Figure 1
Axial CT
A well-defined homogenously hyperdense mass is seen in the left breast.
Primary breast B-cell lymphoma
SectionBreast imaging
Case TypeClinical Cases
AuthorsAttard L1, Reichmuth L2, Cortis K 3
Connected authors
72 years, female
Clinical History
A 72-year-old lady presented to surgical outpatients after noticing a hard lump in her left breast. Physical examination revealed a hard irregular mass in the upper outer quadrant of the left breast. No axillary lymph nodes were palpable. The patient was referred for a mammogram and breast ultrasound.
Imaging Findings
Computed Tomography performed just prior to mammography for an unrelated indication showed a well-defined homogeneously hyperdense mass in the left breast. No lymphadenopathy was noted in the axillae, thorax, abdomen or pelvis. Further imaging was therefore performed. Mammography showed asymmetrical breast composition, secondary to a large dense focal asymmetry within the left breast which was lacking a discrete border. This was more evident on the cranio-caudal view than on the medio-lateral-oblique projection. No associated architectural distortion, skin thickening, or suspicious calcifications were observed. No previous studies were available for comparison. Given the disparity between the well marginated mass seen on CT and the mammographic findings, ultrasound and ultrasound guided biopsy was carried out. Sonography showed a corresponding diffuse heterogeneous hypoechoic mass containing dilated ductal elements with posterior acoustic enhancement.
Discussion
The term primary breast lymphoma (PBL) refers to malignant lymphoma primarily occurring in the breast with or without ipsilateral lymph node involvement and in the absence of previously detected lymphoma localisation. It is a rare disease making up 0.04-0.5% of all malignant breast neoplasms [1]. Non-Hodgkin’s lymphoma (NHL) of the breast represents only between 0.38 and 0.7% of all NHL [2]. Secondary involvement is more common. Primary lymphoma is rare in the breast because the breast contains less lymphoid tissue than other organs, such as the intestines or lungs, where primary lymphomas are more common. The majority of cases are B-cell lymphomas and the most common histological subtype is diffuse large B-cell lymphoma. The age incidence of PBL is variable. It occurs between 9 and 85 years the median age being 58 years [3].
PBL typically presents as a painless unilateral mass in the upper outer quadrant of the breast. Local skin changes such as erythema, skin retraction, peau d’orange appearance and nipple discharge are uncommon. In 50% of cases ipsilateral axillary node involvement is present [1]. Therefore patients undergo the usual workup for a breast mass.
Mammographic finding of PBL are non-specific. Two groups of mammography findings are described, of either a well circumscribed mass (solitary or multiple) or a diffuse infiltrative appearance. A solitary dense uncalcified mass with irregularly or partially defined contours is the commonest finding. Diffuse increased parenchymal density is less common and more often seen in high grade lymphomas.
Ultrasound findings are varied but most commonly sonography reveals a solitary irregular hypo- or hyperechoic mass with indistinct margins and increased vascularity.
MRI demonstrates a hypo- or isointense, usually well defined mass on T1 which is hyperintense on T2 weighted images. Post contrast there is intense global heterogenous enhancement with rapid initial increase and washout kinetics on dynamic contrast enhanced images, characteristic of malignancy.
PET/CT is the image modality of choice for staging and follow-up.
The definitive diagnosis is histological and can be obtained by an excisional or needle core biopsy.
Treatment of breast lymphoma includes systemic chemotherapy and radiotherapy. Surgical treatment is often not indicated. Both clinical stage and histological subtype are important in determining the prognosis of breast lymphomas. 5 year survival rate for primary breast lymphoma ranges from 26 to 66% [4].
Lymphoma of the breast, although a rare entity, should be considered in the differential diagnosis of a breast mass, particularly if this lacks spiculation or microcalcifications.
PBL typically presents as a painless unilateral mass in the upper outer quadrant of the breast. Local skin changes such as erythema, skin retraction, peau d’orange appearance and nipple discharge are uncommon. In 50% of cases ipsilateral axillary node involvement is present [1]. Therefore patients undergo the usual workup for a breast mass.
Mammographic finding of PBL are non-specific. Two groups of mammography findings are described, of either a well circumscribed mass (solitary or multiple) or a diffuse infiltrative appearance. A solitary dense uncalcified mass with irregularly or partially defined contours is the commonest finding. Diffuse increased parenchymal density is less common and more often seen in high grade lymphomas.
