Late Hematoma After Feminizing Augmentation Mammoplasty Mimicking Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

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Hematomas can be a postoperative complication in patients undergoing reconstructive or aesthetic breast surgery with a silicone implant. Most hematomas after insertion of silicone breast implants (SBI) occur within 3 days after surgery, with a relatively high incidence of 2% to 10%.^1-3 In contrast, late hematomas that occur more than 6 months after surgery are rare.⁴ Our patient had late hematoma after feminizing mammoplasty. The clinical presentation of late hematoma in our patient was very similar to that of life-threatening breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which is well known as a late complication after SBI insertion.^5,6 Differential diagnosis between these 2 conditions was necessary. Here we present the first known report of a case of late hematoma after feminizing mammoplasty with comparison of the characteristics with the reported cases of BIA-ALCL after feminizing mammoplasty.

A 56-year-old Japanese transgender individual identifying as a woman had bilateral textured SBI inserted 25 years previously by a cosmetic surgeon for feminizing breast augmentation. She had undergone male to female sex reassignment surgery 12 years before the current presentation. She had taken hormonal drugs for about 5 years in her thirties. She took no oral medications such as anticoagulants or hormonal drugs after age 40. Two years prior to her visit to our department, her right breast became swollen without any specific cause. Redness and pain were observed 2 months prior to her visit. We observed redness, swelling, and abnormal morphology of the right breast (Figure 1). Blood tests showed no elevated inflammatory response or tumor marker or coagulation system abnormality (WBC 5,030/µl, CRP 0.11 mg/dL, PT-INR 0.9, APTT 30.6 seconds, IL-2 657). Computed tomography (CT) image showed a mass had formed under the ruptured SBI, and positron emission tomography (PET/CT) image showed swelling of the right axillary lymph node (Figures 2 and 3). Ultrasound-guided aspiration of fluid was performed and cytologically examined. However, flow cytometry showed no significant findings with few lymphocytes, and Giemsa banding could not be performed with little cell counts. Mammotome biopsy suggested a diagnosis of hematoma, but the possibility of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) could not be ruled out. The SBI ruptured just before surgery, so the mass and the axillary lymph node were surgically removed (Figure 4). Pathologic examination of the excised specimen revealed only hematoma formation and inflammatory granulation. At follow-up at 6 months postoperatively, there was no reformation of hematoma (Figure 5).

Figure 1. Clinical picture at presentation.

Figure 2. Computed tomography findings. Yellow arrow indicates the hematoma, red indicates the ruptured silicone breast implant.

Figure 3. PET-CT findings. Yellow arrow indicates swelling of the right axillary lymph node.

Figure 4. Clinical picture during surgery. The silicone breast implant ruptured just before surgery from ulcer. The hematoma was resected including the ulcered skin (yellow arrow).

Figure 5. Clinical picture 6 months after surgery.

Complications in feminizing augmentation mammoplasty are generally rare, but a small number have been reported.^7,8 Complications are typically divided into early (< 4 weeks) or late complications (> 4 weeks).⁷ Hematomas tend to present early (within 1-2 weeks) after augmentation mammoplasty, typically as a localized or unilateral swelling accompanied by pain and bruising at the surgical site.⁷ Late hematomas (> 6 months postoperatively), however, are much less common.

Various theories have been proposed regarding the etiology of late hematoma, which most likely result from erosion of capsular vessels due to trauma, inflammation, microfracture of the capsule, or friction between the implant and the capsule.^2,4,9,10 Progression of late hematomas has been compared with that of chronic subdural hematomas, with small recurrent bleeds forming clots that create osmotic environments that slowly pull fluid into the capsule over time.^5,11

Late hematomas usually present as unilateral swelling of a breast, sometimes accompanied with redness, pain, fluid retention, mass formation, and ulceration. It is more commonly chronic and progressive, but occasionally there is acute presentation.^5,12-14 These symptoms are similar to BIA-ALCL after breast implant insertion, which is a life-threatening complication. BIA-ALCL is a type of T-cell non-Hodgkin lymphoma, a malignant tumor arising from the capsular tissue formed around breast implants that typically presents as sudden onset unilateral breast swelling 7 to 10 years after implantation.^5,15 Other described symptoms have included spontaneous periprosthetic fluid collection or capsular mass, skin rash, capsular contracture, and lymphadenopathy. Most cases, like ours, have a clinical history of a textured implant.¹⁶

We compared the clinical characteristics between the present case of late hematoma and reported BIA-ALCL cases after feminizing mammoplasty (Table). There have been only 5 reported cases of BIA-ALCL after feminizing mammoplasty in transgender patients.^17-22 The patient’s ages ranged between 27 and 56 years old (mean 45.2 years old). The interval from SBI insertion to initial symptoms ranged between 1 and 9 years (mean 4.6 years). The interval from initial symptoms to diagnosis was between 0.5 and 15 years (mean 6.3 years). All patients had textured type implants. Mass formation was observed in 4 of the 5 reported cases and they belonged to the late stage of BIA-ALCL. The initial and presented symptoms were quite similar between the present case and BIA-ALCL cases.

Breast augmentation using SBI has been widely performed in the field of cosmetic surgery. However, in cases of feminizing mammoplasty or cosmetic breast augmentation, there is typically no regular postoperative checkup. Most delayed complications are therefore assumed to be reported with a delay from the onset, and there may be many untreated cases of late complications. Differentiating between these complications from the initial and presenting symptoms only is likely to be difficult. PET-CT showed axillary lymph node accumulation in our patient, so it was especially difficult to differentiate from BIA-ALCL. When such symptoms are present, it is necessary to retain these 2 complications as important differential diagnosis. Furthermore, long-term follow-up and education of patients about the possibility of late complications are also necessary for early detection, including after cosmetic and feminizing mammoplasty. BIA-ALCL is a rare disease at most medical centers, so inclusion of a clinical history and directions to the pathologist to rule out BIA-ALCL is recommended. The National Comprehensive Cancer Network has recommended guidelines for BIA-ALCL diagnosis and management.⁶ Providers should adhere to the National Comprehensive Cancer Network BIA-ALCL screening guidelines for patients presenting with symptoms mimicking BIA-ALCL.

Late hematoma after feminizing mammoplasty can have similar symptoms to BIA-ALCL. Life-threatening BIA-ALCL should be ruled out from late hematoma adhering to the National Comprehensive Cancer Network BIA-ALCL screening guidelines.