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Concurrent occurrence of metastatic breast carcinoma and acute myeloid leukemia in bone marrow


1 Department of Pathology, KGMU, Lucknow, Uttar Pradesh, India
2 Department of Hematology, SGPGI, Lucknow, Uttar Pradesh, India

Date of Submission21-Jan-2019
Date of Decision11-Feb-2019
Date of Acceptance11-Sep-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Khaliqur Rahman,
Department of Hematology, SGPGI, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_51_19



How to cite this URL:
Qayoom S, Gupta R, Singh P, Gupta A, Rahman K. Concurrent occurrence of metastatic breast carcinoma and acute myeloid leukemia in bone marrow. J Can Res Ther [Epub ahead of print] [cited 2020 Feb 29]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=277104



Therapy-related acute myeloid leukemia (t-AML) occurs as a late complication of cytotoxic chemotherapy, which is administered for a primary malignancy. Breast cancer has been found to be the most common primary malignancy for which these patients have been treated in the past. Any age can be involved; however, the increasing age increases the risk of developing t-AML. The causative cytotoxic agents can be alkylating agents, topoisomerase II inhibitors, antimetabolites, antitubulin agents, and ionizing radiation therapy.[1] Simultaneous occurrence of AML and breast carcinoma metastasis is a rare phenomenon and has occasionally been described as single case reports.[2] Here, we report one of such unusual case in a 43-year-old female patient.

A 43-year-old female presented to the hematology department with complaints of weakness and cytopenias. She was a diagnosed and treated case of infiltrating duct carcinoma left breast, 3 years before. The histopathology showed Grade II carcinoma with estrogen receptor (ER)/progesterone receptor (PR) and Her2 Neu positivity and was staged as Stage II. She was treated with breast conservative therapy and 12 cycles of cyclophosphamide, epirubicin, and paclitaxel, along with hormonal therapy.

At the current presentation, she was very frail with poor performance score. General examination revealed pallor, along with bilateral axillary lymphadenopathy. A complete blood count revealed a white blood cell count of 19 × 109/L with 15% blasts, a hemoglobin of 95 g/L, and a platelet count of 32 × 109/L. Bone marrow aspirate smear showed acute leukemia with ~65% blasts, which were medium sized having high N:C ratio, fine chromatin, and scant-to-moderate amount of cytoplasm. Few blasts showed the presence of cytoplasmic granules. These blasts were weakly positive for myeloperoxidase (MPO). Few small group of atypical large cells, seen in loose aggregates, were also seen. The core biopsy showed separate areas with sheets of blasts as well as metastatic tumor infiltrates, which were positive for ER and PR [Figure 1]. Flow cytometry immunophenotyping revealed these blasts to be positive for CD34, CD13, CD33, CD123, CD38, and MPO, confirming the diagnosis as an AML. Her positron emission tomography scan showed diffuse skeletal uptake along with involvement of the brain, liver, spleen, and multiple nodes over both sides of diaphragm. She could not be administered any chemotherapy and was discharged after central nervous system radiation.
Figure 1: Section shows the presence of blasts in sheets (red arrow) along with cluster of atypical metastatic epithelial cells (blue arrow) (a, H and E, ×4). Higher magnification shows areas with sheet of blasts (b, H and E, ×40) and areas with metastatic tumor deposits (c, H and E, ×40). These metastatic cells were weakly positive for estrogen receptor (d, H and E, ×40), while strongly positive for progesterone receptor (e, H and E, ×40)

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Breast cancer is the most common primary neoplasm which precedes a t-AML. Median age of presentation of these patients is in mid-sixth decade.[3],[4] The latency period between the primary neoplasm and t-AML is ~4 years. Studies have shown that younger age at presentation of primary neoplasm, administration of intercalating agent, and topoisomerase II inhibitors are associated with a shorter latency period.[4] The present case had both an younger age of primary malignancy diagnosis and being treated with eight cycles of topoisomerase II inhibitor. Patients with t-AML usually have a more frequent complex karyotype which includes Chr 11q23 abnormality as compared to de novo AML. The present case, however, did not show any abnormal metaphase or NPM1/FLT3 mutation.

Patients with t-AML are often poor candidates for intensive therapy, as they have some damage from prior cytotoxic therapy, or, in some cases, because of persistence of disease. Simultaneous occurrence of breast cancer and AML is very uncommon, with only seven cases reported till 2016.[5] Even uncommon is the concurrent presence of metastatic breast cancer and AML in marrow. After extensive search, we could find only one case reported by Shomali and Gotlib.[2] All these patients fare very poorly and succumb to any one of these diseases, mainly the AML.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Vardhiman JW, Matutes E, Arber DA, Baumann I, Brunning RD, Kvasnicka HM, et al. Therapy related myeloid neoplasm. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri S, Stein H, et al., editors. WHO Classification of Tumors of Hematopoietic and Lymphoid Tissue. Lyon: International Agency for Research in Cancer; 2017. p. 153-6.  Back to cited text no. 1
    
2.
Shomali W, Gotlib J. Myelophthisic marrow involved by breast cancer and acute myeloid leukemia. Blood 2018;131:1036.  Back to cited text no. 2
    
3.
Valentini CG, Fianchi L, Voso MT, Caira M, Leone G, Pagano L. Incidence of acute myeloid leukemia after breast cancer. Mediterr J Hematol Infect Dis 2011;3:e2011069.  Back to cited text no. 3
    
4.
Kayser S, Döhner K, Krauter J, Köhne CH, Horst HA, Held G, et al. The impact of therapy-related acute myeloid leukemia (AML) on outcome in 2853 adult patients with newly diagnosed AML. Blood 2011;117:2137-45.  Back to cited text no. 4
    
5.
Hu G, Mallik DK, Yang W, Hou Y, Cheng Z, Chen P, et al. Appropriate clinical strategies for breast cancer coexisting with acute myeloid leukemia in the genomic-molecular era: A case report. Breast Care (Basel) 2016;11:145-7.  Back to cited text no. 5
    


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