This is a case of an elderly female who presented for follow-up ultrasound of the right breast after routine mammogram revealed a small benign mass. A subsequent ultrasound detected a small nodular mass that was described as benign in appearance. Although the patient was asymptomatic, a fine-needle biopsy was performed to rule out malignancy. Results from immunohistochemistry and FISH studies of the biopsy were positive for diffuse large B-cell lymphoma (DLBCL). The patient underwent surgery for lumpectomy and removal of breast implants. Intraoperative tissue samples were analyzed by pathology using both flow cytometry and microscopy, and results confirmed DLBCL. With total tumor resection and implant removal completed, the patient did not require additional treatments as the prognosis of DLBCL status post implant removal is excellent. She returned for follow-up six months later and has since had no signs of reoccurrence.
Primary breast lymphoma has a low rate of occurrence comprising an estimated 0.5% of breast malignancies [
A 70-year-old female without significant past medical history presented to the clinic after the results of a routine mammogram revealed the continued presence of a small mass in her right breast. A mammogram dated 3 years prior detected this mass and reported it as small and benign, located inferior to an implant of her right breast. The more recent mammogram findings reported no change in size. The patient was asymptomatic and denied previous history of cancer and no family history of breast cancer, or other malignancies. She denied weight loss, fever, night sweats, or change in appetite. However, she did report mild discomfort with self-palpation to her lower right breast. Her breast implants were placed 28 years ago in Argentina for cosmetic reasons and have not since been revised. Additionally, she reported a long history of smoking tobacco daily.
To rule out malignancy, an ultrasound was performed and confirmed the presence of an elongated nodular density benign in appearance. The mass had multiple areas of hyperechoic densities within it and was located at the 8 o’clock position 10 cm from the right nipple. The size was measured to be
Ultrasound of the right breast before fine-needle biopsy shows a nodular density with multiple areas of hyperechoic densities within it.
Biopsy samples were sent to pathology for analysis using histology, immunohistochemistry, and FISH studies. Histologic sections of the core biopsy fragments showed malignant lymphoma of diffuse pattern. The tumor cells were large in size with anaplastic and focally spindled morphology. Additionally, there were increased mitotic figures and cellular apoptosis. Immunohistochemistry revealed lymphoma cells positive for CD20, PAX5, BCL2, BCL6, and vimentin and negative for CD3, CD5, CD10, cyclin D1, smooth muscle myosin, S100, CD31, CD20, E-cadherin, and keratin. It was determined that the neoplasm had a nongerminal center phenotype with a proliferative index of 80-90%. FISH studies were completed to determine the presence of MYC, BCL2, or BCL6 gene rearrangements. All were negative; however, an abnormal signal pattern suggestive of gains of BCL2 was detected. Overall, testing of the fine-needle biopsy confirmed DLBCL.
The patient underwent surgery for lumpectomy of the right breast, as well as bilateral breast implant removal. During the operation, the presence of a calcified capsule surrounding each nontextured implant was noted. Found within the capsules was silicone. It was unclear if the nontextured implants had ruptured prior to surgery or if there was a rupture during the procedure. Both capsules were removed, and silicone was irrigated and aspirated from the sites. The tumor was found to be in direct contact with the calcified capsule but without evidence of capsule invasion into the tumor. The tumor was also widely excised with ample samples sent to pathology for further testing. The patient was given a one-time dose of cefazolin 1 gm IV and hydrocodone for pain management. She was discharged 2 days later with a complaint of moderate breast pain that was being managed well with hydrocodone.
Intraoperative tissue samples were sent to pathology. The breast lesion was noted to be well circumscribed and consisted of monomorphous cells with large lymphocytic features. No evidence of invasion from the calcified capsule was found. The cells had pleomorphic ovoid to round nuclei with occasional atypical mitotic figures. Atypical cells, as well as foamy macrophages, were present in the touch prep. Atypical lymphoid cells with anaplastic nuclear features were noted to infiltrate into collagenized-sclerotic stroma and at times adjacent fatty lobules. Immunohistochemistry was positive for CD45, BCL2, BCL6, CD43, CD79A, MUM1, and PAX5. Flow cytometry results, in addition to the histologic and immunohistochemistry staining, confirmed the diagnosis of DLBCL. The tumor was ultimately measured as
The patient returned to the clinic 2 weeks after surgery and had well-healing scars without signs of infection. She returned again 6 months later and reported no pain at the surgical sites. Physical exam did not find any lymphadenopathy or mass with palpation. She continues to remain in good health.
In this report, a rare case of DLBCL associated with breast implants is presented. The mass was first detected 3 years prior during routine mammogram. Findings reported the mass to be benign in appearance, which resulted in no additional work-up. Three years later, routine mammogram reported no change in size or appearance. While the patient continued to be asymptomatic, it was decided to order additional testing to rule out any potential malignancy. Fine-needle biopsy with ultrasound guidance was performed, and pathology results revealed the diagnosis of DLBCL.
DLBCL is a non-Hodgkin lymphoma (NHL). It is the most common type of lymphoid malignancy in adults and is B-cell in origin [
NHLs are characterized by the abnormal growth of lymphocytes. In ALCL, the expression of T-cell markers CD4 and CD43 occurs in 82% and 77% of the cases, respectively [
A listing of DLBCL diagnostic markers [
Biomarker expression/genetic alterations | Percentage of cases |
---|---|
CD19, CD20, CD22, CD79A, CD45 | Pan B-cell antigens, highly expressed |
CD30 | 25% (anaplastic variant) |
BCL2 | 25-80% |
BCL6 | 70% |
CD10 | 30-60% |
MUM1/IRF4 | 35-65% |
CD5 | Uncommon, aggressive disease |
(14;18) translocation | 30% |
MYC gene rearranged | 5-15% |
In this patient, the microscopy of the tissue samples from the fine-needle biopsy showed malignant lymphoma in a diffuse pattern. The tumor cells present were large in size and with an anaplastic morphology. DLBCL morphology can be diverse with variants that include centroblastic, immunoblastic, T-cell/histiocyte rich, or anaplastic [
While DLBCL is an aggressive cancer and rapidly fatal if left untreated, DLBCL associated with breast implants has a far better prognosis and is often less aggressive. Nonbreast implant-associated DLBCL requires a treatment combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). Adding rituximab, a chimeric monoclonal antibody against CD20, has proven to increase survival rates [
In this case, a 70-year-old female with 28-year-old nontextured silicone breast implants developed a slow-growing mass in the right breast later identified as DLBCL. While symptomatology is dependent upon the severity of the disease, the common clinical presentation for DLBCL is breast swelling and tenderness. This patient was asymptomatic with benign mammogram findings. Because tumors associated with breast implants can be aggressive and are sometime associated with squamous cell tumors, additional testing was ordered that ultimately revealed the malignancy. Within 6 months from diagnosis, the patient underwent complete tumor resection and implant removal. There were no reported intraoperative or postoperative complications. Subsequent follow-up appointments at 2 weeks, 6 months, and 1 year were highly suggestive of a successful treatment as no new mass was noted and the patient remained asymptomatic.
The authors declare that there is no conflict of interest regarding the publication of this paper.