A rare case of non-invasive ductal carcinoma of the breast coexisting with follicular lymphoma: A case report with a review of the literature

Successful Treatment of Concurrent Follicular Lymphoma and Triple-Negative Breast Cancer Using Rituximab Plus Nab-Paclitaxel and Cisplatin: A Case Report and Literature Review

Background

Co-occurrence of breast cancer and non-Hodgkin's lymphoma is a rare condition with diagnostic and therapeutic challenges. The coexistence of follicular lymphoma (FL) and triple-negative breast cancer (TNBC) has not been described previously.

Case Presentation

A 46-year-old woman, already suffering a history of untreated, advanced-stage, high tumor burden FL, was admitted for a rapidly progressing right breast mass. Ultrasonography showed an 8.3 × 3.6 × 4.1 cm fungating mass in the right breast with enlarged lymph nodes (LNs) in bilateral axillae. PET-CT demonstrated increased 18F- FDG activity in right breast mass, LNs on both sides of the diaphragm, enlarged spleen, and bone marrow. Biopsy of the right breast mass revealed TNBC. The patient underwent neoadjuvant therapy with R-CHOP and achieved partial response of breast tumor. However, TNBC progressed after three cycles of R-CHOP. According to the next-generation sequencing (NGS) assay on breast mass showing a homologous recombination repair (HRR) deficiency (HRD) score of 72, the neoadjuvant regimen was changed to rituximab plus nab-paclitaxel and cisplatin (R-TP) and resulted in significant tumor regression. The patient then underwent right mastectomy with an axillary LN dissection. After the surgery, she was regularly monitored and given adjuvant therapy with R-TP and radiotherapy.

Conclusion

The coexistence of FL and HRD-positive TNBC poses diagnostic and treatment challenges. Well-founded neoadjuvant strategy based on multidisciplinary team (MDT) discussion and NGS warranted a good outcome in this case.

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.

Synchronous or collision solid neoplasms and lymphomas: A systematic review of 308 case reports

BACKGROUND

The presence of a lymphoma associated with a solid synchronous neoplasm or collision neoplasm has been rarely in the literature, and a detailed characterization of these cases is lacking to date.

OBJECTIVE

To describe the main clinicopathological features of synchronous/collision tumors.

METHODS

A systematic search in PubMed, Scielo, and Virtual Health Library literature databases for cases or case series of synchronous or collision lymphoma and other solid neoplasms reported up to March 2021 was performed. Three reviewers independently screened the literature, extracted data, and assessed the quality of the included studies. The systematic review was performed following the Preferred Reporting Items for Systematic Meta-Analyses guidelines.

RESULTS

Mean age of patients was 62.9 years (52.9% men). A total of 308 cases were included (62% synchronous and 38% collision). The most frequent location of both synchronous and collision tumors was the gastrointestinal tract with the most common solid neoplasm being adenocarcinoma, and the most frequent lymphoma diffuse large B-cell lymphoma (21.7%) and mucosa-associated lymphoid tissue lymphoma (20.4%). Of the total number of mucosa-associated lymphoid tissue lymphomas and gastric adenocarcinomas, the presence of Helicobacter pylori infection was documented in 47.3% of them. Only 2% of all cases had a previous history of lymphoma. Thus, in most cases (98%), lymphoma was discovery incidentally. In addition, nodal lymphoma was associated with metastasis in 29 (9.4%) cases as collision tumor, most commonly (90%) in locoregional lymph nodes of the solid neoplasm.

CONCLUSIONS

The frequent association of some type of B-cell lymphoma and adenocarcinoma in synchronous/collision tumors of the gastrointestinal tract points to common pathogenic mechanisms in both neoplasia, particularly related to chronic inflammation in this location. In most cases, lymphoma identified in locoregional lymph nodes or distant of a carcinoma seems to represent an incidental finding during the carcinoma diagnostic/therapeutic approach. A synergy between carcinoma and lymphoma (involving inflammation and immunosuppression mechanisms) may favor tumor progression and dissemination. A better understating of the interactions lymphoma/carcinoma in the setting of synchronous/collision tumors may help to improve patient management and prognosis.

A rare case of synchronous multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma that responded to multidisciplinary treatment: a case report

BACKGROUND

Multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma (DLBCL) are rare. Here, we report a case of advanced breast cancer and DLBCL managed with multidisciplinary therapy preceded by surgery with a successful outcome.

