DOI:10.2214/AJR.04.1789
AJR 2006; 186:1029-1032
© American Roentgen Ray Society
Mammographic, Sonographic, and Pathologic Characteristics of Burkitt's Lymphoma in a Patient Referred for Diagnostic Mammography
Lisa Esserman1,
Russell Sexton1,
Qing Qing Yu2 and
Beria Cabello-Inchausti2
1 Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd., Miami
Beach, FL 33140.
2 Department of Pathology, Mount Sinai Medical Center, Miami Beach, FL
33140.
Received November 18, 2004;
accepted after revision February 1, 2005.
Address correspondence to L. Esserman.
Keywords: breast • lymph nodes • lymphoma • mammography • sonography
Introduction
A 56-year-old woman who presented for diagnostic mammography was found to
have a palpable tender mass in the axillary tail of the right breast.
Pertinent medical history includes HIV seropositivity. Sonographically guided
biopsy revealed Burkitt's lymphoma.
Case Report
A 56-year-old HIV-seropositive woman was referred for mammographic
evaluation of a rapidly enlarging, palpable, and tender mass in the axillary
tail of the right breast. Physical examination revealed a visible right
axillary tail mass with peau d'orange skin changes of the right breast (Figs.
1A and
1B).
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Fig. 1A —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Photographs show mass in inferior axillary region (A) and
peau d'orange changes (B) of breast related to lymphatic
obstruction.
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Fig. 1B —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Photographs show mass in inferior axillary region (A) and
peau d'orange changes (B) of breast related to lymphatic
obstruction.
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Mammography (Figs. 1C and
1D) showed a subtle band of
increased density overlying the pectoralis muscle at the axillary tail. No
calcifications were identified. There were no other mammographic findings.
Sonography (Figs. 1E and
1F) showed a diffuse hypoechoic
mass seen posterior to branching tubular structures, which corresponded to the
mammographic and clinical findings. The branching tubular channels, which
represent dilated lymphatic channels, are seen anterior to the mass. CT
(Fig. 1G) showed involvement of
the right axilla and chest wall.
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Fig. 1C —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Medial lateral oblique mammographic views show asymmetric
increased density (arrows, C) over right pectoralis muscle.
Left medial lateral oblique for comparison (D).
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Fig. 1D —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Medial lateral oblique mammographic views show asymmetric
increased density (arrows, C) over right pectoralis muscle.
Left medial lateral oblique for comparison (D).
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Fig. 1E —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Sonogram shows curvilinear structures representing lymphatic
channels. Ill-defined hypoechoic mass is seen posteriorly. Branching tubular
channels, which represent dilated lymphatic channels, are seen anterior to
mass.
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Fig. 1F —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Sonogram of right axilla shows large ill-defined hypoechoic
mass.
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Fig. 1G —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. CT scan shows soft-tissue mass in right axilla and anterior
chest wall.
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Sonographically guided fine-needle aspiration and core biopsy
(Fig. 1H) specimens were
obtained from the inferior axillary tail. Histology (Figs.
1I,
1J,
1K, and
1L) revealed Burkitt's
lymphoma, which is characterized by a diffuse lymphocytic infiltrate with a
"starry sky" pattern. The cells were medium-sized with slightly
irregular nuclei. The nucleus contained clumped chromatin and multiple
prominent basophilic nucleoli. The tumor showed increased mitoses and numerous
pyknotic nuclei and nuclear fragments, free or engulfed in the actively
phagocytic histiocytes (tingible-body macrophages). A very high growth
fraction was present with nearly 100% of cells positive for labeling with
monoclonal mouse antihuman antibody to Ki-67, a nuclear protein antigen
expressed during mitotic activity.
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Fig. 1H —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Biopsy needle can be seen within hypoechoic lesion on
sonogram.
