- Email: [email protected]
Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy
ARTICLE IN PRESS The Breast (2005) 14, 51–56
THE
BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy J. Coxa,, L. Luntb, L. McLeanc a
University Hospital North Durham, Durham, UK Breast Screening Unit, Gateshead NE9 6SX, UK c Breast Screening Unit, Newcastle upon Tyne NE1 4LP, UK b
Received 30 June 2004; received in revised form 27 September 2004; accepted 13 October 2004
KEYWORDS Breast; Lymphoma
Summary We have reviewed imaging findings of 32 female patients with a proven haematological malignancy in the breast and axilla presenting to two breast units over a 13-year period. Nineteen patients had screen-detected lesions, and 13 presented to symptomatic services. The most common histological diagnosis was of non-Hogdkins lymphoma. Of the 12 patients who presented with disease in the breast, six (all with primary breast lymphoma) presented with a well-defined mass on mammography. The range of radiological appearances is, however, highly variable. & 2004 Elsevier Ltd. All rights reserved.
Introduction Haematological malignancies are rare entities in the breast, accounting for less than 1% of all patients with breast neoplasms. Lymphomatous involvement of breast may occur as a primary disease or as secondary phenomenon with infiltration of breast parenchyma by systemic disease either at the time of diagnosis or as disease recurrence. The radiological features are highly variable and non-specific, but the most common
presentation is of one or several mass lesions, usually without calcification.1 This unusual condition is of some importance because it remains treatable, even carrying a good prognosis even when disseminated. The purpose of this study is to review the imaging features of primary and secondary haematological malignancy in the breast and axilla, and demonstrate the spectrum of appearances.
Materials and methods Corresponding author. Department of Radiology, University Hospital North Durham, North Rd, Durham DH1 5TW, UK. Tel.: +44 1913332491. E-mail address: [email protected] (J. Cox).
A retrospective review of the imaging archive of the Breast Screening and Symptomatic Units at the Royal Victoria Infirmary, Newcastle upon Tyne, and
0960-9776/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2004.10.001
ARTICLE IN PRESS 52
J. Cox et al.
the Queen Elizabeth Hospital, Gateshead yielded 32 female patients with a proven haematological malignancy in the breast and axilla presenting over a 13-year period (January 1990–July 2003). In this period, there were over 500,000 screening episodes, and approximately 3000 screen detected and 6000 symptomatic breast carcinomas diagnosed between the two breast units. The NHS Breast Screening Programme invited women between the ages of 49 and 64 to attend for three yearly screening mammography and some older women chose to self-refer. Women of all ages attended symptomatic breast clinics.
Results Thirty-two female patients with haematological malignancy within the breast and axilla had presented to two breast units over a 13-year period from 1990 to 2003. The age range was from 45 to 75 years. Nineteen patients presented with screen-detected lesions, six of whom had disease within the breast and 13 of whom presented with screendetected axillary lymphadenopathy. Thirteen symptomatic patients presented, seven with axillary lymphadenopathy, and six with disease in the breast. The imaging appearances of the 12 breast lesions are described in detail in Tables 1 and 2. Eight cases were classified as primary breast lymphoma (PBL). All presented as solitary lesions and of these, six lesions were described as a welldefined mass mammographically. In four of the eight patients with PBL, axillary lymphadenopathy
Table 1
Primary Secondary
Table 2
Discussion PBL accounts for 1–5 cases per 1000 breast malignancies.1–5 Our study broadly confirms these results with 3.5 haematological malignancies for every 1000 carcinomas in our series. Overall, there were six cases of
Table 3
Histology of axillary lymphadenopathy.
