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along with a whole-body PET&#47;CT&#44; revealed a liquid collection surrounding the right mammary implant&#44; with an increase in soft tissues in the chondrosternal joint&#44; poor definition of the pectoral planes in its medial portion&#44; and trabeculation of subcutaneous fat&#46; In contrast&#44; multiple pathological adenopathies were observed in the anterior mediastinum&#44; bilateral axillary regions&#44; and supraclavicular fossae &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8210;C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">While a skin biopsy was suggestive of ichthyosis&#44; subsequent biopsy of the right axillary lymph node revealed neoplastic cells with a multilobulated anaplastic morphology and an &#8220;embryoid&#8221; appearance with foci of tumor necrosis&#46; Immunohistochemistry phenotypes were CD45&#43; CD30&#43;&#44; CD43&#43;&#44; Bcl-2&#43;&#44; MUM-1&#43;&#44; MIB-1&#43;&#40;60&#37;&#41;&#44; CD3-&#44; CD20-&#44; CD79a-&#44; CD10-&#44; BCL6-&#44; CD38-&#44; LMP1-&#44; ALK-&#44; suggestive of anaplastic large cell lymphoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#8210;F&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the clinical&#44; radiological&#44; and pathological findings&#44; the diagnosis of BIA-ALCL with a locally aggressive or extensive stage was established &#40;stage III&#44; T4N2M0&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">BIA-ALCL commonly presents as a late peri-implant seroma &#40;&#62;80&#37;&#41;&#44; causing distortion and asymmetry of the breasts&#46; It can manifest with regional lymphadenopathy &#40;predominantly axillary&#44; supra-&#44; or infra-clavicular&#41; in 20&#37; of cases&#44; or concurrent with skin lesions &#40;erythema&#44; rash&#44; erythematous nodules&#41; or as de novo in 8&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case&#44; ichthyosis was the initial cutaneous paraneoplastic manifestation of BIA-ALCL and dermatological management was based on glycerin soap&#44; liquid petroleum jelly&#44; and methylprednisolone aceponate &#40;ointment&#41;&#46; This cutaneous alteration can appear in the same manner in endocrinopathies&#44; immunological disorders&#44; vitamin deficiencies&#44; infections&#44; and with drug use&#46;<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&#44; except in the advanced stages&#44; which involve the surrounding tissue&#46; Stage I was diagnosed in 83&#37; of patients&#44; and only 7&#37; presented with stage IV disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiopathogenesis of BIA-ALCL is multifactorial&#44; namely chronic infection in the textured implant configuration&#44; gram-negative biofilm formation&#44; immune response&#44; chronic inflammation&#44; host genetics &#40;e&#46;g&#46;&#44; JAK&#47;STAT&#44; p53&#41;&#44; and timing of oncogenesis&#46; The presumptive triggers include mechanical friction&#44; silicone implant shell particles&#44; silicone leachate&#44; and bacteria&#46; BIA-ALCL presents at a median time of 8&#8211;10 years after breast prosthetic implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Considering that 2&#37;&#8211;4&#37; of cases can occur bilaterally&#44; both implants of our patient were removed with total capsulectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;8&#44;10</span></a> and chemotherapy was initiated under the CHOP regimen &#40;cyclophosphamide&#44; doxorubicin hydrochloride&#44; vincristine sulfate&#44; and prednisone&#41;&#46; After six cycles&#44; cthe complete morpho-metabolic response of the patient was confirmed by PET&#47;CT&#44; with subsequent disappearance of the skin lesions&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We must establish the role of certain agents &#40;brentuximab vedotin&#41;&#44; adjuvant therapies &#40;radiotherapy&#41;&#44; and autologous stem cell transplantation&#44; mainly in locally aggressive or advanced stages &#40;stages II&#8210;IV&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; the discussed case of a patient with BIA-ALCL who presented with acquired ichthyosis&#44; emphasizes a multidisciplinary approach for early diagnosis and corresponding management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">H&#233;ctor Chiang Wong&#58; Approval of the final version of the manuscript&#44; critical literature review&#44; data collection&#44; analysis and interpretation&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of the studied case&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pilar Mart&#237;nez S&#225;nchez&#58; Approval of the final version of the manuscript&#44; data collection&#44; intellectual participation in propaedeutic and&#47;or therapeutic management of studied case&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Mar&#237;a del Carmen Gonz&#225;lez Guzm&#225;n&#58; Approval of the final version of the manuscript&#44; data collection&#44; analysis&#44; and interpretation&#46;</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&#46;</p></span></span>"
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Letter - Clinical
Paraneoplastic acquired ichthyosis as the first manifestation in breast implant-associated anaplastic large cell lymphoma
Héctor Chiang Wonga,
Autor para correspondência
jhonjoy3@hotmail.com

Corresponding author.
