Primary non-Hodgkin malignant lymphoma of the breast. An immunohistochemical study of seven patients and literature review of 152 patients with breast lymphoma in Japan

Breast lymphoma: General review

BACKGROUND

Lymphoma of the breast can be classified as either primary breast lymphoma (PBL) or secondary to systemic lymphoma (SBL). PBL is a rare disease with Diffuse Large B cell Lymphomas (DLBCL) being the most common subtype.

OBJECTIVES

In the current study, we represented eleven cases diagnosed with breast lymphoma in our trust; two of them had PBL and nine had SBL. We focused mainly on the clinical presentation, diagnosis, management and outcomes.

METHODS

We did this retrospective review for all breast lymphoma patients who were diagnosed in our trust during the periods from 2011-2022. Patients' data were obtained from the hospital recording system. We followed up these patients thus far to identify the outcome of treatment in each patient.

RESULTS

Eleven patients were included in our review. All patients were females. Average age of diagnosis was 66.1 ± 13 years of age. Eight patients were diagnosed with DLBCL, two patients were diagnosed with follicular lymphomas, and the last one had lymphoplasmacytic lymphoma. Chemotherapy +∕- radiotherapy was the standard treatment regimen in all patients. Four patients passed away within one year of chemotherapy, five patients achieved complete remission, one patient had two relapses and is still under treatment, while the last patient was diagnosed recently and still awaiting treatment.

CONCLUSION

Primary breast lymphoma is an aggressive disease. The treatment for PBL is mainly systemic with chemoradiotherapy. The role of surgery is now limited to the diagnosis of the disease. Early diagnosis and proper treatment are crucial for the management of such cases.

Primary lymphoma of the breast: A case report and review of the literature

Primary lymphoma of the breast is a rare disease, accounting for about 0.5% of all primary breast tumors. Often found as a solitary indolent mass, it is difficult to distinguish from breast cancer on imaging and is often diagnosed for the first time based on histological findings. Diffuse large B-cell lymphoma is the most common histological subtype. A 48-year-old woman visited our hospital because of a painless mass in the left breast. Breast cancer was suspected based on the imaging findings. A core needle biopsy was performed, and the invasive ductal carcinoma was diagnosed. Partial mastectomy and sentinel lymph node biopsy were performed. The resected specimen was finally diagnosed as diffuse large B-cell lymphoma based on immunohistochemical staining. The patient was treated with R-CHOP and intrathecal injection of methotrexate. The patient remains alive without recurrence 4 years later. Awareness of primary breast lymphoma is essential for accurate and timely diagnosis and avoidance of unnecessary surgery.

Primary breast lymphoma

Primary breast lymphoma is a rare entity that accounts for only 1% of malignant breast neoplasms. It is characterized by the presence of a breast lump, with or without associated regional adenopathy and without systemic involvement. Imaging findings are nonspecific, and diffuse large B-cell lymphoma is the most common histological type. Given its rarity, there is still no consensus on the best approach, with chemotherapy being the most accepted treatment. This article aims to present a literature review as well as to present a clinical case.

Primary Breast Lymphoma Clinically Mimicking Acute Mastitis: A Case Report

Extranodal non-Hodgkin lymphoma of the breast is a rare disease. We present a case of primary breast lymphoma with atypical clinical manifestations that looked like acute mastitis. A 46-year-old woman had noted a painful swelling in the right breast for 2 months. The mass had an inflammatory appearance and acute mastitis was the clinical impression. She underwent a core biopsy of the mass, and pathology showed inflammatory changes. The inflammatory mass regressed and recurred during hospitalization, and further incision with debridement was done. The histological findings were consistent with diffuse large B cell lymphoma. Systemic examination found stage IIE disease. She received chemotherapy and local radiation is planned.

Breast Involvement by Hematologic Malignancies: Ultrasound and Elastography Findings with Clinical Outcomes

Objective:

Hematological malignancies very rarely involve the breast. The aim of this study is to retrospectively evaluate B-mode ultrasound (US) and elastography (ES) findings of breast involvement by hematologic malignancies with clinical outcomes.

Materials and Methods:

All core-needle biopsy results that were performed at our tertiary breast center from January 2013 to September 2016 were searched. Our search revealed 9 patients with breast involvement either by leukemia or lymphoma. All patients were examined using B-mode US and ES. US and ES findings were analyzed with the consensus of two radiologists, and clinical outcomes were noted.

Results:

The mean age of the study population was 41.6 years (range, 20–83 years). Two patients showed diffuse hypoechoic parenchymal infiltration. The elasticity assessments of these lesions were soft and intermediate. The remaining 7 patients had mass lesions. The elasticity assessment of these masses according to Breast Imaging Reporting and Data System US was as follows: Soft (n = 1), intermediate (n = 4), high (n = 2).

Conclusions:

It is important to consider that hematologic malignancies may appear as soft or intermediate lesions on ES. Patients’ history and clinical background should help us to consider breast involvement. In addition, the clinical outcomes may not be related with elasticity assessments.

