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

[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.

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.

Surgical Excision Versus Medical Management of Primary Breast Lymphoma: A Case Report

Lymphoma of the breast accounts for 0.4-0.5% of all breast-located cancers and is found in a similar fashion to breast cancers. Here we present a 74-year-old woman who presented for a biopsy of a breast mass found on a routine mammogram, which was found to be a primary breast lymphoma. According to current practice guidelines, medical therapy is favorable for the definitive management of primary breast lymphomas. However, biopsy specimen cytology found neoplastic cells positive for human germinal center-associated lymphoma, a nonspecific marker for various types of lymphomas. Without a definitive classification of lymphoma, optimal medical therapy could not be achieved. Therefore, a decision was made to undergo a lumpectomy of the mass, which yielded a specimen that was found pathologically favorable for diffuse large B-cell lymphoma. With this information, the patient was referred to follow-up oncology for adjuvant chemotherapy and radiotherapy.

A Multicenter Study of Clinicopathology and Immunohistochemical Distinction between Adult and Pediatric Large B-Cell Lymphoma

Introduction: Pediatric DLBCL is considered a homogenous group and has superior outcomes compared to adults. This study investigated the clinical pathology and immunohistochemical distinction between adult and pediatric large B-cell lymphoma. Methods: A cross-sectional study of 314 NHLs with the morphology of diffuse pattern, large B-cell, and CD20 expression was investigated. Results: Of 314 cases, there were 6 cases of pleomorphic MCL (all in adults), 19 cases of Burkitt lymphoma (all in children), and 289 cases of DLBCL. Pediatric DLBCL had many striking differences: More frequency in extra-nodal sites; a higher proportion of centroblastic morphology; a predominance of GCB-type; a high proliferation rate; an infrequency of Bcl2 protein expression, and a lack of double-expresser lymphoma. Conclusions: Our study demonstrated the significant biological differences between adult and pediatric DLBCL.

Case of Primary Breast and Ipsilateral Axillary T-Cell Lymphoma: a Rare Occurrence

BACKGROUND

Malignant lymphomas of the breast are rare and can be primary or secondary. Non-Hodgkin Lymphoma involving the breast is even rarer comprising 0.04-0.5% of all breast malignancies (Takemura). The incidence is even lower for T-cell lymphomas compared with B-cell subtype. We report the rare incidence of primary T-cell lymphoma involving both breast and ipsilateral axilla.

CASE

This is the case of an 80-year-old female who initially presented with asymmetry of her right breast. Initial mammograms were inconclusive. MRI could not be performed due to the patient's severe claustrophobia. The patient was then lost to follow-up but re-presented with a new palpable density in the same breast. Subsequent mammogram showed a suspicious lesion with suspicious right axillary lymphadenopathy. Core biopsy was consistent with T-cell lymphoproliferative disorder involving both the breast and the axilla. She was then referred to medical oncology for management.

CONCLUSION

Although rare, lymphoproliferative disorders of the breast can be encountered during workup for suspicious breast lesions. It is imperative that the surgeon is aware of this rare diagnosis to facilitate appropriate therapeutic intervention.

First-Line Treatment for Primary Breast Diffuse Large B-Cell Lymphoma Using Immunochemotherapy and Central Nervous System Prophylaxis: A Multicenter Phase 2 Trial

There are limited data from prospective controlled trials regarding optimal treatment strategies in patients with primary breast diffuse large B-cell lymphoma (DLBCL). In this phase 2 study (NCT01448096), we examined the efficacy and safety of standard immunochemotherapy and central nervous system (CNS) prophylaxis using intrathecal methotrexate (IT-MTX). Thirty-three patients with newly diagnosed primary breast DLBCL received six cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and four fixed doses of IT-MTX (12 mg). The median age was 50 years (range, 29-75), and all patients were females. According to the CNS-International Prognostic Index, most patients (n = 28) were categorized as the low-risk group. Among the 33 patients, 32 completed R-CHOP, and 31 completed IT-MTX as planned. With a median follow-up of 46.1 months (interquartile range (IQR), 31.1-66.8), the 2-year progression-free and overall survival rates were 81.3% and 93.5%, respectively. Six patients experienced treatment failures, which included the CNS in four patients (two parenchyma and two leptomeninges) and breast in two patients (one ipsilateral and one contralateral). The 2-year cumulative incidence of CNS relapse was 12.5%. Although standard R-CHOP and IT-MTX without routine radiotherapy show clinically meaningful survival outcomes, this strategy may not be optimal for reducing CNS relapse and warrants further investigation.

Coincident primary breast lymphoma and gastrointestinal stromal tumor: case series and molecular mechanisms

Gastrointestinal stromal tumor (GIST) is an uncommon mesenchymal tumor, and has been shown to be associated with synchronous or metachronous second malignancies. Rare cases of coincident GIST and non-Hodgkin lymphomas (NHL) have been reported previously. Here, we report two cases of GIST and coincident primary breast lymphoma, an uncommon subtype of extranodal NHL. We propose that the exceedingly low likelihood of both these cancers occurring in these two patients by chance warrants examination for possible common oncogenic pathways in these lesions, possibly involving shared anti-apoptotic mechanisms. Further research is vital to elucidate common oncogenic pathways between such rare lesions.

