Primary breast diffuse large B-cell lymphoma: a population-based study from 1975 to 2014

Central nervous system prophylaxis in large B-cell lymphoma: A British Society for Haematology Good Practice Paper

This Good Practice Paper provides recommendations for the baseline investigation, risk stratification and use of prophylactic interventions for patients with large B-cell lymphoma at risk of central nervous system relapse. Recent evidence which has questioned the role of high-dose methotrexate in this clinical scenario is discussed in detail.

A rare case of primary breast lymphoma presenting as calcifications on screening mammography

Extranodal marginal zone lymphoma (EMZL) is a low-grade subtype of B-cell non-Hodgkin lymphoma that can affect any mucosal tissue, most commonly the GI tract. Primary involvement of the breast, known as primary breast lymphoma (PBL), is a very rare manifestation. We report an unusual case of a 65-year-old woman with primary breast EMZL presenting as calcifications discovered during screening mammography. This represents an exceedingly atypical appearance of primary breast lymphoma that is rarely described in the literature.

Clinical Features and Outcomes of Primary Breast Diffuse Large B-Cell Lymphoma: A Matched-Pair Study

Background

The influence of the breast as the primary site on the outcome of diffuse large B-cell lymphoma (DLBCL) and further changes in therapeutic strategies remain unclear. We aimed to compare the outcomes between primary breast and non-breast DLBCL and analyze the genetic profiles of some of the study cohorts using next-generation sequencing.

Methods

This matched-pair study reviewed the medical records of 19 patients with stage I and II primary breast DLBCL diagnosed between January 2005 and December 2021 on the basis of the Wiseman and Liao criteria, and we used 1:4 propensity score matching to identify patients with non-breast DLBCL as the control group. The overall response rate, progression-free survival (PFS), and overall survival (OS) were the outcome measures.

Results

Patients with primary breast and non-breast DLBCL had a 5-year PFS of 72.6% and 86.9%, respectively (P = .206). These 2 groups also had comparable 5-year OS (86.9% vs 87.8%; P = .772). The breast as the primary site was not associated with inferior PFS (hazard ratio [HR]: 2.14; 95% CI: 0.66-6.96; P = .206) and OS (HR: 1.26; 95% CI: 0.27-5.93; P = .772).

Conclusion

Patients with primary breast DLBCL and those with non-breast DLBCL had comparable PFS and OS under rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or R-CHOP-like regimens. Further investigations of the mutation profile, its clinical impact, potential central nervous system relapse, and prognosis of primary breast DLBCL are required.

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.

Controversies in central nervous system prophylaxis of high-risk diffuse large B-cell lymphoma

PURPOSE OF REVIEW

Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) is an uncommon but devastating complication with an overall survival of less than 6 months. This article will review the recent updates on CNS prophylaxis including new potential advances in the identification of high-risk patients.

RECENT FINDINGS

The identification of patients at a high risk of CNS relapse is based on clinical and biological features has improved over recent years; however, the of different CNS prophylaxis strategies including intrathecal chemotherapy and high-dose methotrexate have been recently questioned in several large retrospective studies. The analysis of cell-free circulating tumor DNA (ctDNA) in the cerebrospinal fluid has been shown to identify patients with a high risk of CNS involvement and work is ongoing to identify how this can be used as a prognostic biomarker.

SUMMARY

Recent clinical retrospective data have questioned the effectiveness of intrathecal and high-dose methotrexate in the prevention of CNS relapse in high-risk DLBCL patients. The role of more sensitive methods to detect CNS involvement and the benefit of novel therapies in CNS relapse prevention are currently under evaluation.

