Emerging Treatment Strategies for Primary Breast Extranodal Marginal Zone Lymphoma of Mucosa-associated Lymphoid Tissue

Primary MALT lymphoma of the breast: pathological and radiological characteristics

PURPOSE

Primary Mucosa-associated lymphoid tissue (MALT) lymphoma is a rare diagnosis in the breast, and clinical diagnosis based on radiological features is often challenging. This study aimed to evaluate the clinicopathological, and radiological characteristics of the patients diagnosed with primary breast MALT lymphoma.

METHODS

This study examined 18 cases of primary MALT lymphoma of the breast diagnosed at a single tertiary center between January 2002 to December 2020. Medical charts, radiological imaging and original pathology slides were reviewed for each case.

RESULTS

All cases were female (gender assigned at birth) and presented with a palpable mass or an incidental imaging finding. Imaging presentation ranged from mammographic asymmetries, circumscribed masses, and ultrasound masses lacking suspicious features. Seventeen cases were biopsied under ultrasound; one received a diagnostic excision biopsy. Microscopic examination of the breast specimens demonstrated atypical small lymphocyte infiltration with plasmacytoid differentiation and rare lymphoepithelial lesions. Immunohistochemistry was performed in all cases and established the diagnosis. Most patients were treated with radiotherapy, and only three were treated with chemotherapy. The median follow-up period was 4 years and 7.5 months, and all patients were alive at the last follow-up.

CONCLUSION

Primary MALT breast lymphomas are usually indolent and non-systemic, and local radiotherapy may effectively alleviate local symptoms. Radiological findings show overlap with benign morphological features, which can delay the diagnosis of this unusual etiology. Although further studies involving a larger cohort could help establish the clinical and radiological characteristics of primary breast MALT lymphomas, pathology remains the primary method of diagnosis.

TRIAL REGISTRATION NUMBER

University Health Network Ethics Committee (CAPCR/UHN REB number 19-5844), retrospectively registered.

Breast mucosa-associated lymphoid tissue lymphoma: A case report and literature review

BACKGROUND

Mucosa-associated lymphoid tissue (MALT) lymphoma, also known as extranodal marginal zone lymphoma, is more commonly detected in the stomach and rarely in the breast. Our study presented a clinical and pathological examination of a patient diagnosed with breast MALT lymphoma, supplemented with pertinent research, to offer guidance for the diagnosis and treatment of this condition.

PEOPLE CONCERNS

The occurrence of breast MALT lymphoma has risen in the past decade, but its etiology, progression and treatment response are less well-studied.

DIAGNOSIS

Breast MALT lymphoma was diagnosed by excisional biopsy and histopathology.

INTERVENTIONS

Following breast MALT lymphoma diagnosis, the patient was transferred to the hematology department for further treatment, and she made the decision to continue observing.

OUTCOMES

After 3 months of observation, the patient remained asymptomatic.

CONCLUSION

Breast MALT lymphoma is an indolent disease with an asymptomatic presentation, There are no standardized treatment guidelines for breast MALT lymphoma, treatment must be tailored to the patient willingness to treat and the severity of the disease. Hence, in order to give patients a better chance of cure, more research is needed to explore its pathogenesis and more clinical trials are needed investigate the treatment of this disease.

Predicting the risk of distant and local recurrence for patients with ocular adnexal extranodal marginal zone lymphoma: a matched case-control study

BACKGROUND/AIMS

Extranodal marginal zone lymphoma of ocular adnexa (OA-EMZL) is the most frequent type of ocular adnexal lymphomas, with a high rate of disease recurrence. Precise patient stratification based on disease recurrence is understudied. This study aims to identify risk factors of distant recurrence (DR) and local recurrence (LR) to construct a prognostic model optimising rapid decision of therapeutic strategies.

METHODS

A total of 104 patients diagnosed with OA-EMZL between January 2011 and February 2020 were enrolled. Propensity score matching was performed for DR and LR groups. A nomogram was generated using a multivariate Cox proportional hazards model.

RESULTS

After matching, different independent risk factors of DR and LR were identified. Monocyte percentage (p=0.015) and M category >0 (p=0.043) were significant independent risk factors of DR. Epiphora (p<0.001) was the significant independent risk factor of LR. Three factors (monocyte percentage, M category >0, age >60) were integrated into the nomogram to predict the risk of DR. It had a relatively better discriminative ability for distant recurrence-free survival (C-index: 3-year, 0.784; 6-year, 0.801) than IPI score (C-index: 3-year, 0.663; 6-year, 0.673) in the cohort of all patients.

CONCLUSION

Our analyses suggested DR and LR as two distinct prognostic events, and additionally identified novel risk factors of them. The nomogram may serve as a practical tool for the prognostic estimation and rapid decision of therapeutic strategies for patients with OA-EMZL.

