Breast – Malignant, Males, Children

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Breast-malignant, males, children

Lymphoma

Author: Nat Pernick, M.D, PathologyOutlines.com, Inc.

Reviewer: Daniel Visscher, M.D., University of Michigan Hospitals, February 2009 (see Reviewers page)

Revised: 5 October 2011

Last major update: October 2009

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

Treatment and prognosis

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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 Apr 1;8:86)

● Treatment is radiation therapy, chemotherapy, Rituximab; no advantage to mastectomy (Ann Surg 2007;245:784)

Xray images

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CLL/SLL - contributed by Dr. Julia Braza, Beth Israel Deaconness Medical Center, Boston, Massachusetts

Subtypes

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Burkitt’s lymphoma:

● In African patients, may present with massive bilateral breast involvement

● Patients may be pregnant or lactating

● Less common than other subtypes (Cancer 2007;110:25)

Diffuse large B cell lymphoma:

● Most common subtype of primary breast lymphoma (Am J Hematol 2009;84:133)

● 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;32:1847)

● Case reports: 55 year old woman whose tumor exhibited clear cell change (Case of Week #217)

Follicular lymphoma:

● Usually stage I (65%) but 20% are stage III/IV

MALT lymphoma:

● Usually stage I, 10% bilateral, survival >90% at 5 years, no MALT1 gene rearrangement (Mod Pathol 2006;19:1402)

Marginal zone lymphoma:

● Relatively indolent behavior compared to other sites (Ann Oncol 2009 Jul 1 [Epub ahead of print])

Case reports

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Anaplastic large cell lymphoma

● ALK- cases associated with silicon implants (Archives 2003;127:e115, Arch Pathol Lab Med 2009;133:1383); odds ration of 18.2, although absolute risk is low (JAMA 2008;300:2030)

● Sarcomatoid variant (Archives 2002;126:723)

Burkitt’s lymphoma:

● 12 year old girl in Africa with giant bilateral tumors (Arch Gynecol Obstet 2009;279:743)

Diffuse large B cell lymphoma

● Bilateral, diagnosed by FNA (Archives 2005;129:694)

Follicular lymphoma

● Diagnosed by biopsy (J Med Case Reports 2007;1:113)

Marginal zone/MALT

● Bilateral MALT lymphoma #1 (Archives 2000;124:1233), #2 (World J Surg Oncol 2008;6:52)

● Marginal zone/MALT lymphoma-CD5+ (Hum Pathol 2003;34:1065)

● Collision tumor of invasive ductal NOS and MALT lymphoma (Archives 2004;128:99)

NK lymphoma, nasal type

● Post-transplant (Mod Pathol 2004;17:125)

T cell lymphoma, peripheral type

● 37 year old woman with breast mass (Case of the Week #192)

Gross description

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● Soft, gray-white

● 25% bilateral

● No skin retraction, no nipple discharge

Gross images

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Diffuse large B cell lymphoma

Follicular lymphoma is bulging and fleshy

Bulging, fleshy tumor (subtype not known)

Microscopic description

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● Varies by subtype - see Lymphoma chapters for more detail

Micro images

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Anaplastic large cell lymphoma:

Large cells with abundant cytoplasm Associated with silicon implant

ALK- cases Various images

Sarcomatoid variant TIA+ and ALK+ Various stains

Burkitt’s lymphoma:

Lymphocytic infiltrate with starry sky pattern Ki-67 staining is diffuse and strong

CLL/SLL, contributed by Dr. Julia Braza, Beth Israel Deaconness Medical Center, Boston, Massachusetts:

CD5 CD20

Diffuse large B cell:

Large cells with 1 or more nucleoli Diffuse proliferation of large centroblasts

and starry sky macrophages

H&E and CD20 Weak bcl10+

Various images Mixed with MALT

Follicular lymphoma:

Follicular lymphoma bcl2 is positive

MALT lymphoma:

Small cells with monocytoid cytoplasm Bilateral tumor

bcl10+

Mantle cell lymphoma:

Various images

NK/T cell lymphoma:

Lobular pattern of infiltration Tumor cells have abundant cytoplasm

and irregular nuclei

Pan-keratin immunostain highlights TIA+ and CD56+

lymphoepithelial lesions

Peripheral T cell lymphoma:

CD8+ tumor

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

Cytology images

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Burkitt’s lymphoma - large cells with deeply Dyscohesive cells:

basophilic cytoplasm and multiple subtype not specified

intracytoplasmic lipid vacuoles, high N/C

ratio, hyperchromatic round nuclei

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+, 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, Archives 1999;123:1208

End of Breast – Malignant, Males, Children > Lymphoma

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