Primary mediastinal/thymic diffuse large B-cell lymphoma: a population-based study on incidence and survival

Primary mediastinal large B-cell lymphoma is a rare subtype of lymphoma. The contemporary incidence of primary mediastinal large B-cell lymphoma remains unknown, and a large population-based study has not been reported. It is essential to provide guidance for further strategies in reducing the disease burden via population-based preventive initiatives. This study aims to explore the epidemiology and effect of therapeutic advances on the survival of patients with primary mediastinal large B-cell lymphoma. This population-based study was conducted using the Surveillance, Epidemiology, and End Results Program (SEER), covering the period from 1975 to 2018. A total of 774 patients in the SEER 9 and 1654 patients in the SEER 18 were analyzed. The age-adjusted incidence rate of primary mediastinal large B-cell lymphoma increased from 0.05/1,000,000 in 1975 to 2.38/1,000,000 in 2018. A significant positive linear increase in the incidence trend was found in primary mediastinal large B-cell lymphoma, with an annual percent change of 8.47% (95% confidence interval 7.7-9.2%, P < 0.001, z test). The survival in primary mediastinal large B-cell lymphoma was significantly superior to nodal diffuse large B-cell lymphoma. The incidence of PMBCL increases over the year. The survival of patients with primary mediastinal large B-cell lymphoma has improved over time.

Linfoma no Hodgkin de células B primario de mama. Reporte de caso y revisión de la literatura

OBJETIVOS

reportar un caso de linfoma no Hodgkin de células B primario de mama (LPM) y realizar una revisión de la literatura de su diagnóstico y tratamiento. Materiales y métodos: se reporta el caso de una paciente de 80 años que acudió a una institución privada de referencia en México por un LPM. Además, se diagnosticó un melanoma primario de hígado, mediante biopsia dirigida y estudio de patología. La paciente recibió tratamiento con R-CHOP (rituximab, ciclofosfamida, doxorrubicina, vincristina y prednisona), cuadrantectomía, resección de cadenas ganglionares y radioterapia. La paciente presenta adecuada respuesta del LPM, sin embargo, el segundo tumor primario progresa llevando a la paciente a cuidados paliativos. Se realizó una búsqueda bibliográfica en Medline vía PubMed, LILACS y Google Scholar. Se incluyeron estudios de cohortes, reportes y series de casos en pacientes con LPM que abordaran el diagnóstico, tratamiento y pronóstico de esta patología, publicados en inglés y español entre los años 2000 a 2022.

RESULTADOS

se identificaron 23 títulos, de los cuales 17 cumplieron con los criterios de inclusión, estos fueron reportes de caso y series de caso. La mayoría de las pacientes recibió un esquema quimioterapéutico R-CHOP, el cual se complementó con radioterapia. Cerca del 80 % presentó remisión completa. El sitio más frecuente de recaída fue el sistema nervioso central. La sobrevida a 5 años fue del 83,6 % en los estudios incluidos.

CONCLUSIONES

en la actualidad, el esquema CHOP -con o sin rituximab- es el más empleado y el único que ha mostrado tener un impacto positivo en la supervivencia, este suele acompañarse de radioterapia. Se requieren más estudios clínicos aleatorizados para establecer de manera más clara la efectividad y seguridad de estos tratamientos.

An overview of the correlation between IPI and prognosis in primary breast lymphoma

Primary breast lymphoma (PBL), with diffuse large B-cell lymphoma (DLBCL) as the most histopathological type, is a rare disease with a poor prognosis. The International Prognostic Index (IPI) is an important clinical characteristic for risk stratification of PBL patients with different prognoses. However, the prognostic value of the IPI in PBL is controversial and needs to be refined. In this review, we described the clinical characteristics, pathogenesis, and treatment of PBL, with emphasis on the prognostic value of the IPI, its updated versions and IPIs for certain subtypes. A total of 9 types of IPIs were presented. In addition, the key issues with the various treatment modalities available were addressed, as well as the role of rituximab in therapy. We also summarized the current evidence and future challenges facing other types of prognostic indices. In particular, prospective clinical studies of treatment are rare, and the available data were mainly obtained from retrospective case series that included a small number of patients. Therefore, our conclusions and recommendations cannot serve as formal guidelines. However, this review attempts to provide an unbiased analysis of published data to provide clinicians with useful assistance in the treatment of this uncommon form of extranodal lymphoma.

The prognostic value of IPI in patients with primary breast lymphoma, a multicenter retrospective study

Background

Due to the rarity of PBL and the lack of large-scale studies, the prognostic value of IPI in PBL was controversial. Especially in the rituximab era, the ability of IPI to stratify prognosis in patients receiving immunochemotherapy was severely reduced. Then revised IPI (R-IPI) and National Comprehensive Cancer Network IPI (NCCN-IPI) were introduced. The present study aimed to evaluate the prognostic value of IPI and the other IPIs in patients with PBL in a Chinese population.

