Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon form of non-Hodgkin lymphoma (cancer of the immune system) that can develop around breast implants. Breast implants are among the most commonly used medical devices for cosmetic or reconstructive purposes. In the past few years, the number of women with breast implants diagnosed with anaplastic large cell lymphoma (ALCL) has increased, and several studies have suggested a direct association between breast implants and an increased risk of this disease. Although it has been hypothesized that chronic stimulation of the immune system caused by implant materials and biofilms as well as a possible genetic predisposition play an important role in this disease, the cellular and molecular causes of BIA-ALCL are not fully understood. This review aims to describe the current understanding around the environmental and molecular drivers of BIA-ALCL as well as the genetic and chromosomal abnormalities identified in this disease to date.

Biological and genetic landscape of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Background Biliary dyskinesia generally refers to a hypofunctioning gallbladder with an ejection fraction (EF) of 80%) cared for by the pediatric surgery services at two tertiary care centers over the span of a three-year period. Age, sex, BMI, CCK-HIDA results, and preoperative testing and post-operative pathology were noted. Resolution of symptoms was determined by subjective patient self-reporting at postoperative visit. Results Eighteen patients met inclusion criteria. Average age 15.7 (range, 10-17 years), median BMI 27.3 (±8.2). Fifteen patients were female and 3 were male. Average CCK-HIDA EF was 91.6% (±5.2), 82.4% of the patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology. Postoperatively, 82.4% of the patients available for follow up (n=17) reported complete or near complete resolution of symptoms. Conclusions Biliary hyperkinesia is an emerging clinical entity in children and adolescents and has a similar presentation to biliary hypokinesia. While the pathophysiologic mechanism of pain is not fully elucidated, laparoscopic cholecystectomy appears to provide a surgical cure for these patients and should be considered in the differential for the patient with an unremarkable workup and history suggestive of biliary colic.

/pdf/biliary-hyperkinesia-in-adolescents-it-isn-t-all-hype-2kcjph2tov.pdf

Biliary hyperkinesia in adolescents-it isn't all hype!

Objective CTV is not routinely used to screen patients presenting with a presumed lower extremity (LE) lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner Syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening in these patients by evaluating the proportion presenting with CTV identified left IVO that is clinically significant. Methods The authors retrospectively reviewed 121 patients that presented to our lymphedema center with LE edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of CTV findings. Results Of patients that completed imaging, 52% (n=26) had an abnormal lymphoscintigraphy, 45% (n=46) reflux on US, and 11.4% (n=9) IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n=4) or bilateral (n=3) LE. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of LE edema in 43% of these cases (n=3) or 2.5% of all patients. Conclusions Six percent of patients presenting to a lymphedema center with LE edema had left-sided IVO on CTV suggestive of MTS. However, cases of IVO were determined to be clinically significant less than 50% of the time, or in 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral LE edema with a greater left-sided component and history findings that raise clinical suspicion for MTS. 

The Utility of CT Venography in the Routine Evaluation of Patients that Present to a Lymphedema Center with Lower Extremity Edema.

Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.

Pediatric Normokinetic Biliary Dyskinesia: Pain with Cholecystokinin on Hepatobiliary Iminodiacetic Acid Scan Predictive of Symptom Resolution After Cholecystectomy.

