Journal of Cytology
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 Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 30  |  Issue : 4  |  Page : 284-286
Cytodiagnosis of the primary breast lymphoma in a young woman


1 Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

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Date of Web Publication6-Feb-2014
 

   Abstract 

Primary breast lymphoma (PBL) is a rare entity. It represents 0.4% of malignant breast lesions and 2% of extranodal lymphomas. A 23-year-old woman presented with a left breast lump followed by palpable left axillary lymphadenopathy. Fine-needle aspiration cytology (FNAC) and histopathology were diagnostic of non-Hodgkin lymphoma-large cell type. Immunohistochemistry was positive against leukocyte common antigen and CD20. Because PBLs are uncommon malignant lesions and they usually do not have characteristic clinical and imaging findings, FNAC may prove to be a simple, rapid, reliable, and cost-effective procedure for successful diagnosis of the PBL.

Keywords: Breast lymphoma; FNAC; immunohistochemistry

How to cite this article:
Patne SC, Kumar M, Khanna R. Cytodiagnosis of the primary breast lymphoma in a young woman. J Cytol 2013;30:284-6

How to cite this URL:
Patne SC, Kumar M, Khanna R. Cytodiagnosis of the primary breast lymphoma in a young woman. J Cytol [serial online] 2013 [cited 2020 May 28];30:284-6. Available from: http://www.jcytol.org/text.asp?2013/30/4/284/126674



   Introduction Top


Primary breast lymphoma (PBL) is a rare neoplasm that accounts for 0.4% of malignant breast lesions and 2% of extranodal lymphomas. [1] Diagnosis of PBL by fine-needle aspiration cytology (FNAC) is reported infrequently. We herein describe the rare cytodiagnosis of the PBL in a young lady.


   Case Report Top


A 23-year-old non-lactating (para 2, gravida 0) lady came with a left breast lump and lymphedema of the left arm of 1-month duration. She recently had lumpectomy done in the same breast 1-month earlier at a peripheral hospital, which was diagnosed as breast abscess on histopathology. Her ultrasound examination previous to lumpectomy was available that showed an irregular hypoechoic mass of size 2.6 Χ 2.1 Χ 1.6 cm in the left breast having both solid and cystic components, perilesional inflammatory changes, and architectural distortion. The ultrasound findings of the left breast suggested focal mastitis with abscess formation. The right breast was normal and bilateral axillary lymphadenopathy was absent at this point of time. Her examination at the present visit revealed an irregular hard tender fixed mass of 6 Χ 4 cm in the outer lower and upper quadrants of the left breast. The skin overlying the mass was erythematous, nodular, and showed a surgical scar mark just above the areola [Figure 1]a. The largest left axillary lymph node measured 4 Χ 2 cm. FNAC of the left breast mass and left axillary lymph nodes was done in Department of Pathology. Ethanol-fixed Papanicolaou-stained smears were prepared for cytological study. The breast mass FNAC showed richly cellular monomorphic population of loosely cohesive single lymphoid cells of two to three times the size of mature lymphocytes with moderate anisonucleosis, 1-3 prominent nucleoli and fragile cytoplasm [Figure 1]b. The ductal epithelial cells of the breast were not seen in the cytology smears. Similar cytomorphologic features were also present in the aspirate from left axillary lymph nodes. A cytological diagnosis of non-Hodgkin lymphoma- large cell type was given. A tru-cut needle biopsy of the breast mass also showed features of non-Hodgkin lymphoma. Her formalin-fixed, paraffin-embedded blocks of the prior lumpectomy specimen was then retrieved from the peripheral laboratory and reviewed. Hematoxylin and eosin (H and E)-stained sections showed replacement of the breast parenchyma by diffuse sheets of monomorphic lymphoid cells [Figure 1]c. On higher magnification, the lymphoid cells showed moderate anisokaryosis, clumped nuclear chromatin, prominent nucleoli, and minimal amount of eosinophilic cytoplasm on a background of lymphoglandular bodies [Figure 1]d. Lymphoepithelial lesion was characterized by infiltration of lymphoma cells into the sparsely present duct epithelium of the breast [Figure 2]a. Immunohistochemical studies were performed on formalin fixed, paraffin-embedded blocks of the lumpectomy specimen. Cytokeratin immunostaining showed strong cytoplasmic reactivity in the duct epithelium while the lymphoma cells stained negative [Figure 2]b. In contrast, the lymphoma cells expressed diffuse strong membranous positivity with antibodies against leukocyte common antigen [Figure 2]c and CD 20 [Figure 2]d while negative for CD 15, CD 30, and CD 3. There was no primary elsewhere as evidenced by the absence of hepatosplenomegaly and the absence of any lymph node enlargement other than left axillary lymph nodes. The final diagnosis was primary diffuse large B-cell lymphoma of the breast, stage II. The patient was planned for chemotherapy, her baseline laboratory investigations and ultrasound examination of abdomen was normal. However, further management and follow up of the patient could not be done as she escaped from the hospital against the medical advice.
Figure 1: (a) Clinical photograph of the patient. (b) FNAC showing dispersed large non-cleaved lymphoma cells aspirated from the breast lump (Pap, x400). (c) Diffuse infiltration of the lymphoma cells resulting in destruction and fibrosis of breast parenchyma (H and E, x200). (d) Magnified view of lymphoma cells against a background of lymphoglandular bodies (H and E, x400)