Non Hodgkin’s Lymphoma Small cell lymphoma/CLL Mantle cell lymphoma Hodgkin’s disease Total
16 2 1 1 20
Mammographic appearance of haematological malignancy in the breast. Well-defined mass
Asymmetric density
Multiple lesions
Ill defined mass
Presence of axillary lymphadenopathy
Total
6 0
2 0
0 3
0 1
4 2
8 4
Ultrasonic appearance of haematological malignancy in the breast. Echogenicity
Primary Secondary
was demonstrated on mammography. Four cases of secondary haematological malignancy were imaged (including one case of disseminated multiple myeloma). Three of these four patients presented with multiple lesions. The range of ultrasonic appearances of primary and secondary breast lymphoma is described in Table 2. Non-Hodgkin’s lymphoma proved to be by far the most common histological diagnosis, in 11 of the 12 breast lesions in our series. Twenty patients presented with axillary lymphadenopathy, either bilateral or unilateral, of which 13 cases were detected by breast screening. As is documented in Table 3, NHL is also by far the most frequent histological diagnosis from the axillary nodes.
Margin
No Ultrasound
Hypoechoic
Mixed
Well defined
Ill defined
Diffuse
4 1
2 3
4 1
1 2
1 1
2 0
ARTICLE IN PRESS Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy screen-detected haematological malignancy to every 1000 cases of screen-detected carcinoma, and two cases of symptomatic haematological malignancy per 1000 cases of symptomatic carcinoma. The much higher proportion of this rare disease detected in the screening population is a new finding, and has not previously been documented. The ratio of primary breast lymphoma to primary breast carcinoma is extremely low although our results indicate it may be more common than was previously thought. Other series have been composed of only symptomatic women, while our study includes both screen-detected lesions and symptomatic malignancies, which may explain our results. The majority of primary breast lymphomas are of the non-Hodgkin’s B cell type, and the most common is diffuse large cell lymphoma (40–70%). Primary breast lymphoma is slightly more common than secondary breast lymphoma, accounting for one-half to two-thirds of patients in a previously reported series. It is predominantly a disease of middle and old age with greatest frequency in the sixth decade, a demographic pattern also confirmed in our series.1–5 There are few reported series of the radiological features of lymphoma in the breast. In the largest reported series of 32 cases of primary and secondary breast lymphoma, twenty two patients (69%) had a solitary non-calcified mass on mammography, with multiple non-calcified masses in three patients, and diffuse opacification with skin thickening in another three patients symptoms were present in 29 of the 31 patients in this study.2 In another series of 12 patients3, all with primary breast lymphoma showed a solitary, round or oval homogeneously dense non-calcified soft tissue mass on mammography. Features seen in carcinoma of the breast such as calcification, spiculation, and
53
parenchymal distortion are distinctively absent in lymphoma. Indeed, primary breast lymphomas can present as a well-defined mass on mammography, mimicking a benign breast lesion (Figs. 1 and 2). Lymphoma is the most common cause of metastases within the breast, representing 17% of breast metastases.4 Cases of secondary breast malignancy can present as multiple circumscribed nodules (Fig. 3), multiple vague densities, as well as multiple miliary densities (Fig. 4) on mammography.5,6 In our series, a multiple lesions of varying sizes are observed in three of the four with secondary breast disease, with an ill-defined mass present on mammography in the other patient. Two of the four patients with secondary breast lymphoma had axillary lymphadenpathy on imaging (Fig. 5). The most common ultrasound appearance of lymphoma within the breast is a hypo echoic homogenous or heterogenous well-defined mass (Fig. 6).1 This appearance is however non-specific and may be found in other malignant and benign lesions. A series of two cases of breast lymphoma presented with ultrasound appearances of an elongated, complex, superficial, ‘‘pseudocystic serpentine’’ mass has been described (Fig. 7).7 Other less common sonographic features include skin thickening and lymphatic dilatation.1 As demonstrated in Table 3, the patients in our study with breast lymphoma demonstrated a wide range of ultrasonic appearances, none of which was specific for the condition (Tables 4 and 5). Two case reports describe the MR appearances of primary breast lymphoma; each showed different features. In a case report from 19978, two illdefined, non-spiculated, hypo intense were demonstrated masses on T1 weighted images, with rapid enhancement of both after intravenous contrast. In
Figure 1 73 year old woman presented with a rapidly growing lump on the upper outer quadrant of the right breast. Mammograms [(a)–(d)] demonstrated a well defined 4 cm mass in the upper outer quadrant of her right breast. The lesion was solid and hypoechoic on ultrasound. FNA was suggestive of a lymphoma and excision biopsy confirmed Non Hodgkin’s B cell lymphoma.