Ultrasound findings are varied but most commonly sonography reveals a solitary irregular hypo- or hyperechoic mass with indistinct margins and increased vascularity.
MRI demonstrates a hypo- or isointense, usually well defined mass on T1 which is hyperintense on T2 weighted images. Post contrast there is intense global heterogenous enhancement with rapid initial increase and washout kinetics on dynamic contrast enhanced images, characteristic of malignancy.
PET/CT is the image modality of choice for staging and follow-up.
The definitive diagnosis is histological and can be obtained by an excisional or needle core biopsy.
Treatment of breast lymphoma includes systemic chemotherapy and radiotherapy. Surgical treatment is often not indicated. Both clinical stage and histological subtype are important in determining the prognosis of breast lymphomas. 5 year survival rate for primary breast lymphoma ranges from 26 to 66% [4].
Lymphoma of the breast, although a rare entity, should be considered in the differential diagnosis of a breast mass, particularly if this lacks spiculation or microcalcifications.
Differential Diagnosis List
Primary breast lymphoma (high grade B cell)
Invasive carcinoma
Phyllodes tumour
Fibroadenoma
Metastatic disease
Infectious disease – chronic abscess
Final Diagnosis
Primary breast lymphoma (high grade B cell)
References
[1] Garg NK, Bagul NB, Rubin G, Shah EF (2008) Primary lymphoma of the breast involving both axillae with bilateral breast carcinoma. World J Surg Oncol 6:52 (PMID: 18492251)
[2] Jeanneret-Sozzi W et al (2008) Primary breast lymphoma: patient profile, outcome and prognostic factors. A multicentre Rare Cancer Network study. BMC Cancer 8:86 (PMID: 18380889)
[3] Meerkotter D et al (2011) Primary breast lymphoma: a rare entity. J Radiol Case Rep 5:1-9 (PMID: 22470790)
[4] Voria P et al (2010) Primary breast lymphoma. Radiology Case Reports Vol 5, No 1
Case information
| URL: | https://www.eurorad.org/case/9968 |
| DOI: | 10.1594/EURORAD/CASE.9968 |
| ISSN: | 1563-4086 |
Figure 2
Coronal CT
Hyperdense left breast mass on reformatted coronal CT image.
Figure 3
Sagittal CT
Hyperdense left breast mass on reformatted sagittal CT image.
Figure 4
CC mammogram
Mammography shows asymmetrical breast composition, secondary to a large dense focal asymmetry within the left breast which is lacking a discrete border. No spiculation, associated architectural distortion, skin thickening, or suspicious calcifications are seen.
Figure 5
MLO mammogram
Asymmetry of the glandular breast tissue as described on the CC views.
Figure 6
Ultrasound
Diffuse heterogeneous hypoechoic mass containing dilated ductal elements with posterior acoustic enhancement.
Axial CT
A well-defined homogenously hyperdense mass is seen in the left breast.
Medical imaging department, Mater Dei Hospital, Malta
Medical imaging department, Mater Dei Hospital, Malta
Coronal CT
Hyperdense left breast mass on reformatted coronal CT image.
Medical Imaging Department, Mater Dei Hospital, Malta
Medical Imaging Department, Mater Dei Hospital, Malta
Sagittal CT
Hyperdense left breast mass on reformatted sagittal CT image.
Medical Imaging Department, Mater Dei Hospital, Malta
Medical Imaging Department, Mater Dei Hospital, Malta
CC mammogram
Mammography shows asymmetrical breast composition, secondary to a large dense focal asymmetry within the left breast which is lacking a discrete border. No spiculation, associated architectural distortion, skin thickening, or suspicious calcifications are seen.
Medical Imaging Department, Mater Dei Hospital, Malta
Medical Imaging Department, Mater Dei Hospital, Malta
MLO mammogram
Asymmetry of the glandular breast tissue as described on the CC views.
Medical Imaging Department, Mater Dei Hospital, Malta
Medical Imaging Department, Mater Dei Hospital, Malta
Ultrasound
Diffuse heterogeneous hypoechoic mass containing dilated ductal elements with posterior acoustic enhancement.
Medical Imaging Department, Mater Dei Hospital, Malta
Medical Imaging Department, Mater Dei Hospital, Malta