Role of fine-needle aspiration cytology in breast lymphoma

Immunohistochemistry Applied to Breast Cytological Material

Fine-needle aspiration biopsies (FNABs) of the breast are minimally invasive procedures enabling the diagnosis of suspicious breast lesions. Unfortunately, they are often perceived as inferior to core-needle biopsies, namely because they are supposedly unable to differentiate between high-grade ductal carcinoma in situ and invasive carcinoma or provide material for ancillary testing. Several studies have shown, however, that FNAB samples, when handled properly, are indeed capable of providing sufficient and adequate material for ancillary testing, namely immunocytochemistry (ICC). We reviewed the published literature regarding the use of ICC for both diagnostic and theranostic uses in the different types of cytological samples obtained from FNABs of the breast, including smears, liquid-based cytology samples, and cellblocks. We found that p63 and 34βE12 show promise in aiding in the differential diagnosis between in situ and invasive lesions and that most other diagnostic markers may be used as in tissue. Regarding theranostic ICC markers, results vary between publications, but with care, these can successfully be performed in cytological samples. Air-dried smears should be avoided, and cellblocks are overall more versatile than cytology slides, enabling the evaluation of not only hormonal receptors and HER2 by ICC, but also of Ki-67. Particular attention should be paid to fixation and antigen retrieval procedures in all cases. We recommend that laboratories without experience perform short validation runs before adopting these techniques into clinical practice.

Indications for biopsy of imaging-detected intramammary and axillary lymph nodes in the absence of concurrent breast cancer

To evaluate the prevalence of malignancy in imaging-detected abnormal lymph nodes (LNs) in women without concurrent cancer and to identify imaging features predictive of malignancy in this population. This is an IRB-approved study with waived informed consent. We retrospectively reviewed medical records of all image-guided LN FNAs and CNBs performed at our institution from 1/1/08 through 12/31/10. LNs sampled in patients without concurrent breast cancer comprised our study group (SG; n = 77), and with concurrent breast cancer our reference group (RG; n = 124). Blinded to cytology/histology, imaging features of the LNs including size, loss of fatty hilum, and cortical thickness were reviewed. A low/high suspicion category was then assigned based on LN appearance. The prevalence of malignancy in LNs in SG was 6% (5/77) and in RG 52% (64/124; P < .0001). Complete loss of fatty hilum had 100% (5/5) sensitivity, and 100% (56/56) NPV for detecting cancer in SG, compared to 39% (25/64) sensitivity and 61% (60/99) NPV in RG. When a "high suspicion" imaging feature was used as a threshold to biopsy, the sensitivity (5/5) and NPV (45/45) in SG were 100%, and in RG 78% (50/64) and 77% (47/61), respectively. The prevalence of cancer in imaging-detected abnormal LNs in patients without concurrent breast cancer is low. In the absence of concurrent cancer, using highly suspicious features of loss of fatty hilum or cortical thickness ≥ 5 mm as a threshold to biopsy will maintain high sensitivity with lower false-positive biopsy rate.

Breast lymphoma in a patient with B-cell Non Hodgkin Lymphoma: A case report study

INTRODUCTION

Breast involvement in Non Hodgkin Lymphoma is a rare entity as it accounts for 2.2% of all extranodal lymphomas.

PRESENTATION OF CASE

A 59-year-old woman was referred to our Breast Unit because of two nodules of the right breast newly discovered during her annual mammography. Moreover, during the physical examination, a red-brown itchy lump of the scalp was discovered. The punch biopsies of the scalp lesion and ultrasound-guided core biopsies of both nodules of the right breast, revealed the presence of diffuse large B-cell Non Hodgkin Lymphoma in all tissue specimen sites.

DISCUSSION

Breast lymphomas represent an uncommon form of localized extranodal lymphomas that can be classified as Primary (PBL) or Secondary (SBL) breast lymphomas.

CONCLUSION

The value of preoperative diagnosis should be underlined as the patient avoids unnecessary surgical intervention and has earlier initiation of chemotherapy.

Role of core needle biopsy in primary breast lymphoma

Primary breast lymphoma (PBL) may mimic carcinoma clinically and also mammographic and ecographic distinction is subtle. Despite its rarity, incidence of PBLs has increased over the last four decades and continues to increase for younger women and for some subtypes, and for this reason it is increasingly important to achieve a preoperative pathological diagnosis using core needle biopsy (CNB) or fine-needle aspiration cytology (FNA). The aim of this retrospective study was to report our single-center experience in CNBs performed for histological diagnosis of PBL compared to FNA. From a total of 10,500 CNBs we found seven patients affected by PBL diagnosed at Careggi Florence University Hospital, between January 2000 and December 2016. Diffuse large B cell lymphoma (DLBCL) was the most frequent PBLs and on CNBs specimens was possible do the fluorescent in situ hybridization analysis to evaluate the presence of chromosomal translocation. CNB is an effective method for the assessment of PBLs, especially for DLBCL, in which a correct and fast classification could change the therapeutic approach and the prognosis.

