AJR 2005; 185:199-202
© American Roentgen Ray Society
MRI Features of Mucosa-Associated Lymphoid Tissue Lymphoma in the Breast
Leandro A. Espinosa1,
Bruce L. Daniel2,
Stefanie S. Jeffrey3,
Kent W. Nowels4 and
Debra M. Ikeda1
1 Department of Radiology, University of Michigan, Ann Arbor, MI.
2 Department of Radiology, Stanford University, 300 Pasteur Dr. H1307, MC5621,
Stanford, CA 94305.
3 Department of Surgery, Stanford University, Stanford, CA.
4 Department of Pathology, Stanford University, Stanford, CA.
Received December 3, 2003;
accepted after revision September 9, 2004.
Address correspondence to B. L. Daniel
(bdaniel{at}stanford.edu).
Supported by NIH grant CA66785.
Introduction
Extranodal marginal zone B-cell lymphoma of mucosa-associated
lymphoid tissue, or MALT lymphoma, is a non-Hodgkin's lymphoma associated with
chronic inflammation. It typically occurs in the gastric mucosa or the thyroid
parenchyma, and is rarely reported in the breast
[1]. Histologically, MALT
lymphoma is characterized by heterogeneous small B-cells infiltrating the
marginal zone of reactive lymphoid follicles and extending into epithelial
tissues. Although usually indolent, this tumor can be locally aggressive and
is treated with local radiation therapy and/or systemic chemotherapy
[2]. Breast lymphomas may
present as a palpable breast lump or as an irregular solitary mass discovered
during a screening mammogram
[3]. A few case reports have
described the MRI appearance of primary breast non-Hodgkin's lymphoma, but
none to our knowledge have described MALT lymphoma
[4,
5]. In this report, we present
the MRI findings of MALT lymphoma arising in the breast.
Case Report
A 56-year-old woman with a strong family history of breast cancer enrolled
in a clinical trial at our institution to evaluate the use of MRI for
breast-cancer screening. Bilateral breast MRI examinations showed multiple
nonspecific foci on contrast enhancement. Subsequent bilateral mammograms and
left breast sonogram confirmed a hypoechoic oval 1.0-cm mass in the lower
inner left breast possibly corresponding to one of the MRI findings, but did
not detect the other lesions. Based on the imaging findings and the patient's
high risk for breast cancer, biopsy of a representative lesion was
recommended. Given that an upper inner left breast lesion had the most
worrisome MRI appearance (i.e., it was minimally spiculated) the patient
underwent MRI-guided needle localized sampling of this lesion.
H and E-stained sections from the lesion showed a patchy lymphoid
infiltrate composed of small to medium lymphocytes with slightly irregular
nuclear outlines. On immunohistochemistry, these cells were CD20 positive, CD3
negative, and CD43 negative, consistent with MALT lymphoma.
Subsequent staging, including CT scans, bone-marrow biopsy, and gallium
scan were negative. Since breast MALT lymphomas are frequently indolent and no
signs of extra-mammary disease were seen, the patient decided on short-term
follow-up as a treatment option. Five months after the original MRI scans,
repeat bilateral MRI revealed interval progression of right breast lesions.
The patient underwent MRI-guided wire localization and biopsy of the largest
right breast lesion. H and E stains showed a similar lymphocytic infiltrate
invading germinal centers as seen in the previous left breast biopsy,
consistent with MALT lymphoma.
The patient decided on a treatment option of bilateral breast irradiation
with 3,600 cGy. The patient did not have surgery or chemotherapy.
Contrast-enhanced bilateral breast MRI after radiation showed complete
resolution of the previous foci of enhancement and no evidence of residual
disease or recurrence.
MRI Technique
Images were obtained on the EchoSpeed 1.5-T scanner (GE Healthcare) using a
phased-array breast coil (MRI Devices). The sequences obtained included axial
T1 large field of view (using a body coil); sagittal T2 fast spin-echo with
chemical fat saturation; high-resolution 3D spectral-spatial excitation
spoiled gradient echo with magnetization transfer (3DSSMT) before and after
contrast enhancement; and T1 3D spoiled gradient echo spiral dynamic MRI every
10.6 sec, with water-selective spectral-spatial excitation repeated 20 times
during the wash-in phase and 26 times during the wash-out phase of
enhancement, as described in Agoston et al.
[6]. Forty seconds after the
start of the wash-in dynamic series, 0.1 mmol/kg of gadopentetate dimeglumine
(Magnevist, Berlex) was injected as a bolus at 2.5 mL/sec via an antecubital
vein through a power injector, followed by a saline flush.
