|
 
 |
| CORRESPONDENCE |
|
| Year : 2013 | Volume
: 9
| Issue : 3 | Page : 526-528 |
|
Hodgkin's lymphoma of the breast
Charles U Osuji1, Gladys I Ahaneku1, Emmanuel I Onwubuya1, Emeka C Okocha2, Cornelius Ukah3, Chinemelum D Emegoakor4, Emeka G Omejua1
1 Department of Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Haematology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
3 Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
4 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| Date of Web Publication | 8-Oct-2013 |
Correspondence Address:
Charles U Osuji
Department of Medicine, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-1482.119369
Hodgkin's lymphoma of the breast is very rare. We report a case of Hodgkin's lymphoma of the breast in a 61 year old post-menopausal female who presented with a 3 month history of left breast painless lump. Excision biopsy was done and histology showed nodular sclerotic Hodgkin's lymphoma confirmed by immunohistochemical staining. Keywords: Breast, Igbo tribe, lymphoma
How to cite this article:
Osuji CU, Ahaneku GI, Onwubuya EI, Okocha EC, Ukah C, Emegoakor CD, Omejua EG. Hodgkin's lymphoma of the breast. J Can Res Ther 2013;9:526-8 |
| > Introduction | |  |
Hodgkin's lymphoma of the breast is very rare. Since the first case report by Keukens, only a few other cases have been added to the literature. We report a case of nodular sclerosis Hodgkin's lymphoma of the left breast in a postmenopausal Nigerian woman. This is the first case of Hodgkin's lymphoma of the breast recorded at Nnamdi Azikiwe University Teaching Hospital.
| > Case Report | | |
A 61-year-old postmenopausal Nigerian woman of the Igbo tribe presented with a 3-month history of painless lump in the left breast. The lump increased progressively with eventual ulceration of the overlying skin and associated foul-smelling discharge. There was no nipple retraction or discharge. There were associated enlarging nodular swellings in the lower jaw, neck, axillae and groins, first seen two months after noticing the breast lump. There was associated moderate grade intermittent fever, anorexia, weight loss and drenching night sweats.
On examination, there was a circumscribed hard mobile mass in the upper outer quadrant of the left breast, lying deep to an ulcer measuring 3 × 8 × 10 cm. The skin over the rest of the left breast had a peau d'orange appearance with pitting oedema of the anterior chest wall and both upper limbs. The right breast was normal. Lymphadenopathy was noted in the left submandibular and anterior cervical regions and bilaterally in the supraclavicular, axillary and inguinal regions. The nodes were non-tender, firm, rubbery and discrete with the largest measuring about 6 ΄ 3 cm. The patient was pale, febrile (temperature 37.9°C) and markedly emaciated. She was in respiratory distress with features of pleural effusion (left). She weighed 48 kg with BMI of 17.67 kg/m 2 .
Haematological tests showed anaemia (haemoglobin 5 g/dl (normal values 12 g/dl-16 g/dl)) with microcytosis and hypochromia. Leukocyte and platelet counts were normal. Urinalysis and serum electrolytes, urea and creatinine were also normal. HIV screening was negative.
Chest x-ray showed left pleural effusion. Abdominal ultrasound revealed no evidence of abdominal organ disease.
Examination of routinely stained Haematoxylin and Eosin slides of wedge biopsy of left breast mass showed a malignant mammary neoplasm composed of classic Reed-Sternberg tumour giant cells in a background of lymphocytic cell infiltrate [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. Immunohistochemical stains done showed the Reed-Sternberg tumour giant cells strongly positive for CD30 [Figure 5] but negative for CD15 [Figure 6]. | Figure 1: Photomicrograph of breast ΄40 Magnification showing nodules of mononuclear inflammatory cells seen infiltrating and replacing breast parenchymal and stromal structures. The arrow points the overlying skin (H and E)
Click here to view |
 | Figure 2: Photomicrograph of breast ΄100 Magnification showing nodules of mononuclear inflammatory cells seen infiltrating and replacing breast parenchymal and stroma structures Higher magnification of the tumour in Figure 1 showing infiltration of breast stroma by the tumour (here, remnant fat cells depicted by arrow heads) {H and E}
Click here to view |
 | Figure 3: Photomicrograph of breast ΄1000 Magnification showing both classic Reed-Sternberg's cells -Binucleated - (arrows) and mono nuclear Giant Cells (arrow heads) {H and E}
Click here to view |
 | Figure 4: Photomicrograph of breast ΄1000 Magnification showing both classic Reed-Sternberg's (Binucleated) and mono nuclear Giant Cells and sclerosis of the stroma. (H and E)
Click here to view |
 | Figure 5: CD -30 positivity: Both the mononuclear and Reed- Sternberg tumour giant cells show positivity to CD 30 antibodies as demonstrated by the intracytoplasmic brownish pigmentation (arrows). It is worthy of note that the surrounding mature lymphocytes in the background show no reaction (arrow heads)
Click here to view |
 | Figure 6: CD 15 antibodies are negative as can be seen in the section above
Click here to view |
Following the histopathology report, a final diagnosis of Hodgkin's lymphoma with involvement of the left breast (at least Ann Arbor stage III EB ) was made. The patient was transfused 3 units of whole blood and worked up for chemotherapy. So far, she has received 2 (two) out of 6 (six) cycles of Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD), with remarkable clinical improvement - resolution of all oedema, reduction in the sizes of all the previously enlarged lymph nodes, cessation of fever and drenching night sweats, improvement in general well-being and functional status. She was discharged after the first cycle of ABVD and has continued her management as an out-patient.
| > Discussion | | |
Lymphoma involving the breast either as a primary site or resulting from lymphogenous or haematogenous spread from other sites is rare, representing 0.04 - 0.5% of malignant breast neoplasms. [1] Most cases of breast lymphoma reported in the literature are histologically non-Hodgkin's, accounting for about 70 - 90% of all breast lymphomas. [2],[3],[4],[5] Hodgkin's lymphoma of the breast is very rare. [5]
The relative paucity of lymphoid tissue in the breast has been cited as a possible explanation for the low incidence of lymphomas in the breast when compared with other extra-nodal sites such as the liver, bone marrow and gastrointestinal tract.