Diffuse Large B-Cell Breast Lymphoma: A Case Series

Primary breast lymphoma (PBL) is a rare disease, and few clinicohistopathologic features of the disease have been discussed in previous studies. It represents 2.2% of extranodal lymphomas and constitutes 0.04% to 0.5% of malignant breast neoplasms, despite the clinical and radiographic similarities between breast lymphoma and carcinoma, the prognosis, as reported in the literature, varies. No consensus exists on the best way to treat PBL. However, radiotherapy and chemotherapy were used alone or in combination to treat various cases of PBL. We retrospectively studied 3 cases of PBL of the breast seen in patients attending a tertiary cancer center in Qatar, between 2012 and 2015, in an attempt to determine the common clinical features, therapy, and prognosis of PBL.

Hematolymphoid lesions of the breast

Hematolymphoid malignancies of the breast are most commonly neoplasms of mature B-lymphocytes, and may arise as a primary disease or by secondary involvement of a systemic disease. Primary breast lymphomas (PBL) account for 0.04-0.5% of breast malignancies, less than 1% of all non-Hodgkin's lymphomas (NHL), and less than 5% of extranodal lymphomas (Lakhani et al., 2012; Swerdlow et al., 2008; Joks et al., 2011; Barişta et al., 2000; Giardini et al., 1992; Brogi and Harris, 1999; Topalovski et al., 1999).^1-7 Secondary breast lymphomas (SBL) are also rare, with an estimated annual incidence of 0.07% (Domchek et al., 2002; Talwalkar et al., 2008).^8,9 Recognition of breast lesions as hematolymphoid is critical to distinguish them from other entities that can occur in the breast.

Primary Breast Lymphoma: A Case Report and Review of the Literature

Primary breast lymphoma (PBL) represents 0.04-0.5% of all malignant breast tumors, <1% of all patients with non-Hodgkin's lymphomas and 1.7-2.2% of all patients with extra nodal lymphomas. Despite the high prevalence of breast cancer, primary breast lymphoma is very rare. We report a rare case of PBL, successfully treated with surgery, chemotherapy and radiotherapy. This is the first case of PBL to be reported from Sudan to our knowledge.

Primary Breast Lymphoma: Analysis of 55 Cases of the Spanish Lymphoma Oncology Group

INTRODUCTION

Primary breast lymphoma is a rare form of localized extranodal lymphoma, which affects the mammary glands unilaterally or bilaterally, and can also affect the regional lymph nodes.

MATERIALS AND METHODS

We reviewed 55 patients, with disease stages IE and IIE, diagnosed in 16 Spanish institutions between 1989 and 2016. A serial of clinical variables and treatment were collected, and overall survival (OS) and progression-free survival (PFS) were calculated.

RESULTS

Of the 55 patients, 96.4% were women with an average age of 69 years. A total of 53 patients corresponded to non-Hodgkin lymphoma (NHL), of whom 36.3% had lymph node involvement upon diagnosis. Of the patients, 58.2% were stage IE, and 41.8% were stage IIE. Treatments received included radiotherapy (36.3%), chemotherapy (85.5%), and rituximab (in 38 of the 45 patients with NHL treated with chemotherapy). In all, 82.2% of complete responses were achieved. OS and progression-free survival at 5 years in NHL patients was 76% and 73%, respectively.

CONCLUSION

Current treatments (chemotherapy, immunotherapy, and radiotherapy) achieve good control of the disease, with an OS of 5 years in 80% of the patients, although there is no consensus in treatment, given the scarce incidence of these lymphomas.

Frequent MYD88 L265P and CD79B Mutations in Primary Breast Diffuse Large B-Cell Lymphoma

Primary breast diffuse large B-cell lymphoma (PB-DLBCL) is a rare disease comprising <3% of extranodal lymphomas. It frequently reveals an activated B-cell (ABC)-like phenotype. ABC-like DLBCL was reported to have gain-of-function mutations in MYD88, CD79B, CARD11, and TNFAIP3, resulting in constitutive activation of the NFκB pathway. Because of the rare occurrence of PB-DLBCL, the frequency of MYD88 and CD79B mutations is still unknown. We used Sanger sequencing to study these mutations from 46 breast DLBCL cases and also investigated the associated clinicopathologic factors. MYD88 L265P was confirmed by allele-specific polymerase chain reaction and compared with the Sanger sequencing results. MYD88 L265P and CD79B mutations were detected in 27/46 (58.7%) and 11/33 (33.3%) cases, respectively. Twenty-eight of 46 cases met the criteria for PB-DLBCL, and the latter 18 cases were further classified as clinical breast DLBCL (CLB-DLBCL). The frequency of MYD88 L265P and CD79B mutations was 16/28 (57.1%) and 9/23 (39.1%), respectively, in PB-DLBCL and 11/18 (61.1%) and 2/10 (20%), respectively, in CLB-DLBCL. When the cutoff value was set at ΔCt≤1, the result of allele-specific polymerase chain reaction for MYD88 corresponded to those of the Sanger sequence at 92.6% sensitivity and 100% specificity. According to Choi's algorithm, 16/27 (59.3%) demonstrated an ABC-like phenotype in PB-DLBCL, and 15/18 (83.3%) demonstrated an ABC-like phenotype in CLB-DLBCL. In conclusion, MYD88 L265P and CD79B mutations were frequently detected in PB-DLBCL, and they may be key molecules associated with PB-DLBCL lymphomagenesis. Further analysis will be required to clarify the mechanism of its pathogenesis.