View larger version (151K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. Sagittal T2-weighted fast spin-echo fat-suppressed MR image
of right breast; (TR/TE 4,000/98, slice thickness 3 mm, slice spacing 3 mm;
field of view 20 cm, acquisition matrix 256 x 192) shows ovoid 1.6
x 0.7 cm lesion (arrow) in upper breast, with slightly higher
signal intensity than adjacent glandular tissue (A). Contrast-enhanced
water-specific 3D gradient-echo image (centric 3D spectral-spatial excitation
spoiled gradient echo with magnetization transfer [3DSSMT] after 0.1 mmol/kg
IV of gadopentetate dimeglumine, TR/TE 31.3/8.73, slice thickness 1.5 mm,
field of view 20 cm, matrix 512 x 192) revealed multiple foci of
contrast enhancement, largest being 1.6 x 0.7 cm in upper outer quadrant
(arrow) (B) that had increased in size and number since
previous study 5 months earlier (not shown). Time signal-intensity curves from
dynamic 3D spiral MRI (scans repeated every 10.6 sec; see reference
[6] for scan parameter details)
performed during initial contrast enhancement ("wash-in" phase)
and after high-resolution 3DSSMT ("wash-out" phase) revealed rapid
initial enhancement during wash-in phase followed by gradual enhancement
during wash-out phase (C). MRI localized biopsy of upper breast lesion
revealed dense lymphoid infiltrate composed of monomorphous small lymphocytes
involving breast parenchyma and surrounding benign breast ducts (D) (H
and E stain x100). Histologic findings were same as MRI-guided biopsy of
initial left breast lesion (not shown).
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. Sagittal T2-weighted fast spin-echo fat-suppressed MR image
of right breast; (TR/TE 4,000/98, slice thickness 3 mm, slice spacing 3 mm;
field of view 20 cm, acquisition matrix 256 x 192) shows ovoid 1.6
x 0.7 cm lesion (arrow) in upper breast, with slightly higher
signal intensity than adjacent glandular tissue (A). Contrast-enhanced
water-specific 3D gradient-echo image (centric 3D spectral-spatial excitation
spoiled gradient echo with magnetization transfer [3DSSMT] after 0.1 mmol/kg
IV of gadopentetate dimeglumine, TR/TE 31.3/8.73, slice thickness 1.5 mm,
field of view 20 cm, matrix 512 x 192) revealed multiple foci of
contrast enhancement, largest being 1.6 x 0.7 cm in upper outer quadrant
(arrow) (B) that had increased in size and number since
previous study 5 months earlier (not shown). Time signal-intensity curves from
dynamic 3D spiral MRI (scans repeated every 10.6 sec; see reference
[6] for scan parameter details)
performed during initial contrast enhancement ("wash-in" phase)
and after high-resolution 3DSSMT ("wash-out" phase) revealed rapid
initial enhancement during wash-in phase followed by gradual enhancement
during wash-out phase (C). MRI localized biopsy of upper breast lesion
revealed dense lymphoid infiltrate composed of monomorphous small lymphocytes
involving breast parenchyma and surrounding benign breast ducts (D) (H
and E stain x100). Histologic findings were same as MRI-guided biopsy of
initial left breast lesion (not shown).
|
|
View larger version (14K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. Sagittal T2-weighted fast spin-echo fat-suppressed MR image
of right breast; (TR/TE 4,000/98, slice thickness 3 mm, slice spacing 3 mm;
field of view 20 cm, acquisition matrix 256 x 192) shows ovoid 1.6
x 0.7 cm lesion (arrow) in upper breast, with slightly higher
signal intensity than adjacent glandular tissue (A). Contrast-enhanced
water-specific 3D gradient-echo image (centric 3D spectral-spatial excitation
spoiled gradient echo with magnetization transfer [3DSSMT] after 0.1 mmol/kg
IV of gadopentetate dimeglumine, TR/TE 31.3/8.73, slice thickness 1.5 mm,
field of view 20 cm, matrix 512 x 192) revealed multiple foci of
contrast enhancement, largest being 1.6 x 0.7 cm in upper outer quadrant
(arrow) (B) that had increased in size and number since
previous study 5 months earlier (not shown). Time signal-intensity curves from
dynamic 3D spiral MRI (scans repeated every 10.6 sec; see reference
[6] for scan parameter details)
performed during initial contrast enhancement ("wash-in" phase)
and after high-resolution 3DSSMT ("wash-out" phase) revealed rapid
initial enhancement during wash-in phase followed by gradual enhancement
during wash-out phase (C). MRI localized biopsy of upper breast lesion
revealed dense lymphoid infiltrate composed of monomorphous small lymphocytes
involving breast parenchyma and surrounding benign breast ducts (D) (H
and E stain x100). Histologic findings were same as MRI-guided biopsy of
initial left breast lesion (not shown).