[Malignant non-hodgkin's lymphoma of the breast and HIV: about a case]

Malignant non-Hodgkin's lymphoma (NHL) accounts for 0.5% of all breast cancers. Diagnosis is essentially based on histology. We report the case of a 42-year old female patient with MNHL of the breast and positive HIV serology. This study aimed to highlight the clinical, radiological and therapeutic aspects of this disease and to emphasize the importance of HIV testing in patients with extraganglionar MNHL.

Extranodal Lymphoproliferative Processes and Flow Cytometry

OBJECTIVE

Fine-needle aspiration (FNA) cytology is a safe and cost-effective technique for the diagnosis of lymphoproliferative processes, especially when correlated with clinical and imaging studies. However, cytology alone may be unable to detect a lymphoid neoplastic process, as architectural features are less obvious than in histologic preparations and, in certain cases, reactive processes may mimic lymphoma. Flow cytometry (FC) has been recognized as an important ancillary technique in the diagnosis of lymphoid neoplasms and it can be used in conjunction with FNA in the evaluation of lymphoproliferative processes.

STUDY DESIGN

We performed a review of the published literature concerning FC applied to the detection of salivary glands and thyroid lymphoproliferative processes, which are frequently related to autoimmune diseases and difficult to diagnose by cytomorphology alone.

RESULTS

FC is able to detect and subtype non-Hodgkin lymphomas and may contribute to the exclusion of a neoplastic process in cytologically unclear cases.

CONCLUSIONS

FC can be successfully applied in the differential diagnosis of lymphoproliferative processes in the head and neck region. The FNA-FC combined approach can reduce time to therapy and may prevent unnecessary surgical biopsies.

FDG PET/CT manifestations of hematopoietic malignancies of the breast

Hematopoietic malignancies that can be encountered in the breast include lymphoma, leukemia, and multiple myeloma/plasmacytoma. These are readily imaged via [18]F-fluorodeoxyglucose position emission tomography (PET)/computed tomography (CT) and can manifest as unilateral, bilateral, single, multiple, round/oval masses, or diffuse. These malignancies can occasionally mimic primary breast cancers. Conversely, benign conditions, such as the lactating breast can resemble hematopoietic malignancies of the breast. Although uncommon, familiarity with hematopoietic malignancies of the breast is important for proper interpretation of PET/CT. In this pictorial review, the PET/CT imaging features of patients with hematopoietic malignancies of the breast will be described, including pathology-proven cases of acute myelogenous leukemia, diffuse B-cell lymphoma, follicular lymphoma, acute myeloid leukemia with neutropenic granulocytic) sarcoma, and plasmacytoma. In addition, potential pitfalls will be discussed.

Primary non-Hodgkin's breast lymphoma: Surgical approach

We report the case of a 38-year old woman affected by primary lymphoma of the right breast, with disease progression after chemotherapy and subsequent radiotherapy, successfully treated with a modified radical mastectomy. The literature of primary breast lymphomas has been reviewed and discussed in relation to our case. Our experience stresses the importance of a radical surgical approach in a locally advanced non-Hodgkin's lymphoma of the breast unresponsive to radio and chemotherapy.

Secondary breast lymphoma diagnosed by vacuum-assisted breast biopsy: a case report

INTRODUCTION

Breast lymphoma, either as a manifestation of primary extranodal disease or as secondary involvement, is a rare malignancy, and its diagnosis, prognosis, and treatment have not been clearly defined. On the other hand, Vacuum-assisted breast biopsy (VABB) is a minimally invasive technique with ever-growing use for the diagnosis of mammographically detected, non-palpable breast lesions.

CASE PRESENTATION

A symptom-free, 56-year-old woman presented with a non-palpable BI-RADS 4B lesion without microcalcifications. She had a positive family history for breast cancer and a history of atypical ductal hyperplasia in the ipsilateral breast four years ago. She reported having been treated for non-Hodgkin lymphoma 12 years ago. With the suspicion of breast cancer, mammographically guided VABB with 11-gauge probe (on the stereotactic Fisher's table) was performed. VABB made the diagnosis of a non-Hodgkin, grade II, B-cell germinal-center lymphoma. VABB yielded enough tissue for immunohistochemistry/WHO classification.