, Pilar Martínez Sánchezb, María del Carmen González Guzmánc
a Hematology Unit, José Carrasco Arteaga Hospital, Cuenca, Ecuador
b Hematology Unit, 12 de Octubre Hospital, Madrid, España
c Rheumatology Unit, José Carrasco Arteaga Hospital, Cuenca, Ecuador
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anaplastic large cell lymphoma &#40;ALCL&#41; accounts for 1&#37;&#8211;3&#37; of non-Hodgkin&#39;s lymphomas and approximately 15&#37; of T-lymphomas&#46; The 5th edition of the World Health Organization &#40;WHO&#41; classification of hematolymphoid tumors recognizes four different subtypes of ALCL&#58; ALK-positive&#44; ALK-negative&#44; primary cutaneous&#44; and those associated with breast implants &#40;BIA-ALCL&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In January 2011&#44; the Food and Drug Administration &#40;FDA&#41; published 34 cases collected between 1997 and 2010&#44; with a probable association between ALCL and the use of breast implants&#46; Owing to the implementation of the PROFILE registry&#44; approximately 900 cases have been reported worldwide&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Implants are categorized according to their internal fill &#40;saline or silicone&#41;&#44; shape &#40;symmetric or asymmetric&#41;&#44; or external surface &#40;smooth or textured&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Textured implants have the greatest association with this type of lymphoma&#46;</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 &#40;silicone-textured&#41;&#44; 6-years ago for aesthetic reasons&#46; She visited the clinic because of the presence of scaly plaques with cracks and erythematous edges throughout her body&#44; with a 3-month history&#46; In some plaques&#44; fine superficial scaling was prominent in the intermammary fold&#44; scalp&#44; and on the edge of the eyelids&#46; Physical examination revealed a fixed&#44; painless&#44; 1&#46;5&#8239;cm adenopathy in the right axillary region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Chest CT scan&#44; along with a whole-body PET&#47;CT&#44; revealed a liquid collection surrounding the right mammary implant&#44; with an increase in soft tissues in the chondrosternal joint&#44; poor definition of the pectoral planes in its medial portion&#44; and trabeculation of subcutaneous fat&#46; In contrast&#44; multiple pathological adenopathies were observed in the anterior mediastinum&#44; bilateral axillary regions&#44; and supraclavicular fossae &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8210;C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">While a skin biopsy was suggestive of ichthyosis&#44; subsequent biopsy of the right axillary lymph node revealed neoplastic cells with a multilobulated anaplastic morphology and an &#8220;embryoid&#8221; appearance with foci of tumor necrosis&#46; Immunohistochemistry phenotypes were CD45&#43; CD30&#43;&#44; CD43&#43;&#44; Bcl-2&#43;&#44; MUM-1&#43;&#44; MIB-1&#43;&#40;60&#37;&#41;&#44; CD3-&#44; CD20-&#44; CD79a-&#44; CD10-&#44; BCL6-&#44; CD38-&#44; LMP1-&#44; ALK-&#44; suggestive of anaplastic large cell lymphoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#8210;F&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the clinical&#44; radiological&#44; and pathological findings&#44; the diagnosis of BIA-ALCL with a locally aggressive or extensive stage was established &#40;stage III&#44; T4N2M0&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">BIA-ALCL commonly presents as a late peri-implant seroma &#40;&#62;80&#37;&#41;&#44; causing distortion and asymmetry of the breasts&#46; It can manifest with regional lymphadenopathy &#40;predominantly axillary&#44; supra-&#44; or infra-clavicular&#41; in 20&#37; of cases&#44; or concurrent with skin lesions &#40;erythema&#44; rash&#44; erythematous nodules&#41; or as de novo in 8&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case&#44; ichthyosis was the initial cutaneous paraneoplastic manifestation of BIA-ALCL and dermatological management was based on glycerin soap&#44; liquid petroleum jelly&#44; and methylprednisolone aceponate &#40;ointment&#41;&#46; This cutaneous alteration can appear in the same manner in endocrinopathies&#44; immunological disorders&#44; vitamin deficiencies&#44; infections&#44; and with drug use&#46;<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&#44; except in the advanced stages&#44; which involve the surrounding tissue&#46; Stage I was diagnosed in 83&#37; of patients&#44; and only 7&#37; presented with stage IV disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiopathogenesis of BIA-ALCL is multifactorial&#44; namely chronic infection in the textured implant configuration&#44; gram-negative biofilm formation&#44; immune response&#44; chronic inflammation&#44; host genetics &#40;e&#46;g&#46;&#44; JAK&#47;STAT&#44; p53&#41;&#44; and timing of oncogenesis&#46; The presumptive triggers include mechanical friction&#44; silicone implant shell particles&#44; silicone leachate&#44; and bacteria&#46; BIA-ALCL presents at a median time of 8&#8211;10 years after breast prosthetic implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Considering that 2&#37;&#8211;4&#37; of cases can occur bilaterally&#44; both implants of our patient were removed with total capsulectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;8&#44;10</span></a> and chemotherapy was initiated under the CHOP regimen &#40;cyclophosphamide&#44; doxorubicin hydrochloride&#44; vincristine sulfate&#44; and prednisone&#41;&#46; After six cycles&#44; cthe complete morpho-metabolic response of the patient was confirmed by PET&#47;CT&#44; with subsequent disappearance of the skin lesions&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We must establish the role of certain agents &#40;brentuximab vedotin&#41;&#44; adjuvant therapies &#40;radiotherapy&#41;&#44; and autologous stem cell transplantation&#44; mainly in locally aggressive or advanced stages &#40;stages II&#8210;IV&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; the discussed case of a patient with BIA-ALCL who presented with acquired ichthyosis&#44; emphasizes a multidisciplinary approach for early diagnosis and corresponding management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">H&#233;ctor Chiang Wong&#58; Approval of the final version of the manuscript&#44; critical literature review&#44; data collection&#44; analysis and interpretation&#59; intellectual participation in propaedeutic and&#47;or therapeutic management of the studied case&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pilar Mart&#237;nez S&#225;nchez&#58; Approval of the final version of the manuscript&#44; data collection&#44; intellectual participation in propaedeutic and&#47;or therapeutic management of studied case&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Mar&#237;a del Carmen Gonz&#225;lez Guzm&#225;n&#58; Approval of the final version of the manuscript&#44; data collection&#44; analysis&#44; and interpretation&#46;</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&#46;</p></span></span>"
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Informação do artigo
ISSN: 03650596
Idioma original: Inglês
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