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CASE REPORT
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 846-848

Metachronous bilateral breast cancer diagnosed with primary breast lymphoma and mucinous carcinoma: The first case in the literature


1 Bezmialem Vakif University, Medical Faculty, Department of Medical Oncology, Istanbul, Turkey
2 Yozgat City Hospital, Department of Hematology, Yozgat, Turkey
3 Diyarbakir SBU Gazi Yasargil Education and Research Hospital, Department of Medical Oncology, Diyarbakir, Turkey

Date of Submission01-Sep-2020
Date of Decision20-Dec-2020
Date of Acceptance10-Feb-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Melih Simsek
Bezmialem Vakif University, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1008_20

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 > Abstract 


Introduction: Breast cancer is the most common cancer in women and 2-11% of the cases are bilateral. Bilateral breast cancer frequently emerges as a second primary cancer. Lymphoma and mucinous carcinoma of breast are very rare. Here we present a case, of bilateral breast cancer with metachronous lymphoma and mucinous carcinoma.
Case History: 57-year old female had received chemotherapy and radiotherapy for stage IA Diffuse Large B Cell Lymphoma (DLBCL) located in right breast. At 14th month of her breast DLBCL diagnosis, a diagnosis of mucinous carcinoma was determined in her left breast. After surgery, adjuvant anastrozole was initiated. The patient is still in follow-up with remission at her sixth year of DLBCL diagnosis and fifth year of mucinous carcinoma diagnosis.
Conclusions: The evaluation of unilateral breast cancer patients in terms of bilateral breast cancer occurrence risk has become important.

Keywords: Breast cancer, chemotherapy, lymphoma


How to cite this article:
Simsek M, Aykas F, Yildirim AO. Metachronous bilateral breast cancer diagnosed with primary breast lymphoma and mucinous carcinoma: The first case in the literature. J Can Res Ther 2022;18:846-8

How to cite this URL:
Simsek M, Aykas F, Yildirim AO. Metachronous bilateral breast cancer diagnosed with primary breast lymphoma and mucinous carcinoma: The first case in the literature. J Can Res Ther [serial online] 2022 [cited 2022 Aug 10];18:846-8. Available from: https://www.cancerjournal.net/text.asp?2022/18/3/846/347673




 > Introduction Top


Breast cancer is the most cancer type in women; 2%–11% of all breast cancer cases are bilateral.[1] Bilateral breast cancer (BBC) is separated into two subtypes as synchronous and metachronous. Although BBC can occur as the spread of unilateral cancer, frequently, it emerges as a second primary cancer.[2] The histopathological subtype of the primary tumor is closely associated with the occurrence of BBC. Although invasive lobular carcinoma is known to be the most common subtype to have the potential of bilateral occurrence, invasive ductal carcinoma as being the most frequent tumor of the breast and in situ ductal carcinoma tend to be bilateral with a high rate.[3] Lymphoma and mucinous carcinoma is very rarely seen in the breast. We aimed to present our case, to the best of our knowledge the first case in the literature, a BBC with metachronous lymphoma and mucinous carcinoma.


 > Case Report Top


A 57-year-old female was diagnosed with Stage IA diffuse large B-cell lymphoma (DLBCL) with tru-cut biopsy of a lesion in the right breast. The immunoprofile of the specimen was concordant with DLBCL as the tumor cells were CD20 positive. The maximum diameter of the tumor was 2 cm. The patient had received the six cycles of R-CHOP chemotherapy regimen (rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, vincristine 1.4 mg/m2, adriamycin 50 mg/m2, methylprednisolone 100 mg/day, every 21 days) and radiotherapy at another center [Figure 1]. After six cycles of R-CHOP chemotherapy, there was no evidence of residual tumor in the positron emission tomography-computed tomography scan. Follow-up decision had been chosen for the patient after disease remission. However, she had not applied to the hospital for her follow-up controls for the past 5 months, and she mentioned that she wanted to continue her follow-up from our clinic. She had the diagnosis of diabetes mellitus and hypertension and a breast cancer history in her mother. In her physical examination performed at the 14th month of her breast DLBCL diagnosis, a palpable mass lesion was detected in the upper lateral quadrant of her left breast. In her breast ultrasonography and mammography, a hypoechoic lobular countered, 1.5 cm × 1.2 cm in the diameter solid lesion, in line of 10–11 o'clock of the left breast about 7 cm from areola, and bilateral multiple cystic focuses were detected. The excisional biopsy result of the patient was reported as estrogen receptor positive (90%), progesterone receptor positive (90%), c-erbB2 negative, Ki67 proliferation index, and 50% hypercellular variant of mucinous carcinoma. Complete blood count, renal and hepatic function tests, lactate dehydrogenase level, carcinoembryonic antigen, and cancer antigen 15-3 levels were in the normal ranges in her biochemical analyzes. A positron emission tomography was performed for disease staging. A 1.5 cm diameter mass lesion with an increased fluorodeoxyglucose uptake (SUVmax = 10.2) in the upper external quadrant of the left breast was determined. There was no distant metastasis. Modified radical mastectomy to the left breast was performed to the patient with the diagnosis of T1N0M0 mucinous carcinoma. Anastrozole 1 mg/day was initiated as hormonal therapy in the postoperative period. The patient is still in follow-up with remission at her 6th year of DLBCL diagnosis and 5th year of mucinous carcinoma diagnosis.
Figure 1: Light microscope appearance of breast mucinous carcinoma (H and E, ×200)