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Fig. 1I —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Photomicrograph shows diffuse uniform lymphocytic infiltrate
with evenly interspersed tingible-body macrophages resulting in characteristic
"starry sky" pattern. (H and E, x20)
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Fig. 1J —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Photomicrograph of sample from fine-needle aspiration shows
classical appearance of Burkitt's lymphoma cells (arrow): Cells have
round, strongly basophilic nuclei; high nuclear-to-cytoplasmic ratio; deeply
basophilic cytoplasm; and multiple intracytoplasmic lipid vacuoles. (Giemsa
stain, x40)
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Fig. 1K —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. Immunohistochemical stain for Ki-67 antigen shows diffuse and
strong positive reaction. (x20)
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Fig. 1L —56-year-old HIV-seropositive woman was referred for mammographic
evaluation of rapidly enlarging, palpable, and tender mass in axillary tail of
right breast. High-power magnification of core biopsy specimen shows dilated
lymphatic channel.
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Fine-needle aspiration cytology from the right axilla showed cells with
deeply basophilic cytoplasm and round nuclei, high nuclear-to-cytoplasmic
ratio, and multiple intracytoplasmic lipid vacuoles that were negative for
periodic acid-Schiff stain. Multiple dilated lymphatic channels were seen on
the core biopsy specimens.
Discussion
Primary lymphoma of the breast accounts for up to 0.5% of all breast tumors
and 2.2% of extranodal lymphomas
[1]. The association of
increased lymphoma incidence and HIV-seropositive status is well recognized.
Burkitt's lymphoma is thought to be responsible for one third of the 3% of
AIDS-associated lymphomas [2].
Burkitt's lymphoma has been classically divided into African endemic or
American sporadic varieties based on divergent clinical and epidemiologic
characteristics. The African variety is associated with the Epstein-Barr virus
in 90% of cases and commonly occurs where malaria is endemic
[3]. The American variety
shares an association with Epstein-Barr virus in only 20% of cases; is
responsible for 2% of all lymphomas; and tends to occur sporadically, often
presenting as an abdominal tumor
[3].
There is no single imaging finding diagnostic of lymphoma. The mammography
findings of lymphoma are nonspecific but typically include noncalcified single
or multiple mass lesions, which may have variable border characteristics
[4]. The sonographic appearance
is most often that of a solid hypoechoic mass
[4]. In this case, branching
tubular hypoechoic structures are the result of lymphatic obstruction but can
be seen with edema resulting from other causes
[5] (Figs.
1E and
1L).
Fine-needle aspiration in combination with core biopsy is an effective
technique used in the evaluation of breast nodules and axillary lymph nodes.
The core biopsy provides an assessment of lesion architecture. Fine-needle
aspiration delineates morphologic features of the neoplastic cells, which is
especially useful in hematologic malignancies. This case illustrates the
utility of mammography in conjunction with sonographically guided biopsy in
the evaluation of an axillary mass. Success in cytologic characterization of
lymphoma with the use of fine-needle aspiration technique ranges from 80% to
90% in the diagnosis of non-Hodgkin's lymphoma and from 67.5% to 86% in its
subtyping [6]. In this case, a
rapid diagnosis was made by a combination of fine-needle aspiration and core
biopsy, which facilitated appropriate outpatient staging and workup. In this
unusual presentation of Burkitt's lymphoma with typical aggressive
characteristics, expedient diagnosis set the stage for potentially curative
therapy.
References
- Whitfill CH, Feig SA, Webner D. Breast imaging case of the day.
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- Beral V, Peterman T, Berkelman R, Jaffe H. AIDS-associated
non-Hodgkin lymphoma. Lancet 1991;337
: 805-809[CrossRef][Medline]
- Cohen JI. Epstein-Barr virus infection. N Engl J
Med 2000; 343:481
-492[Free Full Text]
- Liberman L, Giess CS, Dershaw DD, Louie DC, Deutch BM. Non-Hodgkin
lymphoma of the breast: imaging characteristics and correlation with
histopathologic findings. Radiology 1994;192
: 157-160[Abstract/Free Full Text]
- Das DK. Value and limitations of fine-needle aspiration cytology in
diagnosis and classification of lymphomas: a review. Diagn
Cytopathol 1999; 21:240
-249[CrossRef][Medline]
- Cardenosa E. Breast imaging companion, 2nd
ed. Philadelphia, PA: Lippincott Williams & Wilkins,2000
: 218-220
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Introduction
Case Report