Clinically, breast lymphoma typically presents as painless palpable breast mass as was seen in our patient. [6] Our patient also presented with axillary (bilateral), supraclavicular, cervical, and submandibular lymphadenopathy as well as oedema of the chest wall and upper limbs, similar to the earlier reported cases (rare cases). [7] In a series of 84 patients with primary breast lymphoma, most of the patients had painless palpable breast mass, only 10 (11.9%) had pain in the breast; while another 10 (11.9%) had their diagnoses during routine mammography as they did not have any palpable breast mass. [4] An overwhelming majority of patients presenting with breast lymphoma are middle aged and elderly women with preponderance in the right breast, though bilateral disease has been reported. [1] Our patient however had a left breast disease.
There are no pathognomonic features of breast lymphoma on imaging hence diagnosis can only be confirmed on histology. [3] Imaging techniques are however useful in delineating the extent and number of lesions. Excision biopsy, as was eventually done for our patient, has been advocated as the preferred biopsy option since it also represents an important component of the therapy. Fine needle aspiration cytology and core needle biopsy are alternatives with reasonable yield. Criteria for primary lymphoma of the breast have been defined as adequate biopsy specimen with mammary tissue and lymphoma infiltrate in close association; and no evidence of concurrent widespread disease or preceding extra mammary lymphoma. [8] These criteria were met in this case.
Classical Hodgkin's lymphoma is characterized pathologically by few neoplastic cells in a mixed inflammatory background and the malignant Reed-Sternberg cells with two nucleoli in two separate nuclear lobes, prominent nuclear membranes, and abundant amphophilic cytoplasm [Figure 3]. Immunophenotypically; the Reed-Sternberg cells stain strongly positive for CD30 [Figure 5].
Treatment for Hodgkin's lymphoma of the breast has not been standardized, principally because of its rarity. Therapeutic options available however include: chemotherapy alone, radiotherapy alone, radiotherapy with chemotherapy, and surgery (lumpectomy, partial mastectomy, modified radical mastectomy) with or without radiotherapy and/or chemotherapy. [9] The combination of radiotherapy with chemotherapy appears to be the most effective therapy and has been recommended as the gold standard. [9],[10]
The treatment outcome and overall prognosis depend on the clinical stage and histological type of the tumour as well as the treatment modality, and appears to be generally good. [9],[10]
To the best of the authors' knowledge, this case represents the first report of Hodgkin's lymphoma of the breast in south east Nigeria, and thus the need to consider Hodgkin's lymphoma in the differential diagnosis of a breast mass. A high index of suspicion coupled with a sound knowledge of the clinical characteristic and natural history of breast lymphoma are needed for early diagnosis which is crucial for proper management.
| > Acknowledgement | | |
Irene Amat of Complejo Hospitalario de Navarra, Anatomía Patológica, Irunlarrea s/n 31008 Pamplona (Spain).
| > References | | |
| 1. | Fischer MG, Chideckel NJ. "Primary" lymphoma of the breast. Breast 1984;10:7-12. 
|
| 2. | Pruthi S, Stafyla VK, Phillips SW, Porrata LF, Reynold CA. Primary mammary (non-Hodgkin) lymphoma presenting as locally advanced breast cancer. Mayo Clin Proc 2004;79:1310-4.
|
| 3. | Zack JR, Trevisan SG, Gupta M. Primary breast lymphoma originating in a benign intramammary lymph node. AM J Roentgenol 2001;177:177-8.
|
| 4. | Jeanneret-Sozzi W, Taghian A, Epelbaum R, Poortmans P, Zwahlen D, Amsler B, et al. Primary breast lymphoma: Patient profile, outcome and prognostic factors. A multicentre rare cancer network study. BMC Cancer 2008;8:86.
|
| 5. | Pullen CM, Cass AJ. Bilateral primary lymphoma of the breast. Aust N Z J Surg 1996;66:845-7.
|
| 6. | Lyons JA, Myles J, Pohlman B, Macklis RM, Crowe J, Crownover RL. Treatment and prognosis of primary breast lymphoma: A review of 13 cases. Am J Clin Oncol 2000;23:334-6.
|
| 7. | Hoimes CJ, Selbst MK, Shafi NQ, Rose MG, Rosado MF. Hodgkin's lymphoma of the breast. J Clin Oncol 2010;2:e11-3.
|
| 8. | Wiseman C, Liao KT. Primary lymphoma of the breast. Cancer 1972;29:1705-12.
|
| 9. | Aviles A, Delgado S, Nambo MJ, Neri N, Murillo E, Cleto S. Primary breast lymphoma: Results of a controlled clinical trial. Oncology 2005;69:256-60.
|
| 10. | Liu M, Hsieh C, Wang A, Pi CP, Chang TH, Huang CC, et al. Primary breast lymphoma: A pooled analysis of prognostic factors and survival in 93 cases. Ann Saudi Med 2005;25:288-93.
|
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
|
Search Pubmed for