The aim of this study was to investigate the prevalence of radiological left common iliac vein (LCIV) compression among the asymptomatic population and identify possible predictors.Contrast-enhanced abdominal and/or pelvic computed tomography scans of eligible asymptomatic patients were examined. The LCIV diameter was measured from different horizontal planes in the venous phase using PACSView. Degree of LCIV compression (Dc) was calculated by a predefined formula and graded as insignificant (Dc < 25%), mild (≥25% Dc < 50%), moderate (≥50% Dc <75%), and severe (Dc ≥ 75%). Venous stenosis was defined as a Dc of ≥50%. Comparison of variables, including gender, age, body mass index (BMI), and comorbidities was performed between the different grades of LCIV compression.Between November 2019 and July 2022, 1698 eligible asymptomatic patients (53.1% females; mean age, 39.3 ± 11.8 years; mean BMI, 22.9 ± 3.6 kg/m2) were reviewed. The mean Dc was 46.2% (range, 0.29%-90.4%). Insignificant, mild, moderate, and severe compression were distributed in 14.5%, 38.0%, 42.2%, and 5.2% of the cohort population, respectively. Prevalence of venous stenosis was higher in females than males (58.1% vs 42.2%; χ2 = 15.52; P < .001). Females aged ≥25 and <35 years accounted for the highest proportion of venous stenosis than other age groups and was a significant predictor (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.74-7.79; P < .001). In the Asian BMI classification group, being underweight is associated with venous stenosis (OR, 4.69; 95% CI, 2.70-8.14; P < .001) and obesity may be a protective factor (OR, 0.38; 95% CI, 0.23-0.64; P < .001). There is an inverse relationship between Dc and age and BMI.The prevalence of radiological LCIV compression on computed tomography scans was high, but all patients were asymptomatic. Female gender, especially those aged ≥25 and <35 years, and underweight were possible predictors for venous stenosis. 

Prevalence and Predictors of Radiological Left Common Iliac Vein Compression in Asymptomatic Patients.

Background: May-Thurner syndrome (MTS) is an anatomical variant that results in compression of the left common iliac vein by the right common iliac artery. Although often asymptomatic, lower extremity swelling/edema, deep venous thrombosis, post-thrombotic syndrome, and eventual lymphedema (due to long-standing venous obstruction) can develop. The clinical management of patients presenting for lymphedema surgery with concomitant or undiagnosed MTS is not well described. Methods: This review investigates two patients who were evaluated for unilateral lower extremity lymphedema, both of whom were subsequently diagnosed with MTS. Standard imaging (including lymphoscintigraphy, indocyanine green lymphangiography, and magnetic resonance venography) were performed to identify proximal venous obstruction. Treatment was accomplished using vascular surgical management, including stenting of the iliac vein before lymphedema reconstruction with vascularized lymph node transfer and multiple lymphovenous bypass. Results: Both patients we examined in this review had improvement of lymphedema with vascular surgical management. Literature review reveals that MTS has an incidence as high as 20% in the population, although commonly unidentified due to lack of symptomatology. Conclusions: There are no studies documenting the incidence of MTS in patients referred for lymphedema surgical management. Routine studies should be obtained to screen for proximal venous obstruction in patients presenting for surgical management of lower extremity lymphedema. Additional research is needed regarding the approach to managing patients with both MTS and lymphedema. Careful observational and prospective studies may elucidate the appropriate time interval between venous stenting and lymphedema microsurgical reconstruction.

May-Thurner Syndrome and Lymphedema Reconstruction

The complications associated with breast implants are under perpetual scrutiny to maximize patient safety. In this era of plastic surgery, a new concern being addressed is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Patients with BIA-ALCL most commonly present several years after implant placement with a periprosthetic fluid collection. The body of literature and reports of BIA-ALCL continues to grow with additional nuances in proposed causes as well as management. Most recently, this has led to a recall of breast implants manufactured utilizing a specific texturing. We describe here the time course, diagnosis, and management of BIA-ALCL in a 52-year-old patient who underwent submuscular implant-based reconstruction and subsequent revision of that reconstruction with the creation of a neosubpectoral pocket. The patient was managed in accordance with current guidelines under the supervision of a multidisciplinary team. In our review of the literature, several case reports, case series, and guideline publications were identified. Current guidelines for management are based on the staging of BIA-ALCL at diagnosis and span from only surgical with implant removal, excision of the lymphoma, and excision of the surrounding fibrous capsule to addition of chemotherapeutic regimens or radiation for distant and locally advanced disease.

Breast Implant-associated Anaplastic Large Cell Lymphoma Affecting a Neosubpectoral Pocket.

Biliary hyperkinesia, a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report.

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May-Thurner Syndrome and Lymphedema Reconstruction

Breast Implant-associated Anaplastic Large Cell Lymphoma Affecting a Neosubpectoral Pocket.

Biliary hyperkinesia, a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report.