Acute lymphoblastic leukemia presenting as a breast lump: A report of two cases
A 30-year-old female, 6 weeks after delivery, presented with bilateral painless breast-swellings which she had developed in her 9 month of pregnancy. She complained of early fatigability but had no history of bleeding tendency, weight loss, or loss of appetite. Her general physical examination revealed pallor but was otherwise unremarkable. On local examination, a 3 × 3 cm, firm, irregular, non-tender and partly mobile swelling was felt in the left breast and a similar swelling, 2 × 2 cm in the right. There was no axillary lymphadenopathy. A complete blood-count revealed a total leukocyte count of 1.21 × 103/mm3 with a differential leukocyte count showing 90% blasts, a hemoglobin level of 5.3 mg/dL, and a platelet count of 180 × 103/μL. A mammography was advised and showed diffuse nodular infiltration in both breasts []. No focal mass was seen. Breast ultrasound revealed a coarse echo pattern with no fixity to any structure and normal ducts. FNAC was performed on both breast lumps. Microscopy revealed benign groups of ductal cells, clumps of degenerated cells along with scattered round cells with scanty cytoplasm and inconspicuous nucleoli (lymphoblasts) []. Some of the blasts showed nuclear indentation. Features were in favor of leukemic infiltration in both breasts — most likely ALL.\nA bone marrow aspirate obtained was hypercellular with >25% blasts having coarse chromatin, inconspicuous nucleoli and scant cytoplasm. An impression of acute lymphoblastic leukemia–L2 (ALL-L2) was made. Flow cytometry of bone marrow was positive for CD19, CD10, CD22, CD33, CD45, terminal deoxynucleotidyl transferase (TdT), HLA DR4, CD34 and negative for T-cell markers. The aberration detected was CD33. Scatter parameters and antigen expression as studied by flow cytometry were suggestive of a B-cell ALL, common acute lymphoblastic leukemia antigen (CALLA) -positive with myeloid co-expression. Her cerebrospinal fluid examination was unremarkable.\nThe patient received chemotherapy — modified Berlin — Frankfurt — Munich (BFM) protocol. She went into remission and her breast nodules regressed. She is on regular follow-up and remains disease-free 1 year later.