(1/5) PP7 - Spinal Epidural Anaplastic Large Cell Lymphoma associated with breast implants

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1 (1/5) PP7 - Spinal Epidural Anaplastic Large Cell Lymphoma associated with breast implants Athanasiou A 1, Iliadis A 2, Kostopoulos I 2, Tsona A 3, Spiliotopoulos A st Department of Neurosurgery, AHEPA University General Hospital, Thessaloniki, Greece 2 Department of Pathology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece 3 1 st Department of Internal Medicine, AHEPA University General Hospital, Thessaloniki, Greece

2 Introduction (2/5) Background Breast-implant associated anaplastic large cell lymphoma (BIA-ALCL) is a rare tumor (0.3% per 100,000 women/year, mean age 50years) Most common type of presentation is peri-implant effusion Less commonly a mass adjacent to the effusion Objective To present an uncommon case of BIA-ALCL with a distant extradural location at the thoracic spine Case presentation: 36 years old female patient presenting with back pain and anterior T6 bilateral radicular thoracic projection Fig. 1 Plain chest AP x-ray at presentation: pleural effusions (especially large left) and pleural nodes history of silicone breast implant placement over 10 years ago removal of implants 1.5 year ago due to local inflammation radiologic examination with chest x-ray, thoracic CT scan and thoracic MRI scan

3 Radiologic Examination & Initial Treatment (3/5) Radiologic examination revealed : Initial radiologic findings were interpreted as an exudative enhancing extradural spinal pleural effusion and so an evacuation was performed: mass lesion at T6-T7 level and left intervertebral 1-2 gr/dl, LDH 146 IU/l, negative cultures foramen, cytologic examination: inflammatory elements, mainly mass and infiltration of lymphocytes, many mesothelial cells, no neoplastic cells found vertebra and ribs at T6 level pleural effusions with pleural Rifampicin & (sulfamethoxazol + trimethoprim) were nodules. administered and a new MRI scan was ordered in four weeks Fig. 2 Thoracic CT scan and initial MRI scan showing the mass and infiltration of vertebra and ribs at the T6 level and possible expansion inside the spinal canal. Left pleural effusion and nodules are also shown. Fig. 3 MRI scan 4 weeks later showing extradural spinal mass lesion at T6-T7 level and left intervertebral foramen

4 Treatment & Results (4/5) Operation: A dorsal approach, T6 and partial T5 and T7 laminectomy, extradural mass excision along with a bilateral decompression of T6 roots were performed. The postoperative period was uneventful and the patient s symptoms were improved. The patient was discharged at the 5th post-op day. Lesion and bone specimens were sent for histologic examination. Fig. 4 - Histology of ALCL: population of large cells with irregular nuclei. Large hallmark cells showing eccentric horseshoe or kidney shaped nucleus. Malignant cells strongly positive for CD30/Ki-1. Histologic examination showed soft tissue and bone infiltration by an aggressive BIA-ALCL. She underwent chemotherapy and consolidation therapy with autologous hematopoietic stemcell transplantation (HSCT) and is in complete remission, at 3 years follow-up.

5 Conclusions (5/5) BIA-ALCL is an uncommon atypical lymphoid tumor presenting rarely at a spinal location. The clinical neurosurgeon should take into consideration reported history of breast implants and possible related complications when evaluating neurological symptoms at the thoracic level. Neoplastic nature should always be contemplated when imaging shows spinal lesions even when inflammation is apparently considered the cause. Integration of clinical and pathological data and awareness of these entities is crucial for diagnosis The role of adjunctive treatment (chemotherapy, immunotherapy, radiation, and HSCT) is still under investigation. REFERENCES: Adrada BE et al (2014) Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients. Breast Cancer Res Treat Brody GS et al (2015) Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases. Plast Reconstr Surg Hu H et al (2016) Bacterial biofilm infection detected in breast implant associated anaplastic large cell lymphoma. Plast Reconstr Surg Miranda RN et al (2014) Breast implant-associated anaplastic large-cell lymphoma: long-term follow-up of 60 patients. J Clin Oncol Ye X et al (2014) Anaplastic large cell lymphoma (ALCL) and breast implants: breaking down the evidence. Mutat Res Rev Mutat Res