ARTICLE IN PRESS 54
J. Cox et al.
Figure 2 59 year old woman presented in 1990 with a rapidly growing lump in her right breast. Mammography [(a)–(c)] was performed and revealed a well defined mass in the right upper outer quadrant. FNA of the lesion was suggestive of lymphoma, and excision biopsy revealed a high grade lymphoma. Bone marrow metastases were found at presentation, making her stage IVa. She was treated with chemotherapy. In 1995, she noticed a lump in her left breast. Mammography [(d)–(g)] then revealed an asymmetric density in the left upper outer quadrant, which was excised and found to be recurrent lymphoma. Treatment with chemotherapy and radiotherapy was given. She is still alive with no evidence of recurrent disease.
Figure 3 69 year old woman with known disseminated multiple myeloma presented with multiple small lumps in both breasts. Symptomatic mammograms [(a) revealed muliple discrete mass lesions in both breasts, hypoechoic and solid on ultrasound. FNA of a lesion was compatible with multiple myeloma.
Figure 4 63 year old woman recalled to assessment in 1999 after screening mammograms [(a)–(d)] revealed multiple ill defined densities in both breasts. At assessment, the patient gave a history of disseminated NHL, for which she was undergoing treatment. FNA of a breast lesions was consistent with a lymphomatous infiltrate.
the latter case report9, a well-circumscribed hyperintense mass was evident on T2 weighted images, isointense on T1 weighted images, also
with rapid post-contrast enhancement. In both cases, therefore, MR findings were consistent with a breast neoplasm, with no specific features.
ARTICLE IN PRESS Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy
55
Figure 5 59 year old woman was recalled for assessment because screening MLO mammograms (a) and (b) in 1993 showed bilateral axillary lymphadenopathy. Excision biopsy of a lymph node revealed small cell lymphoma/CLL. Screening mammograms (c) and (d) performed in 1996 show a decrease in the size and density of the nodes with treatment. The patient was then in remission.
Table 4
Histology of breast lesions.
Non-Hodgkin’s lymphoma (primary) Non-Hodgkin’s lymphoma (secondary) Multiple myeloma Total
Table 5
Figure 6 Primary breast lymphoma presenting as a well defined solid hypoechoic mass on ultrasound.
Figure 7 Primary breast lymphoma presenting as a more unusual serpentine ‘‘pseudocystic’’ mass on ultrasound.
The detection of occult lymphoma in the axilla by screening mammography is not a topic, which has been directly addressed previously. Normal axillary lymph nodes are a frequent finding on up to 50% of breast screening mammograms. A retrospective
8 3 1 12
Histology of axillary lymphadenopathy.
Non-Hodgkin’s lymphoma Small cell lymphoma/CLL Mantle cell lymphoma Hodgkin’s disease Total
16 2 1 1 20
study10 has analysed the incidence and causes of pathological axillary lymphadenopathy detected by screening mammography. In a review of over 95,000 screening mammograms, 37 cases of pathological axillary lymphadenopathy were identified. Eleven of this showed evidence of malignancy and six of these were non-Hodgkin’s lymphoma. Screen-detected axillary lymph nodes derived from a smaller study population of 23707 women yielded nine cases of pathological axillary lymphadenopathy alone. Five were malignant and two of the malignancies were NHL. As the authors state, this incidence of lymphoma of 0.1 per 1000 women screened compared with an expected incidence of 0.3 per women in the age group 50–64, represents a substantial proportion of the lymphomas detected in this age group.11 Our study confirms these finding.
ARTICLE IN PRESS 56 In conclusion, primary breast lymphoma and NHL in axillary lymph nodes may be detected on mammography. Our study demonstrates that more breast and axillary haematological malignancy is detected through breast screening, while asymptomatic, than is currently presenting to symptomatic breast services.
