Acute lymphoblastic leukemia relapse in the breast diagnosed with gray-scale and color Doppler sonography

Imaging findings of breast leukaemia: a case series

Aims/Background Breast leukaemia (BL) is a rare breast malignancy that is treated differently from other malignant conditions. However, it is easily confused with other conditions; therefore, how to accurately diagnose is crucial. We retrospectively analysed the imaging findings of 13 patients to provide a diagnostic reference. Methods From January 2015 to April 2023, 13 patients with BL confirmed by biopsy who underwent imaging in Peking University People's hospital were retrospectively analysed. The imaging findings obtained via ultrasound (US), mammography (MMG), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT) were analysed, and the detection rates of these methods for diagnosing BL were compared. Results Twenty-nine lesions were detected in the 13 patients. These patients presented with palpable masses or breast swelling several months after treatment for leukaemia, mainly involving the bilateral breasts. Ultrasonography was performed for 13 patients, and all lesions were detected. Most of the identified masses were hypoechoic and had indistinct boundaries, irregular shapes, no enhancement of the posterior echo, and no abundant blood flow. MMG was performed for five patients, revealing breast masses, architectural distortion, and no abnormalities. MRI was performed for four patients, and all lesions were detected; most of the lesions were hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging and diffusion-weighted imaging, with a decreased apparent diffusion coefficient and inhomogeneous enhancement. The enhancement curves were mostly inflow patterns. PET/CT was performed for four patients; two patients had hypermetabolism, and the other two had no obvious radioactive uptake. Conclusion Compared to MMG and PET/CT, US and MRI have higher detection rates. Furthermore, compared to MRI, US is inexpensive, convenient and efficient; therefore, it should be the first choice for diagnosing BL.

Extramedullary Relapse of B Cell Acute Lymphoblastic Leukemia in Bilateral Breasts Treated with Whole Breast Radiotherapy

Isolated extramedullary relapse of acute lymphoblastic leukemia (ALL) in the breast is extremely rare. We herein report a case of a 38-year-old female with B cell ALL, who had isolated extramedullary relapse initially in the left breast and subsequently in the right breast, 3 and 4 years, respectively, after hematopoietic allogenic stem cell transplantation. She was successfully salvaged with bilateral whole breast radiotherapy, 24 Gy/12 fractions/2.5 weeks. This brief report highlights the importance of awareness of extramedullary leukemic relapse in the breast as one of the differential diagnoses of breast masses in the context of ALL. Since these tumors are extremely radioresponsive, radiation therapy is a safe and effective treatment option for isolated extramedullary relapse of ALL in the breast.

Acute lymphoblastic leukemia simulating breast carcinoma

Background

Breast metastasis in hematological malignancies is a rare phenomenon, and it is primarily seen in acute myeloid leukemia (AML). In patients with acute lymphoblastic leukemia (ALL), this condition is even rarer.

Case presentation.

We present a case of a precursor B cell ALL involving breast in a 40-year-old female and its imaging features on mammography and ultrasound. Histopathology of core needle biopsy (CNB) specimen allowed us to diagnose ALL with extramedullary metastases. The patient was referred to oncology for further management.

Conclusion

To conclude, ALL infiltrating breast is rare but should be given due consideration, especially in the cases of known primary hematopoietic malignancy, particularly in patients presenting with a history of sudden lumps in the breast. A CNB can give reliable results in combination with flow cytometry and immunocytochemistry, circumventing the need for an excisional biopsy and allowing the commencement of early treatment.

Isolated Central Nervous System Chloroma as a Presenting Sign of Relapsed Pediatric Acute Lymphoblastic Leukemia

Central nervous system (CNS) chloromas are an exceedingly rare presentation of CNS relapse in acute lymphoblastic leukemia (ALL). We report a relapsed ALL patient who presented with 2 separate chloromas and cerebrospinal fluid lymphoblastocytosis, and outline a treatment plan of systemic chemotherapy and CNS-directed radiation therapy. A review of the literature indicates that multiagent chemotherapy combined with CNS radiotherapy is effective, with hematopoietic stem cell transplantation used in half of reported cases. We conclude that intensive systemic multiagent chemotherapy with CNS-directed radiation therapy can be successfully used to treat relapsed pediatric ALL with CNS lymphoblastic chloroma.

Relapse of Biphenotypic Acute Leukemia as a Breast Mass

In acute leukemia, leukemic infiltration of the breast is extremely rare. We report a case of biphenotypic acute leukemia (BAL) that presented as a breast mass. A 30-year-old woman presented with a 4-month history of a right breast mass with nipple discharge and easy fatigue. She had received chemotherapy and peripheral blood stem cell transplantation for BAL and had been in complete remission for the last 2 years. Core needle biopsy of the breast mass revealed monomorphous infiltrates of blast cells with round nuclei and fine chromatin, consistent with leukemic infiltration. Subsequent bone marrow biopsy showed diffuse infiltration of immature cells. However, bone marrow karyotyping showed 46, XY, suggesting complete engraftment of transplanted donor cells. This is the report of BAL recurring as a breast mass. In the differential diagnosis of a breast mass, extramedullary relapse should be considered when the patient has a history of leukemia.