A rare case of synchronous mucosa-associated lymphoid tissue (MALT) lymphoma involving bilateral breasts and subcutaneous tissues

Marginal zone lymphoma of mucosa-associated lymphoid tissue is a B-cell lymphoma which arises in extranodal sites, most commonly the stomach. Involvement of the breast is very rare. We present a case of an asymptomatic 63-year-old woman with synchronous mucosa-associated lymphoid tissue lymphoma involving both breasts and subcutaneous tissues. This represents a form of secondary breast lymphoma (given the concurrent involvement of the breast and non-mammary organ systems) and is an exceedingly rare diagnosis which, to our knowledge, has only been discussed in a few case series.

A single-center analysis of patients with extranodal marginal zone lymphoma of the breast

Breast extranodal marginal zone lymphoma (EMZL) is a rare malignancy. We performed the largest published to date single-center retrospective analysis of 13 patients with breast EMZL focusing on clinical characteristics and treatment-related outcomes. The rarity of this disease at our center was concordant with the prevalence reported in the literature, with breast EMZL comprising 2% of 654 MZL cases. Most patients presented with stage I-II disease however four (30.8%) patients had stage IV disease mostly due to occult bone marrow (BM) involvement. Interestingly, EMZL was frequently non-FDG avid (66.7%) on staging PET/CT. With a median follow-up of 3.1 years (range 5 months to 10.2 years), the 3-year progression free survival was 68.7% (95%CI 30.2%-88.9%) and overall survival 80.2% (95%CI 40.3%-94.8%). No patient experienced higher-grade transformation. Herein we show that localized breast EMZL can be effectively treated with radiation therapy providing long term disease control.

Efficacy of low-dose radiotherapy (2 Gy × 2) in the treatment of marginal zone and mucosa-associated lymphoid tissue lymphomas

OBJECTIVES

To investigate the efficacy of a schedule of low-dose radiotherapy (LDRT) with 4 Gy (2 Gy x 2) in a cohort of unselected MALT or MZL patients.

METHODS

We retrospectively collected all patients receiving LDRT, either for cure or palliation, for a stage I-IV histologically proven MALT or MZL between 2016 and 2020. Response to LDRT was evaluated with the Lugano criteria. Local control (LC), distant relapse-free survival (DRFS), progression-free survival (PFS) and overall survival (OS) were stratified for treatment intent (curative vs palliative) and estimated by the Kaplan-Meier product-limit.

RESULTS

Among 45 consecutively enrolled patients with a median age of 68 years (range 22-86), 26 (58%) were female. Thirty-one patients (69%) with a stage I-II disease received LDRT as first line therapy and with a curative intent. Overall response rate was 93%, with no significant difference among curative and palliative intent. With a median follow-up of 18 months, LC, DRFS, PFS and OS at 2 years were 93, 92, 76 and 91%, respectively, in the overall population. Patients receiving curative LDRT had a better PFS at 2 years (85% vs 54%, p < 0.01) compared to patients receiving palliative treatment. LDRT was well tolerated in all patients, without any significant acute or chronic side-effect.

CONCLUSIONS

LDRT is effective and well tolerated in patients affected with MALT or nodal MZL, achieving high response rates and durable remission at 2 years.

ADVANCES IN KNOWLEDGE

This study shows the efficacy of LDRT in the treatment of MALT and MZL.

Conventional Treatments Cannot Improve Outcomes of Early-Stage Primary Breast Marginal Zone Lymphoma

Introduction

Primary breast marginal zone lymphoma (PBMZL) is a rare occurrence and less is known about its characteristics, treatments, and outcomes.

Methods

We retrospectively reviewed 370 cases of early-stage PBMZL from the Surveillance, Epidemiology, and End Results database. Statistical analyses were performed to describe clinical features, determine prognostic factors, and compare different therapeutic strategies.

Results

At a median follow-up of 68.5 months, the 5-year overall survival (OS) and disease-specific survival (DSS) rate were 81.2 and 95.4%, respectively. We divided the cohort into four treatment groups and compared their characteristics and survival: radiotherapy (RT) ± surgery (Sx) (n = 142, 38.4%), Sx alone (n = 71, 19.2%), any chemotherapy (CT) (n = 63, 17.0%), and none of the above (n = 94, 25.4%). Age of onset and laterality of lesions tended to relate to the choice of different treatments. Multivariate Cox analysis showed that advanced age (>60 years), concomitant tumor, and any CT (vs RT ± Sx) predicted poorer OS, while for DSS, there was no meaningful indicator (P > 0.05). Patients aged >60 years or treated with any CT seemed to have shorter DSS, but the difference only approached statistical significance. Then we applied a propensity score-matched analysis to demonstrate that neither RT- nor Sx-containing therapy could bring a better OS or DSS. The competing risk model suggested that CT was the only contributor to higher PBMZL-specific mortality.