Hematologic Malignancies Discovered on Investigation of Breast Abnormalities

OBJECTIVES

Hematological malignancies of the breast share a presentation similar to primary breast carcinomas but differ substantially in therapeutic approach and clinical outcomes. In this study, we investigate the frequency of hematological malignancies, their relative primary and secondary occurrences, and further characterize the distinct histopathologies of these malignancies with a special focus on lymphomas. To our knowledge this is one of the largest and most comprehensive studies of breast hematologic malignancies.

METHODS

We conducted a retrospective review of our institution's pathology database for hematologic neoplasms diagnosed in breast tissue during a period of 22 years (1992-2014). Clinical characteristics, patient history, histologic subtype, and patient outcomes were analyzed.

RESULTS

We identified 52 cases; 46 lymphomas, 4 plasmacytomas, and 2 myeloid sarcomas. The lymphoma cases were 15 diffuse large B-cell lymphomas (DLBCLs), 14 follicular lymphomas (FLs), 8 marginal zone lymphomas (MZLs), 2 anaplastic large T-cell lymphomas, 2 peripheral T-cell lymphomas-not otherwise specified, 1 each of small lymphocytic lymphoma, Burkitt lymphoma, mantle cell lymphoma, B-cell lymphoblastic lymphoma, and T-cell lymphoblastic lymphoma. In total, 30 cases were primary and 22 cases were secondary to the breast. Primary lymphomas accounted for 60% of lymphomas. Most FLs and almost all MZLs were primary.

CONCLUSIONS

Primary hematological malignancies of the breast are more common than secondary: 58 % versus 42%. This finding is more evident in lymphomas: 63% versus 37%. The most common hematological malignancy in our study was DLBCL, followed by FL and MZL. Most FLs and almost all MZLs were primary. At the same time, the percentage of primary DLBCLs in our study is lower than the percentage reported in previous studies. We suggest that this could be the result of transformation from low-grade lymphomas. Although rare, hematological malignancies of the breast warrant a higher level of clinical suspicion as they present similarly to breast carcinomas but require a substantially different therapeutic approach.

Radiological imaging characteristics of intramammary hematological malignancies: results from a german multicenter study

To assess radiological procedures and imaging characteristics in patients with intramammary hematological malignancies (IHM). Radiological imaging studies of histopathological proven IHM cases from ten German University affiliated breast imaging centers from 1997-2012 were retrospectively evaluated. Imaging modalities included ultrasound (US), mammography and magnetic resonance imaging (MRI). Two radiologists blinded to the histopathological diagnoses independently assessed all imaging studies. Imaging studies of 101 patients with 204 intramammary lesions were included. Most patients were women (95%) with a median age of 64 years. IHM were classified as Non Hodgkin lymphoma (77.2%), plasmacytoma (11.9%), leukemia (9.9%), and Hodgkin lymphoma (1%). The mean lesion size was 15.8 ± 10.1 mm. Most IHM presented in mammography as lesions with comparable density to the surrounding tissue, and a round or irregular shape with indistinct margins. On US, most lesions were of irregular shape with complex echo pattern and indistinct margins. MRI shows lesions with irregular or spiculated margins and miscellaneous enhancement patterns. Using US or MRI, IHM were more frequently classified as BI-RADS 4 or 5 than using mammography (96.2% and 89.3% versus 75.3%). IHM can present with miscellaneous radiological patterns. Sensitivity for detection of IHM lesions was higher in US and MRI than in mammography.

Synchronous breast cancer and breast lymphoma: two case reports and literature review

Synchronous breast cancer and breast lymphoma are rare. It is of high rate of misdiagnosis in clinical practice. Here we present two cases with this presentation. They are both middle-aged women, with stage I invasive ductal carcinoma of the breast. One patient happened to have primary breast lymphoma (PBL); the other was secondary breast lymphoma (SBL). Their pathology and immunohistochemistry (IHC) findings supported the diagnosis of multiple primary carcinoma. Both patients had a surgery. Then they both received CHOP regime chemotherapy and subsequent endocrine therapy.

Malignant lymphoma of the breast in a male patient: ultrasound imaging features

Non-Hodgkin lymphoma (NHL) of the breast is a rare disease. Herein, we report a rare case of secondary involvement of the breast by NHL in a male patient and the ultrasound imaging findings. A 70-year-old man noticed an induration of the subareolar region of the right breast. He had been diagnosed as having mantle cell lymphoma 5 years before and treated with several series of chemoradiotherapy. On supine examination, palpation revealed bilateral breast enlargement, but detection of a lump was difficult. Ultrasonography showed a hypoechoic non-mass image-forming lesion in the subareolar region of the right breast. The final pathological diagnosis was recurrence of mantle cell lymphoma in the right breast. The diagnosis of malignant lymphoma of the breast by imaging modalities is difficult because there are no specific features. Breast lymphoma should be included with gynecomastia and breast cancer in the differential diagnosis of male patients with breast enlargement.

Bulky disease has an impact on outcomes in primary diffuse large B-cell lymphoma of the breast: a retrospective analysis at a single institution

OBJECTIVES

Primary breast lymphoma (PBL) is rare, and its clinical behavior and standard initial treatment are not yet established.