Diffuse large B-cell lymphoma of the breast: prognostic factors and treatment outcomes

Background

The breast is a rare site of extranodal involvement of diffuse large B-cell lymphoma (DLBCL). We aimed to assess the clinical characteristics, prognostic factors, and treatment outcomes of breast DLBCL.

Patients and methods

We retrospectively analyzed 113 patients (from our institution and the literature) between 1973 and 2014. The primary end point was overall survival (OS). Kaplan–Meier OS curves were compared with the log-rank test. Cox regression analysis was applied to determine the prognostic factors for OS, progression-free survival (PFS), local control (LC), and cause-specific survival (CSS).

Results

A total of 113 patients were included in the study: 42 cases from our hospital and 71 cases from 12 publications. The median age at diagnosis was 58 years. With a median follow-up time of 39.2 months, the estimated 5-year OS, PFS, LC, and CSS were 71.4%, 58.8%, 75.6%, and 74.9%, respectively. In multivariate analysis, more than four cycles of chemotherapy, having localized cancer, lumpectomy with or without axillary lymph node (ALN) dissection, and low to low-to-intermediate International Prognostic Index were favorable factors for OS. For PFS, significant prognostic factors were rituximab use, B symptoms, and tumor size. As for the local group, lumpectomy with or without ALN dissection and more than four cycles of chemotherapy were favorable factors for OS. Tumor size >4 cm and nonuse of rituximab were adverse factors for PFS. Twenty-one patients (18.6%) developed local relapse and 33 (29.2%) developed systemic relapse. Eight patients had central nervous system relapse (7.3%).

Conclusion

Our results reveal that local and extended staging criteria can reflect the different prognosis and treatment outcomes of breast DLBCL. Rituximab use, lumpectomy, and more than four cycles of chemotherapy are recommended as a treatment regimen. However, further study is warranted to validate our data.

A Case of Primary Breast Diffuse Large B-Cell Lymphoma Treated with Chemotherapy Followed by Elective Field Radiation Therapy: A Brief Treatment Pattern Review from a Radiation Oncologist's Point of View

We here report a case of primary breast lymphoma (PBL). A 44-year-old woman presented with a painless mass in the right breast. Fine needle aspiration cytology and excisional biopsy were performed. Excisional biopsy revealed low grade lymphoma, which was subsequently confirmed with histopathology and diagnosed as diffuse large B-cell lymphoma (DLBCL). A chest computed tomography scan revealed a 3.5 cm sized breast mass with skin thickening and a small sized lymphadenopathy in the ipsilateral axilla. Radiation therapy including the right whole breast and ipsilateral axilla and supraclavicular lymph node was performed after the patient received four courses of R-CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone plus rituximab) chemotherapy. At the follow-up period of 42 months, the patient is surviving with no evidence of disease. No morbidities occurred in this patient during the follow-up period. We also briefly review the current practice pattern in PBL patients with DLBCL.

Clinicopathological features of thirty patients with primary breast lymphoma and review of the literature

Primary breast lymphoma (PBL) is a rare disease accounting for 0.4-0.5 % of all breast malignancies. Accumulating evidence indicates that the diagnosis, prognostic factors, and optimal management of PBL are difficult. The present study aims to investigate the clinicopathological features and optimal treatment of PBL and to evaluate the institutional experience in this patient population. A total of 30 patients with PBL from January 2002 to December 2012 treated in He'nan Province Tumor Hospital were selected. The patients' clinical and pathological characteristics, treatment and response data, patterns of recurrence, and outcomes were retrospectively analyzed, and the relevant literatures were reviewed. All the cases were female, and the median age was 45. Diffuse large B cell lymphoma was the most common histological subtype seen in 23 of 30 patients. With a median follow-up time 32 months, median OS was 42 months (95 % CI 25-58 months), with 5-year OS rates 48 % (95 % CI 36-59 %). The median PFS was 14 months (95 % CI 6-30 months), with 5-year PFS rates 32 % (95 % CI 20-45 %). The prognostic factors that retained statistical significance for OS were IPI (P < 0.001), age (P = 0.04), and stage (P < 0.001). For PFS, significant prognostic factors were IPI (P = 0.01), radiotherapy given (P = 0.02) and stage (P = 0.02). PBL appears to have a worse prognosis. The present treatment method for PBL is a comprehensive way of diagnostic surgery together with radiotherapy and chemotherapy.

