Abstract
Abstract 5113
Breast is a rare extranodal site of non-Hodgkin's lymphoma. Traditionally, primary breast lymphoma (PBL) is defined as disease localized to one or both breasts with or without regional lymph nodes involvement (ipsilateral axillary and/or supraclavicular lymph nodes). Recently, there is a suggestion to define breast lymphoma by the number of involved extranodal disease. The commonest histology of PBL is diffuse large B-cell lymphoma (DLBCL). Treatment with CHOP-like regime (cyclophosphamide, doxorubicin, vincristine and prednisolone) in PBL-DLBCL remains unsatisfactory with 5-year progressive free survival rates of approximately 50–65%, which is generally worse than the localized nodal or other extranodal disease. The reason to the poorer outcome might be explained by the genotype. About 80% of the PBL-DLBCL is non-germinal center B-cell or activated B-cell (ABC) subtype, a poorer prognostic genotype compared to germinal center B-cell (GCB) subtype. The data of rituximab (R) overcoming genotypic effect of PBL-DLBCL is still inconclusive. However, the recent matched pair analysis showed similar 3-year overall survival rate to nodal DLBCL if using rituximab and CHOP. Immunoblast morphology appeared to be one of the prognostic factors besides the bulkiness of the disease and the high proliferation index (PI). We present our case series of DLBCL who presented with primary breast swelling from 2009 till June 2012.
All the DLBCL cases diagnosed from 1st January 2009 till 30th June 2012 were filtered for breast involvement from database. Only cases presented with primary breast swelling and biopsy-proved DLBCL breast lesion were studied. Six cases were identified. All are female.
Summary of DLBCL cases presented with primary breast swelling from 1st January 2009 till 30th June 2012 in Ampang Hospital
| No . | Age, ethnic . | Morphology, PI, genotype . | Stage by CT . | IPI . | Extranodal site . | Lymph node >1cm site . | Induction regime . | Response after induction . | Subsequent therapy . | Outcome on 30th June 2012 . | Progression free survival time on 30th June 2012 (month) . | Survival time on 30th June 2012 (month) . |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 47, M | Ki-67 50%, * | IV, A, H, S | 3 | Right breast, liver | Supra & infra-diaphragmatic | R-Block AB x 2.5 pairs | CR by PETCT | R-ICE x2, autologous HSCT with BEAM conditioning | Alive, no relapse | 35.3 | 35.3 |
| 2 | 82, M | * | II, E, A, X | 0 | Left breast | Left axilla | R-CEOP + IT MTX x6 + R1 x1 | Unknown (PR by CT after 4th cycle) | - | Alive, no relapse | 19.7 | 19.7 |
| 3 | 42, M | * | I, E, A, X | 1 | Right breast | nil | R-Block AB x 3 pairs | PR as PET positive (Interim CT- CR) | Failed PBSC mobilization x2, proceeded with DXT | Progressed and died | 12.7 | 14.4 |
| 4 | 30, M | * | II, E, B | 0 | Left breast | Mediastinum | 6R-7CHOP + 4IT MTX | CR by CT | Relapse in mediastinum, DHAP x2, CR by CT, autologous HSCT with BEAM conditioning | Alive, no evidence of relapse | 7.9 | 12 |
| 5 | 34, Filipino | Immunoblast, Ki-67 80%, * | II, E | 1 | Left breast | Left axilla | RCHOP + tripple IT x4 | Unknown as defaulted, relapsed Feb 2011 | Block A & B (breast lesion regressed but disease progressed with biopsy proven skin lesion) RICE (the skin lesion progressed) Autologous HSCT with FLAM conditioning | Died | 6.4 | 16.8 |
| 6 | 35, Chinese | Centroblastic, MIB-1 80%, ABC | II, E, A, X | 1 | Left breast | Left axilla | R-CHOP + IT MTX x6 | Primary refractory (interim CT and US – PR, progressed 3 weeks after last chemotherapy) | Velcade-Block ABC, planning DHAP x2, then autologous HSCT | Alive, no relapse | 5.1 | 8.5 |
| No . | Age, ethnic . | Morphology, PI, genotype . | Stage by CT . | IPI . | Extranodal site . | Lymph node >1cm site . | Induction regime . | Response after induction . | Subsequent therapy . | Outcome on 30th June 2012 . | Progression free survival time on 30th June 2012 (month) . | Survival time on 30th June 2012 (month) . |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 47, M | Ki-67 50%, * | IV, A, H, S | 3 | Right breast, liver | Supra & infra-diaphragmatic | R-Block AB x 2.5 pairs | CR by PETCT | R-ICE x2, autologous HSCT with BEAM conditioning | Alive, no relapse | 35.3 | 35.3 |
| 2 | 82, M | * | II, E, A, X | 0 | Left breast | Left axilla | R-CEOP + IT MTX x6 + R1 x1 | Unknown (PR by CT after 4th cycle) | - | Alive, no relapse | 19.7 | 19.7 |
| 3 | 42, M | * | I, E, A, X | 1 | Right breast | nil | R-Block AB x 3 pairs | PR as PET positive (Interim CT- CR) | Failed PBSC mobilization x2, proceeded with DXT | Progressed and died | 12.7 | 14.4 |
| 4 | 30, M | * | II, E, B | 0 | Left breast | Mediastinum | 6R-7CHOP + 4IT MTX | CR by CT | Relapse in mediastinum, DHAP x2, CR by CT, autologous HSCT with BEAM conditioning | Alive, no evidence of relapse | 7.9 | 12 |
| 5 | 34, Filipino | Immunoblast, Ki-67 80%, * | II, E | 1 | Left breast | Left axilla | RCHOP + tripple IT x4 | Unknown as defaulted, relapsed Feb 2011 | Block A & B (breast lesion regressed but disease progressed with biopsy proven skin lesion) RICE (the skin lesion progressed) Autologous HSCT with FLAM conditioning | Died | 6.4 | 16.8 |
| 6 | 35, Chinese | Centroblastic, MIB-1 80%, ABC | II, E, A, X | 1 | Left breast | Left axilla | R-CHOP + IT MTX x6 | Primary refractory (interim CT and US – PR, progressed 3 weeks after last chemotherapy) | Velcade-Block ABC, planning DHAP x2, then autologous HSCT | Alive, no relapse | 5.1 | 8.5 |
other features are in the process of retrospective analysis
M – Malay
IPI – International Prognostic Index, X – bulky; S – spleen
Block ABC - German Multicenter Acute Lymphoblastic Leukemia 05/93 Protocol; R1 - MTX 500mg/m2 based protocol; CEOP - cyclophosphamide, epirubicin, vincristine and prednisolone; IT – intrathecal; MTX – methotrexate; triple IT – MTX, cytarabine, dexamethasone; ICE – ifosphamide, carboplatin, etoposide; DHAP – cisplatin, cytarabine, dexamethasone; DXT – radiotherapy; HSCT – hematopoietic stem cell transplant; BEAM – carmustine, etopodise, cytarabine, melphalan; FLAM – fludarabine, cytarabine, melphalan, PBSC – peripheral blood stem cell
CT – computerized tomography; PET – positron emission tomography; US – ultrasonography; CR – complete remission; PR – partial remission
Looking at the six cases of primary breast DLBCL, the outcome is poor despite rituximab based chemotherapy. Better chemotherapy regime other than CHOP and agent like bortezomib and upfront autologous HSCT should be explored.
No relevant conflicts of interest to declare.
Author notes
Asterisk with author names denotes non-ASH members.
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