References 1. Yang WT, Muttarak M, Ho LWC. Nonmammary malignancies of the breast: ultrasound, CT, and MRI. Semin Ultrasound, CT and MRI 2000;21(5):375–94. 2. Lieberman L, Gless CS, Dershaw DD, et al. Non-Hodgkin lymphoma of the breast: imaging characteristics and correlation with histopathologic findings. Radiology 1999;192:157–60. 3. Meyer JE, Kopans DB, Long JC. Mammographic appearance of malignant lymphoma of the breast. Radiology 1980;135:623–6.
J. Cox et al. 4. Bartella L, Kaye J, Perry NM, et al. Metastases to the breast revisited: radiological–histopathological correlation. Clin Radiol 2003;58:524–31. 5. Pameijer FA, Beijerinck D, Hoogenboon HH, et al. NonHodgkin’s lymphoma of the breast causing miliary densities on mammography. AJR 1995;164:609–10. 6. Slanetz PJ, Whitman GJ. Non-Hodgkin’s lymphoma of the breast causing multiple vague densities on mammography. AJR 1998;167:537–8. 7. Gal-Gombos EC, Esserman LE, Poniecka AW, Poppiti RJ. Is a pseudocystic serpentine mass a sonographic indicator of breast lymphoma? Radiologic–histologic correlation of an unusual finding. AJR 2001;176(3):734–6. 8. Mussurakis S, Carleton PJ, Turnbull LW. MR Imaging of primary non-Hodgkin’s breast lymphoma: a case report. Acta Radiol 1997;38:104–7. 9. Darnell A, Galllardo X, Sentis M, et al. Primary lymphoma of the breast: MR imaging features: a case report. Magn Reson Imaging 1999;17(3):479–82. 10. Murray ME, Given-Wilson RM. The clinical importance of axillary lymphadenopathy detected on screening mammography. Clin Radiol 1997;52:458–61. 11. Lim ET, O’Doherty A, Hill AD, Quinn CM. Pathological axillary lymph nodes detected at mammographic screening. Clin Radiol 2004;59:86–91.
THE
BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy J. Coxa,, L. Luntb, L. McLeanc a
University Hospital North Durham, Durham, UK Breast Screening Unit, Gateshead NE9 6SX, UK c Breast Screening Unit, Newcastle upon Tyne NE1 4LP, UK b
Received 30 June 2004; received in revised form 27 September 2004; accepted 13 October 2004
KEYWORDS Breast; Lymphoma
Summary We have reviewed imaging findings of 32 female patients with a proven haematological malignancy in the breast and axilla presenting to two breast units over a 13-year period. Nineteen patients had screen-detected lesions, and 13 presented to symptomatic services. The most common histological diagnosis was of non-Hogdkins lymphoma. Of the 12 patients who presented with disease in the breast, six (all with primary breast lymphoma) presented with a well-defined mass on mammography. The range of radiological appearances is, however, highly variable. & 2004 Elsevier Ltd. All rights reserved.
Introduction Haematological malignancies are rare entities in the breast, accounting for less than 1% of all patients with breast neoplasms. Lymphomatous involvement of breast may occur as a primary disease or as secondary phenomenon with infiltration of breast parenchyma by systemic disease either at the time of diagnosis or as disease recurrence. The radiological features are highly variable and non-specific, but the most common
presentation is of one or several mass lesions, usually without calcification.1 This unusual condition is of some importance because it remains treatable, even carrying a good prognosis even when disseminated. The purpose of this study is to review the imaging features of primary and secondary haematological malignancy in the breast and axilla, and demonstrate the spectrum of appearances.
Materials and methods Corresponding author. Department of Radiology, University Hospital North Durham, North Rd, Durham DH1 5TW, UK. Tel.: +44 1913332491. E-mail address: [email protected] (J. Cox).