Methods

We performed a multicenter retrospective study of 71 patients with PBL from 3 institutions in China. The Kaplan–Meier method and log-rank tests were used for the survival analysis. Cox regression analysis was performed to evaluate the prognostic factors. Subgroup analysis was performed to assess the prognostic significance of IPI scores, R-IPI scores, and NCCN-IPI scores.

Results

The median follow-up was 4.7 years (0.7–21.8 years). The 5-year progression-free survival (PFS) and overall survival (OS) rates were 90.2% and 96.3%. In the multivariate analysis, only IPI scores and radiotherapy were significantly associated with OS and PFS (P < 0.05). Applying the R-IPI in our patient cohort indicates a significant difference in PFS between the two groups of R-IPI (P = 0.034) but not for OS (P = 0.072). And the NCCN-IPI was prognostic for OS (P = 0.025) but not for PFS (P = 0.066). Subgroup analyses of IPI showed that survival analysis of IPI scores for the PFS and OS of patients using rituximab were not significantly different (P > 0.05).

Conclusions

Our study confirms the prognostic value of IPI in patients with PBL, but the predictive value of IPI proved to be relatively low with the addition of the rituximab. The R-IPI and NCCN-IPI can accurately assess the high and low-risk groups of PBL patients but were insufficient to evaluate the intermediate risk group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-022-02772-y.

Patterns of treatment and their outcomes in primary breast lymphoma; a comprehensive population-based analysis

BACKGROUND

Primary breast lymphoma (PBL) is managed differently among centers, using surgery, systemic therapy and/or radiation. With data derived from the National Cancer Database (NCDB), we aim to describe treatments utilized in the United States, estimate the overall survival (OS) of different therapeutic modalities and determine the role of systemic therapy in patients with PBL.

METHODS

We conducted a retrospective cohort study using de-identified data from the NCDB. The NCDB provided records of 4616 patients diagnosed with PBL between 2004 and 2015. We excluded patients diagnosed with HIV, with no survival data, not treated in the reporting facility, without histologic confirmation, with stage III/ IV disease and for whom surgery, radiation, or systemic therapy was contraindicated. Both propensity score weighting and Cox models were used to obtain adjusted estimates. Based on histopathology, PBL was classified into indolent (I-PBL) and aggressive (A-PBL).

RESULTS

In a sample size of 2063 PBL patients, the median age was 67 years (interquartile range (IQR): 57-78), and 97% were females. In 1027 patients with I-PBL, the median follow-up was 66 months (95% confidence interval (CI): 32.6-107.2) and 60% of patients had extranodal marginal zone subtype. Systemic therapy did not improve adjusted-OS (median: 154 vs. 143 months, P = 0.36) (Hazard ratio (HR): 0.86, 95% CI: 0.60-1.25, P = 0.42). The treatment arms associated with the highest adjusted 5-year OS were as follows: radiation (85%), surgery (79%), systemic & radiation (87%) and radiation & surgery (87%) (P = 0.9). In 1036 patients with A-PBL, the median follow-up was 67.4 months (95% CI: 35.9-105), and 87% of patients had diffuse large B-cell subtype. Patients with A-PBL who received systemic therapy had an improved adjusted-OS (median: 115 vs. 72 months, P < 0.01) (HR: 0.45, 95% CI: 0.38-0.53, P < 0.001). The treatment arms associated with the highest adjusted 5-year OS were: systemic (69%), systemic & radiation (77%), systemic & radiation & surgery (79%) and systemic & surgery (79%) (P = 0.4).

CONCLUSIONS

Systemic therapy used as first-line treatment is essential in A-PBL. Local therapy in the I-PBL using surgery and/or radiation is effective in long-term disease control. There is significant variation in front-line treatment modalities utilized in PBL across the US, many associated with similar outcomes.

Vitreoretinal Lymphoma as the Initial Presentation of a Breast Diffuse Large B-cell Lymphoma

PURPOSE

We report a case of vitreoretinal lymphoma as the initial presentation of diffuse large B-cell lymphoma of the breast.

