Can breast implant associated Anaplastic Large Cell Lymphoma (ALCL) be present with normal ultrasound and Magnetic Resonance Imaging (MRI) exams of the breasts?

Can BIA-ALCL Be Present with Normal Ultrasound and MRI?

Yes, breast implant-associated ALCL can be present even when ultrasound and MRI appear normal, particularly in early disease when only microscopic malignant cells exist in the periprosthetic fluid without detectable effusion or mass formation.

Understanding the Diagnostic Limitations

The imaging sensitivity for BIA-ALCL is imperfect, and normal imaging does not exclude the diagnosis:

• Ultrasound has 84% sensitivity for detecting effusions but can miss early disease when fluid collections are minimal or when malignant cells are present without significant fluid accumulation 1
• MRI demonstrates 82% sensitivity for effusion detection and only 50% sensitivity for mass detection, with specificity of just 33% for effusions 1
• Both modalities can fail to detect disease when BIA-ALCL presents with microscopic involvement of the capsule without gross fluid or mass 1

Critical Clinical Context

The most important consideration is the clinical presentation, not imaging findings:

• Late-onset seroma (>1 year post-implantation) is the hallmark presentation, occurring at a median of 8-10 years after implant placement 1
• Clinical symptoms include breast swelling, asymmetry, fullness, or pain - these symptoms mandate investigation regardless of imaging findings 1
• A small incidental volume of periprosthetic fluid may be normal, but any symptomatic presentation warrants aspiration 1

Diagnostic Algorithm When BIA-ALCL is Suspected

If a patient with breast implants presents with new symptoms (swelling, asymmetry, sensation of fullness, pain) occurring >1 year after implantation:

1. Perform ultrasound examination first to assess for effusion or mass 1

2. If ultrasound shows ANY fluid collection (even if minimal), proceed immediately to ultrasound-guided aspiration for cytology, regardless of the volume 1, 2

   • Minimum 10-50 mL is ideal, but aspirate whatever volume is present 1
   • Send for: cytopathology smears, cell block with CD30 immunohistochemistry, flow cytometry, and molecular studies 1

3. If ultrasound is negative but clinical suspicion remains high, consider MRI as a second-line test 1

   • MRI may detect small volume effusions or mass components not visible on ultrasound 1
   • MRI findings include peri-implant tissue edema, effusion, capsule enhancement, and irregular capsule thickness 1

4. If both ultrasound and MRI are negative but symptoms persist or worsen, do NOT rule out BIA-ALCL 2, 3

   • Consider repeat imaging in 4-6 weeks if symptoms continue
   • Maintain high clinical suspicion, as imaging can be falsely negative in early disease

Critical Pitfalls to Avoid

Never dismiss symptoms based solely on negative imaging:

• Late seroma in the absence of infection should always undergo aspiration and cytological analysis, even if imaging appears normal or shows only minimal fluid 3
• BIA-ALCL can present with variable clinical signs: palpable mass, painless seroma, or painful seroma - each requires investigation 3
• Previous serial drainages may artificially lower tumor burden, making diagnosis more difficult and potentially causing false-negative results 1

The diagnosis is made by cytopathology, not imaging:

• CD30 positivity is required by definition for BIA-ALCL diagnosis 1
• Imaging serves to guide aspiration or biopsy, not to exclude disease 1
• Mammography has only 73% sensitivity and 50% specificity for detecting abnormalities and should not be relied upon 1

When to Proceed to Surgery Despite Normal Imaging

If clinical suspicion remains high despite negative imaging and negative or non-diagnostic aspiration:

• Consider proceeding to capsulectomy with complete pathologic examination of the capsule, as microscopic disease may be present without detectable fluid or mass 2
• This is particularly important if the patient has textured implants, which carry higher BIA-ALCL risk 1

Bottom Line for Clinical Practice

Normal ultrasound and MRI do not exclude BIA-ALCL. The key is recognizing the clinical presentation: any patient with breast implants who develops new swelling, asymmetry, fullness, or pain >1 year after implantation requires aspiration of any detectable fluid for cytology with CD30 immunohistochemistry, regardless of how "normal" the imaging appears 1, 2. When imaging is negative but symptoms persist, maintain high suspicion and consider repeat imaging or surgical exploration 3.