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 > Discussion Top


Breast cancer is the most common cancer type in women. Breast cancer itself is one of the risk factors. It was reported that the breast cancer risk in the contralateral breast of woman that breast cancer was determined in one breast was 2–6 folds greater than the normal population.[4],[5] Contralateral breast cancer occurs in 0.3%–1% of the patients with breast cancer every year.[5] BBC is separated into two subtypes as synchronous and metachronous. There are authors who consider the time period between two tumor diagnoses as 1, 3, or 12 months for synchronous tumor definition. The development of cancer in the contralateral breast within 1 year of initial diagnosis was defined as synchronous breast cancer, and any second tumor found in the contralateral breast after 1 year was defined as metachronous breast cancer.[1],[4] In our case, the time period between two cancer diagnoses was 14 months, and this is a metachronous BBC.

The factors that increase BBC risk were defined as younger age, family history, histology of lobular carcinoma, multicentric disease, histological differences in primary tumor, presence of fibrocystic disease, nulliparity, and history of radiotherapy.[4],[5] Family history plays an important role in BBC.[4] The determination of the risk factors for BBC occurrence provides the early diagnosis of contralateral breast cancer, high overall survival rate, and long life span. The most important risk factors for BBC in our case are breast cancer history in herself and her mother, radiotherapy history for the treatment of first breast cancer. The bilateral multiple cystic foci defined in ultrasound may be another risk factor.

The histopathological subtype of the primary tumor is closely associated with the occurrence of BBC. Although invasive lobular carcinoma is known to be the most common subtype to have the potential of bilateral occurrence, it was shown with studies that invasive ductal carcinoma and in situ ductal carcinoma also tend to be bilateral with high rates.[3] BBC tends to be seen in younger ages than unilateral breast cancer.

Lymphoma and mucinous carcinoma in the breast is very rare and diagnosed at a median age of 60 years. Lymphoma in the breast may occur as breast involvement of lymphoma cases or as a primary breast lesion. Metastatic breast lymphoma is 2–3 times more frequent than primary breast lymphoma. Although the most common lymphoma subtype is reported to be DLBCL with more than 50% rate, there are also cases reported as follicular lymphoma, MALT lymphoma, and Burkitt lymphoma.[6] The prognosis is related to tumor stage and histological subtype. Mucinous cancer of the breast is a well-defined specific subtype of breast cancer with a good prognosis. It tends to be seen in elderly patients and is a mucin-producing tumor that has low or moderate grade.[7],[8] Our case is a very rare BBC case with DLBCL diagnosis in the left breast and mucinous carcinoma diagnosis in the right breast, and to the best of our knowledge, the first case in the literature. The prognosis of our case is concordant with data in the literature and has a good course related to histology of the tumors and stage.

Nowadays, overall survival times are steadily increasing due to new developments in the breast cancer diagnosis and treatment. Thus, the evaluation of unilateral breast cancer patients in terms of BBC occurrence risk has become important.

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 initial s 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.
Pan B, Xu Y, Zhou YD, Yao R, Wu HW, Zhu QL, et al. The prognostic comparison among unilateral, bilateral, synchronous bilateral, and metachronous bilateral breast cancer: A meta-analysis of studies from recent decade (2008-2018). Cancer Med 2019;8:2908-18.  Back to cited text no. 1
    
2.
Li X, Yang M, Zhang Q, Fan Y, Zhu T, Chen F, et al. Whole exome sequencing in the accurate diagnosis of bilateral breast cancer: A case study. J Breast Cancer 2019;22:131-40.  Back to cited text no. 2
    
3.
Soyder A, Taşkın F, Özbaş S. Senkron bilateral meme kanserli hastaların klinik özellikleri. J Breast Health 2012;8:63-7.  Back to cited text no. 3
    
4.
Ozturk A, Alco G, Sarsenov D, Ilgun S, Ordu C, Koksal U, et al. Synchronous and metachronous bilateral breast cancer: Along-term experience. JBUON 2018;23:1591-600.  Back to cited text no. 4
    
5.
Tudu R, Kumar A, Singh R, Raina P. Bilateral breast cancer: A case study. Journal of Radiotherapy in Practice 2020;19:305-8. doi:10.1017/S1460396919000761.  Back to cited text no. 5
    
6.
Sonkaria M, Tanwar RK, Saxena B, Vashishtha N, Sing R. Primary breast lymphoma: A case series and review. Indian J Case Rep 2020;6:288-91.  Back to cited text no. 6
    
7.
Tsoukalas N, Kiakou M, Tolia MN, Kostakis ID, Galanopoulos M, Nakos G. Mucinous breast carcinoma with tall columnar cells. Ann R Coll Surg Engl 2018;100:32-5.  Back to cited text no. 7
    
8.
Luna-Abanto J, Tisoc GM. Mucinous carcinoma of the breast: A case report and review of the literature. Medwave 2017;17:7003.  Back to cited text no. 8
    


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