J Breast Cancer.  2014 Mar;17(1):91-97.

Concurrent Invasive Ductal Carcinoma of the Breast and Malignant Follicular Lymphoma, Initially Suspected to Be Metastatic Breast Cancer: A Case Report

• Hahm MH
• Kim HJ
• Shin KM
• Cho SH
• Park JY
• Jung JH
• Jeong JY
• Bae JH

Abstract

This report describes a case of a 40-year-old female patient with concurrent invasive ductal carcinoma of the breast and malignant follicular lymphoma, initially suspected to be metastatic breast cancer. During the initial evaluation of invasive ductal carcinoma of right breast, multiple lymphadenopathies were noted throughout the body on ultrasonography and positron emission tomography/computed tomography images. Clinically, metastatic breast cancer was suggested, and the patient was administered chemotherapy, including hormonal therapy. The breast cancer improved slightly, but the lymphadenopathies progressed and excisional biopsy of a cervical lymph node revealed malignant follicular lymphoma.

Keyword

Breast; Follicular lymphoma; Invasive ductal carcinoma

MeSH Terms

Adult
Biopsy
Breast Neoplasms*
Breast*
Carcinoma, Ductal*
Drug Therapy
Electrons
Female
Humans
Lymph Nodes
Lymphoma, Follicular*
Ultrasonography

Figure

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  Figure 1 Mammograms of both breasts. Bilateral mediolateral oblique view of mammograms show a large high density mass (arrows) and skin thickening on the right breast and bilateral lymphadenopathies (arrowheads).

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  Figure 2 Ultrasonographic (US) images of the right breast cancer and regional lymph nodes. US images reveal an 8 cm irregular hypoechoic mass in the right breast (arrows) and abnormal lymph nodes in the right (white arrowheads) and left axilla (red arrowheads) and the left supraclavicular area (crosses).

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  Figure 3 Maximal intensity projection images of positron emission tomography/computed tomography (PET/CT) scans. (A) Maximal intensity projection image of the initial PET/CT scan shows multiple lymphadenopathies with mildly increased 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) uptake in the axillae on both sides, in the neck, and in the left external iliac and inguinal areas (arrows). The arrowhead indicates high FDG uptake in the right breast mass. (B) PET/CT scan after the discontinuation of chemotherapy shows that the systemic lymphadenopathies are aggravated. (C) Follow-up PET/CT scan demonstrates aggravated lymphadenopathies throughout the torso. Note the newly appeared splenomegaly (arrow). Excisional biopsy of a neck lymph node reveals malignant follicular lymphoma.

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  Figure 4 Histologic images of follicular lymphoma. (A) Hematoxyline and eosin staining photomicrograph of a lymph node shows effaced nodal architecture due to closely packed neoplastic follicles (H&E stain, × 40). Inset: The neoplastic follicles show a monotonous population of cells without germinal center and lack any significant mantle zones (H&E stain, × 400). (B) Bcl-2 immunostaining photomicrograph of a lymph node demonstrates positive in follicular cells. Expression of Bcl-2 oncoprotein by follicular cells is a feature of lymphoma and not reactive follicular center cells (Bcl-2 immunostain, × 100).

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  Figure 5 Ultrasonographic (US) images of left breast cancer. (A) On comparison of transverse images of the left breast (left: initial; right: follow-up), US images reveal a benign looking ovoid nodule in the initial and follow-up images (arrows) and a new heterogenous hypoechoic area in the follow-up image (arrowheads). (B) Transverse US image shows a heterogenous hypoechoic area in the left upper outer breast (arrows).

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  Figure 6 Histologic images of right breast cancer. (A) Hematoxyline and eosin (H&E) staining photomicrograph of right breast cancer shows proliferation of high nuclear grade malignant ductal epithelial cells which represent ductal carcinoma in situ (white arrows) and portions of invasion under basement membrane mean invasive ductal carcinoma (black arrow) (H&E stain, × 40), Inset: Note tumor emboli in lymphatic channels that provide more chance of lymphangitic or hematogenous metastasis (H&E stain, × 40). (B-D) Immunohistochemical staining of surgical specimen is positive for estrogen receptor (×100) (B) and progesterone receptor (×100) (C), equivocal (2+) for human epidermal growth factor receptor 2 (×100) (D). Fluorescence in situ hybridization reveals negativity for HER2 (not shown).

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  Figure 7 Histologic images of left breast cancer. (A, B) Hematoxyline and eosin (H&E) staining photomicrographs of left breast cancer demonstrate multifocal infiltrative distribution of tumor cells in periductal area under the basement membrane (arrows). Note that normal ductal epithelium without ductal carcinoma in situ component that often accompanies primary cancer (arrowheads) (H&E stain, A: ×20, B: ×100). (C-E) Immunohistochemistry results are positive for estrogen receptor (×100) (C) and progesterone receptor (×100) (D), and negative for human epidermal growth factor receptor 2 (× 100) (E). (F) Immunoperoxidase staining photomicrograph of left breast cancer shows E-cadherin expression that is lost in lobular carcinoma (Immunohistochemical stain for E-cadherin, × 100).

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