Cytodiagnosis of the primary breast lymphoma in a young woman
A 23-year-old non-lactating (para 2, gravida 0) lady came with a left breast lump and lymphedema of the left arm of 1-month duration. She recently had lumpectomy done in the same breast 1-month earlier at a peripheral hospital, which was diagnosed as breast abscess on histopathology. Her ultrasound examination previous to lumpectomy was available that showed an irregular hypoechoic mass of size 2.6 × 2.1 × 1.6 cm in the left breast having both solid and cystic components, perilesional inflammatory changes, and architectural distortion. The ultrasound findings of the left breast suggested focal mastitis with abscess formation. The right breast was normal and bilateral axillary lymphadenopathy was absent at this point of time. Her examination at the present visit revealed an irregular hard tender fixed mass of 6 × 4 cm in the outer lower and upper quadrants of the left breast. The skin overlying the mass was erythematous, nodular, and showed a surgical scar mark just above the areola []. The largest left axillary lymph node measured 4 × 2 cm. FNAC of the left breast mass and left axillary lymph nodes was done in Department of Pathology. Ethanol-fixed Papanicolaou-stained smears were prepared for cytological study. The breast mass FNAC showed richly cellular monomorphic population of loosely cohesive single lymphoid cells of two to three times the size of mature lymphocytes with moderate anisonucleosis, 1-3 prominent nucleoli and fragile cytoplasm []. The ductal epithelial cells of the breast were not seen in the cytology smears. Similar cytomorphologic features were also present in the aspirate from left axillary lymph nodes. A cytological diagnosis of non-Hodgkin lymphoma- large cell type was given. A tru-cut needle biopsy of the breast mass also showed features of non-Hodgkin lymphoma. Her formalin-fixed, paraffin-embedded blocks of the prior lumpectomy specimen was then retrieved from the peripheral laboratory and reviewed. Hematoxylin and eosin (H and E)-stained sections showed replacement of the breast parenchyma by diffuse sheets of monomorphic lymphoid cells []. On higher magnification, the lymphoid cells showed moderate anisokaryosis, clumped nuclear chromatin, prominent nucleoli, and minimal amount of eosinophilic cytoplasm on a background of lymphoglandular bodies []. Lymphoepithelial lesion was characterized by infiltration of lymphoma cells into the sparsely present duct epithelium of the breast []. Immunohistochemical studies were performed on formalin fixed, paraffin-embedded blocks of the lumpectomy specimen. Cytokeratin immunostaining showed strong cytoplasmic reactivity in the duct epithelium while the lymphoma cells stained negative []. In contrast, the lymphoma cells expressed diffuse strong membranous positivity with antibodies against leukocyte common antigen [] and CD 20 [] while negative for CD 15, CD 30, and CD 3. There was no primary elsewhere as evidenced by the absence of hepatosplenomegaly and the absence of any lymph node enlargement other than left axillary lymph nodes. The final diagnosis was primary diffuse large B-cell lymphoma of the breast, stage II. The patient was planned for chemotherapy, her baseline laboratory investigations and ultrasound examination of abdomen was normal. However, further management and follow up of the patient could not be done as she escaped from the hospital against the medical advice.