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CASE REPORT
Year : 2015  |  Volume : 29  |  Issue : 1  |  Page : 54-56

Primary breast lymphoma: A report of two cases


Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication17-Jun-2015

Correspondence Address:
Dr. Sushma Khuraijam
Department of Pathology, Regional Institute of Medical Sciences, Lamphel, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.158945

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  Abstract 

Involvement of breast by lymphoma is rare. It occurs as a primary breast tumor or as an extranodal manifestation of a systemic disease. Bilateral primary breast lymphoma (bilateral PBL) is still rarer. The most common type is diffuse large B-cell lymphoma (DLBCL). We are reporting two cases of primary breast lymphoma (PBL), one in a 62-year-old married female and another in a 26-year-old unmarried female. Both the cases were diagnosed by aspiration cytology and confirmed by immunohistochemistry. Early diagnosis of PBL by fine-needle aspiration cytology (FNAC) can avoid unnecessary surgical treatments.

Keywords: Bilateral primary breast lymphoma (bilateral PBL), Diffuse large B-cell lymphoma (DLBCL), Fine-needle aspiration cytology (FNAC), Primary breast lymphoma (PBL)


How to cite this article:
Khuraijam S, Khuraijam SD, Mutum R, Debnath K. Primary breast lymphoma: A report of two cases. J Med Soc 2015;29:54-6

How to cite this URL:
Khuraijam S, Khuraijam SD, Mutum R, Debnath K. Primary breast lymphoma: A report of two cases. J Med Soc [serial online] 2015 [cited 2019 Dec 13];29:54-6. Available from: http://www.jmedsoc.org/text.asp?2015/29/1/54/158945


  Introduction Top


Involvement of breast by lymphoma could be either primary or secondary. Primary non-Hodgkin lymphoma (NHL) of the breast is rare and accounts for 1.7-2.2% of all extranodal lymphomas, 0.7% of all NHLs, and 0.04-1.1% of all malignant tumors of the breast. [1],[2] Primary breast lymphomas (PBLs) are classified according to the Revised European-American Classification of Lymphoid Neoplasms (REAL) classification and most of them are of the B-cell type; diffuse large B-cell lymphoma (DLBCL) is the most common histological type. Other common types are the mucosa-associated lymphoid tissue (MALT) lymphoma and peripheral T-cell lymphoma. [1] The prognosis varies according to the treatment modalities used. [2] The rarity of PBL may be related to the relatively small amount of lymphoid tissue that is present in the breast as compared to the gut or the lungs where the occurrence of primary lymphomas are much more frequent. Instances of secondary breast lymphoma occurring in association with extra mammary lymphoma is more and it represents the largest group of tumors that are metastatic to the breast. Surgery, radiation, and chemotherapy have been used in isolation or in combination for the treatment of PBL. No clear consensus for therapy has emerged, although chemotherapy seems to be the more common choice either in isolation or in combination with other treatments. [3]


  Case Reports Top


Case 1

A 62-year-old married female presented with a lump on the left breast and 2 weeks later, another lump developed on the right breast. On examination, the left breast lump [Figure 1] and the right breast lump measured 6 cm × 5 cm and 1 cm × 1 cm, respectively, and there was no axillary lymph node enlargement. Fine-needle aspiration cytology (FNAC) from the breast lumps showed monotonous and dispersed malignant lymphoid cells [Figure 2]. Histopathological examination (HPE) of cell block preparation [Figure 3] from the aspirated material showed large, monotonous malignant lymphoid cells having scant cytoplasm, noncleaved nuclei, and immunostaining showing positivity for CD20 [Figure 4] and no reactivity for CD3. A whole body scan at this stage revealed negative results. Hence, the patient was diagnosed with PBL. On the 2nd month, she developed multiple cutaneous nodules over her neck, abdomen, and back. Three months after the initial lesion, she developed proptosis in her left eye. At this stage, the breast lumps had markedly increased in size. Contrast-enhanced computed tomography (CECT) of the thorax and abdomen showed multiple nodules in the lungs, the peritoneum, and the para-aortic, mesenteric, and subcutaneous regions. HPE of the epigastric nodule showed diffuse large B-cell NHL. Complete hemogram showed hypochromic microcytic anemia; serum lactate dehydrogenase (LDH) had risen (1414IU) and liver function test (LFT), kidney function test (KFT), thyroid function test, and electrocardiogram (ECG) were within normal limits. The patient refused chemotherapy and she expired after 2 months.
Figure 1: Left breast lump with inflamed overlying skin


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Figure 2: Photomicrograph of FNAC of the left breast lump showing relatively monotonous malignant lymphoid cell population; giemsa; ×400


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Figure 3: Photomicrograph of cell block preparation showing monotonous large malignant lymphoid cells; H&E; ×400


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Figure 4: Photomicrograph of cell block preparation showing positive immunostain for CD20; ×400