A retrospective review of the imaging archive of the Breast Screening and Symptomatic Units at the Royal Victoria Infirmary, Newcastle upon Tyne, and
0960-9776/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2004.10.001
ARTICLE IN PRESS 52
J. Cox et al.
the Queen Elizabeth Hospital, Gateshead yielded 32 female patients with a proven haematological malignancy in the breast and axilla presenting over a 13-year period (January 1990–July 2003). In this period, there were over 500,000 screening episodes, and approximately 3000 screen detected and 6000 symptomatic breast carcinomas diagnosed between the two breast units. The NHS Breast Screening Programme invited women between the ages of 49 and 64 to attend for three yearly screening mammography and some older women chose to self-refer. Women of all ages attended symptomatic breast clinics.
Results Thirty-two female patients with haematological malignancy within the breast and axilla had presented to two breast units over a 13-year period from 1990 to 2003. The age range was from 45 to 75 years. Nineteen patients presented with screen-detected lesions, six of whom had disease within the breast and 13 of whom presented with screendetected axillary lymphadenopathy. Thirteen symptomatic patients presented, seven with axillary lymphadenopathy, and six with disease in the breast. The imaging appearances of the 12 breast lesions are described in detail in Tables 1 and 2. Eight cases were classified as primary breast lymphoma (PBL). All presented as solitary lesions and of these, six lesions were described as a welldefined mass mammographically. In four of the eight patients with PBL, axillary lymphadenopathy
Table 1
Primary Secondary
Table 2
Discussion PBL accounts for 1–5 cases per 1000 breast malignancies.1–5 Our study broadly confirms these results with 3.5 haematological malignancies for every 1000 carcinomas in our series. Overall, there were six cases of
Table 3
Histology of axillary lymphadenopathy.
Non Hodgkin’s Lymphoma Small cell lymphoma/CLL Mantle cell lymphoma Hodgkin’s disease Total
16 2 1 1 20
Mammographic appearance of haematological malignancy in the breast. Well-defined mass
Asymmetric density
Multiple lesions
Ill defined mass
Presence of axillary lymphadenopathy
Total
6 0
2 0
0 3
0 1
4 2
8 4
Ultrasonic appearance of haematological malignancy in the breast. Echogenicity
Primary Secondary
was demonstrated on mammography. Four cases of secondary haematological malignancy were imaged (including one case of disseminated multiple myeloma). Three of these four patients presented with multiple lesions. The range of ultrasonic appearances of primary and secondary breast lymphoma is described in Table 2. Non-Hodgkin’s lymphoma proved to be by far the most common histological diagnosis, in 11 of the 12 breast lesions in our series. Twenty patients presented with axillary lymphadenopathy, either bilateral or unilateral, of which 13 cases were detected by breast screening. As is documented in Table 3, NHL is also by far the most frequent histological diagnosis from the axillary nodes.
Margin
No Ultrasound
Hypoechoic
Mixed
Well defined
Ill defined
Diffuse
4 1
2 3
4 1
1 2
1 1
2 0
ARTICLE IN PRESS Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy screen-detected haematological malignancy to every 1000 cases of screen-detected carcinoma, and two cases of symptomatic haematological malignancy per 1000 cases of symptomatic carcinoma. The much higher proportion of this rare disease detected in the screening population is a new finding, and has not previously been documented. The ratio of primary breast lymphoma to primary breast carcinoma is extremely low although our results indicate it may be more common than was previously thought. Other series have been composed of only symptomatic women, while our study includes both screen-detected lesions and symptomatic malignancies, which may explain our results. The majority of primary breast lymphomas are of the non-Hodgkin’s B cell type, and the most common is diffuse large cell lymphoma (40–70%). Primary breast lymphoma is slightly more common than secondary breast lymphoma, accounting for one-half to two-thirds of patients in a previously reported series. It is predominantly a disease of middle and old age with greatest frequency in the sixth decade, a demographic pattern also confirmed in our series.1–5 There are few reported series of the radiological features of lymphoma in the breast. In the largest reported series of 32 cases of primary and secondary breast lymphoma, twenty two patients (69%) had a solitary non-calcified mass on mammography, with multiple non-calcified masses in three patients, and diffuse opacification with skin thickening in another three patients symptoms were present in 29 of the 31 patients in this study.2 In another series of 12 patients3, all with primary breast lymphoma showed a solitary, round or oval homogeneously dense non-calcified soft tissue mass on mammography. Features seen in carcinoma of the breast such as calcification, spiculation, and
