A 56-year-old woman came to our Breast Unit for her annual follow-up. A newly developed, non-palpable solid lesion of diameter equal to 0.8 cm was present in the upper outer quadrant of the left breast. The lesion did not contain microcalcifications, and axillary lymph nodes of small size were detected on the mammogram. The ultrasound examination was negative.
From the personal history, 12 years ago, a low-grade, stage I, Non-Hodgkin lymphoma confined to the lymph nodes of the neck was diagnosed and treated with radiation therapy. The patient was symptom-free, and able to function normally in her everyday life.
The woman had risk factors for breast cancer: positive family history for breast cancer (mother with postmenopausal breast carcinoma), a history of atypical ductal hyperplasia (ADH) 4 years ago, diagnosed by excisional biopsy under local anesthesia for a palpable lesion. Her BMI was equal to 25, and she was a housewife. The age at menarche was 15 years old and the age at drug-induced menopause was 44 years. The patient has had two induced abortions and three full-term pregnancies. The duration of lactation for all three full-term pregnancies was 15 months. There was no family history for ovarian and prostate cancer. There was no history of intake of estrogen.
The radiologist of our Unit characterized the suspicious lesion as BI-RADS 4B (lesion with an intermediate suspicion of malignancy) and a VABB was scheduled. Lymphoma was not suspected at presentation. VABB was performed on a digital prone table (Mammotest, Fischer Imaging, Denver, CO, USA) using 11-gauge Mammotome vacuum probes, under local anesthesia (Figures , ). Using one main target-offset and one offset inside the solid lesion, 24 cores were excised from the suspicious lesion (Figures , , ). The length of the cores varied between 0.5 and 2.8 cm. A clip marker was placed after biopsy and a mammogram to the affected breast confirmed the excision of cores in the lesion.
The suspicious lesion on the screen (Fischer workstation, VABB device).
The lesion at the onset of sampling.
According to the pathological examination, the lesion was a non-Hodgkin, grade II, germinal-center lymphoma of B-cell origin and exhibited a nodular pattern (> 75%) (Figure ). More specifically, the nodules were formed by cells with morphology of centroblasts and centrocytes; the number of centroblasts did not exceed 15 per optical field (×40). The stroma exhibited hyalinization where the malignant lymphoid tissue was present. The malignant lymphoid cells were occasionally present within the fatty breast tissue, and a few entrapped mammary ducts were recognized within the sclerotic stroma. Immunohistochemically, the lymphoid cells were positive for CD20, bcl-2 (Figure ) and CD10, whereas some CD10-positive cells were present outside the nodules. There was indication of kappa chain clonality. The Ki-67 proliferation marker was positive in 10% of cells.
Invasion of the breast parenchyma by the nodular non-Hodgkin B-cell lymphoma (H+E × 100).
Immunoreaction of the lymphoid cells to bcl-2 protein (× 200).
Subsequently, after second contact with the patient, and the establishment of the diagnosis, the patient disclosed that she had stopped her hematological follow-up 6 years ago. She was then referred to the hematologists for further evaluation and treatment.