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Case 2

A 26-year-old unmarried female complained of bilateral breast lumps [Figure 5], which gradually grew to huge proportions within a span of 3 months. There was no lymphadenopathy. Ultrasonography of the bilateral breast swellings showed well-defined, lobulated, and heterogeneous echotexture with areas of hyperechogenicity and small, rounded hypoechoiec nodules. No microcalcification or axillary lymphadenopathy was seen. The impression was that of a lobulated heteroechoiec bilateral breast focal mass lesion, a giant fibroadenoma . FNAC of both breasts showed monomorphic population of immature lymphoid cells in a diffused arrangement and in singles, with a few cells showing cytoplasmic vacuoles [Figure 6]. The impression of the bilateral breast swellings was of NHL. Trucut biopsy was done on both the breasts, which showed diffuse infiltration by the relatively monomorphic population of large lymphoid cells arranged in sheets. Occasional benign ductal cells were identified. The lymphoid cells were positive for CD20 and showed no reactivity to CD3. As full body scan was negative, the diagnosis of bilateral primary breast (DLBCL) was given. Other investigations like complete hemogram; LFT, KFT, and LDH tests; and urine routine examination (RE) were within normal limits. She was started on chemotherapy and responded well to treatment.
Figure 5: Bilateral diffuse breast swelling


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Figure 6: Photomicrograph of FNAC of breast lump showing dispersed malignant lymphoid cells; giemsa; ×100


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  Discussion Top


Primary breast lymphoma (PBL) is rare. The occurrence is thought to be similar to lymphoma of the same histologic types and stages arising at other sites. The age group can be widely variable, as found in many reported studies. [3],[4],[5],[6],[7] The patient usually presents with a solitary mass or multiple masses with or without axillary lymph nodes. Unilateral PBL manifests in a way that is clinically similar to breast carcinoma, like our first case, [4],[5],[6],[7] and bilateral diffuse type is usually seen in younger patients who are pregnant or lactating. [8] However, other studies have reported bilateral diffuse breast lumps without pregnancy or lactation as in our second case. [8] The histology of PBL is primarily DLBCL, although other histologic and rare cases of T-cell phenotype have been reported. Both our cases were that of DLBCL, which showed positivity to CD20 and nonreactivity to CD3 that was similar to other studies. [1],[2],[3],[4],[5],[6],[7] The diagnosis of our first case was done by FNAC with cell block preparation while that of our second case was done by aspiration cytology and was confirmed by biopsy. A similar diagnosis by FNAC and confirmation by biopsy was also reported by others, and mastectomy was avoided. [1],[4],[8]

Primary breast lymphoma, though rare, has a radically different treatment and outcome as compared to carcinoma. Early diagnosis of PBL is significant as then, unnecessary mastectomies can be avoided. FNAC supplemented by immunocytochemistry can be applied as a reliable and cost-effective tool in the early diagnosis of PBL, while histopathology and immunohistochemistry are conclusive.

 
  References Top

1.
Vardar E, Ozkok G, Cetinel M, Postaci H. Primary breast lymphoma cytologic diagnosis. Arch Pathol Lab Med 2005;129:694-6.  Back to cited text no. 1
    
2.
Joks M, Mys´liwiec K, Lewandowski K. Primary breast lymphoma: A review of literature and report of three cases. Arch Med Sci 2011;7:27-33.  Back to cited text no. 2
    
3.
Jennings WC, Baker RS, Murray SS, Howard CA, Parker DE, Peabody LF, et al. Primary breast lymphoma: The role of mastectomy and the importance of lymph node status. Ann Surg 2007;245:784-9.  Back to cited text no. 3
    
4.
Ryan G, Martinelli G, Kuper-Hommel M, Tsang R, Pruneri G, Yuen K, et al. International Extranodal Lymphoma Study Group. Primary diffuse large B-cell lymphoma of the breast: Prognostic factors and outcomes of a study by the International Extranodal Lymphoma study group. Ann Oncol 2008;19:233-41.  Back to cited text no. 4
    
5.
Cabras MG, Amichetti M, Nagliati M, Orrù P, Mamusa AM, Angelucci E. Primary Non Hodgkin's Lymphoma of the breast: A report of 11 cases. Haematologica 2004;89:1527-8.  Back to cited text no. 5
    
6.
Shpitz B, Witz M, Kaufman Z, Griffel B, Manor Y, Dinbar A.Bilateral primary malignant lymphoma of the breast. Postgrad Med J1985;61:729-31.  Back to cited text no. 6
    
7.
Shapiro CM, Mansur D. Bilateral primary breast lymphoma. Am J Clin Oncol 2001;24:85-6.  Back to cited text no. 7
    
8.
Poureisa M, Daghighi MH, Mazaheri-Khameneh R, Ghadirpour A. Bilateral primary breast lymphoma in a teenage girl with multi-organ involvement. Acta Med Iran 2013;51:572-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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