CASE PRESENTATION

During a medical examination, a 71-year-old woman was diagnosed with a right breast mass, enlarged lymph nodes throughout the body, and a splenic tumor. The results of the clinical examination and imaging were suggestive of widely spread breast cancer with lymph node metastasis and malignant lymphoma with systemic metastasis. The histological evaluation of the biopsied breast tissue revealed human epidermal growth factor receptor 2 (HER2)-positive breast cancer, whereas the histological evaluation of the excised inguinal lymph node revealed DLBCL. ¹⁸F-FDG PET/computed tomography was performed, and it was determined that both breast cancer and DLBCL were in an advanced stage. Thus, mastectomy was performed, and the axillary lymph nodes showed mixed metastasis of breast cancer and DLBCL. Soon after, the R-CHOP therapy was initiated (375-mg/m² rituximab, 2-mg/m² vincristine, 50-mg/m² doxorubicin, 750-mg/m² cyclophosphamide, and 125-mg methylprednisolone). After irradiation of the spleen, trastuzumab was administered for 1 year.

CONCLUSIONS

We experienced a case of combined breast cancer and DLBCL, which was difficult to treat because both were in advanced stages. Thorough staging of the malignancy and discussion by a multidisciplinary team are necessary to determine the optimal treatment strategy.

Synchronous early-stage breast cancer and axillary follicular lymphoma diagnosed by core needle biopsy: A case report

Synchronous double cancers are an infrequent finding. The focus of this study was a case of diagnosed synchronous double breast cancer (BC) and axillary (Ax) follicular lymphoma (FL). The patient was a 73-year-old woman who had been visiting her local doctor for follow-up of a fibroadenoma of the left breast, and was referred to our hospital after being diagnosed with invasive ductal carcinoma (IDC) of the left breast. Ultrasonography (US) revealed enlarged Ax lymph nodes (LNs) and US-guided core needle biopsy (CNB) was performed. CNB revealed no metastasis of IDC; however, a diagnosis of FL was made. Therefore, the patient was diagnosed with synchronous double BC and Ax FL and underwent partial surgical resection of the BC and close monitoring of the FL. To the best of our knowledge, this is the first case of malignant lymphoma diagnosed by CNB of Ax LNs during preoperative BC screening. CNB allows for a shorter waiting time for the examination, and it is considered to be minimally invasive, cost-effective and non-inferior to surgical resection in terms of specimen volume. Therefore, active preoperative evaluation of Ax LNs using US-guided CNB may contribute to BC staging, and may also help diagnose synchronous cancers.

Primary Extranodal Follicular T-Cell Lymphoma and Ductal Breast Carcinoma Diagnosed by a Magnetic Resonance Imaging-Guided Vacuum-Assisted Biopsy: A Case Report

BACKGROUND Extranodal non-Hodgkin lymphomas (NHL) are low-grade B-cell lymphomas and the breast is not a common site for this condition. This case report describes a 62-year-old woman with a primary NHL and ductal carcinoma in situ (DCIS) of the left breast diagnosed by a magnetic resonance imaging (MRI)-guided vacuum-assisted breast biopsy. The simultaneous diagnosis of breast cancer and NHL is rare, with few cases described in the literature. Primary breast lymphomas account only for 0.04% to 0.5% of breast malignancies. CASE REPORT In November 2016, a 62-year-old woman was treated for a peripheral T-cell lymphoma (follicular helper T-cell phenotype) of the left upper central breast; later she underwent periodic breast imaging follow-ups. In October 2018, MRI revealed a focal 33-mm non-mass contrast enhancement (according to the Breast Imaging Reporting and Data System -MRI lexicon of the American College of Radiology) in the lower external quadrant of the left breast. Neither mammography nor ultrasonography demonstrated any suspicious features. The multidisciplinary medical team performed an MRI-guided vacuum-assisted breast biopsy and the histological analysis confirmed the diagnosis of a DCIS. Subsequently, she underwent surgery resulting in eradication of the disease and has had regular follow-ups, including mammography, ultrasonography, and MRI. CONCLUSIONS This is a rare case of both a primary NHL of the breast and DCIS, which was detected only by MRI. It highlights the role of an MRI-guided vacuum-assisted breast biopsy, which allows an accurate and economic diagnosis in case of suspicious findings on MRI. We recommend the use of MRI in follow-ups for patients with previous breast lymphomas (high-risk patients).