METHODS

We retrospectively analyzed the clinicopathological features and treatment outcomes of 14 patients with primary breast diffuse large B-cell lymphoma.

RESULTS

There were nine patients with stage IE and five with stage IIE disease. The median largest tumor diameter was 4.5 cm, and five patients had bulky disease >5 cm. The complete response rate was 94%. However, the 5-year progression-free survival rate was 52% with a median follow-up of 5.2 years. Patients with bulky disease had an unfavorable prognosis. All five patients with bulky disease progressed or relapsed. Of the four patients that recurred in the central nervous system (CNS), three had bulky disease although some received rituximab. There were no CNS recurrences in the three patients who received CNS prophylaxis. All eight patients who responded to radiotherapy (RT) did not have recurrences in the ipsilateral breast, although one patient with bulky disease relapsed in the adjacent regional lymph nodes within the RT field despite immunochemotherapy.

CONCLUSIONS

Patients with bulky disease had a poorer prognosis and recurred frequently in the CNS. CNS prophylaxis might yield better outcomes, but a larger, prospective trial is needed to elucidate the optimal initial treatment of PBL in the rituximab era.

Non-Hodgkin's lymphoma presenting as breast masses: a series of 10 cases diagnosed on FNAC

Primary breast lymphoma (PBL) is a rare disease, which comprises 0.04-0.53% of all primary malignant tumors of the breast. The most frequent histological subtype is diffuse large B-cell type (DLBCL) (40-70%). Differentiation of PBLs from other breast tumors such as poorly differentiated carcinomas and lobular carcinoma may at times be difficult on cytomorphology alone. An audit of breast lymphomas diagnosed on fine needle aspiration cytology (FNAC) over a period of 9 years (2001-2009) was performed. Ten cases were retrieved and the cytomorphology was reviewed along with immunochemistry (IHC), flow cytometry as well as histopathology, wherever available. The age of patients ranged from 17 to 83 years. Eight cases were diagnosed as non-Hodgkin's lymphoma, high-grade on FNAC. Histopathology was available in four of these cases and cell block was available in one case. Lymphoid cells were positive for leukocyte-common antigen (LCA) and CD20 and negative for CD3 in these cases. The same was confirmed by flow cytometry on aspirated material in one case. A diagnosis of DLBCL was offered in these five cases. One case was a low-grade NHL and another case was a young male, a known case of acute leukemia and had leukemic infiltration in the breast lump. We wish to emphasize the potential importance of FNAC in breast lymphoma and the same can be helpful to avoid unnecessary surgery in these cases. The differential diagnostic entities have been discussed. IHC and flow cytometry can be performed on the aspirated material and provide valuable information.

Primary bilateral Burkitt lymphoma of the lactating breast: a case report and review of the literature

Burkitt lymphoma (BL) is a highly aggressive neoplasm, which frequently affects the ileocecal region in the sporadic form and the jaw in the endemic form; however, the breast is a rare primary site of this tumor. Here we describe a case of primary bilateral breast BL presenting during lactation in a 23-year-old woman. Excisional biopsy of breast masses demonstrated a B-cell lymphoma with a characteristic 'starry sky' pattern highly suggestive of BL. The neoplastic cells strongly expressed CD20 and CD10, and showed proliferative activity as measured by Ki-67. An IGH-MYC gene fusion indicating the presence of a typical Burkitt translocation t(8;14)(q24;q32) in the tumor tissue was detected by fluorescent in situ hybridization. The present case, along with a comprehensive review of the literature, demonstrates that BL of the breast should be considered in the differential diagnosis of lesions of the breast during lactation. Whether hormonal or antigenic factors trigger Burkitt lymphomagenesis in the lactating breast warrants further investigation.

Primary breast lymphomas: a multicentric experience

Background

The Primary Breast Lymphomas (PBL) represent 0,38-0,70% of all non-Hodgkin lymphomas (NHL), 1,7-2,2% of all extranodal NHL and only 0,04-0,5% of all breast cancer. Most frequent PBLs are the diffuse large B cell lymphomas; in any case-reports MALT lymphomas lack or are a rare occurrence. Their incidence is growing. From 1880 (first breast resection for "lymphadenoid sarcoma" carried out by Gross) to the recent past the gold standard treatment for such diseases was surgery. At present such role has lost some of its importance, and it is matter of debate.

Methods

Twenty-three women affected by PBL underwent surgery. Average age was 63 years (range: 39-83). Seven suffered of hypothyroidism secondary to autoimmune thyroiditis. Fourteen patients underwent mastectomy, nine patients received quadrantectomy (average neoplasm diameter: 1,85 cm, range: 1,1-2,6 cm). In 10 cases axillary dissection was carried out. Pathologic examination revealed 16 diffuse large B cell lymphomas and 7 MALT lymphomas.