METHODS

A case report is presented.

RESULTS

A 72-year-old woman was referred for evaluation of vitritis in both eyes. Diagnostic vitrectomy and pathology workup demonstrated atypical lymphoid cells consistent with the presence of diffuse large B-cell lymphoma. Brain magnetic resonance imaging and lumbar puncture findings were negative for central nervous system lymphoma. Positron emission tomography/computed tomography imaging showed a mass in the left breast, and breast biopsy confirmed aggressive B-cell lymphoma.

CONCLUSIONS

When vitreoretinal lymphoma is diagnosed, it is important to evaluate for other forms of systemic lymphoma in addition to central nervous system lymphoma.

Predictive impact of soluble interleukin-2 receptor and number of extranodal sites for identification of patients at very high risk of CNS relapse in diffuse large B-cell lymphoma

There remains an unmet clinical need to identify which patients with diffuse large B-cell lymphoma (DLBCL) would benefit from central nervous system (CNS) prophylaxis, due to the low positive predictive value (PPV; 10%-15%) of the currently available predictive models. To stratify patients at high risk of developing CNS relapse, we retrospectively analyzed 182 patients with DLBCL initially treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), or a R-CHOP-like regimen. Among them, 17 patients relapsed with CNS involvement, and the 2-year rate of CNS relapse was 7.9%. Upon carrying out multivariate analysis, ≥3 extranodal sites and elevated soluble interleukin-2 receptor (sIL-2R) levels at diagnosis were identified as independent risk factors for CNS relapse. The 2-year and 3.5-year rates of CNS relapse were 57.1% and 78.6%, respectively, in patients with both elevated sIL-2R and ≥3 extranodal sites. Furthermore, combined use of these risk factors of both elevated sIL-2R and ≥3 extranodal sites resulted in a high PPV (71.4%), negative predictive value (93.1%), and overall accuracy (92.3%) for undergoing CNS relapse. In conclusion, we propose a simple and valuable tool to predict patients with DLBCL at very high risk of CNS relapse.

Primary breast double-hit lymphoma management and outcomes: a real-world multicentre experience

Background

Primary breast double-hit lymphoma (PB-DHL) is a rare, highly aggressive malignancy that poses challenges regarding accurate diagnosis and selecting optimal treatment regimens.

Methods

We retrospectively reviewed 48 cases of patients diagnosed with PB-DHL in six academic centres between June 2014 and June 2020 in China. Study-specific data were recorded, including treatment options, therapeutic evaluation, prognostic factors and relapse patterns, and the overall survival (OS) and progression-free survival (PFS) were evaluated.

Results

In total, 48 patients were enrolled, with 14 patients treated with DA-EPOCH-R/MA (rituximab, dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, alternating with high-dose methotrexate and cytarabine), 18 patients treated with DA-EPOCH-R (rituximab, dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin), and 16 patients treated with R-HyperCVAD (rituximab, hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone, alternating with cytarabine plus methotrexate). The overall 5-year OS and PFS rates were 41.7% (95% confidence interval [CI], 27.6–56.8%) and 37.5% (95% CI, 24.0–52.6%), respectively. Of the three treatment regimens, the 5-year OS was higher in DA-EPOCH-R/MA group than in the DA-EPOCH-R or R-HyperCVAD subgroups (57.1% vs. 38.9% vs. 31.3%; P = 0.016), as was the 5-year PFS (50.0% vs. 38.9% vs. 25.0%; P = 0.035). Autologous stem cell transplantation (ASCT) prolonged the OS and PFS compared with non-ASCT patients (5-year OS: 72.2% vs. 23.3%; P < 0.001; 5-year PFS: 72.2% vs. 16.7 %, P < 0.001). Multivariate analysis identified tumour size, risk stratification, treatment with DA-EPOCH-R/MA, breast irradiation, and ASCT as significant prognostic factors.

Conclusions

DA-EPOCH-R/MA is a promising regimen for PB-DHL, and breast irradiation yields complementary benefits for prognosis. ASCT significantly decreased disease relapse, providing a potential curative PB-DHL intervention and justifying ASCT as first-line therapy for young patients. More effective treatment strategies for PB-DHL patients remain encouraging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-021-02198-y.