53
parenchymal distortion are distinctively absent in lymphoma. Indeed, primary breast lymphomas can present as a well-defined mass on mammography, mimicking a benign breast lesion (Figs. 1 and 2). Lymphoma is the most common cause of metastases within the breast, representing 17% of breast metastases.4 Cases of secondary breast malignancy can present as multiple circumscribed nodules (Fig. 3), multiple vague densities, as well as multiple miliary densities (Fig. 4) on mammography.5,6 In our series, a multiple lesions of varying sizes are observed in three of the four with secondary breast disease, with an ill-defined mass present on mammography in the other patient. Two of the four patients with secondary breast lymphoma had axillary lymphadenpathy on imaging (Fig. 5). The most common ultrasound appearance of lymphoma within the breast is a hypo echoic homogenous or heterogenous well-defined mass (Fig. 6).1 This appearance is however non-specific and may be found in other malignant and benign lesions. A series of two cases of breast lymphoma presented with ultrasound appearances of an elongated, complex, superficial, ‘‘pseudocystic serpentine’’ mass has been described (Fig. 7).7 Other less common sonographic features include skin thickening and lymphatic dilatation.1 As demonstrated in Table 3, the patients in our study with breast lymphoma demonstrated a wide range of ultrasonic appearances, none of which was specific for the condition (Tables 4 and 5). Two case reports describe the MR appearances of primary breast lymphoma; each showed different features. In a case report from 19978, two illdefined, non-spiculated, hypo intense were demonstrated masses on T1 weighted images, with rapid enhancement of both after intravenous contrast. In
Figure 1 73 year old woman presented with a rapidly growing lump on the upper outer quadrant of the right breast. Mammograms [(a)–(d)] demonstrated a well defined 4 cm mass in the upper outer quadrant of her right breast. The lesion was solid and hypoechoic on ultrasound. FNA was suggestive of a lymphoma and excision biopsy confirmed Non Hodgkin’s B cell lymphoma.
ARTICLE IN PRESS 54
J. Cox et al.
Figure 2 59 year old woman presented in 1990 with a rapidly growing lump in her right breast. Mammography [(a)–(c)] was performed and revealed a well defined mass in the right upper outer quadrant. FNA of the lesion was suggestive of lymphoma, and excision biopsy revealed a high grade lymphoma. Bone marrow metastases were found at presentation, making her stage IVa. She was treated with chemotherapy. In 1995, she noticed a lump in her left breast. Mammography [(d)–(g)] then revealed an asymmetric density in the left upper outer quadrant, which was excised and found to be recurrent lymphoma. Treatment with chemotherapy and radiotherapy was given. She is still alive with no evidence of recurrent disease.
Figure 3 69 year old woman with known disseminated multiple myeloma presented with multiple small lumps in both breasts. Symptomatic mammograms [(a) revealed muliple discrete mass lesions in both breasts, hypoechoic and solid on ultrasound. FNA of a lesion was compatible with multiple myeloma.
Figure 4 63 year old woman recalled to assessment in 1999 after screening mammograms [(a)–(d)] revealed multiple ill defined densities in both breasts. At assessment, the patient gave a history of disseminated NHL, for which she was undergoing treatment. FNA of a breast lesions was consistent with a lymphomatous infiltrate.
the latter case report9, a well-circumscribed hyperintense mass was evident on T2 weighted images, isointense on T1 weighted images, also
with rapid post-contrast enhancement. In both cases, therefore, MR findings were consistent with a breast neoplasm, with no specific features.
ARTICLE IN PRESS Haematological cancers in the breast and axilla: a drop in an ocean of breast malignancy
55
Figure 5 59 year old woman was recalled for assessment because screening MLO mammograms (a) and (b) in 1993 showed bilateral axillary lymphadenopathy. Excision biopsy of a lymph node revealed small cell lymphoma/CLL. Screening mammograms (c) and (d) performed in 1996 show a decrease in the size and density of the nodes with treatment. The patient was then in remission.