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Figure 2: (a) Lymphoepithelial lesion demonstrating invasion of ductal epithelium of the breast by lymphoma cells (H and E, x200). (b) Cytokeratin immunostaining strongly positive in ductal epithelium, negative in surrounding lymphoma cells (IHC, x200). (c) Diffuse strong LCA positive immunostaining in tumour cells (IHC, x400). (d) Lymphoma cells showing diffuse strong positivity against CD 20 (IHC, x400)

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   Discussion Top


This case report highlights the usefulness of FNAC in correct diagnosis of the PBL. The deceptive benign appearance on clinical and ultrasound examinations was diagnosed as non-Hodgkin Lymphoma. FNAC provided the earliest clue to diagnosis of PBL which was later confirmed by histology and immunohistochemistry in this case. Because breast lymphoma is a rare condition, it is not usually considered when a patient presents with the breast lump. However, clinician should be aware of the deceiving benign appearance of PBL in contrast to much more commonly seen breast carcinoma. [2],[3] On physical examination, PBL often appears as a rapidly growing single palpable nodule of mean size 3.5 cm that is mobile and non-tender. [1],[4] This probably results from the relatively rapid growth of these lesions in comparison to breast carcinomas, especially in the younger patients. [4] Ipsilateral axillary lymph nodes are palpable in 30% to 70% cases. [1] Clinical signs of advanced breast malignancy are rare, such as inflammatory changes, nipple retraction, puckering of the skin or tumor fixation. [5] Breast lymphoma can occasionally present as a diffuse rapid breast enlargement in the younger age group, or as breast skin thickening due to lymphatic blockage by lymphoma resulting in retrograde edema. [4] On diagnostic mammography, PBL often appears as a well-defined mass with smooth margins and homogeneous appearance. Again, signs of breast malignancy such as microcalcification, spiculation, and distortion of surrounding tissue are usually absent. [1] Lymphomas in the body when imaged with ultrasound generally appear as hypoechoic masses. [4] Likewise PBL will most often demonstrate a well-defined hypoechoic lesion without enhancement suggesting a wrong notion of benignity.

The specific criteria for diagnosis of PBL were first defined by Wiseman and Liao in 1972. [6] These are: (a) the clinical site of appearance is the breast; (b) a history of prior lymphoma or evidence of widespread disease are absent at diagnosis; (c) demonstration of lymphoma in proximity to breast tissue; and (d) involvement of ipsilateral lymph nodes may be present if they develop simultaneously with the primary breast tumor. [1] The entire criteria for diagnosis of PBL are satisfactorily present in our case.

At the time of initial lumpectomy, patient had stage I disease with the tumor limited to the breast only. However, when patient came to us she had significant enlargement of the ipsilateral axillary lymph nodes in association with the recurring breast lump (Stage II disease). This offers evidence that excision biopsy alone is not curative in patients with PBL; rather such a procedure may upstage the disease process in these patients. Thus, if a young patient presents with a rapidly growing breast tumor, lymphoma should be considered before undertaking any surgical intervention. In such cases, a meticulously performed FNAC is vital for an accurate preoperative diagnosis of the breast lymphoma.

In summary, PBL is a rare entity that accounts for only a small fraction of the breast malignancies. As none of the clinical or imaging features of the disease is characteristic, a rapidly growing breast lump in a young female should warn the attending clinician of this rare possibility. FNAC is very useful, simple, rapid, reliable, and cost-effective procedure for an accurate diagnosis of the lesion.


   Acknowledgement Top


Authors are thankful to Mr. Kanhaiya Lal and Mr. Vikash Agrawal for providing excellent technical assistance in immunohistochemistry.

 
   References Top

1.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. 1
    
2.Sabaté JM, Gómez A, Torrubia S, Camins A, Roson N, De Las Heras P, et al. Lymphoma of the breast clinical and radiologic features with pathologic correlation in 28 patients. Breast J 2002;8:294-304.  Back to cited text no. 2
    
3.Brogi E, Harris NL. Lymphomas of the breast: Pathology and clinical behavior. Semin Oncol 1999;26:357-64.  Back to cited text no. 3
    
4.Watson AP, Fraser SE. Primary lymphoma of the breast. Australas Radiol 2000;44:234-6.  Back to cited text no. 4
    
5.Hugh JC, Jackson FI, Hanson J, Poppema S. Primary breast lymphoma. Cancer 1990;66:2602-11.  Back to cited text no. 5
    
6.Wiseman C, Liao KT. Primary lymphoma of the breast. Cancer 1972;29:1705-12.  Back to cited text no. 6
    

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Correspondence Address:
Shashikant C.U. Patne
Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: Revolving fund of Department of Pathology, IMS, BHU, Varanasi., Conflict of Interest: None


DOI: 10.4103/0970-9371.126674

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    Abstract
   Introduction
   Case Report
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