Letter - Clinical
Paraneoplastic acquired ichthyosis as the first manifestation in breast implant-associated anaplastic large cell lymphoma
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Clinical</span>" "titulo" => "Paraneoplastic acquired ichthyosis as the first manifestation in breast implant-associated anaplastic large cell lymphoma" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621" "paginaFinal" => "624" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Héctor Chiang Wong, Pilar Martínez Sánchez, María del Carmen González Guzmán" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Héctor" "apellidos" => "Chiang Wong" "email" => array:1 [ 0 => "jhonjoy3@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Pilar" "apellidos" => "Martínez Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María del Carmen" "apellidos" => "González Guzmán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hematology Unit, José Carrasco Arteaga Hospital, Cuenca, Ecuador" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hematology Unit, 12 de Octubre Hospital, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Rheumatology Unit, José Carrasco Arteaga Hospital, Cuenca, Ecuador" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1733 "Ancho" => 2925 "Tamanyo" => 485171 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A, B and C) scaly plaques with cracks and erythematous edges (ichthyosis).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anaplastic large cell lymphoma (ALCL) accounts for 1%–3% of non-Hodgkin's lymphomas and approximately 15% of T-lymphomas. The 5th edition of the World Health Organization (WHO) classification of hematolymphoid tumors recognizes four different subtypes of ALCL: ALK-positive, ALK-negative, primary cutaneous, and those associated with breast implants (BIA-ALCL).</p><p id="par0010" class="elsevierStylePara elsevierViewall">In January 2011, the Food and Drug Administration (FDA) published 34 cases collected between 1997 and 2010, with a probable association between ALCL and the use of breast implants. Owing to the implementation of the PROFILE registry, approximately 900 cases have been reported worldwide.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Implants are categorized according to their internal fill (saline or silicone), shape (symmetric or asymmetric), or external surface (smooth or textured).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Textured implants have the greatest association with this type of lymphoma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 43-year-old woman with a history of bilateral breast prosthesis implantation (silicone-textured), 6-years ago for aesthetic reasons. She visited the clinic because of the presence of scaly plaques with cracks and erythematous edges throughout her body, with a 3-month history. In some plaques, fine superficial scaling was prominent in the intermammary fold, scalp, and on the edge of the eyelids. Physical examination revealed a fixed, painless, 1.5 cm adenopathy in the right axillary region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Chest CT scan, along with a whole-body PET/CT, revealed a liquid collection surrounding the right mammary implant, with an increase in soft tissues in the chondrosternal joint, poor definition of the pectoral planes in its medial portion, and trabeculation of subcutaneous fat. In contrast, multiple pathological adenopathies were observed in the anterior mediastinum, bilateral axillary regions, and supraclavicular fossae (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A‒C).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">While a skin biopsy was suggestive of ichthyosis, subsequent biopsy of the right axillary lymph node revealed neoplastic cells with a multilobulated anaplastic morphology and an “embryoid” appearance with foci of tumor necrosis. Immunohistochemistry phenotypes were CD45+ CD30+, CD43+, Bcl-2+, MUM-1+, MIB-1+(60%), CD3-, CD20-, CD79a-, CD10-, BCL6-, CD38-, LMP1-, ALK-, suggestive of anaplastic large cell lymphoma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A‒F).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the clinical, radiological, and pathological findings, the diagnosis of BIA-ALCL with a locally aggressive or extensive stage was established (stage III, T4N2M0).</p><p id="par0040" class="elsevierStylePara elsevierViewall">BIA-ALCL commonly presents as a late peri-implant seroma (>80%), causing distortion and asymmetry of the breasts. It can manifest with regional lymphadenopathy (predominantly axillary, supra-, or infra-clavicular) in 20% of cases, or concurrent with skin lesions (erythema, rash, erythematous nodules) or as de novo in 8% of cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case, ichthyosis was the initial cutaneous paraneoplastic manifestation of BIA-ALCL and dermatological management was based on glycerin soap, liquid petroleum jelly, and methylprednisolone aceponate (ointment). This cutaneous alteration can appear in the same manner in endocrinopathies, immunological disorders, vitamin deficiencies, infections, and with drug use.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">BIA-ALCL originates from the fibrous capsule surrounding the implant, except in the advanced stages, which involve the surrounding tissue. Stage I was diagnosed in 83% of patients, and only 7% presented with stage IV disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiopathogenesis of BIA-ALCL is multifactorial, namely chronic infection in the textured implant configuration, gram-negative biofilm formation, immune response, chronic inflammation, host genetics (e.g., JAK/STAT, p53), and timing of oncogenesis. The presumptive triggers include mechanical friction, silicone implant shell particles, silicone leachate, and bacteria. BIA-ALCL presents at a median time of 8–10 years after breast prosthetic implantation.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Considering that 2%–4% of cases can occur bilaterally, both implants of our patient were removed with total capsulectomy,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,8,10</span></a> and chemotherapy was initiated under the CHOP regimen (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone). After six cycles, cthe complete morpho-metabolic response of the patient was confirmed by PET/CT, with subsequent disappearance of the skin lesions.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We must establish the role of certain agents (brentuximab vedotin), adjuvant therapies (radiotherapy), and autologous stem cell transplantation, mainly in locally aggressive or advanced stages (stages II‒IV).</p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, the discussed case of a patient with BIA-ALCL who presented with acquired ichthyosis, emphasizes a multidisciplinary approach for early diagnosis and corresponding management.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Héctor Chiang Wong: Approval of the final version of the manuscript, critical literature review, data collection, analysis and interpretation; intellectual participation in propaedeutic and/or therapeutic management of the studied case.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pilar Martínez Sánchez: Approval of the final version of the manuscript, data collection, intellectual participation in propaedeutic and/or therapeutic management of studied case.</p><p id="par0090" class="elsevierStylePara elsevierViewall">María del Carmen González Guzmán: Approval of the final version of the manuscript, data collection, analysis, and interpretation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-11-01" "fechaAceptado" => "2022-12-14" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the 12 de Octubre Hospital, Madrid, España.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1733 "Ancho" => 2925 "Tamanyo" => 485171 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A, B and C) scaly plaques with cracks and erythematous edges (ichthyosis).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1956 "Ancho" => 2508 "Tamanyo" => 297450 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A‒B) Liquid collection surrounding the right mammary implant, with an increase in soft tissues in the chondrosternal joint, poor definition of the pectoral planes in its medial portion, and trabeculation of subcutaneous fat. (C) Multiple pathological adenopathies were observed in the anterior mediastinum, and bilateral axillary regions and supraclavicular fossae.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1740 "Ancho" => 3341 "Tamanyo" => 1487155 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A‒F) Biopsy of the right axillary lymph node: CD45+ CD30+, CD43+, Bcl-2+, MUM-1+, MIB-1+(60%), CD3-, CD20-, CD79a-, CD10-, BCL6-, CD38-, LMP1, ALK-, suggestive of anaplastic large cell lymphoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breast Implant-associated anaplastic large cell lymphoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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