|
|
View larger version (187K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. Sagittal T2-weighted fast spin-echo fat-suppressed MR image
of right breast; (TR/TE 4,000/98, slice thickness 3 mm, slice spacing 3 mm;
field of view 20 cm, acquisition matrix 256 x 192) shows ovoid 1.6
x 0.7 cm lesion (arrow) in upper breast, with slightly higher
signal intensity than adjacent glandular tissue (A). Contrast-enhanced
water-specific 3D gradient-echo image (centric 3D spectral-spatial excitation
spoiled gradient echo with magnetization transfer [3DSSMT] after 0.1 mmol/kg
IV of gadopentetate dimeglumine, TR/TE 31.3/8.73, slice thickness 1.5 mm,
field of view 20 cm, matrix 512 x 192) revealed multiple foci of
contrast enhancement, largest being 1.6 x 0.7 cm in upper outer quadrant
(arrow) (B) that had increased in size and number since
previous study 5 months earlier (not shown). Time signal-intensity curves from
dynamic 3D spiral MRI (scans repeated every 10.6 sec; see reference
[6] for scan parameter details)
performed during initial contrast enhancement ("wash-in" phase)
and after high-resolution 3DSSMT ("wash-out" phase) revealed rapid
initial enhancement during wash-in phase followed by gradual enhancement
during wash-out phase (C). MRI localized biopsy of upper breast lesion
revealed dense lymphoid infiltrate composed of monomorphous small lymphocytes
involving breast parenchyma and surrounding benign breast ducts (D) (H
and E stain x100). Histologic findings were same as MRI-guided biopsy of
initial left breast lesion (not shown).
|
|
View larger version (175K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. MR images show response of MALT lymphoma to whole breast
irradiation. Initial contrast-enhanced 3D spectral-spatial excitation spoiled
gradient-echo with magnetization transfer (3DSSMT) MR image of left breast
(E) shows focal enhancement in the lower breast (arrow). No
significant areas of contrast enhancement are seen in left breast on 3DSSMT MR
image performed after whole-breast irradiation, with normal nonenhancing
breast parenchyma noted in region of previous abnormal enhancement (F,
arrow).
|
|
View larger version (193K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F —56-year-old woman presenting with a typical region of MALT
lymphoma on MRI. MR images show response of MALT lymphoma to whole breast
irradiation. Initial contrast-enhanced 3D spectral-spatial excitation spoiled
gradient-echo with magnetization transfer (3DSSMT) MR image of left breast
(E) shows focal enhancement in the lower breast (arrow). No
significant areas of contrast enhancement are seen in left breast on 3DSSMT MR
image performed after whole-breast irradiation, with normal nonenhancing
breast parenchyma noted in region of previous abnormal enhancement (F,
arrow).
|
|
Imaging Findings
The morphology of the abnormal areas of contrast enhancement on MRI was
nonspecific. All had slightly irregular borders (Figs.
1A and
1B), except for the slightly
spiculated left breast lesion that prompted the initial biopsy. No suspicious
architectural features were seen, such as rim enhancement, enhancing
septations, or skin thickening, nor were specifically benign features such as
nonenhancing septations seen. Fat-saturated T2-weighted precontrast images of
the lesions showed slightly higher signal intensity than surrounding glandular
tissue, but not high enough to suggest a benign cause. On dynamic imaging, all
foci of enhancement showed rapid initial enhancement during the wash-in phase
followed by gradual sustained enhancement during the wash-out phase
(Fig. 1C), a pattern that was
not specific for malignancy. The typical microscopic appearance of the lesions
with standard H and E staining is shown in
Figure 1D. MRI images performed
before and after bilateral whole breast irradiation showed complete resolution
of all areas of abnormal contrast enhancement after treatment (Figs.
1E and
1F).
Discussion
The incidence of primary breast lymphoma is less than 0.6% of all breast
malignancies [4]. Among the
types of breast lymphomas, MALT lymphomas constitute a variable subgroup with
frequencies ranging from 0% to 44% in the literature
[2]. The 5-year survival rate
for all primary breast lymphoma is 70% and the relapse-free rate is 42%
[7]. MALT lymphomas tend to be
indolent and have a good prognosis
[2]. On mammography, primary
breast lymphomas are reported as a unilateral diffuse involvement (25%),
bilateral diffuse involvement (8.3%), or masses (solitary, 58%; multiple
unilateral masses, 8.3%), with irregular (50%), partially defined (37.5%), or
well-defined borders [3]. They
are usually mistaken for primary breast cancers since primary breast lymphomas
are rare.