Primary Breast Diffuse Large B-Cell Lymphoma in a 42-Year-Old Female: A Case Report and Review of Literature

Primary breast diffuse large B-cell lymphoma (PB-DLBCL) is a rare localized extranodal lymphoma. It is mainly diagnosed by pathological examination due to the lack of specific clinical and imaging manifestations. Whole-body positron emission tomography-computed tomography (PET-CT) is widely used in determining clinical staging and guiding clinical treatment. As part of comprehensive treatment, targeted therapy with rituximab, intrathecal methotrexate injection and consolidation radiotherapy remain controversial in treating PB-DLBCL, but the comprehensive treatment based on full-course of chemotherapy is still widely used as the first-line treatment. Comprehensive treatment often leads to a sharp decline in the immunity of elderly patients with malignancy. In this situation, surgery may be a good chance to improve their life quality without serious complications. We present a rare case of PB-DLBCL during the coronavirus disease 2019 (COVID-19) pandemic. The patient underwent chest CT scan to screen COVID-19 and a mass of left breast was accidentally found. Because of the city lockdown policy in Wuhan, she did not seek medical help until noticing that the mass was gradually enlarged. Both ultrasonography and mammography indicated that the lesion was breast cancer. However, ultrasound-guided core needle biopsy revealed diffuse large B-cell lymphoma of breast and PET-CT scan showed that the lesion was a primary hypermetabolic tumor of left breast. The patient subsequently received comprehensive treatment based on six cycles of rituximab-cyclophosphamide, hydroxydaunomycin, oncovin, prednisone (R-CHOP) chemotherapy.

Comparison of Clinical Features Between Primary and Secondary Breast Diffuse Large B Cell Lymphoma: A Yokohama Cooperative Study Group for Hematology Multicenter Retrospective Study

We performed a retrospective analysis of DLBCL with breast involvement to compare the prognosis of primary breast lymphoma (PBL) to secondary breast lymphoma (SBL; especially in limited stage cases). We retrospectively reviewed records of 25 diffuse large B-cell lymphoma (DLBCL) patients with breast involvement who received chemotherapy between January 2000 and August 2012. We compared clinical features and prognosis among patients with PBL (n = 11), limited stage SBL (LSBL; n = 6), and advanced stage SBL (ASBL, n = 8). The PBL group had significantly lesser patients with breast tumours (BTs) > 5 cm than the SBL group (P = 0.02). After a median follow-up of 71.3 months, we observed significantly better 5-year overall survival (OS) in the PBL group (90.0%) than in the LSBL (33.3%, P = 0.01) group, but not for progression-free survival (PFS). Patients with BT > 5 cm had worse OS (P = 0.01) and PFS (P = 0.04) than those with BT ≤ 5 cm. PBL had a better prognosis than SBL among limited stage DLBCL.

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.

Clinical characteristics and outcomes of primary adrenal diffuse large B cell lymphoma in a large contemporary cohort: a SEER-based analysis

Primary adrenal lymphoma (PAL) is an extremely rare lymphoma, and the most common histologic type is diffuse large B cell lymphoma (DLBCL). Primary adrenal DLBCL has a quite poor prognosis, but the prognostic determinants are rarely reported. With the Surveillance, Epidemiology, and End Results (SEER) program, we collected the demographic, clinical, therapeutic information of patients with primary adrenal DLBCL from 1983 to 2015. The Kaplan-Meier method was used to obtain overall survival (OS) and cause-specific survival (CSS) curves. The prognostic values of OS and CSS were assessed using Cox proportional hazards regression model with univariate and multivariate analyses. A total of 136 patients were included in our cohort. Adrenal DLBCL predominantly affected male and the aged, and there was a high rate of unilateral adrenal origin. The patients were more likely to present advanced stage disease. The OS rates of the entire cohort of patients with adrenal DLBCL at 5 and 10 years were respectively 19.17% and 3.33%, and the similar results were shown in 5-year and 10-year CSS rates. Age more than 70 years old and bilateral were identified as independent prognostic factors that were correlated with both adverse OS and CSS, and patients with chemotherapy had a superior OS and CSS to the patients without any treatment.