Breast imaging findings in haematological malignancies

Objectives

The objectives of this article are to review and illustrate the imaging appearances of haematological malignancies in the breast.

Methods

With Institutional Review Board approval, a search of the surgical pathology records from 1st January 2000 to 1st July 2012 was performed for haematological malignancies.

Results

Forty-eight cases of haematological malignancies (42 women and 6 men) were identified with imaging available for review: 39 cases of breast lymphoma, 6 cases of chronic lymphocytic leukaemia, 2 cases of acute leukaemia and 1 case of known multiple myeloma.

Conclusions

Breast manifestations of haematological malignancies are rare. They can have a variable appearance at imaging and can mimic primary breast carcinoma. In the setting of suspicious breast imaging findings, pathological diagnosis of haematological malignancy is concordant. Correlation with a clinical history of prior haematological malignancy can be helpful in suggesting the diagnosis and help prevent unnecessary surgical treatment.

Teaching Points

• Breast haematological malignancies are rare but the imaging appearances can mimic breast carcinoma.

• Breast lymphoma, most often B-cell non-Hodgkin lymphoma, may be primary or due to secondary disease.

• At ultrasound, haematological malignancies may present as a heterogeneous or predominantly echogenic mass.

• Haematological malignancies show intense activity on PET/CT except myeloma which has low FDG uptake.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

Giant breast involvement in acute lymphoblastic leukemia: MRI findings

Breast metastases in cases of leukemia are rare. We aimed to report the conventional-advanced magnetic resonance imaging (MRI) findings of unilateral breast involvement of acute lymphoblastic leukemia (ALL) and review the literature. A 32-year-old woman was first diagnosed with ALL in treated in 2004. She did not continue the follow-up after 2008. She was presented with a giant, progressive right breast palpable mass in 2010. Mass, contralateral breast tissue were evaluated with MRI, diffusion weighted imaging and MR spectroscopy. With MRI findings, lesion was evaluated as malignant, tru-cut biopsy revealed recurrence of ALL. Lymphoma, malignant melanoma, rhabdomyosarcoma are most common tumors metastase to breast. Breast metastases of leukemia are rare and occur primarily in patients with acute myeloid leukemia. Secondary ALL breast involvement is uncommon. In a patient with malignancy, any enlarging breast mass, even with benign radiologic appearance, should be investigated carefully and metastasis should not be forgotten.

Breast leukemia: an update

BACKGROUND

Breast leukemia is extremely rare. The published data on this manifestation include predominantly case reports and do not provide any statistical information.

PURPOSE

To identify clinical signs and radiological features of breast leukemia.

MATERIAL AND METHODS

PubMed and Medline databases between 1980 and 2010 were screened using 'breast leukemia' and 'leukemia of the breast' as keywords. Secondary references were also reviewed. By this search, a total of 139 patients were identified from the literature.

RESULTS

In most patients (n = 85, 61.2%) acute myeloid leukemia was diagnosed. Acute lymphatic leukemia occurred in 35 patients (25.2%). Isolated BL before bone marrow infiltration was seen in 24 patients (17.3%). Involvement of the breast during the course of leukemia was diagnosed in 25 cases (18%). Intramammary leukemic relapse after therapy/stem cell transplantation occurred in 59 patients (42.4%). In 71 cases (51.1%) the lesions were solitary and in 57 (41%) multiple. The number of lesions was not reported in 11 patients (7.9%). There was no significant difference between the number of lesions in ML and LL. Clinically, 73% of the patients presented with palpable breast masses. Most of them were painless. Mammography was performed in 39 patients, allowing the identification of the following three mammographic patterns: breast masses (28 patients, 72%), architectural distortion (5 patients, 13%), no abnormalities (6 patients, 15%). On ultrasound, most identified masses were homogeneously hypoechoic with microlobulated or indistinct margins. On MRI, on T2-weighted images breast lesions were hyperintense. After venous administration of contrast medium, BL showed marked inhomogeneous contrast enhancement. Treatment of BL is the same as for other localizations and is based on chemotherapy and/or radiotherapy.

CONCLUSION

In the present study the clinical and radiological features of BL are described. They are non-specific. However, BL should be considered in the differential diagnosis of breast disorders, especially in patients with leukemia.