Primary breast lymphoma

Primary breast lymphoma is a rare form of extranodal lymphoma, defined by the presence of a primary lesion within the breast with or without regional nodal involvement but no other extra-mammary sites of involvement. It comprises diverse histologic subtypes, but diffuse large B-cell lymphoma is the most common. In this review, we describe in detail the clinical features, diagnosis and staging, pathogenesis, risk factors and therapy of primary breast diffuse large B-cell lymphoma. We consider choice and number of cycles of chemotherapy, the indications for radiotherapy and discuss the need for central nervous system prophylaxis. We also provide a brief overview of the less commonly encountered histologic subtypes including marginal zone, follicular, Burkitt and breast implant associated anaplastic large cell lymphoma. We conclude with a suggested treatment approach and potential areas of future research.

Three Cases of Combined Therapy in Primary Breast Lymphoma (PBL) with Successful Outcomes

Primary malignant lymphoma of the breast is a rare tumor, defined as a tumor localized in the breast with or without axillary lymph-node metastases. Such a tumor is mainly found in female patients and located more frequently in the right breast. It is difficult to make primary breast lymphoma (PBL) diagnosis before operation, and PBL diagnosis is mainly based on pathological biopsy and immunohistochemical staining. In this paper, the cases of three patients who had PBL, and who were treated for it at the Institute for Oncology and Radiology of Serbia between 2008 and 2012, are reviewed and discussed. These cases of PBL had no recorded reoccurrence of the disease and were originally treated by surgery, radiotherapy R-CHOP, and/or chemotherapy. While there is no consensus to the question of how to best treat PBL (ie, with chemotherapy, radiotherapy, or combined therapy), it is hoped that this review will offer insight into successful treatment procedures for tumors of this category.

Primary diffuse large B-cell lymphoma of the breast: looking at pathogenesis, clinical issues and therapeutic options

Primary breast lymphoma is a rare form of non-Hodgkin lymphoma with some distinct clinical features. The most common histopathological type is diffuse large B-cell lymphoma (DLBCL), but other less frequent subtypes are also encountered. In this review, we describe the characteristics of primary breast DLBCL, with emphasis on pathogenesis, staging, risk stratification and prognosis. In addition, key issues regarding therapy and various available therapeutic modalities are addressed, as well as the role of rituximab in therapy and whether central nervous system prophylaxis is still routinely required. There are very few prospective clinical studies addressing therapy, and available data rely mostly on retrospective case series involving small numbers of patients. Our conclusions and proposed recommendations are therefore not offered as formal guidelines. This review attempts to represent an unbiased analysis of the published data and is intended as a useful aid for clinicians treating this uncommon type of extra nodal lymphoma.

Clinicopathologic analysis of localized nasal/paranasal diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) comprises 2 molecularly distinct subgroups of non-germinal center B-cell-like (non-GCB) and germinal center B-cell-like (GCB) DLBCLs, with the former showing relatively poor prognosis. In the present study, we analyzed the clinicopathological features of 39 patients with localized nasal/paranasal DLBCL. Immunohistochemistry-based subclassification revealed that 11 patients (28%) were of the GCB-type according to Hans’ algorithm and 11 (28%) were of the GCB-type according to Choi’s algorithm. According to both Hans’ and Choi’s algorithms, the non-GCB type was predominant. Nevertheless, prognosis was good. Overall survival did not differ significantly between the GCB and non-GCB subgroups (Hans’ algorithm: p = 0.57, Choi’s algorithm: p = 0.99). Furthermore, the prognosis of localized nasal/paranasal DLBCL was better than that of other localized extranodal DLBCLs. The prognosis of extranodal DLBCL is usually considered poorer than that of nodal DLBCL. However, in our study, no difference was noted between patients with localized nasal/paranasal DLBCL and patients with localized nodal DLBCL. In conclusion, although the non-GCB subtype is thought to show poor prognosis, in our study, the prognosis for localized nasal/paranasal DLBCL patients was good irrespective of subclassification.

The role of genotype in 104 cases of diffuse large B-cell lymphoma primary of breast

OBJECTIVES

To analyze the role of genotype in patients with diffuse large B-cell lymphoma primary of breast (DLBCL-PB) treated with chemotherapy or immunochemotherapy.

METHODS

We carried out a retrospective analysis in 104 patients with DLBCL-PB who were treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or immunochemotherapy: R-CHOP (adding rituximab) and also carried out an analysis of genotype, studied with immunohistochemistry, as a prognostic factor.

RESULTS

Seventy-seven percent of patients showed the non-GCB (germinal center B) genotype. Patients treated with CHOP had a complete response of 70%; actuarial curves at 5 years showed that disease-free survival was 66 % and overall survival was 52% and that it was not statistically different than patients treated with R-CHOP: 78%, 61%, and 53%, respectively. When genotype was analyzed to assess the impact in prognosis, no statistical differences were observed. Patients treated with R-CHOP and non-GCB genotype have a complete response of 77%, disease-free survival of 56%, and overall survival of 66% that were not statistically different than patients with GCB: 80%, 60%, and 60% respectively, (P: 0.81, 0.5, and 0.66, respectively).

CONCLUSIONS

We confirm that the non-GCB genotype is most frequent in DLBCL-PB, but the addition of rituximab did not improve outcome in primary breast lymphoma with non-GCB phenotype.