Results

Seven patients in the mastectomy group had a recurrence (50%), and all of them with diffuse large B cell lymphomas at stage II. Two of these had not received chemotherapy. No patient undergoing quadrantectomy had recurrence. In the mastectomy group disease free survival (DFS) at 5 and 10 years was 57 and 50%. Overall survival (OS) at 5 and 10 years was 71.4% and 57.1% respectively. All recurrences were systemic. DFS and OS at 5 and 10 years was 100% in the quadrantectomy group. In the patients with recurrence mortality was 85.7%. For stage IE DFS and OS at 5 and 10 years were 100%. For stage II DFS at 10 years was 62.5% and 56.2% respectively; OS at 5 and 10 years was 75% and 62.5% respectively. For MALT lymphomas DFS and OS at 5 and 10 years were 100%. For diffuse large B cell lymphomas DFS at 5 and 10 years was 62.5% and 56.2% respectively; OS at 5 and 10 years was 75% and 62,5% respectively.

Conclusions

The role of surgery in this disease should be limited to get a definitive diagnosis while for the staging and the treatment CT scan and chemio/radioterapy are repectively mandatory. MALT PBLs have a definitely better prognosis compared to large B cell lymphomas. The surgical treatment must always be oncologically radical (R0); mastectomy must not be carried out as a rule, but only when tissue sparing procedures are not feasible. Axillary dissection must always be performed for staging purposes, so avoiding the risk of under-staging II o IE, due to the possibility of clinically silent axillary node involvement.

Cross-sectional evaluation of thoracic lymphoma

Thoracic lymphomas most frequently involve mediastinal lymph nodes in the anterior mediastinum and paratracheal areas. The lymphomas may also involve lung, thymus, pleura, pericardium, chest wall, and the breast and their radiologic manifestations are diverse. Lymphomas (mostly BALT lymphoma and large B-cell lymphoma) may arise primarily from the lung with various imaging features including single or multiple nodule(s) and area(s) of consolidation. CT is currently the most important imaging modality for the evaluation of thoracic lymphoma but FDG PET also plays a crucial role in the clinical management of these cases.

Primary breast lymphomas

The diagnosis, prognostic factors, and optimal management of primary breast lymphomas (PBL) is difficult. Seven patients recorded at the Geneva Cancer Registry between 1973–1998 were reviewed. Five patient had diffuse large B-cell lymphoma, one a follicular lymphoma and one a MALT-lymphoma. All patients had clinical and radiological findings consistent with breast cancer and underwent mastectomy, which is not indicated in PBL. Diagnosis should be established prior to operative interventions, as fine needle aspiration missed the diagnosis for one patient and intra-operative frozen sections for 3 patients in our study. Five-year and 10-year overall survivals were 57% and 15%, respectively. Of the 3 patients who died from PBL, 2 had tumors that were Bcl-2 positive but Bcl-6 negative. All 3 surviving patients have positive Bcl-2 and Bcl-6 immunostaining, which could be important prognostic factors if confirmed by a larger study.

Primary breast lymphoma: Long-term treatment outcomeand prognosis

Between 1980 and 2002, 32 cases diagnosed as primary breast lymphoma were reviewed. Among them, 18 patients were stage I and 14 were stage II. Four patients underwent mastectomy and the remainder underwent lumpectomy. Twenty-eight patients received postoperative chemotherapy and 20 patients received postoperative radiotherapy. After a median follow-up of 76 (range 25 - 245) months, the 5-year overall survival and relapse-free survival was 69.3% and 47.7%, respectively. Ann Arbor stage, International Prognostic Index (IPI) excluding stage, lactic dehydrogenase (LDH) and radiotherapy were significant factors for relapse-free survival. We conclude that younger age and elevated LDH were apparent characters of the patients in our study. IPI excluding stage was a valuable prognostic factor. Combined radiotherapy and chemotherapy appeared to be important for treatment.

Primary non-Hodgkin lymphoma of the breast as third malignancy in one patient

We report a case of primary non-Hodgkin lymphoma of the breast as third metachronous neoplasm in the same patient. Primary non-Hodgkin lymphoma of the breast occurred about 2 years after endometrial cancer and 1 year after bladder cancer. The patient underwent quadrantectomy with level I-II axillary lymph nodes dissection plus rituximab-cyclophosphamide, doxorubicin, vincristine, prednisone chemotherapy. Patient's health status gradually got worse and 11 months after surgery the patient died.

Cross-sectional evaluation of thoracic lymphoma

In patients who have lymphoma, the presence and distribution of thoracic involvement is important in both tumor staging and treatment. Thoracic involvement in Hodgkin lymphoma (HL) is more common than in non-Hodgkin lymphoma (NHL). In HL, mediastinal lymphadenopathy with contiguous spread is a hallmark, and lung parenchymal involvement at the initial presentation is almost always associated with mediastinal lymphadenopathy. NHL is more heterogeneous and generally presents at a more advanced stage than HL. Most often, mediastinal involvement occurs as a disseminated or recurrent form of extrathoracic lymphoma. Bulky mediastinal disease with compression of adjacent structures can occur, particularly with high-grade subtypes of NHL and isolated lung disease without mediastinal lymphadenopathy can occur in contrast to HL.