Synchronous occurrence of breast cancer and refractory diffuse large B-cell abdominal lymphoma: Management and review of the literature

The synchronous occurrence of primary breast cancer and lymphoid tissue malignant tumors has been rarely reported in the literature. We present an exceedingly rare case of synchronous breast invasive ductal carcinoma with an abdominal diffuse large B-cell lymphoma (DLBCL). A 78-year-old woman who was diagnosed with a luminal A invasive breast cancer on core biopsy, and complaint of progressively worsening low back pain. An abdominal computed tomography (CT) scan that was performed as part of the preoperative staging showed a large abdominal mass measuring 10.5 × 4.8 × 9.5 cm surrounding the lower part of the abdominal aorta, the right common iliac, right external, right internal iliac, and the left internal iliac arteries. A CT-guided fine-needle aspiration biopsy (FNAB) of the abdominal mass was then performed, to exclude the possibility of being an abdominal tumor metastasis of the known primary breast cancer. Histopathological findings were suggestive of DLBCL. Following a multidisciplinary team discussion, chemotherapy was initiated for DLBCL. The tumor however was refractory to multiple chemotherapy regimens and exhibited a highly aggressive clinical course. The diagnostic evaluation and management of the patient are discussed, along with a review of the relevant literature. This case underscores the fact that the presence of synchronous malignancies may pose both diagnostic and treatment challenges. Accurate staging of both malignancies and multidisciplinary team discussion is of utmost importance to guide an optimal therapeutic approach. Histopathological evaluation is essential for both tumors, for the second malignancy not to be misinterpreted as a secondary deposit of the primary one.

Asymptomatic cervical stiffness as the sole presenting feature of ovarian follicular lymphoma: The value of hands-on medicine

A primary care visit is the first encounter of a patient with health care. In context to malignancies, breast cancer and primary ovarian lymphomas are NA clinically and morphologically different malignancies. The rare concurrence of breast cancer and non-Hodgkin lymphoma (NHL) does not warrant any routine surveillance through testing but we present a case of a 71-year-old female with the history of invasive ductal carcinoma of the breast in remission who was diagnosed with follicular carcinoma after an abnormal pelvic examination during her routine primary care visit. This highlights that a routine PC visit with a skilled physical examination can prove to be one of the most cost-effective tools for screening high-risk cancer patients in remission.

A rare case of bilateral breast lobular carcinoma coexisting with primary breast follicular lymphoma

CLINICAL PRACTICE POINTS

● Co-existence of breast cancer and lymphoma is a rare condition. A few cases of synchronous breast ductal carcinoma and lymphoma have been reported in the literature. However, to our knowledge this is the first case report of a bilateral breast lobular carcinoma co-presenting with follicular lymphoma.

● Little is known about the pathophysiology of synchronous cancers of different tumor types, especially solid tumors co-existing with hematologic malignancies. In-depth review of these cases can shed light on underlying mechanism leading to synchronous cancer development.

Risk of lymphoma subtypes by occupational exposure in Southern Italy

Background

Occupational exposure is known to play a role in the aetiology of lymphomas. The aim of the present work was to explore the occupational risk of the major B-cell lymphoma subtypes using a case–control study design.

Methods

From 2009 to 2014, we recruited 158 lymphoma cases and 76 controls in the provinces of Bari and Taranto (Apulia, Southern Italy). A retrospective assessment of occupational exposure based on complete work histories and the Carcinogen Exposure (CAREX) job-exposure matrix was performed.

Results

After adjusting for major confounding factors, farmers showed an increased risk of diffuse large B-cell lymphoma (DLBCL) [odds ratio (OR) = 10.9 (2.3–51.6)] and multiple myeloma (MM) [OR = 16.5 (1.4–195.7)]; exposure to the fungicide Captafol was significantly associated with risk of non-Hodgkin lymphoma (NHL) [OR = 2.6 (1.1–8.2)], particularly with the risk of DLBCL [OR = 5.3 (1.6–17.3)].

Conclusions

Agricultural activity seems to be a risk factor for developing lymphoma subtypes, particularly DLBCL, in the provinces of Bari and Taranto (Apulia Region, Southern Italy). Exposure to the pesticides Captafol, Paraquat and Radon might be implicated.

Trial registration

Protocol number UNIBA 2207WEJLZB_004 registered 22/09/2008.

Multifocal Bilateral Breast Cancer and Breast Follicular Lymphoma: A Simple Coincidence?

Breast cancer coexisting with lymphoma is a rare condition with various diagnostic and therapeutic implications. In this report, we describe the case of a 55-year-old Caucasian woman who presented with simultaneous ductal carcinoma in situ of the right breast, and follicular lymphoma involving an inguinal lymph node and the left breast. The patient underwent local excision and radiotherapy for the ductal carcinoma in situ, while a watch and wait strategy was adopted for the lymphoma. Two years later, the patient presented with multifocal ductal carcinoma of the left breast and reappearance of the lymphoma in the left axillary lymph nodes. She underwent bilateral mastectomy, left sentinel node biopsy, and chemotherapy. Synchronous follicular lymphoma and bilateral metachronous breast carcinoma has not been described previously. Diagnosis is based on tissue histology after excision or a needle biopsy. Treatment for these two diseases is distinct, and a multidisciplinary approach should be adopted.