Clinical implications of the molecular subtypes of diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma and responds to standard treatment with chemoimmunotherapy in most patients. Standard prognostic scoring systems such as the International Prognostic Index (IPI) are useful for risk stratification, but are unreliable in predicting outcomes in individual patients because of the biologic heterogeneity of this disease. Gene expression profiling has revealed molecular subtypes of DLBCL: those derived from the lymph node germinal center (GCB) and others derived from an activated B-cell (ABC). A third entity, primary mediastinal B-cell lymphoma (unclassifiable DLBCL), displays pathobiologic features distinct from ABC and GCB subtypes. Patients with ABC-DLBCL have inferior progression-free survival and overall survival relative to those with the GCB subtype. In conclusion, molecular subtyping is a powerful tool for discriminating cases of DLBCL into groups that display very disparate biology and clinical outcomes. Although immunohistochemistry (IHC)-based algorithms predict both the molecular subtype as defined by gene expression profiling and clinical outcomes with reasonable concordance, not all experienced centers have been able to reproduce these findings. As techniques to subclassify DLBCL become universally adopted, large prospective trials will be needed to confirm the benefit of therapy tailored to molecular subtype.

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.

Diffuse large B-cell lymphoma primary of lung

Primary lung lymphoma (PLL) and diffuse large B-cell lymphoma (DLBCL) is a rare entity and the biological features, clinical presentation, prognosis markers and treatment have not been well defined. We present 82 cases of PLL-DLBCL in a uniform population and treated with conventional chemotherapy: CHOP (cyclophosphamide, doxorubicin vincristine and prednisone). To the best of our knowledge, this is the largest series with long term follow reported. We also performed immunohistochemical studies to determine if the cell of origin [germinal center (GC) and non-GC] have a prognostic significance. All patients were at an early stage and low-clinical risk without bulk disease and normal levels of lactic dehydrogenase and beta 2 microglobulin. Complete response was achieved in 77 cases (94%), actuarial curves at 10 years showed that event-free survival (EFS) was 90% and overall survival was 92%. Fifty-nine patients were of GC phenotype and 23 of non-GC phenotype. Complete response (93% versus 91%), EFS (91% versus 80%) and overall survival (89% versus 78%) respectively, were not statistically different. Treatment was well tolerated, and second late events have not been seen. We conclude that PLL-DLBCL is an extranodal lymphoma with a good prognosis event in patients of non-GC phenotype.

Primary breast lymphoma - a review of the literature and report of three cases

Primary breast lymphoma (PBL) is a rare disease accounting for 0.4-0.5% of all breast malignancies. Diffuse large B-cell lymphoma (DLBCL) is the most common histological diagnosis. The clinical presentation of PBLs is usually no different from that of carcinoma. In this paper we review the literature on the clinical presentation, diagnosis, prognostic factors and treatment options of PBL. In the light of the information gained we discuss three patients with primary breast lymphoma (one with a central nervous system relapse) who were treated in our department in the years 2002-2007.

IN CONCLUSION

there is no consensus on the question of how to best treat PBL: chemotherapy, radiotherapy or combined therapy. However, the last approach to be the most successful one. Due to high incidence of central nervous system (CNS) involvement in PBL patients, many authors strongly believe that patients with aggressive forms of PBL should receive CNS infiltration prophylaxis, even in the early stages, as this may improve the outcome and significantly reduce the risk of a CNS disease relapse.

Primary diffuse large B-cell lymphoma of the oral cavity: germinal center classification

Primary lymphomas of the oral cavity are rare and the most frequent type is diffuse large B-cell lymphoma (DLBCL). Recently, several reports have highlighted the value of classifying DLBCL into prognostically important subgroups, namely germinal center B-cell like (GCB) and non-germinal center B-cell like (non-GCB) lymphomas based on gene expression profiles and by immunohistochemical expression of CD10, BCL6 and MUM-1. GCB lymphomas tend to exhibit a better prognosis than non-GCB lymphomas. Studies validating this classification have been done for DLBCL of the breast, CNS, testes and GI tract. Therefore we undertook this study to examine if primary oral DLBCLs reflect this trend. We identified 13 cases (age range 38-91 years) from our archives dating from 2003-09. IHC was performed using antibodies against germinal center markers (CD10, BCL6), activated B-cell markers (MUM1, BCL2) and Ki-67 (proliferation marker). Cases were sub-classified as GCB subgroup if CD10 and/or BCL6 were positive and MUM-1, was negative and as non-GCB subgroup if CD10 was negative and MUM-1 was positive. Immunoreactivity was noted in 2/13 cases for CD10, in 12/13 for BCL6, in 8/13 for MUM-1, and in 6/13 for BCL2. Therefore, 8/13 (58%) were sub-classified as non-GCB DLBCLs and 5/13 (42%) as GCB subgroup. All tumors showed frequent labeling with Ki-67 (range 40-95%). Four of the 8 patients with non-GCB subgroup succumbed to their disease, with the mean survival rate of 16 months. Two patients in this group are alive, one with no evidence of disease and another with disease. No information was available for the other 3 patients in this group. Four of the 5 patients in the GCB subgroup were alive with no evidence of disease and one patient succumbed to complications of therapy and recurrent disease after 18 months. In conclusion, our analysis shows that primary oral DLBCL predominantly belongs to the non-GCB subgroup, which tends to exhibit a poorer prognosis. These findings could allow pathologists to provide a more accurate insight into the potential aggressive behavior and poorer prognosis of these lymphomas.