Breast lymphoma: imaging findings of 32 tumors in 27 patients

PURPOSE

To retrospectively evaluate the imaging findings of breast lymphomas in patients who had undergone mammography, ultrasonography (US), magnetic resonance (MR) imaging, or combined positron emission tomography (PET)/computed tomography (CT) scanning.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant study and waived informed consent. Twenty-seven women who had been diagnosed with breast lymphoma (32 tumors) and had undergone preoperative imaging were identified from the surgical pathology database (mean age, 51 years; median, 55 years; range, 19-78 years at time of diagnosis). Two radiologists reviewed the mammographic, US, and MR images. One nuclear medicine physician reviewed the PET/CT scans. All available pathologic specimens were reviewed by a hematologic pathologist.

RESULTS

The mean tumor size at diagnosis was 2.9 cm (range, 1-5 cm). Seventeen tumors manifested with a palpable mass, two with diffuse enlargement of the breast, and 13 were asymptomatic. Twenty-two women underwent mammography; 24, US; one, MR imaging; and 10, PET/CT scanning. Mammograms of 25 tumors showed a noncalcified mass in 19, global asymmetry in four, focal asymmetry in one, and no abnormality in one. US of 29 tumors showed a mass in 26 and diffuse architectural distortion in three. Masses typically were irregular, hypoechoic, and hypervascular and demonstrated indistinct margins or an echogenic boundary. Dynamic contrast material-enhanced MR imaging of one tumor showed an intensely and heterogeneously enhancing mass with rapid enhancement and washout characteristics. PET/CT scans of 13 tumors showed intense diffuse hypermetabolism in 12 and response to therapy in all 12 tumors.

CONCLUSION

The imaging findings reported in this study should alert the radiologist to a possible diagnosis of breast lymphoma.

Non-Hodgkin's lymphoma of the breast: a review of 18 primary and secondary cases

We evaluated the clinical features, morphology, and incidence of 18 cases of breast lymphoma over 10 years at the University of Alabama at Birmingham. Fine needle aspiration was performed in 7 of 18 patients, and tissue biopsy/resection was available for all 18 cases. Patients were 33 to 91 years old (median, 61); 17 were women and 1 was a man. Fine needle aspiration was consistent with the tissue diagnosis in 6 of the 7 cases (86%). One case was diagnosed by fine needle aspiration as atypical cells, favor benign; the biopsy revealed diffuse large B-cell lymphoma. Tissue diagnoses revealed that 11 cases (61%) represented diffuse large B-cell lymphoma and 3 (17%) were follicular lymphomas. The remaining 4 cases (22%) were plasma cell neoplasm, T-cell neoplasm, Burkitt's lymphoma, and precursor B-cell lymphoblastic lymphoma. Flow cytometry and/or gene rearrangement supported the diagnosis of lymphoma in 8 cases. Although rare, lymphoma should be considered in the differential diagnosis of a breast mass. Fine needle aspiration can facilitate appropriate triage of patients for further management.

Breast Lymphoma: Favorable Prognosis after Treatment with Standard Combination Chemotherapy

PURPOSE

This paper is to determine the clinicopathological features and outcome of patients with breast lymphoma seen at a single institution.

PATIENTS AND METHODS

We have reviewed data on 14 patients with breast lymphoma seen at our institution from 1990 to 2003.

RESULTS

All patients were female, with a median age of 47.6 years. Diffuse large B-cell lymphoma (DLBCL) was observed in 9 cases, while follicular, Burkitt's, small lymphocytic, MALT and T-cell lymphoma were observed in 1 case each. 5 patients (35.7%) had stage IE disease, 6 patients (42.9%) had stage IIE disease and 3 patients (21.4%) had stage IV disease. Standard CHOP with or without rituximab was given to all patients with aggressive breast lymphoma (n = 10), while 1 patient with Burkitt's lymphoma received a CHOP-based regimen. The 3-year actuarial survival estimate among all 11 patients with aggressive breast lymphoma was 73%. Among those with localized disease, the estimated 3-year survival was 90%. The actuarial 3-year overall survival (OS) estimate for the entire cohort of 14 patients was 76.9%.

CONCLUSION

Our results indicate that breast lymphoma is not associated with an inferior outcome when treated with standard CHOP-based chemotherapy.

High Grade Primary Breast Lymphoma: is it a Different Clinical Entity?

Primary lymphoma of the breast (PBL) is a rare neoplasm, its outcome remains unclear compared to other lymphomas. We performed a retrospective study of 19 cases of high grade PBL. There were 17 Diffuse large B cell lymphoma (DLBCL) and 2 follicular and diffuse grade 3 lymphomas. Four patients were treated with local treatment only, 15 received chemotherapy including 11 treated with CHOP or ACVBP regimens followed by involved field radiotherapy. The actuarial survival for the whole population was 38%. Three of the 4 patients treated only with a local treatment died of their lymphoma. Three patients progressed on therapy and 5 relapsed in the first year of follow-up including 2 central nervous system recurrences. Among the 11 patients treated with chemotherapy, 2 died of their lymphoma. The overall survival of this subgroup was 73% (median follow-up of 57 months). We observed, like others in the literature, a better prognosis for lymphomas co-expressing Bcl6 and CD 10. The treatment should be based on the same modalities, but including a CNS prophylaxis even if poor prognosis factors are lacking. A radical mastectomy increases the risk of treatment failure and has to be avoided.

