Leukemic infiltration of the breast in acute lymphocytic leukemia (ALL)

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.

SET-NUP214 Fusion Gene Involved Early T-Cell Precursor Acute Lymphoblastic Leukemia in Adult with B Marker Expression

Early T-cell precursor acute lymphoblastic leukemia (ETP-ALL) is rare and associated with poor clinical outcome especially in adults. ETP tumor cells that express cross-lineage antigens or lack pan T markers usually pose big challenges to diagnosis, and their prognostic implications are therefore more uncertain. This study reports the unique case of a 44-year-old woman with breast mass as the initial presentation of acute leukemia possessing both T- and B-cell features (cytoplasmic CD3⁺CD7⁺CD19⁺CD79a⁺). Despite the presence of gene rearrangements of IGH and IGK probably in a small amount of B cells, the patient was diagnosed with T-ALL mainly according to WHO criteria, and further ETP-ALL rather than mixed phenotype ALL based on additional positive expression of stem/myeloid lineage antigens (CD34⁺CD13⁺CD33⁺HLA-DR⁺). Moreover, in spite of normal karyotype, SET-NUP214 gene fusion is identified, which has not been described in ETP-ALL with bi-phenotype. After intensive chemotherapy, the patient achieved short-term morphologic complete remission but relapsed within one month. This report may expand immunophenotype and clinical behavior of ETP-ALL in adults. Comprehensive evaluations are emphasized in making a differential diagnosis and distinguishing subtypes of acute leukemia.

Differentiation of secondary involvement of the breast by lymphoreticular malignancy from fibroadenoma using ultrasound elastography: A report of two cases

Extramedullary lymphoma infiltration of the breast by lymphoblastic lymphoma is very rare and most cases are of B-cell lineage; T-cell neoplasms represent less than 10% of all breast lymphomas. Here, we report one patient with lymphoblastic lymphoma and one patient with leukemia, who have similar lesions in breasts with different ultrasound elastography findings. Ultrasound-guided tru-cut biopsies were performed and the first lesion was confirmed as lymphoma infiltration and the second as fibroadenoma. In cases of breast mass presence in patients with a history of hematologic malignancies such as lymphoma or leukemia, breast infiltration should be kept in mind. Elastography findings can assist in the differentiation of these lesions and further investigations or biopsies can be avoided.

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.

Case of CML lymphoid blast crisis presenting as bilateral breast masses

A woman aged 42 years with a 1-month history of rapidly expanding bilateral breast masses presented with severe leucocytosis, anaemia, blurry vision, headaches and shortness of breath. Evaluation revealed chronic myeloid leukaemia in lymphoid blast crisis with extramedullary leukaemia involving her breasts.

Molecular mechanisms of rosmarinic acid from Salvia miltiorrhiza in acute lymphoblastic leukemia cells

ETHNOPHARMACOLOGICAL RELEVANCE

Rosmarinic acid (RA), a major hydrosoluble bioactive compound found in the Chinese medicinal herb, Salvia miltiorrhiza Bunge, which has been used in traditional Chinese medicine to treat various diseases, including cancer. However, the mechanisms have not been fully elucidated.

AIM OF THE STUDY

Guided by microarray hybridization and Ingenuity Pathway Analysis, we identified modes of action of rosmarinic acid (RA) isolated from S. miltiorrhiza on acute lymphoblastic leukemia cells.

MATERIALS AND METHODS

Microarray data were verified by independent methods: Real-time RT-PCR (mRNA expression), resazurin assay (cytotoxicity of RA towards parental CCRF-CEM, multidrug-resistant CEM/ADR5000 cells and normal lymphocytes), flow cytometry (cell cycle arrest, apoptosis, necroptosis, generation of reactive oxygen species (ROS), disruption of mitochondrial membrane potential (MMP)), single cell gel electrophoresis (DNA damage), molecular docking and gene promoter binding motif analysis (NFκB), Western blotting (nuclear NFκB translocation, PARP cleavage, caspase 3/7/9 expression), and fibronectin-based cell adhesion assay.

RESULTS

RA dose-dependently inhibited CCRF-CEM and CEM/ADR5000 cells, but caused less cytotoxicity towards normal lymphocytes. RA simultaneously induced apoptosis and necrosis, as shown by cell morphology and annexin V-PI assay. DNA damage was dose-dependently induced without ROS generation, which subsequently led to cell cycle arrest. RA-stimulated MMP dysfunction activated PARP-cleavage and caspase-independent apoptosis. In accordance with molecular docking and gene promoter binding motif analyses, p65 translocation from the cytosol to the nucleus was blocked by RA, indicating a mechanistic role of the NFκB pathway to explain RA's action. RA affected cellular movement as evaluated by ameliorating cell adhesion to fibronectin.

CONCLUSIONS

RA induced apoptosis and necrosis in a ROS-independent DNA damage and caspase-independent manner. These results may contribute to the rationale use of S. miltiorrhiza and RA in traditional medicine of leukemia.

Granulocytic sarcoma of the breast in acute myeloid leukemia: Two case reports

Granulocytic sarcoma (GS) of the breast is extremely rare in patients with acute myeloid leukemia (AML) and therefore, is often misdiagnosed as lymphoma or other benign tumors. The current report presents two cases of GS of the breast, of which, one was considered to be a fibroma, as observed by fine-needle aspiration, and the other was misdiagnosed as lymphoma by frozen section. Previous literature that described the clinical and pathological characteristics, treatments and prognosis of GS of the breast in AML were reviewed. In addition to the treatment of mastectomy with/without radiotherapy, lumpectomy may also be received as a good treatment plan.

Acute lymphoblastic leukemia presenting as a breast lump: A report of two cases

Extra-medullary leukemic infiltration of the breast by acute lymphoblastic leukemia (ALL) is very rare. We report two cases of ALL presenting as breast masses and diagnosed on fine-needle aspiration (FNA). Our first patient, a post-partum 30-year-old female, developed bilateral breast lumps in her last trimester of pregnancy and complained of easy fatigability. Our second patient, a 14-year-old girl, presented with a right-breast lump of 1-week duration. She had received treatment for ALL 1 year back and had been in complete remission for the last 1 year. FNA of the breast nodules done in both the cases revealed diffuse infiltration by lymphoblasts. Subsequent hematological investigations confirmed bone marrow involvement by ALL in the first case and extra-medullary relapse in the second case. Fine-needle aspiration cytology (FNAC) is an easy and cost effective method for the early diagnosis of metastatic leukemic infiltration, avoiding unnecessary excisional biopsies in such cases.

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.