Primary testicular diffuse large B-cell lymphoma shows an activated B-cell-like phenotype

The most common type of primary testicular lymphoma is diffuse large B-cell type, which has a poor prognosis relative to other extra-nodal diffuse large B-cell lymphomas (DLBCL). These constitute a heterogeneous group of lymphomas with germinal center B-cell-like and activated B-cell-like subtypes. Such a distinction theoretically utilizes the immunohistochemical expression of CD10, Bcl-6, and MUM1. The purpose of this study was that we could stratify primary testicular lymphoma of diffuse large B-cell type according to this scheme, and further elucidate the reason why primary testicular diffuse large B-cell lymphoma possesses a poor clinical outcome. Seventeen Chinese patients with primary testicular DLBCL were examined by means of a 3-antibody panel (CD10, Bcl-6, MUM1). Among these 17 cases, 16 were assigned to the activated B-cell-like subtypes. One case was classified as germinal center B-cell-like type. Twelve of these 17 cases expressed high proliferative activity (>or=40% Ki-67 labeling). The majority of primary testicular DLBCLs have activated B-cell-like subtype characteristics and high proliferative activity. These features might be a significant factor; moreover, they are associated with poor prognosis.

Activation-induced cytidine deaminase expression in diffuse large B-cell lymphoma with a paracortical growth pattern: a lymphoma of possible interfollicular large B-cell origin

CONTEXT

Activation-induced cytidine deaminase, necessary for immunoglobulin somatic hypermutation and class switch recombination, is usually expressed within the follicular dendritic network but is also expressed in a population of interfollicular large B cells outside the germinal center.

OBJECTIVE

To report 7 cases of diffuse large B-cell lymphoma with a distinct paracortical distribution. Expression of activation-induced cytidine deaminase, previously described in interfollicular large B cells, was evaluated.

DESIGN

A panel of immunohistochemical markers, including double staining for activation-induced cytidine deaminase and CD20, was used to illustrate the cases. Molecular studies were performed by polymerase chain reaction in the paraffin-embedded tissue for t(14;18) chromosomal translocation and immunoglobulin heavy chain and T-cell receptor rearrangements.

RESULTS

Patients included 3 males and 4 females ranging in age from 11 to 59 years (mean, 39 years). All specimens were lymph nodes (4 from the groin, 2 from the neck, and 1 from the axilla). Malignant lymphocytes were positive for CD20 and negative for CD5 and CD10. Staining for CD30, CD43, and BCL-2 was variable. The malignant cells showed at least focal staining with activation-induced cytidine deaminase. All cases were found to be monoclonal by immunoglobulin heavy-chain gene rearrangement or showed light-chain restriction. None of the tested cases showed t(14;18).

CONCLUSIONS

Diffuse large B-cell lymphoma with a paracortical distribution is unusual and may be a distinct morphologic variant. More study is necessary to determine the stage of B-cell development and the cell of origin of these tumors. However, activation-induced cytidine deaminase expression suggests they may arise from a putative interfollicular large B cell.

Diffuse large B-cell lymphoma in Chinese patients: immunophenotypic and cytogenetic analyses of 124 cases

In diffuse large B-cell lymphoma (DLBCL), BCL2 expression usually correlates with the t(14;18) (q32;q21) in germinal center B-cell (GCB) subtype and with gain/amplification of chromosome 18q21 in the activated B cell-like subtype. Studies have suggested that the GCB subtype is less common in Chinese than in Western populations. We studied 124 Chinese DLBCL cases using immunohistochemical, conventional cytogenetics, and interphase fluorescence in situ hybridization analyses. A cohort of 114 well-characterized DLBCL cases from Western populations was also analyzed for comparison. Lower incidences of the GCB subtype (P = .0001) and the t(14;18) translocation (P = .0001) were present in Chinese cases. However, BCL2 overexpression was more frequent in Chinese compared with Western cases (P = .0054). BCL2 expression was associated with gain of chromosome 18/18q in the Chinese and Western cohorts. More interestingly, BCL2 expression was associated with gain of chromosome 3/3q in Chinese DLBCL cases, whereas this association was less significant in Western cases.