Conclusion

Our results show an indolent behavior of early-stage PBMZL with long-term survival. Conventional oncological treatments fail to bring survival benefits; especially CT is detrimental to survival, suggesting that observation may be advisable in the management of early-stage PBMZL, and further research on novel targeted agents is warranted for patients in need.

Primary Breast Extranodal Marginal Zone Lymphoma in Primary Sjögren Syndrome: Case Presentation and Relevant Literature

The association between autoimmune diseases, mostly rheumatoid arthritis, systemic lupus erythematosus, celiac disease and Sjögren syndrome, and lymphoma, has been widely demonstrated by several epidemiologic studies. By a mechanism which has not yet been entirely elucidated, chronic activation/stimulation of the immune system, along with the administration of specific treatments, may lead to the onset of different types of lymphoma in such patients. Specifically, patients affected by Sjögren syndrome may develop lymphomas many years after the original diagnosis. Several epidemiologic, hematologic, and histological features may anticipate the progression from Sjögren syndrome into lymphoma but, to the best of our knowledge, a definite pathogenetic mechanism for such progression is still missing. In fact, while the association between Sjögren syndrome and non-Hodgkin lymphoma, mostly extranodal marginal zone lymphomas and, less often, diffuse large B-cell, is well established, many other variables, such as time of onset, gender predilection, sites of occurrence, subtype of lymphoma, and predictive factors, still remain unclear. We report on a rare case of primary breast lymphoma occurring three years after the diagnosis of Sjögren syndrome in a 57-year-old patient. The diagnostic work-up, including radiograms, core needle biopsy, and histological examination, is discussed, along with emerging data from the recent literature, thus highlighting the usefulness of breast surveillance in Sjögren syndrome patients.

Bilateral Primary Marginal Zone Lymphoma of the Breast - A Rare Breast Malignancy

Extranodal marginal zone lymphoma (EMZL) presents only rarely within the breast, although the incidence of breast EMZL has increased in the past decade for unclear reasons. Due to its rarity, the etiology, course, and treatment response of this cancer are less studied. Case Report: We present the case of a 64-year-old female who had bilateral diffuse irregularity in a trabecular pattern on screening mammogram. Random ultrasound-guided breast biopsy of the right breast demonstrated an extra-nodal marginal zone B-cell lymphoma. She also had approximately 25% marrow involvement by mucosa-associated lymphoid tissue-type marginal zone lymphoma and splenomegaly. Clinically she remained asymptomatic during a 1-year follow-up. Although she presented with advanced-stage disease involving both breasts, spleen and bone marrow, given her lack of associated symptoms, she was observed with active surveillance. Conclusion: Asymptomatic cases of breast EMZL can be managed with close observation as exemplified by our case.

Clinical Characteristics and Outcomes of Primary Breast Lymphoma: The Cleveland Clinic Experience

Introduction Primary breast lymphoma (PBL) is a rare malignancy that accounts for less than 0.5% of all breast malignancies. Materials and Methods We retrospectively analyzed 36 PBL patients to report the clinical characteristics and outcomes of patients with indolent and aggressive histologic subtypes. Results Thirteen (36%) patients had aggressive and 23 (64%) had indolent PBL. Marginal zone lymphoma was the most common histologic subtype (33%). Stage IE, IIE, and IV disease were seen in 27 (75%), six (17%), and three (8%) patients, respectively. Patients with aggressive PBL more often presented with a breast lump and/or B symptoms (unexplained weight loss, fever, night sweats) (78% vs. 31%, p = 0.005). Commonly used treatment modalities for aggressive vs. indolent PBL were chemotherapy alone (23% vs. 26%, p = 0.8), chemoradiotherapy (46% vs. 9%, p = 0.009), radiotherapy alone (15% vs. 22%, p = 0.6), and observation (0% vs. 26%, p = 0.07), respectively. The five-year overall survival (OS) and progression-free survival (PFS) of PBL patients were 82% (95% CI: 67 - 100) and 63% (95% CI: 45 - 89), respectively. The five-year OS of patients with aggressive vs. indolent PBL were 92% (95% CI: 77 - 100) vs. 80% (95% CI: 63 - 100), respectively (p = 0.6). The five-year OS of patients who received > 1, 1, and 0 treatment modalities were 92% (95% CI: 77 - 100), 86% (95% CI: 63 - 100), and 53% (95% CI: 21 - 100), respectively. Conclusion In our cohort, the higher utilization of chemoradiotherapy in aggressive PBL was able to overcome the worse prognosis of these patients. At least one treatment modality should be considered in patients with indolent PBL, given that observation alone was associated with a poor prognosis.