Non-Hodgkin's Lymphoma of the Breast: A Report of 19 Cases and a Review of the Literature

PURPOSE

Non-Hodgkin's lymphoma of the breast represents 0.04%-0.50% of malignant lesions of the mammary gland. In this article, we report a single institution's experience with this rare disease.

MATERIALS AND METHODS

Between 1982 and 1997, 19 patients with breast lymphoma were diagnosed, treated, and followed at this institution.

RESULTS

There were 18 female patients and 1 male patient. All but one were cases of aggressive B-cell lymphoma. Ann Arbor stages were IE (n=5), IIE (n=9), IIIE (n=2), and IV (n=3). International Prognosis Index scores were 0 (n=2), 1 (n=8), 2 (n=7), and 3 (n=2). According to the Wiseman and Liao classification established in 1972, 11 cases were primary lymphomas of the breast, and 8 cases were secondary involvement of the breast. Median survival time was 21.5 months (range, 5.1-114.7 months). The 5-year overall survival was 29%. Median event-free survival time was 8.3 months. The clinical, radiologic, and histologic patterns of presentation match previously published data, even if the response rates and the survival times seem disappointing, probably because of the initial treatment by tumorectomy or mastectomy for some patients.

CONCLUSIONS

Systemic chemotherapy should be the mainstay of treatment. Based on our experience and a review of the literature, the use of Wiseman and Liao's classification is questionable. In fact, it fails to detect whether some lymphomas of the breast present a specific natural history and therefore require specific management. New clinical and histologic criteria are to be identified.

Primary T-lymphoma of the breast with bilateral involvement, unusual presentation

Primary or secondary involvement of the breast is a rare form of extranodal lymphoma. Most reported primary non-Hodgkin lymphomas of the breast have a B-cell phenotype, those of T-cell phenotype are even more rare. Bilateral breast involvement at diagnosis also is very rare. We herein report a young female patient with bilateral breast involvement by low-grade T-cell malignant lymphoma.

Extranodal primary B-cell non-Hodgkin lymphoma of the breast mimicking acute mastitis

We report a case of primary, high-grade non-Hodgkin B-cell lymphoma in the breast of a young woman. The clinical and sonographic presentation was not of a mass but of an infiltrating anechoic process mimicking mastitis. Primary breast lymphoma is a rare entity, especially in young females. Early detection and treatment are crucial because the results of salvage treatment are generally poor. In previous imaging reports of breast lymphoma, it has always been considered as a mass, though the presence of markedly hypoechoic regions that look like fluid collections is a well known sonographic characteristic of lymphoma.

Primary breast diffuse large B-cell lymphoma shows a non-germinal center B-cell phenotype

Primary breast diffuse large B-cell lymphoma has a poor prognosis relative to other extranodal diffuse large B-cell lymphoma. Recently, diffuse large B-cell lymphoma has been subclassified as germinal center B-cell-like and nongerminal center B-cell types using tissue microarrays. The 5-year overall survival rate of the germinal center B-cell group is better than that of the nongerminal center B-cell group. To elucidate the reason for which primary breast diffuse large B-cell lymphoma has a poor clinical outcome, we investigated 15 patients with primary breast diffuse large B-cell lymphoma (stage IE; 13 cases, stage IIE; two cases) by immunohistochemistry using various markers including CD10, Bcl-6, MUM1 and MIB-1 and by molecular analysis of the immunoglobulin heavy chain gene variable region. Immunohistochemistry showed 0/15 (positive cases/examined cases) for CD10, 5/15 for Bcl-6, 15/15 for MUM1, 10/15 for Bcl-2, 2/15 for CD5 and 4/15 for CD40. The expression pattern of CD10(-) MUM1(+) in primary breast diffuse large B-cell lymphoma corresponded to the nongerminal center B-cell group. Moreover, the MIB-1 index was distributed from 60 to 95% with a mean of 79%, indicating a high proliferation of the lymphoma cells. The immunoglobulin heavy chain gene variable region of primary breast diffuse large B-cell lymphoma had a mutation frequency of 1-10% (seven cases) and 0-1 additional mutations in ongoing mutation analysis (five cases). Primary breast diffuse large B-cell lymphoma had characteristics of the nongerminal center B-cell group. In conclusion, primary breast diffuse large B-cell lymphoma has a nongerminal center B-cell phenotype and has a high MIB-1 index. These features might therefore be associated with poor prognosis.

Bilateral primary lymphoma of the breast: A case report initially diagnosed by FNAC

Primary lymphoma of the breast (PLB) is a rare disease, representing 0.04-0.5% of all malignant breast neoplasms. We present a patient with bilateral breast involvement by a high-grade diffuse large B-cell lymphoma, which was diagnosed initially by fine-needle aspiration cytology (FNAC). Mammography revealed a diffuse increase in density of the right breast and a large solitary mass on the left breast, suggestive of an inflammatory carcinoma. The patient underwent FNAC and the diagnosis of a non-Hodgkin's lymphoma (NHL) was suggested. Physical examination revealed palpable bilateral axillary lymph nodes but no evidence of concurrent widespread disease. The patient underwent complete staging evaluation. The only positive findings were an elevated lactate dehydrogenase (LDH) and evidence of axillary lymphadenopathy on CT. Excisional biopsy was performed on the left breast. The morphological and immunohistochemical analysis confirmed the diagnosis of a high-grade diffuse large B-cell lymphoma with an immunophenotype suggestive of a germinal center cell origin.