Table 4
Histology of breast lesions.
Non-Hodgkin’s lymphoma (primary) Non-Hodgkin’s lymphoma (secondary) Multiple myeloma Total
Table 5
Figure 6 Primary breast lymphoma presenting as a well defined solid hypoechoic mass on ultrasound.
Figure 7 Primary breast lymphoma presenting as a more unusual serpentine ‘‘pseudocystic’’ mass on ultrasound.
The detection of occult lymphoma in the axilla by screening mammography is not a topic, which has been directly addressed previously. Normal axillary lymph nodes are a frequent finding on up to 50% of breast screening mammograms. A retrospective
8 3 1 12
Histology of axillary lymphadenopathy.
Non-Hodgkin’s lymphoma Small cell lymphoma/CLL Mantle cell lymphoma Hodgkin’s disease Total
16 2 1 1 20
study10 has analysed the incidence and causes of pathological axillary lymphadenopathy detected by screening mammography. In a review of over 95,000 screening mammograms, 37 cases of pathological axillary lymphadenopathy were identified. Eleven of this showed evidence of malignancy and six of these were non-Hodgkin’s lymphoma. Screen-detected axillary lymph nodes derived from a smaller study population of 23707 women yielded nine cases of pathological axillary lymphadenopathy alone. Five were malignant and two of the malignancies were NHL. As the authors state, this incidence of lymphoma of 0.1 per 1000 women screened compared with an expected incidence of 0.3 per women in the age group 50–64, represents a substantial proportion of the lymphomas detected in this age group.11 Our study confirms these finding.
ARTICLE IN PRESS 56 In conclusion, primary breast lymphoma and NHL in axillary lymph nodes may be detected on mammography. Our study demonstrates that more breast and axillary haematological malignancy is detected through breast screening, while asymptomatic, than is currently presenting to symptomatic breast services.
References 1. Yang WT, Muttarak M, Ho LWC. Nonmammary malignancies of the breast: ultrasound, CT, and MRI. Semin Ultrasound, CT and MRI 2000;21(5):375–94. 2. Lieberman L, Gless CS, Dershaw DD, et al. Non-Hodgkin lymphoma of the breast: imaging characteristics and correlation with histopathologic findings. Radiology 1999;192:157–60. 3. Meyer JE, Kopans DB, Long JC. Mammographic appearance of malignant lymphoma of the breast. Radiology 1980;135:623–6.
J. Cox et al. 4. Bartella L, Kaye J, Perry NM, et al. Metastases to the breast revisited: radiological–histopathological correlation. Clin Radiol 2003;58:524–31. 5. Pameijer FA, Beijerinck D, Hoogenboon HH, et al. NonHodgkin’s lymphoma of the breast causing miliary densities on mammography. AJR 1995;164:609–10. 6. Slanetz PJ, Whitman GJ. Non-Hodgkin’s lymphoma of the breast causing multiple vague densities on mammography. AJR 1998;167:537–8. 7. Gal-Gombos EC, Esserman LE, Poniecka AW, Poppiti RJ. Is a pseudocystic serpentine mass a sonographic indicator of breast lymphoma? Radiologic–histologic correlation of an unusual finding. AJR 2001;176(3):734–6. 8. Mussurakis S, Carleton PJ, Turnbull LW. MR Imaging of primary non-Hodgkin’s breast lymphoma: a case report. Acta Radiol 1997;38:104–7. 9. Darnell A, Galllardo X, Sentis M, et al. Primary lymphoma of the breast: MR imaging features: a case report. Magn Reson Imaging 1999;17(3):479–82. 10. Murray ME, Given-Wilson RM. The clinical importance of axillary lymphadenopathy detected on screening mammography. Clin Radiol 1997;52:458–61. 11. Lim ET, O’Doherty A, Hill AD, Quinn CM. Pathological axillary lymph nodes detected at mammographic screening. Clin Radiol 2004;59:86–91.