CONCLUSION

This is the first case in the literature demonstrating the successful diagnosis of breast lymphoma by VABB, irrespectively of the level of clinical suspicion. It should be stressed that VABB was able to yield enough tissue for WHO classification. In general, lymphoma should never be omitted in the differential diagnosis, since no pathognomonic radiologic findings exist for its diagnosis.

Fine needle aspiration for evaluation of breast masses

PURPOSE OF REVIEW

Fine needle aspiration has been used for many years as a diagnostic tool for breast lesions, with high sensitivity and specificity. There is controversy as to whether this technique should be replaced by other diagnostic procedures such as core biopsy. This review aims to re-evaluate the usefulness of breast fine needle aspiration.

RECENT FINDINGS

During the past 10 years many institutions have replaced fine needle aspiration by core biopsy and related techniques such as vacuum-assisted core biopsy and advanced breast biopsy instrument action. Other institutions continue to use fine needle aspiration as a first line of investigation for breast lesions. This technique is especially useful in radiologically benign lesions and when combined with image guidance. The use of the 'triple test' (combined cytologic, clinical and radiologic findings) decreases false-negative and false-positive results.

SUMMARY

Fine needle aspiration continues to be an acceptable and reliable procedure for the preoperative diagnosis of breast lesions, particularly in developing countries, and when used as part of the 'triple test'. Accurate diagnosis requires experience in both aspiration technique and specimen interpretation. Clinicians should be mindful of the limitations of the technique. The choice between fine needle aspiration and core biopsy should be individualized for the patient.

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.

Primary Breast mucosa-associated lymphoid tissue (malt) lymphoma with high-grade transformation evidenced by prominent lymphoepithelial lesions

Primary breast lymphoma, particularly primary mucosa-associated lymphoid tissue (MALT) lymphoma, is a rare disease. We report here a case of a MALT lymphoma of the breast with high-grade transformation. An 84-year-old woman presented with a Pagetoid mass in her right breast. After a clinical diagnosis of breast cancer, T2N1M0, stage II B, she underwent mastectomy with axillary lymph node dissection. She had no history of autoimmune disease such as Hashimoto thyroiditis or Sjögren disease. Pathologically the tumor tissue was composed of small to large lymphoid cells. The large cells contained a considerable number of centroblasts, forming a sheet-like proliferation centrally. Among the small cells many small cleaved cells were present, which were more predominant in the peripheral areas. Immunohistochemistry revealed that these cells were positive for CD20 and CD79a. The tumor cells infiltrated the ductular epithelial cells, distorting the duct structures, to form lymphoepithelial lesions. Immunohistochemistry for cytokeratin and CD20 was helpful for identification. No germinal centers were formed. MALT lymphoma with high-grade transformation was diagnosed. Rituximab (anti-CD20 antibody) was prescribed as systemic treatment without chemotherapy or irradiation. After 18 months, no tumor recurrence was observed. We emphasize the importance of lymphoepithelial lesions for the diagnosis of MALT lymphoma of the breast.

Fine needle biopsy cytology of breast lesions: a review of interpretative difficulties

Screening mammography and greater community awareness of breast carcinoma have led to an increase in fine needle biopsies of the breast. As a consequence, a wide variety of cytologic patterns have been encountered and studied in benign, proliferative, and malignant breast lesions. We review the main reasons for diagnostic difficulties in breast cytology, the situations in which either a false positive or a false negative diagnosis is possible, as well as conditions whose incorrect typing can lead to inappropriate management.

Best Practice No 185. Cytological and molecular diagnosis of lymphoma

With the advances in molecular pathology, the cell as a morphological and functional unit has become essential in the diagnosis of lymphoma. Conventional staining, preparation, and interpretation of cells, as seen in fine needle aspiration cytology (FNAC), often used as a first line investigation of lymphadenopathy, is being supplemented with an array of immunocytochemical and molecular analyses, aimed not only at a more precise disease definition, but also at recognising factors that can predict prognosis and response to treatment. Accepting the pitfalls of conventional cytomorphology, this review looks at molecular changes characteristic to particular lymphomas and explores the currently available technology for their detection, with particular reference to cytological material. Future protocols for the diagnosis and management of patients with lymphadenopathy should include FNAC as an initial investigation, followed by immunocytochemistry and molecular investigations. Tissue biopsy, the conventional method of diagnosis, may be avoided in selected cases.

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.