Primary non-Hodgkin’s malignant lymphoma of the breast: long-term follow-up

A 56-year-old woman patient was treated for non-Hodgkin's lymphoma in the left breast and subsequently for four recurrences over the next 109 months. This case illustrates the importance of close and long-term follow-up after the initial treatment of this rare disease.

Role of fine-needle aspiration cytology in breast lymphoma

Lymphomas of the breast are rare and may mimic carcinoma clinically. We investigated the ability of fine-needle aspiration (FNA) biopsy combined with adjunctive flow cytometry (FC), immunofluorescence microscopy (IFM), and immunocytochemistry (ICH) to diagnose and eventually subclassify lymphomas of the breast according to the Revised European American Lymphoma/World Health Organization classification. We retrieved 21 breast aspirates from 19 patients with a cytologic diagnosis of lymphoma or plasmacytoma over a 10-year period (1992-2002), excluding 98 benign intramammary lymph nodes and 1 atypical lymphohistiocytic proliferation (Rosai Dorfman disease). FC was performed in 15/21 aspirates, IFM in 1/21, ICH in 3/21. Histologic follow-up (HF) was obtained for 10 patients, most of them with primary lymphoma. For the remaining nine patients without HF, flow cytometric analysis, comparative morphology, or remission after chemotherapy regimens supported the cytologic diagnosis. Of 19 patients, 11 patients had a secondary lymphoma (SL) and 8 patients had a primary lymphoma (PL). FNA and FC/IFM/ICH classified 7/8 PLs as B-cell lymphomas and 1/8 PLs as plasmacytoma. However, FNA could only subclassify 3 of 8 PLs. FNA and/or FC subclassified accurately 10/11 SLs. All cases were accurately immunophenotyped as B-, T-cell non-Hodgkin's lymphomas or plasmacytoma. World Health Organization classification was achieved in 3/8 PLs (42%) and 10/11 SLs (91%; P = 0.04). Subclassification (which has an impact on long-term management and prognosis) was significantly better in SL, when a previous histologic diagnosis had already been made, when compared to PL, of which 5/8 cases (62.5%) could not be accurately classified.

Nongastric mucosa-associated lymphoid tissue lymphomas

Nongastric mucosa-associated lymphoid tissue (MALT)-derived lymphomas arise from various extranodal locations and are usually related to a particular pathogenesis with a possible external (environmental or autoimmune) event inducing the disease. We reviewed 165 patients with nongastric MALT lymphoma among the 243 patients with MALT lymphoma in our database and reviewed reports in the literature to analyze the clinical features of nongastric MALT lymphomas. The site of clinical presentation was related to the lymphoma location and was usually indolent. Dissemination of the disease at diagnosis was noticed in 48% of cases because of the involvement of multiple mucosal sites (48%) or because of a nonmucosal site involvement such as bone marrow, spleen, or liver (52%). With a median follow-up of 4 years, the estimated 5-year overall survival and 5-year freedom-from-progression rates were 89% and 50%, respectively, without any difference between patients with localized or disseminated disease or among different locations. Treatment recommendations for localized disease are based on surgery, local therapy, or chlorambucil. For disseminated disease, treatment recommendations include chemotherapy with fludarabine or chlorambucil or chemotherapy with CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) in cases of large tumor mass

High frequency of MALT lymphoma in a series of 14 cases of primary breast lymphoma

This article reports the clinicopathologic and immunohistochemical findings of 14 cases fulfilling the criteria of Wiseman and Liao for primary lymphoma of the breast (PBL), with emphasis on the frequency of mucosa-associated lymphoid tissue (MALT) lymphomas. The tumors were reclassified according to the revised European-American classification of lymphoid neoplasms. Immunohistochemistry was used to assist in the classification and subtyping of PBL, to demonstrate lymphoepithelial lesions (LEL), and to assess estrogen/progesterone receptor expression. Nine tumors were classified as MALT lymphomas (seven low grade and two high grade), four as diffuse large cell lymphomas and one as follicle center lymphoma. Extensive lymphoid cell infiltration of mammary ducts and acini was also found in non-MALT lymphoma cases. None of the 14 cases expressed hormonal receptors. Primary lymphoma of the breast is a rare and morphologically heterogeneous entity. There is similarity on the clinicopathologic overall profile of the current series of patients and those previously reported, but we recorded a higher incidence of MALT lymphoma (64.3%). Immunohistochemistry is mandatory to identify "true" LEL because epithelial permeation by lymphoid cells can also be found in non MALT-type lymphomas.

Ga-67 scintigraphy in patients with breast lymphoma

PURPOSE

The authors studied the utility of Ga-67 citrate scintigraphy in patients with breast lymphoma.

