Primary Lymphomas of the Breast: A Review

The Genetic Landscape of Primary Breast Marginal Zone Lymphoma Identifies a Mutational-driven Disease With Similarities to Ocular Adnexal Lymphoma

Extranodal marginal zone lymphomas (eMZL) can occur in any organ and site of the body. Recent research has shown that they differ from organ to organ in terms of their mutational profile. In this study, we investigated a cohort of primary breast marginal zone lymphomas (PBMZL) to get a better insight into their morphologic and molecular profile. A cohort of 15 cases (14 female and 1 male) was characterized by immunohistochemistry (IHC) for 19 markers, fluorescence in situ hybridization (FISH), and high throughput sequencing (HTS) using a lymphoma panel comprising 172 genes. In addition, PCR for the specific detection of Borrelia spp. and metagenomics whole genome sequencing were performed for infectious agent profiling. Follicular colonization was observed in most cases, while lymphoepithelial lesions, though seen in many cases, were not striking. All 15 cases were negative for CD5, CD11c, and CD21 and positive for BCL2 and pan B-cell markers. There were no cases with BCL2 , BCL10 , IRF4 , MALT1 , or MYC translocation; only 1 had a BCL6 rearrangement. HTS highlighted TNFAIP3 (n=4), KMT2D (n=2), and SPEN (n=2) as the most frequently mutated genes. There were no Borrelia spp. , and no other pathogens detected in our cohort. One patient had a clinical history of erythema chronicum migrans affecting the same breast. PBMZL is a mutation-driven disease rather than fusion-driven. It exhibits mutations in genes encoding components affecting the NF-κB pathway, chromatin modifier-encoding genes, and NOTCH pathway-related genes. Its mutational profile shares similarities with ocular adnexal and nodal MZL.

Ultrasound Diagnosis of Bilateral Primary Breast Burkitt Lymphoma in a 28-Year-Old Lactating Patient: A Case Report

Primary breast Burkitt lymphoma (PB-BL) is an exceedingly rare form of primary breast lymphoma. Ultrasonography is the preferred modality for diagnosing breast diseases; however, the ultrasonic features of Burkitt lymphoma have rarely been reported. Herein, we report a case of ultrasonically diagnosed bilateral PB-BL in a lactating patient and present a literature review. A 28-year-old female patient experienced bilateral breast engorgement starting more than a month after childbirth. At three months postpartum, the patient experienced extreme bilateral breast engorgement, with the skin appearing dark purple and jaundiced. Based on the imaging diagnosis, pathological, immunohistochemical, and molecular biological findings, she was diagnosed with Burkitt lymphoma involves bilateral breasts, right adrenal glands, uterus, and multiple bones. After 4 cycles of combination chemotherapy, the tumor basically disappeared, and then after autologous stem cell transplantation and one cycle of combination chemotherapy, the patient is generally in good condition and is under follow-up. We found that the ultrasonic characteristics of PB-BL are different from those of common breast cancer or lactation mastitis. PB-BL lesions are often multiple, large masses, and even involve the whole breast. The characteristic reticular structures are common in lesions, and irregular hyperechoic masses can be seen around it. The mass has abundant peripheral and internal blood flow signals, but internal calcification and attenuated posterior echoes of masses are rarely observed. Thus, the ultrasonic features of breast Burkitt lymphoma are somewhat specific and understanding these features is conducive to its early identification.

Non-Hodgkin's Lymphoma Within a Breast Abscess in a Male Patient: A Presentation and Literature Review of a Rare Case

Breast abscesses are a common cause of presentation to the hospital. These should be treated with caution due to the possibility of rare pathology. We present a rare case of a 59-year-old diabetic gentleman who presented to the emergency department with a two-day history of a large right-sided breast swelling along with an area of induration, consistent with an abscess, extending to the right axillary region. Initial laboratory findings revealed elevated inflammatory markers. He was admitted for intravenous antibiotics. A computed tomography (CT) of the thorax performed on admission showed an ill-defined collection in the subcutaneous tissue of the right breast and axilla and an irregular right-sided peribronchial nodule with multiple enlarged pathological lymph nodes. This patient's case was discussed with tertiary specialist breast services and local respiratory teams. He underwent an ultrasound-guided right axillary lymph node biopsy. The histopathology of this revealed a high-grade malignant non-Hodgkin's lymphoma of the diffuse large B-cell (DLBCL) type. He was referred for a positron emission tomography (PET) scan and hematological oncology services for further treatment in the form of chemotherapy. This case presentation brings forward the importance of considering rare diagnoses and unusual histopathology when assessing a male breast lesion.