A basis for updating our approach to resistant acute leukemia

No studies exist documenting that chemotherapy alone eradicates tumors composed of leukemic cells in a large group of patients with tumors at any one site. Yet, its use has continued over 40 years in the absence of data. Consensus protocols exist only for testis and meningeal tumors, relying on local therapy. To constitute a body of knowledge about tumors at one site, the breast was chosen and all published cases were analyzed, with follow-up obtained, to document the behavior of acute leukemia tumors and survival after presentation. Among 235 cases (52% published since 2000), overall survival was poor, particularly for the 43% with concurrent morphologic marrow relapse, with 66-73% one-year mortality. Only 4 of 106 patients treated with chemotherapy alone survived 4 years. The majority of AML and ALL tumors were only transiently responsive to anti-leukemia treatments, including transplant, and next relapses were as, or more, common in further tumors than in marrow. A pattern of tumors similar to the metastases of invasive lobular breast cancer was revealed. When relapse occurred in marrow, durable remission was only rarely obtained. These data suggest a potential benefit of incorporating extent of disease workup at diagnosis and relapse into prospective trials. This could yield an accurate incidence of extramedullary tumors and a means to identify occult residual disease which could lead to marrow relapse. This approach could potentially result in greater success in curing acute leukemias.

Isolated extramedullary relapse of acute lymphoblastic leukemia in the breast of an adolescent girl: radiologic findings and discussion

We report a case of isolated extramedullary leukemia relapse in the breast of an adolescent girl. A 13-year-old girl with acute lymphoblastic leukemia in remission, post-chemotherapy and unrelated cord blood transplant, presented with a breast lump. US and mammography demonstrated a large hypervascular heterogeneous mass. Examination of tissue provided by US-guided core biopsy confirmed focal leukemic relapse. US is a commonly used diagnostic tool in children and adolescents with a breast mass, for both characterization and guided biopsy.

Acute lymphoblastic leukemia presented as multiple breast masses

Breast metastases in cases leukemia are very rare and occur primarily in patients with acute myeloid leukemia. We report the involvement of breast metastases in a 30-year-old woman with acute T cell lymphoblastic leukemia. The patient's mammograms revealed an extremely dense pattern with ill-defined, denser mass-like lesions in both breasts. A bilateral breast ultrasonographic evaluation revealed lobular-shaped and partly ill-defined hypoechoic masses with a multi-septated nodular (mottled) appearance.

A clinical review of breast involvement in acute leukemia

The breast continues to be reported as a site of resistant leukemia despite current curative protocols. To characterize disease behavior and potential for lengthy survival after breast relapse, a study was undertaken of 153 cases reported between 1969 and 2005. Authors were contacted for follow-up. There were 105 AML and 48 ALL cases identified. Ninety percent of female patients were younger than 50 and leukemia was temporally related to pregnancy in 13. Eight cases were males. Remissions were typically of short duration, principally due to further extramedullary relapses, in 3 main sites in both AML and ALL: contralateral breast, gynecologic organs, and CNS. However, there are cases of disease-free survival up to 26+ years after intensive treatment. Leukemia growing in the breast may follow a distinctive pattern, and prompt initiation of intensive multi-cycle treatment, assuming occult site involvement, with consideration of CSF prophylaxis, should increase the potential for disease eradication.

Isolated relapse of acute lymphoblastic leukemia in the breast of a young female

A 20-year-old female developed a relapse of B-precursor acute lymphoblastic leukemia (ALL) as a mass in her left breast after 6 years of maintained continuous complete remission. No leukemic lesions were identified in other sites such as the bone marrow or cerebrospinal fluid. The relapsed leukemic cells in the breast revealed the same immunophenotypes (CD10(+), CD19(+), CD20(+), HLA-DR(+), CD34(+)) as those of the onset ALL cells in the bone marrow. A literature survey found 10 other cases of ALL relapse in the breast without bone marrow involvement, mostly consisting of adolescent girls. Including the present report, a total of 11 cases were analyzed; the onset ages of ALL were a median of 16.5 (range 5-50) years old and the ages of relapse in the breast a median of 20 (range 12-51) years old. Data suggest that, although rare, the breast could become one of the extramedullary relapse sites of ALL developed in adolescent girls.

Unusual Breast Cancers: Useful Clues to Expanding the Differential Diagnosis

Invasive ductal carcinoma and ductal carcinoma in situ account for about 85% of breast cancers. Unusual breast neoplasms may be broadly divided into invasive lobular carcinoma, well-differentiated subtypes of invasive ductal carcinoma, cancers of stromal origin, and metastatic neoplasms. Clues are often present in imaging characteristics, patient demographics, and/or clinical features that may suggest that the finding is not the usual type of breast cancer. Some rare malignancies also provide specific clues to their diagnosis. This review provides an overview of unusual and a few rare malignant breast neoplasms, highlighting particular or specific clinical or imaging findings that will enable residents to expand their differential diagnosis of breast lesions beyond invasive ductal carcinoma.