What is the best course of action for a woman with a contraceptive implant (intrauterine device) who is experiencing cramps, breast tenderness, and a breast mass?

Evaluation and Management of Breast Symptoms in a Woman with Contraceptive Implant

This patient requires urgent ultrasound evaluation of the breast mass and aspiration if fluid is present, as late-onset breast symptoms (>1 year after implant placement) with a palpable mass raise concern for breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), which presents with effusion or mass at a median of 8-10 years post-implantation. 1

Critical First Step: Rule Out BIA-ALCL

The combination of breast tenderness and a palpable mass in a woman with a contraceptive implant (assuming this refers to a breast implant, not an intrauterine device) mandates immediate evaluation for BIA-ALCL, regardless of how benign the symptoms may appear. 1, 2

Key Clinical Features of BIA-ALCL:

• Late-onset presentation: Symptoms occurring >1 year after implantation (median 8-10 years) are the hallmark of BIA-ALCL 1, 2
• Common presentations: Breast swelling, asymmetry, sensation of fullness, or pain—exactly what this patient describes 1, 2
• Higher risk with textured implants: If the patient has textured implants, suspicion should be even higher 1

Diagnostic Algorithm

Step 1: Ultrasound Examination

Perform targeted ultrasound immediately to assess for effusion or mass. 1, 2

• Ultrasound has 84% sensitivity for detecting effusions but can miss early disease 2
• If ANY fluid collection is identified (even minimal volume), proceed immediately to ultrasound-guided aspiration 1, 2
• A minimum of 10-50 mL should be aspirated when possible to provide adequate material for cytology, cell block with CD30 immunohistochemistry, flow cytometry, and molecular studies 1

Step 2: Aspiration and Cytologic Analysis

If fluid is present, aspiration is essential for diagnosis—percutaneous aspiration is diagnostic, not therapeutic. 1

• CD30 positivity is required by definition for BIA-ALCL diagnosis 1, 2
• The specimen should be sent for:
  • Cytopathology smears
  • Cell block with immunohistochemistry (CD30, ALK1, EMA, CD4, CD43, CD2, CD3, CD5, CD7, TIA-1, granzyme B, perforin) 1
  • Flow cytometry when possible 1
  • Molecular genetic studies 1

Step 3: If Ultrasound is Negative but Clinical Suspicion Remains

Consider MRI as a second-line test, though it has limited sensitivity (82% for effusions, only 50% for masses). 2

If imaging is negative but clinical suspicion remains high, consider proceeding to capsulectomy with complete pathologic examination, as microscopic disease may be present without detectable fluid or mass. 2

Common Pitfall to Avoid

Do not assume this is simple mastalgia or a benign breast condition without excluding BIA-ALCL first. While breast pain alone is rarely associated with malignancy in most contexts 3, 4, 5, the presence of a breast implant fundamentally changes the differential diagnosis. 1, 2

• Small incidental periprosthetic fluid may be normal, but any symptomatic presentation warrants aspiration 1, 2
• Do not rely on mammography alone—it has only 73% sensitivity and 50% specificity for detecting abnormalities in implant patients 2
• Early recognition is critical: Patients with disease limited to the implant capsule have much better prognosis than those with masses or systemic disease 1

Symptomatic Management While Awaiting Workup

While diagnostic evaluation proceeds, provide symptomatic relief:

• Prescribe ibuprofen or naproxen for pain control (safe and effective NSAIDs) 6, 7, 3, 4
• Recommend a well-fitting supportive bra to reduce mechanical stress 6

Clarification on "Contraceptive Implant"

If the question refers to a subdermal contraceptive implant (etonogestrel) rather than a breast implant, the approach differs entirely:

• Breast tenderness and cramping are common side effects of hormonal contraceptives 1
• However, a breast mass is NOT a normal side effect and requires the same urgent evaluation outlined above 3, 5
• Evaluate the breast mass with ultrasound (preferred in younger women to avoid radiation) 1, 3
• Any suspicious mass detected on physical examination or imaging should be biopsied 3

The presence of a palpable breast mass always requires histologic diagnosis regardless of contraceptive method. 3, 5