METHODS

Seven patients with histologically proved breast lymphoma were examined. In three patients, both breasts were involved, and all patients had rapidly growing breast masses. Planar and SPECT images were obtained 72 hours after injection of Ga-67.

RESULTS

Ga-67 scintigraphy showed intense accumulation in all lymphomas. SPECT images provided better contrast than did planar images. In one of the seven patients, the axilla and mediastinum were also involved. In six of the seven patients, Ga-67 scintigraphy was also performed after treatment and showed the disappearance of Ga-67 accumulation. In one patient with local recurrence and lung involvement, abnormal accumulation was depicted on follow-up Ga-67 scintigraphy.

CONCLUSIONS

Ga-67 scintigraphy was helpful to confirm the diagnosis and the systemic extent of lymphoma and to evaluate the therapeutic effect during follow-up in patients with breast lymphoma.

Lymphomas of the breast: primary and secondary involvement

BACKGROUND

The involvement of the breast by lymphoma is a rare form of extralymph node lymphoma and represents either primary disease or systemic involvement. The authors hypothesized that screening mammography may influence the detection of lymphomatous involvement of the breast.

METHODS

All patients (n = 81 patients) who were diagnosed with lymphomatous involvement of the breast at the study institution between 1988 and 1999 were evaluated retrospectively.

RESULTS

Clinical information was available for 73 patients who could be classified into three major groups according to their diagnosis: primary breast lymphoma (PBL) (44%), breast involvement from disseminated disease at the time of initial diagnosis (29%), and recurrence of preexisting lymphoma to the breast (27%). The majority of PBL were of intermediate or high grade, and the majority of disseminated lymphomas involving the breast were of low grade. Lymphomatous recurrence to the breast was slightly more likely to be of intermediate grade rather than low grade. In 91% of patients, the diagnosis of lymphoma was made after the evaluation of a palpable mass. All patients who were identified after the evaluation of an abnormal screening mammogram (9%) had low-grade lymphomas. Of the 32 patients with PBL, screening mammography discovered only 1. Nineteen percent of patients with PBL also had a history of an autoimmune disorder.

CONCLUSIONS

These findings suggest that screening mammography has not altered substantially the detection of breast lymphoma. The clinical outcome of patients with breast lymphoma is dependent on histology and appears to parallel that of patients with lymphoma of similar histology involving other sites.

Breast lymphoma associated with breast implants: two case-reports and a review of the literature

Breast lymphoma is a rare entity consisting mostly of B-cell lymphomas that affects older women. Very few cases of breast lymphomas of T-cell origin have been reported. Even fewer cases of breast lymphomas have been reported in women who have received breast implants. Silicone, a frequent component of breast implants, has been extensively investigated as a possible etiologic agent for some neoplasias and autoimmune disorders, including non-Hodgkin's lymphoma. We herein report two unusual cases of anaplastic large cell lymphoma of T-cell phenotype developing in the breasts of women who had received breast implants.

Breast involvement in immunolymphoproliferative disorders: report of two cases of multiple myeloma of the breast

Breast involvement by immunolymphoproliferative disorders is rare. Primary and secondary malignant lymphomas of the breast are much more common than multiple myeloma, of which only 16 cases have been described. We report two cases of patients with an established diagnosis of multiple myeloma in whom breast involvement appeared during the course of the disease. We underline diagnostic difficulties caused by the lack of clinical and radiological features which allow us to differentiate between breast carcinoma and breast involvement by lymphoproliferative disease. Only fine needle aspiration and/or excisional biopsy can differentiate between immunolymphoproliferative disorders and epithelial or mesenchymal tumors of the breast.

Treatment of prognosis of primary breast lymphoma: a review of 13 cases

Primary non-Hodgkin's lymphoma (NHL) of the breast is a rare entity that does not have a well-defined treatment strategy. At presentation, most patients are clinically thought to have a primary breast carcinoma, and the diagnosis of lymphoma is made at biopsy. Once the diagnosis of lymphoma is made, patients are treated with some combination of chemotherapy, radiation therapy, and surgery. We review The Cleveland Clinic Foundation experience with primary breast lymphoma. Between 1980 and 1996, 17 patients with primary breast lymphoma were seen at The Cleveland Clinic Foundation, and 13 had follow-up information available. All patients underwent a staging workup including computed tomography (CT) scan of the chest, abdomen, and pelvis, as well as bilateral bone marrow biopsies; all patients staged IE (breast involvement only) or IIE (limited to the breast and ipsilateral axilla) were included. We did not include patients with more extensive supradiaphragmatic nodal involvement who were stage IIE. Patients received some combination of surgery, radiation, and chemotherapy. The median follow-up was 34 months, with a range of 7 to 138 months. There was an equal incidence of right- versus left-sided lesions. Five patients survived at least 5 years from the time of diagnosis. Long-term survival in patients with primary NHL of the breast is possible. We recommend treating patients with aggressive NHL of the breast with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy, followed by involved field radiation and treating those patients with indolent lymphoma with involved field radiation alone.