Most primary central nervous system diffuse large B-cell lymphomas occurring in immunocompetent individuals belong to the nongerminal center subtype: a retrospective analysis of 31 cases

Primary central nervous system lymphomas are rare neoplasms characterized by a dismal prognosis relative to other extranodal lymphomas. Approximately 98% of primary central nervous system lymphomas are of B-cell origin, and most belong to the diffuse large B-cell type. Recently, diffuse large B-cell lymphomas have been subcategorized into germinal center and nongerminal center types based on gene expression profiles and immunohistochemical expression of CD10, Bcl-6, and MUM1. Studies have shown that the overall survival rate of the germinal center group is better than that of the nongerminal center lymphomas. In this study, 31 cases of primary central nervous system lymphomas of the diffuse large B-cell type were retrieved, reviewed, and immunostained for CD10, Bcl-6, MUM1, and Ki-67. Subclassification was carried out as described earlier, where CD10 and/or Bcl-6 positivity and negativity for MUM1 were considered characteristic of germinal center subtype and the opposite expression of nongerminal center subtype. Furthermore, the proliferative activity was semiquantitatively assessed using percent positive cells staining with Ki-67. Of the 31 cases examined, 26 (84%) were found to belong to the nongerminal center type. The Ki-67 index in these 26 cases ranged from 30 to 90% (mean, 69%). Five cases were categorized as the germinal center subtype. They had an Ki-67 index between 70 and 90% (mean, 78%). Interestingly, none of our patients were known to be HIV positive. One patient had a 10-year history of orthotopic liver transplant. We also performed fluorescence in situ hybridization analysis on formalin-fixed material and found that 38% of the cases where tissue was available had abnormalities of MYC/IGH and/or IGH/BCL2. We conclude that most primary central nervous system diffuse large B-cell lymphomas are of the nongerminal center origin. Regardless of the germinal center status, all cases showed a high proliferative rate. A statistically significant difference in the overall survival between the two groups was not seen.

Primary lymphomas of the breast: a report on 5 cases studied in a period of 5 years at the Hospital General de México

Breast lymphomas can be primary or secondary. Among the primary lymphomas, the most common histologic types are the large B-cell diffuse lymphomas and the extranodal B mucosa-associated lymphatic tissue lymphomas. We studied 5 cases of primary breast lymphoma in female patients. The criteria for the diagnosis were based on the proposal of Wiseman and Liao: (1) in the biopsy or surgical specimen, the lymphoma involves the breast parenchyma, and (2) nonsystemic disease at diagnosis. Clinical data, histologic findings, immunohistochemical reactions, treatment, and clinical follow-up were reviewed. The 5 patients were young women with average age of 27 years; the youngest was 20 years old, and the oldest was 44 years old. The right breast was the most affected, and 1 patient was HIV positive. The most common symptoms were the presence of nodes, progressive increase of volume, collateral venous network, and hemorrhagic discharge from the nipple. The clinical course was of 1 to 14 months before diagnosis. Three patients died because of central nervous system infiltration, one is still alive, and the other was lost during follow-up. Histologically, all primary breast lymphomas were large B-cell lymphomas; one had focal starry sky pattern, and the other 3 were centroblastic. All were positive to CD20 and CD79(a), 3 expressed bcl2, and 2 expressed bcl6. The proliferation index was between 60% and 80%. Primary breast lymphomas are rare. The average age of our patients was 27 years, and their clinical course was aggressive with central nervous system infiltration. The most common histologic type was the large B-cell diffuse lymphoma. Differential diagnosis must be established in the presence of poorly differentiated lobules and ductal carcinoma.

Primary breast non-Hodgkin's lymphoma: a large single center study of initial characteristics, natural history, and prognostic factors

The aims of this study were to define the initial pathological and clinical characteristics, and prognostic factors of patients with primary breast malignant lymphoma (PBL). All patients treated at the Institut Curie for lymphoma with breast involvement were reviewed. A pathological review of all cases was performed. Forty-five cases were selected in whom 38 cases were of diffuse large B-cell lymphoma. A complete analysis was then performed on these 38 patients. Twenty out of 28 cases (71%) of cases were Bcl-2 positive and four out of 28 (14%) had a CD10 positive staining. Peculiar initial characteristics showed nodal involvement in 58% of the cases and two or more extra-nodal sites in 31% of the cases. Among the 37 patients for whom all data were available, and according to the International Prognostic Index, 19 patients (51%) were classified in the low-risk group, 5 cases (14%) in the low- to intermediate-risk group, 6 patients (16%) in the intermediate- to high-risk group, and 7 (19%) case in the high-risk group. At the end of initial therapy, 34 patients (89%) achieved CR. With a median follow-up of 96 months, 18 patients (47%) relapsed of whom 3 had a relapse in central nervous system site. The 5-year disease-free (DFS) and overall survivals (OS) were 54% and 61%, respectively. In multivariate analysis, the presence of 2 or more extranodal sites was prognostic for lower DFS (P = 0.0008) and OS (P = 0.09), and a performance status > or = 1 was prognostic for lower OS (P = 0.005). Finally, when our series was compared with a historical series of 111 patients with aggressive nodal lymphomas, we observed significant lower survival rates in localized PBL (P < 0.03). Initial breast localization has a pejorative impact on the outcome of patients with Non-Hodgkin's Lymphoma (NHL), with an impressive adverse influence of additional extranodal sites. These results suggest a specific management of NHL with breast involvement.

