A Rare Case of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) in a Transgender Patient With Exclusive Smooth Implant Exposure.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of T-cell lymphoma that has been strongly associated with textured breast implants. Cases of BIA-ALCL occurring exclusively in patients with smooth breast implant exposure have not been reported. We present the case of a 56-year-old transgender female patient with a history of multiple bilateral breast implant exchanges involving exclusively smooth silicone implants between 2006 and 2023 who presented with progressive unilateral breast swelling and tenderness. Breast imaging demonstrated an enlarged left axillary lymph node without evidence of implant rupture or discrete mass. The patient underwent bilateral implant removal with en bloc total capsulectomy, bilateral pectoralis major repair, and balancing mastopexy. Intraoperatively, a large periprosthetic seroma and thickened left breast capsule were both identified. On further histopathological evaluation, the specimen demonstrated large pleomorphic CD30-positive and anaplastic lymphoma kinase (ALK)-negative lymphoma cells lining the capsule, consistent with BIA-ALCL; this was further confirmed via immunophenotyping and positive T-cell receptor (TCR) gamma gene rearrangement studies. The left breast capsule was also found to have low-grade follicular lymphoma. The contralateral breast demonstrated only reactive histological changes without evidence of malignancy. Ultimately, following complete surgical excision, it was determined that adjuvant therapy was not indicated for this patient. Postoperative follow-up imaging has demonstrated no evidence of disease recurrence thus far. This case challenges current assumptions of BIA-ALCL disease pathogenesis and highlights the need for ongoing investigation into confounding factors associated with the development of this rare form of lymphoma.