AJR 2001; 177:177-178
© American Roentgen Ray Society
Primary Breast Lymphoma Originating in a Benign Intramammary Lymph Node
Justin R. Zack1,2,
Susan G. Trevisan1 and
Monali Gupta1
1
Department of Radiology, North Shore University Hospital, 300 Community Dr.,
Manhasset, NY 11030.
2
Present address: Division of Cardiovascular and Interventional Radiology, The
University of Texas Health Science Center, 7703 Floyd Curl Dr., San Antonio,
TX 78229.
Received October 27, 2000;
accepted after revision January 3, 2001.
Address correspondence to J. R. Zack.
Introduction
Primary breast lymphoma is rare and constitutes less than 0.6% of all
breast malignancies. Most breast lymphomas are the non-Hodgkin's type, which
represent approximately 70-90%
[1]. In patients diagnosed with
non-Hodgkin's lymphoma, primary involvement of the breast is seen in 0.4-0.7%
of the cases. The development of lymphoma within a previously diagnosed benign
intramammary lymph node has, to our knowledge, not been previously reported.
The following is a case report of primary breast lymphoma that developed
within a previously benign-appearing intramammary lymph node.
Case Report
A 76-year-old woman with a medical history of endometrial cancer, a family
history significant for breast cancer, and no history of lymphoma presented
for a yearly mammogram. A physical examination revealed a palpable abnormality
in the left upper outer breast. Mammography showed a well-circumscribed dense
mass measuring 1.4 cm in the upper outer quadrant of the left breast, which
corresponded to the area of palpable abnormality. The mass was found to
originate at the site of a previously identified, mammographically benign
lymph node. A previous left craniocaudal mammogram
(Fig. 1A), obtained October 4,
1996, showed a well-circumscribed oval mass with a radiolucent center
representing an intra-mammary lymph node. A left mediolateral oblique
mammogram further defined the benign intramammary lymph node
(Fig. 1B). The most recent left
craniocaudal mammogram, dated January 14, 1998, revealed a 1.4-cm dense mass
(Fig. 1C). The mediolateral
oblique image obtained the same day depicted similar findings
(Fig. 1D). The lymph node had
increased in size and density when compared with the 1996 mammogram (Figs.
1A and
1B).
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Fig. 1A. —76-year-old woman with history of endometrial cancer, family
history significant for breast cancer, and no history of lymphoma. Left
craniocaudal mammogram that was obtained October 4, 1996, shows benign lymph
node in lateral aspect of breast (arrow).
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Fig. 1B. —76-year-old woman with history of endometrial cancer, family
history significant for breast cancer, and no history of lymphoma.
Mediolateral oblique mammogram that was obtained same day as A further
shows benign intramammary lymph node (arrow).
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Fig. 1C. —76-year-old woman with history of endometrial cancer, family
history significant for breast cancer, and no history of lymphoma. Left
craniocaudal mammogram that was obtained January 14, 1998, shows mass
(arrow) in region of previously recognized benign intramammary lymph
node shown in B. BB pellet was placed over area of palpable
abnormality.
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Fig. 1D. —76-year-old woman with history of endometrial cancer, family
history significant for breast cancer, and no history of lymphoma.
Mediolateral oblique mammogram that was obtained same day as C shows
nodular density (arrow) in region of previously identified benign
lymph node shown in B. BB pellet was placed over palpable mass.
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A sonogram of the left breast was subsequently obtained in the region of
the mass and revealed a well-circumscribed hypoechoic lesion with a
hyperechoic center and a surrounding irregular hyperechoic rim
(Fig. 1E). The lesion measured
1.0 x 0.7 x 1.1 cm. A biopsy was recommended because the lymph
node had increased in size and density, become a palpable abnormality, had
lost its radiolucent center on mammography, and because sonographic findings
were suggestive of tumor infiltrating a lymph node. Pathology revealed
non-Hodgkin's lymphoma, follicular B-cell type.
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Fig. 1E. —76-year-old woman with history of endometrial cancer, family
history significant for breast cancer, and no history of lymphoma. Sonogram of
palpable mass in left breast. Lesion shows central hyperechogenicity
surrounded by well-circumscribed hypoechoic region, which is further
surrounded by irregular hyperechoic rim (arrow).
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Discussion
Histologically, primary breast lymphoma is predominately of B-cell origin
and most commonly large cell type
[2]. Numerous authors have
found that lymphoma occurs more frequently in the right breast and that the
rate of secondary lymphoma metastatic to the breast only slightly exceeds
primary breast involvement [2,
3].
Clinically, primary breast lymphoma most commonly presents as a solitary
palpable mass. Less common presentations include unilateral or bilateral
diffuse breast enlargement. The most frequent radiographic appearance of
breast lymphoma is as a well-circumscribed mass without associated
calcification. Other radiographic patterns include the following: multiple
amorphous or poorly circumscribed noncalcified masses; diffusely increased
parenchymal density with or without skin thickening; spiculated masses; or,
rarely, miliary densities on mammography
[3,4,5,6].
Because the radiographic features of breast lymphoma are nonspecific, the
diagnosis of primary breast lymphoma cannot be determined on the basis of
mammographic findings alone. Lesions such as primary breast cancer,
fibroadenoma, phyllodes tumor, and metastatic disease must be included in the
list of differential diagnoses.
Intramammary lymph nodes are often encountered in routine mammography.
Benign intramammary lymph nodes are characterized by their well-circumscribed
borders, lobulation, and central radiolucency, which represents fatty
replacement. Intramammary nodes are considered abnormal if they have become
enlarged, lost their well-defined borders, increased in density, or lost their
fatty hilum. These features are encountered in both benign and malignant
processes. The differential diagnosis of an abnormal intramammary lymph node
includes inflammation, infection, and neoplasia. More specific conditions
include dermatitis, psoriasis, lymphadenitis, sarcoidosis, lymphoma, HIV, and
metastatic disease [7].
Sonographically, breast lymphoma lesions are commonly hypoechoic and may be
so significantly hypoechoic that they can be mistaken for simple cysts if
careful technique is not used. Biopsy is necessary to establish a diagnosis.
Treatment regimens for primary breast lymphoma may include surgery, radiation
therapy, and chemotherapy [8].
Mammography can be used to monitor a patient's response to therapy.
Although primary or secondary lymphoma of the breast represents an uncommon
diagnosis in the spectrum of breast disease, it should be considered in the
list of differential diagnoses when an enlarged intramammary lymph node is
encountered.
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Introduction
Case Report
