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Breast malignant, males, children

Other malignancies

Lymphoma


Reviewer: Monika Roychowdhury, M.D. (see Reviewers page)
Revised: 16 November 2012, last major update August 2012
Copyright: (c) 2001-2012, PathologyOutlines.com, Inc.

Definition
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● Criteria for primary breast lymphoma: (a) sufficient tissue for diagnosis; (b) close interaction between lymphoma infiltrate and breast tissue; (c) no evidence of widespread lymphoma at time of diagnosis; (d) no prior diagnosis of nonbreast lymphoma (Cancer 1972;29:1705)
● Secondary breast lymphoma has similar incidence as primary breast lymphoma and is most common metastatic disease to breast

Epidemiology
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● Rare, < 1% of all breast malignancies are primary breast lymphoma
● Usually ages 30-35 years (diffuse large B cell) or 55-60 years (diffuse large B cell or MALT-type)
● Screening mammography may be increasing detection of low-grade lymphoma
● No association between implants and lymphoma (Plast Reconstr Surg 2009;123:790), but see anaplastic lymphoma below

Prognostic features
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● Low stage is favorable prognostic factor
● Unfavorable factors are young age and high stage (Leuk Lymphoma 2009;50:918)
● CNS is common site of relapse (BMC Cancer 2008;8:86)

Treatment
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● Radiation therapy, chemotherapy and Rituximab
● No advantage to mastectomy (Ann Surg 2007;245:784)

Gross description
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● Soft, gray-white
● 25% bilateral
● No skin retraction, no nipple discharge

Micro description
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● Varies by subtype - see lymphoma chapters for more detail

Cytology images
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Dyscohesive cells - subtype not specified

Positive stains
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● CD45, B or T cell markers
● Other markers vary by subtype

Negative stains
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● Keratin (may stain lymphoepithelial lesions)

Differential diagnosis
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Lobular carcinoma: usually linear or targetoid patterns, keratin+ and CD45-
Lymphoid hyperplasia: may resemble low grade B cell lymphomas
Lymphocytic mastitis: may be difficult to differentiate on core biopsy (Breast Cancer 2009;16:141)

Additional references
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Am J Surg Pathol 1993;17:574, Mod Pathol 2000;13:599 (T cell lymphomas), Am J Surg Pathol 1994;18:288, Arch Pathol Lab Med 1999;123:1208


Subtypes
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● 94% B cell and 4% T cell lymphomas in one study (Br J Radiol 2012;85:e195)


Anaplastic large cell lymphoma:
● Associated with implants, particularly if ALK negative: odds ratio is 18.2, although absolute risk is low (JAMA 2008;300:2030)
● Median age 52 years (Arch Pathol Lab Med 2009;133:1383)
● 33 year old woman with silicon implant and ALK negative tumor (Arch Pathol Lab Med 2003;127:e115)
● 92 year old woman with sarcomatoid variant (Arch Pathol Lab Med 2002;126:723)


           
Large cells with abundant cytoplasm  Associated with silicon implant

           
ALK- cases                 Various images

   
Sarcomatoid variant  TIA+ and ALK+


Burkitt’s lymphoma:
● In African patients, may present with massive bilateral breast involvement
● Patients may be pregnant or lactating
● Less common than other subtypes
● 12 year old girl in Africa with giant bilateral tumors (Arch Gynecol Obstet 2009;279:743)


      
Lymphocytic infiltrate    Ki-67 staining is diffuse and strong


Large cells with deeply basophilic cytoplasm and multiple intracytoplasmic lipid vacuoles, high N/C ratio and hyperchromatic round nuclei


CLL / SLL:

               
Xray, H&E, CD5, CD20
Contributed by Dr. Julia Braza, Beth Israel Deaconness Medical Center, Boston, Massachusetts



Diffuse large B cell lymphoma:
● Most common subtype of primary breast lymphoma (Am J Hematol 2009;84:133, Cancer 2007;110:25)
● Typically poorer prognosis if high proliferative (Ki-67) activity and nongerminal center B cell phenotype (CD10-, MUM1+, Mod Pathol 2005;18:398); better prognosis if germinal center phenotype (Leuk Res 2008;32:1837)
● 40 year old woman with bilateral tumors, diagnosed by FNA (Arch Pathol Lab Med 2005;129:694)
● 55 year old woman whose tumor exhibited clear cell change (Case of the Week #217)



Rapidly growing mass

   
Large cells with 1    Diffuse proliferation of large centroblasts
or more nucleoli    and starry sky macrophages

   
H&E and CD20     Weak BCL10+

   
Various images     Mixed with MALT

   
Various images


Follicular lymphoma:
● Usually stage I (65%), but 20% are stage III/IV
● 56 year old woman a non-palpable BI-RADS 4B lesion without microcalcifications, diagnosed by biopsy (J Med Case Rep 2007;1:113)



Bulging and fleshy tumor

   
Follicular lymphoma  BCL2+


Mantle cell lymphoma:


Various images


Marginal zone / MALT lymphoma:
● Usually stage I, 10% bilateral, survival > 90% at 5 years and no MALT1 gene rearrangement (Mod Pathol 2006;19:1402)
● Relatively indolent behavior compared to other sites (Ann Oncol 2009;20:1993)
● Bilateral MALT lymphoma (57 year old woman-World J Surg Oncol 2008;6:52, 64 year old woman-Arch Pathol Lab Med 2000;124:1233)
● 62 year old woman (Breast Care (Basel) 2011;6:391)
● 79 year old woman with collision tumor of invasive ductal NOS and MALT lymphoma (Arch Pathol Lab Med 2004;128:99)
● 87 year old woman with CD5+ marginal zone / MALT lymphoma (Arch Pathol Lab Med 2004;128:99)


H&E, CD20, BCL10


NK lymphoma, nasal type:
● 20 year old woman with post-transplant lymphoproliferative disorder (Mod Pathol 2004;17:125)

       
Lobular pattern of        Tumor cells have abundant cytoplasm
infiltration           and irregular nuclei

       
Pan-keratin immunostain high- TIA+ and CD56+
lights lymphoepithelial lesions


Peripheral T cell lymphoma:
● 37 year old woman with palpable breast mass (Case of the Week #192)

   
CD4+ large cell tumor   Cells have clear cytoplasm and mitotic activity

   
CD8+ tumor

End of Breast malignant, males, children > Other malignancies > Lymphoma


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