Secondary Breast Burkitt Lymphoma Involving the Stomach, Ovary, Pancreas, and Bones: A Case Report

Breast lymphomas are rare, malignant breast neoplasms with a heterogeneous pattern of clinical symptoms. Burkitt's lymphoma is a rare, highly aggressive, and rapidly growing B-cell non-Hodgkin lymphoma. We report about a 27-year-old woman diagnosed as having secondary breast Burkitt's lymphoma, probably originating from the stomach, with multiple distant metastases. Breast ultrasonography revealed multiple, variable sized, heterogeneous masses with posterior acoustic enhancement and echogenic rims. These imaging findings may sometimes overlap with those of other breast malignancies. However, unlike other breast malignancies, lymphoma can be diagnosed by biopsy and does not require surgical excision. To avoid unnecessary treatment, radiologists and clinicians should be aware of the characteristic imaging features of breast lymphomas.

Breast Implants and the Risk of Squamous Cell Carcinoma of the Breast: A Systematic Literature Review and Epidemiologic Study

Squamous cell carcinoma may arise primarily from the breast parenchyma (PSCCB) or from the periprosthetic capsule in patients with breast implants (breast implant-associated squamous cell carcinoma [BIA-SCC]). A systematic literature review was performed to identify all PSCCB and BIA-SCC cases, and to estimate prevalence, incidence rate (IR), and risk. Studies up to November 2023 were searched on PubMed, Web of Science, Google Scholar, and Cochrane Library for predefined keywords. The numerator for PSCCB and BIA-SCC was the number of cases obtained from the literature; the denominator for PSCCB was the female population aged from 18 to 99, and the denominator for BIA-SCC was the population with breast implants. Overall, 219 papers were included, featuring 2250 PSCCB and 30 BIA-SCC cases. PSCCB prevalence was 2.0 per 100,000 (95% CI, 0.2:100,000 to 7.2:100,000) individuals, with a lifetime risk of 1:49,509 (95% CI, 0.2:10,000 to 5.6:10,000); and BIA-SCC prevalence was 0.61 per 100,000 (95% CI, 0.2:100,000 to 1.3:100,000), with a lifetime risk of 1:164,884 (95% CI, 0.2:100,000 to 5.6:100,000). The prevalence of BIA-SCC is 3.33 times lower than that of PSCCB, while the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is 3.84 times higher than that of primary breast ALCL. When comparing the BIA-SCC prevalence of 1:164,910 individuals with breast implants regardless of texture to the BIA-ALCL prevalence of 1:914 patients with textured implants, the BIA-SCC risk is 180 times lower than the BIA-ALCL risk. BIA-SCC occurs less frequently than PSCCB and considerably less than BIA-ALCL. The association between textured implants and BIA-SCC cases is relevant for patient education regarding uncommon and rare risks associated with breast implants, and ongoing vigilance, research, and strengthened reporting systems remain imperative.

[Rare tumours of the breast]

Breast tumours are the most common tumours in women but represent a very heterogeneous group. On the one hand, there are ductal and lobular carcinomas of the breast, representing 90% of tumours, whose clinicopathologic characteristics are well known. On the other hand, there are rare breast tumours, each of which represents less than 1% that limits their study through large cohorts. The objective of this work was to collect, update and synthesize knowledge on these rare tumours. A literature review was performed on the Medline and Google Scholar databases. We present here a selection of several rare tumours, providing updated data at the epidemiological, histopathological, genetic, clinical and radiographic, prognostic and therapeutic levels, taking into account the place of radiotherapy. Each tumour histology is unique and has its own characteristics, the management must therefore be adapted as much as possible and decided in a multidisciplinary meeting.

Comparative analysis of conventional ultrasound and shear wave elastography features in primary breast diffuse large B-cell lymphoma

BACKGROUND

Primary breast diffuse large B-cell lymphoma (PB-DLBCL) is a rare subtype of non-Hodgkin lymphoma that accounts for < 3% of extranodal lymphomas and 1% of breast tumors. Its diagnosis and management are challenging because of its rarity, heterogeneity, and aggressive behavior. Conventional ultrasound (US) is the first-line imaging modality for breast lesions; however, it has limited specificity and accuracy for PB-DLBCL. Shear wave elastography (SWE) is a novel US technique that measures tissue stiffness and may reflect the histological characteristics and biological behavior of breast lesions.

AIM

To compare the conventional US and SWE features of PB-DLBCL and evaluate their diagnostic performance and prognostic value.

METHODS

We retrospectively reviewed the clinical data and US images of 32 patients with pathologically confirmed PB-DLBCL who underwent conventional US and SWE before treatment. We analyzed conventional US features (shape, margin, orientation, echo, posterior acoustic features, calcification, and vascularity) and SWE features (mean elasticity value, standard deviation, minimum elasticity value, maximum elasticity value, and lesion-to-fat ratio) of the PB-DLBCL lesions. Using receiver operating characteristic curve analysis, we determined the optimal cutoff values and diagnostic performance of conventional US and SWE features. We also performed a survival analysis to assess the prognostic value of conventional US and SWE features.