Using contrast-enhanced breast MRI, Darnell et al.
[4] described a 6.0-cm
well-circum-scribed non-Hodgkin's lymphoma in the outer upper breast, which
was hyperintense on T2 images, isointense on T1 images, and showed a strong
and rapid enhancement, reaching four-fifths of its peak enhancement within 3
minutes of contrast injection on 3D dynamic images
[4]. Demirkazik
[5] describes the MRI findings
of recurrent breast lymphoma after local excision and chemotherapy showing
multiple well-defined rapidly enhancing, hypointense (T1-weighted) masses, the
largest being 2.0 x 1.0 cm, consistent with findings on mammography and
sonography. Stoutjesdijk et al.
[8] describe a case series
comparing MRI with mammography for detecting early cancer in women with a
hereditary risk for breast cancer. Among the subjects, one patient with MALT
lymphoma was detected with MRI but not with mammography. The authors do not
comment on the extent or MRI features of this lesion.
Our case report is the first to our knowledge to describe the breast MRI
features of bilateral breast MALT lymphoma at primary diagnosis, progression,
and after treatment. In our case, primary breast MALT lymphoma presented as
nonspecific irregular enhancing foci on 3DSSMT postcontrast images, isointense
on T1-weighted images, and hyperintense on T2-weighted images. The lesions
displayed a relatively brisk initial enhancement during the wash-in phase of
dynamic imaging, an enhancement pattern similar to that described in previous
case reports of non-MALT-type lymphomas
[4,
5]. However, in our case, the
extent of breast abnormality and the presence of extensive bilateral disease
were clearly shown by MRI, while only a single lesion in one breast was seen
by sonography and mammography. When comparing therapy MRI scans before and
after irradiation, complete resolution of the lower inner quadrant focus of
lymphoma occurred. Given these findings, MRI may be useful to detect and stage
multifocal breast MALT lymphoma that might be underrepresented on mammography
and sonography. Moreover, MRI may be useful to monitor the progression of the
MALT lymphoma and its response to irradiation or chemotherapy.
In our case, the diagnosis was established by preoperative needle
localization and surgical excision biopsy. Given advances in MRI-guided core
biopsy, it is possible that future diagnoses of lymphoma may be established by
this method rather than surgery.
Acknowledgments
The authors thank Daniel Margolis for his assistance in the preparation of
the figures.
References
- Lamovec J, Jancar J. Primary malignant lymphoma of the breast:
lymphoma of the mucosa-associated lymphoid tissue.
Cancer 1987;60:3033
-3041[CrossRef][Medline]
- Brogi E, Harris NL. Lymphomas of the breast: pathology and clinical
behavior. Semin Oncol1999; 26:357
-364[Medline]
- Sabate JM, Gomez A, Torrubia S, et al. Lymphoma of the breast:
clinical and radiologic features with pathologic correlation in 28 patients.
Breast J 2002;8:294
-304[CrossRef][Medline]
- Darnell A, Gallardo X, Sentis M, Castaner E, Fernandez E, Villajos
M. Primary lymphoma of the breast: MR imaging features—a case report.
Magn Reson Imaging1999; 17:479
-482[CrossRef][Medline]
- Demirkazik FB. Case report: MR imaging features of breast lymphoma.
Eur J Radiol2002; 42:62
-64[CrossRef][Medline]
- Agoston AT, Daniel BL, Herfkens RJ, et al. Intensity-modulated
parametric mapping for simultaneous display of rapid dynamic and
high-spatial-resolution breast MR imaging data.
RadioGraphics2001; 21:217
-226[Abstract/Free Full Text]
- Wong WW, Schild SE, Halyard MY, Schomberg PJ. Primary non-Hodgkin
lymphoma of the breast: the Mayo Clinic experience. J Surg
Oncol 2002;80:19
-25[CrossRef][Medline]
- Stoutjesdijk MJ, Boetes C, Jager GJ, et al. Magnetic resonance
imaging and mammography in women with a hereditary risk of breast cancer.
J Natl Cancer Inst2001; 93:1754
-1755[Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
O. Maksimovic, W. A. Bethge, J. P. Pintoffl, M. Vogel, C. D. Claussen, R. Bares, and M. Horger
Marginal Zone B-Cell Non-Hodgkin's Lymphoma of Mucosa-Associated Lymphoid Tissue Type: Imaging Findings
Am. J. Roentgenol.,
September 1, 2008;
191(3):
921 - 930.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Report