Patients with localized primary non-tonsillar oral diffuse large B-cell lymphoma exhibit favorable prognosis despite a non-germinal center B-cell-like phenotype

Diffuse large B-cell lymphomas are detected frequently in the oral cavity. Although tonsillar lymphomas have been rather well characterized, lymphomas originating from non-tonsillar regions, such as the gingiva, palate, and tongue, have not been well studied. We examined the pathology of clinical samples obtained from 21 patients with localized primary non-tonsillar oral diffuse large B-cell lymphoma. Immunohistological examination of CD10, Bcl-6, and MUM1 determined that 17 of 21 (81%) samples exhibited non-germinal center B-cell type, an increased proportion of non-germinal center B-cell type compared with previous reports in samples of tonsillar origin (P<0.05). The four remaining samples exhibited germinal center B-cell type, although one sample expressed MUM1. Follow-up clinical survival data were obtained from the 17 patients over a range from 4 to 173 months (mean 52 months). All patients were treated with chemotherapies, irradiation, or surgical resection. Sixteen patients achieved complete remission and two patients relapsed, but no patient has died of disease. Extranodal diffuse large B-cell lymphomas of non-germinal center B-cell type are generally characterized by poor prognosis, regardless of localized disease. Interestingly, our results indicate that, unlike similar lymphomas of tonsillar origin, localized primary non-tonsillar oral diffuse large B-cell lymphomas exhibit favorable prognosis, suggesting that these lymphomas may be clinicopathologically distinct.

Lymphomas involving the breast: a study of 106 cases comparing localized and disseminated neoplasms

Lymphomas involving the breast account for approximately 2% of extranodal and <1% of all non-Hodgkin lymphomas. Our aim in this study was to classify breast lymphomas using the World Health Organization classification and then compare this classification with clinical, histologic, and radiologic findings as well as survival. The study group included 106 patients with breast lymphoma (105 women and 1 man). The neoplasms were divided into 2 groups based on extent of disease at initial diagnosis: localized disease (n=50) and disseminated disease (n=56). The follow-up period ranged from 4 to 252 months (median, 49 mo). Almost all (97%) patients presented with a palpable breast mass or masses. In the localized group, diffuse large B-cell lymphoma (DLBCL) was most frequent (n=32, 64%). In the disseminated group, follicular lymphoma was most frequent and exclusive to this group (P=0.0004). Mucosa-associated lymphoid tissue lymphomas occurred in both groups without a significant difference in frequency. A variety of other types of B-cell and T-cell non-Hodgkin lymphomas and classical Hodgkin lymphoma involved the breast at much lower frequency; most of these neoplasms involved the breast as part of disseminated disease. The clinical presentation correlated with radiologic findings: localized lymphomas presented as solitary masses, whereas disseminated lymphomas commonly presented as multifocal masses. There was a significant difference in the disease-free survival between patients with localized and disseminated DLBCL (P=0.003). In the disseminated group, patients with DLBCL had a worse disease-free survival compared with patients with mucosa-associated lymphoid tissue lymphoma or follicular lymphoma (P=0.01).

Recurrence of primary breast lymphoma in contralateral breast: case report and review of the literature

Lymphoma presenting as a breast mass is rare, although well documented. Although recurrence rates can reach approximately 50%, recurrence in the contralateral breast is rare. We report a case of recurrent primary breast lymphoma (PBL), which was discovered on screening mammography after a 5-year disease-free interval from initial diagnosis.

B-Cell and T-Cell Lymphomas of the Breast: Clinical—Pathological Features of 53 Cases

Breast involvement by non-Hodgkin lymphomas is rare. We studied the morphological, immunophenotypical, and clinical features of 53 cases of malignant lymphomas involving the breast in a population of Brazilian patients. Most of the cases were of B-cell phenotype. Four of the patients with primary breast lymphomas had T-cell lymphomas, 3 had CD30-positive anaplastic large cell lymphomas, and 1 had panniculitis-like T-cell lymphoma. Most patients presented with an incidental breast mass. Secondary breast lymphoma was seen in 19 patients and most commonly occurred as part of widespread nodal disease. Two patients presented with bilateral breast involvement. The most prevalent histological subtype was also diffuse large B-cell lymphoma, followed by follicular lymphoma. This study shows that the broad morphological and immunophenotypical spectrum of malignant lymphoma of the breast occurring in a large series of Brazilian patients has many similarities with that seen in Western countries, with a higher proportion of high-grade lymphomas in both primary and secondary cases.

Identification and characterization of nonapeptide targeting a human B cell lymphoma, Raji

Here, we identified a novel peptide specifically targeting a human B cell lymphoma, Raji, through a conventional phage display method. The amino acid sequence, 'CTLPHLKMC' was obtained with the highest frequency from a nonapeptide-expressing phage library. The phage clone encoding CTLPHLKMC peptide sequence avidly bound to Raji cells compared with control phage clones. Furthermore, flow-cytometric analysis on the biotinylated synthetic CTLPHLKMC peptide demonstrated the high binding affinity to Raji cells in a dose-dependent manner whereas it has binding activity to neither human peripheral blood mononuclear cells including normal B cell derived from healthy donors nor other leukemia cells including THP-1, HL-60, Jurkat and IM-9. MALDI-TOF mass spectrometry following immunoprecipitation assay showed that a potential host receptor for the peptide is a variable region of human immunoglobulin heavy chain which would be a specific phenotypic marker of Raji. In conclusion, these results suggest that the peptide, 'CTLPHLKMC', is a specific ligand to a Raji cell.