RESULTS

The results showed that the PB-DLBCL lesions were mostly irregular in shape (84.4%), microlobulated or spiculated in margins (75%), parallel in orientation (65.6%), hypoechoic in echo (87.5%), and had posterior acoustic enhancement (65.6%). Calcification was rare (6.3%) and vascularity was variable (31.3% avascular, 37.5% hypovascular, and 31.3% hypervascular). The mean elasticity value of PB-DLBCL lesions was significantly higher than that of benign breast lesions (113.4 ± 46.9 kPa vs 27.8 ± 16.4 kPa, P < 0.001). The optimal cutoff value of the mean elasticity for distinguishing PB-DLBCL from benign breast lesions was 54.5 kPa, with a sensitivity of 93.8%, specificity of 92.9%, positive predictive value of 93.8%, negative predictive value of 92.9%, and accuracy of 93.3%. The mean elasticity value was also significantly correlated with Ki-67 expression level (r = 0.612, P < 0.001), which is a marker of tumor proliferation and aggressiveness. Survival analysis showed that patients with higher mean elasticity values (> 54.5 kPa) had worse overall survival (OS) and progression-free survival (PFS) than those with lower mean elasticity values (< 54.5 kPa) (P = 0.038 for OS and P = 0.027 for PFS).

CONCLUSION

Conventional US and SWE provide useful information for diagnosing and forecasting PB-DLBCL. SWE excels in distinguishing PB-DLBCL from benign breast lesions, reflects tumor proliferation and aggressiveness, and improves disease management.

A Rare and Isolated Presentation of Primary Cutaneous Anaplastic Large Cell Lymphoma on the Breast

Primary cutaneous anaplastic large-cell lymphoma (PC-ALCL) is a subtype of non-Hodgkin lymphoma belonging to the CD30+ spectrum of lymphoproliferative disorders. It constitutes the second most prevalent category within cutaneous T-cell lymphomas (CTCL), encompassing approximately 25% of cases. This disorder is characterized by its exclusive cutaneous involvement and favorable overall prognosis. Patients typically present with reddish-brown nodules, which may evolve into ulcers. Although some cases experience regression, complete resolution is uncommon. While most lesions manifest on the extremities, followed by the head and neck, the breast region may rarely be affected by PC-ALCL. Distinctions between anaplastic lymphoma kinase (ALK)-positive and ALK-negative subtypes have been documented in breast presentations, often associated with breast implants. In this context, we present an isolated PC-ALCL instance in a 26-year-old woman with no history of breast implants.

Diagnostic Pitfalls in Breast Cancer Pathology With an Emphasis on Core Needle Biopsy Specimens

CONTEXT.—

Breast pathology has many mimics and diagnostic pitfalls. Evaluation of malignant breast lesions, particularly in the biopsy setting, can be especially challenging, with diagnostic errors having significant management implications.

OBJECTIVE.—

To discuss the pitfalls encountered when evaluating ductal carcinoma in situ and invasive breast carcinomas, providing histologic clues and guidance for appropriate use and interpretation of immunohistochemistry to aid in the correct diagnosis.

DATA SOURCES.—

Data were obtained from review of pertinent literature of ductal carcinoma in situ and invasive breast carcinomas and from the experience of the authors as practicing breast pathologists.

CONCLUSIONS.—

Awareness of the pitfalls in diagnosing breast cancers is important when creating a differential diagnosis for each breast lesion evaluated. This review will cover some of these scenarios to aid in the diagnostic process.

A Rare Case of Primary Breast Diffuse Large B-cell Lymphoma in an Acquired Immunodeficiency Syndrome Patient

Primary breast lymphoma (PBL) is not a commonly seen subtype of breast cancer, and it is also unusual for an extranodal variant of diffuse large B-cell lymphomas (DLBCLs) to appear in the breast. In this case report, we recount the presentation of painful masses in the right axillary and right breast regions in an acquired immunodeficiency syndrome (AIDS) patient, shortly after a mammogram described her breast lesion as BI-RADS 3, probably benign, in the breast imaging reporting and data system. This case demonstrated that painful breast and axillary masses in an acquired immunodeficiency syndrome (AIDS) patient can grow quickly, be misdiagnosed, and require an expedient workup, as extranodal DLBCL can be a debilitating disease.

Clinical recommendations for diagnosis and treatment according to current updated knowledge on BIA-ALCL

Shared strategies and correct information are essential to guide physicians in the management of such an uncommon disease as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). A systematic review of the literature was performed to collect the most relevant evidence on BIA-ALCL reported cases. A panel of multidisciplinary experts discussed the scientific evidence on BIA-ALCL, and updated consensus recommendations were developed through the Delphi process. The lastest reported Italian incidence of BIA-ALCL is 3.5 per 100.000 implanted patients (95% CI, 1.36 to 5.78), and the disease counts over 1216 cases worldwide as of June 2022. The most common presentation symptom is a late onset seroma followed by a palpable breast mass. In the event of a suspicious case, ultrasound-guided fine-needle aspiration should be the first step in evaluation, followed by cytologic and immunohistochemical examination. In patients with confirmed diagnosis of BIA-ALCL confined to the capsule, the en-bloc capsulectomy should be performed, followed by immediate autologous reconstruction, while delayed reconstruction applies for disseminate disease or radically unresectable tumor. Nevertheless, a multidisciplinary team approach is essential for the correct management of this pathology.