医生对该疾病并未重视。 2017年10月18日，《美国医学会杂志外科学分册》在线发表宾夕法尼亚州立大学医学院密尔顿·史内夫里·赫尔希医学中心的研究报告，对BIA-ALCL的发生发展、风险因素、诊断、后续治疗、医疗领域信息传播进行了评定。 证据：该研究针对学术型医疗环境，检索所有与BIA-ALCL相关的文献，包括综述述评、病例报道、原始研究。提取BIA-ALCL数据，例如病理生理学、患者人口统计学、表现、诊断、治疗和转归，尤其年龄、发病时间、植入假体类型、初始症状、治疗、生存。该检索于2017年1月进行。 结果：排除重复之后，对304篇相关文献进行评定，1997年8月首例个案记录至2017年1月共有115篇符合本文评定要求，其中综述30篇、个案或系列病例报道44篇、原始研究15篇、其他26篇（例如操作技术、专题、通讯）。 趋势：上述文献报道患者93例，此外还有宾夕法尼亚州立大学医学院密尔顿·史内夫里·赫尔希医学中心未报道患者2例，合计患者95例被纳入系统回顾。虽然对于发病率仍有争议，但是似呈上升趋势，由于患者和医生都越来越重视该问题。 机制：几乎所有记录在案的BIA-ALCL病例均与假体表面纹理相关，可能发病机制为惰性感染所致慢性炎症，引起间变淋巴瘤激酶阴性和CD30阳性T细胞的恶性转化。 表现：临床表现平均出现时间约为植入术后10年，83例患者其中55例（66%）最初表现为孤立的迟发血清肿、7例（8%）最初表现为孤立的乳房新肿块。 诊断：超声引导液体抽吸检查。 治疗：必须包括移除植入假体和周围包膜，较晚期病变可能需要化疗、放疗和淋巴结清扫。 总结：间变大细胞淋巴瘤是乳房假体植入患者的罕见癌症，但是发病率正呈上升趋势。所有涉及乳房假体植入患者的医生都必须重视该问题，并且有能力识别最初症状。在隆乳或乳房重建之前，外科医生需要向患者告知乳房假体植入相关间变大细胞淋巴瘤的风险，尤其强调与植入假体纹理的相关性；必须教育患者接受假体植入后常规监测的重要性，并且随着随访增加，可能导致该诊断率进一步上升。 相关阅读 JAMA Surg. 2017 Oct 18. [Epub ahead of print] Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Systematic Review. Ashley N. Leberfinger; Brittany J. Behar; Nicole C. Williams; Kevin L. Rakszawski; John D. Potochny; Donald R. Mackay; Dino J. Ravnic. Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania. This systematic review assesses how breast implant-associated anaplastic large cell lymphoma develops; describes its risk factors, diagnosis, and subsequent treatment; and aims to disseminate information about this entity to the medical field at large. KEY POINTS QUESTION: What is the incidence of breast implant-associated anaplastic large cell lymphoma? FINDINGS: In this systematic review of 115 articles and 95 patients, the incidence of breast implant-associated anaplastic large cell lymphoma remains controversial, but the diagnosis appears to be increasing as both patients and practitioners become more aware of this entity. MEANING: Before breast augmentation or reconstruction, surgeons need to convey the risk of breast implant-associated anaplastic large cell lymphoma to patients, with particular emphasis on the established linkage to textured implants; patients must be educated on the importance of routine surveillance after implantation, and it is likely that increased follow-up will lead to a further rise in this diagnosis. IMPORTANCE: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a rare peripheral T-cell lymphoma, is increasing in incidence. However, many practitioners who treat patients with breast cancer are not aware of this disease. OBJECTIVES: To assess how BIA-ALCL develops, its risk factors, diagnosis, and subsequent treatment and to disseminate information about this entity to the medical field. EVIDENCE REVIEW: A literature review was performed in an academic medical setting. All review articles, case reports, original research articles, and any other articles relevant to BIA-ALCL were included. Data on BIA-ALCL, such as pathophysiology, patient demographics, presentation, diagnosis, treatment, and outcomes, were extracted. Particular focus was paid to age, time to onset, implant type, initial symptoms, treatment, and survival. The search was conducted in January 2017 for studies published in any year. FINDINGS: After duplicates were excluded, 304 relevant articles were assessed, and 115 were included from the first documented case in August 1997 through January 2017. Thirty review articles, 44 case reports or series, 15 original research articles, and 26 "other" articles (eg, techniques, special topics, letters) were reviewed. A total of 93 cases have been reported in the literature, and with the addition of 2 unreported cases from the Penn State Health Milton S. Hershey Medical Center, 95 patients were included in this systematic review. Almost all documented BIA-ALCL cases have been associated with a textured device. The underlying mechanism is thought to be due to chronic inflammation from indolent infections, leading to malignant transformation of T cells that are anaplastic lymphoma kinase (ALK) negative and CD30 positive. The mean time to presentation is approximately 10 years after implant placement, with 55 of 83 (66%) patients initially seen with an isolated late-onset seroma and 7 of 83 (8%) with an isolated new breast mass. Ultrasonography with fluid aspiration can be used for diagnosis. Treatment must include removal of the implant and surrounding capsule. More advanced disease may require chemotherapy, radiotherapy, and lymph node dissection. CONCLUSIONS AND RELEVANCE: Breast implant-associated anaplastic large cell lymphoma is a rare cancer in patients with breast implants but is increasing in incidence. It is important for all physicians involved in the care of patients with breast implants to be aware of this entity and be able to recognize initial symptoms. DOI: 10.1001/jamasurg.2017.4026 |
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