Approximately 3900 patients had a pathological diagnosis of breast cancer between April 1994 and August 2007. Nineteen (F = 16) were found to have non-mammary breast malignancies (). Mean age was 61.6 years (range 25-86). Seventeen patients presented to a symptomatic breast out-patient clinic with either a history of a breast lump, skin change or mastalgia. Two patients were referred to the breast clinic for further follow-up because of a screening detected abnormality on mammography.
Clinical data for all 19 patients
The histological types of non-epithelial malignancies were as follows: lymphoma (n = 8, 0.21% of all breast malignancies), sarcoma (n = 5, 0.13%), malignant melanoma (n = 3, 0.07%), multiple myeloma (n = 1, 0.03%), metastatic renal cell carcinoma (n = 1, 0.03%) and metastatic carcinoid tumour (n = 1, 0.03%) ( – ). The mean follow-up was 1541 days (32-4589 days). Nine patients were alive at the end of follow-up. Only 1 of 11 deaths was not disease related. The mean time from surgery to death was 798.5 days (range 32-3248 days).
High-grade non-Hodgkin's breast lymphoma (haemotoxylin and eosin × 200) (Inset CD45 staining). This field shows large blast-like lymphoid cells with conspicuous background apoptosis, features in keeping with a diffuse large B-cell lymphoma.
Metastatic renal cell carcinoma of breast (H&E × 200). This section shows the typical morphology of renal cell carcinoma with small pleomorphic nuclei, clear cytoplasm and a fine vascular background.
Five female patients (patients 1-5 from ) were diagnosed with a primary breast lymphoma (mean age 70.4 years, range 59-86 years). Four patients presented with a breast lump. An asymptomatic patient was referred from the breast screening unit. All patients had unilateral disease (left = 2, right = 3). The mean duration of symptoms was 37.3 days (range 7-93 days). Three patients had mammography performed (Grade: M3 = 1 from screening, M4 = 2). One patient had an ultrasound scan (Grade: U3). Four patients had FNA cytology performed (Grade: C1 = 1, C3 = 3). The lymphoma diagnosis was made following core biopsy in two cases and excision biopsy in three cases. Pathological analysis identified primary diffuse large B-cell non-Hodgkins lymphoma (NHL) (n = 4) () and a primary MALT-type lymphoma (n = 1). Four patients had chemotherapy with the CHOP regimen (cyclophosphamide, doxorubicin HCl, vincristine (Oncovin), prednisolone). There is no documentation of whether chemotherapy was administered in patients 2 and 4 who both had advanced metastatic disease from their primary breast lymphoma. Patient 3 underwent subsequent radiotherapy for metastatic axillary node disease. Three patients are currently still alive. Patient 5 has had several recurrences and has had further courses of chemotherapy for lung involvement. Patient 1 also required a further course of chemotherapy for recurrence. Patients 2 and 4 died from metastatic spread of their primary breast lymphoma where the mean time from diagnosis to death was 3248 and 32 days respectively.
Three patients (patients 6-8 from , male = 1) were diagnosed with a metastatic breast lymphoma from a remote primary lesion (mean age 65.3 years, range 52-79 years). All three patients presented with a breast lump while one complained of mastalgia. All patients had unilateral disease (left = 2, right = 1). The mean duration of symptoms was 186.0 days (range 7-365 days). One patient had mammography performed (Grade: M4). One patient had an ultrasound scan (Grade: U4). Two patients had FNA cytology performed (Grade: C2 = 1, C5 = 1). The lymphoma diagnosis was made following core biopsy in one case and excision biopsy in two cases. Pathological analysis identified the presence of metastatic B-cell NHL in all three patients. Two patients had chemotherapy with the CHOP regimen. Patient 6 underwent simple mastectomy without adjuvant therapy. Patient 8 underwent subsequent radiotherapy to treat cerebral metastases. Unfortunately all three patients have died where the mean time from diagnosis to death was 775, 1045 and 133 days for patients 6-8 respectively.
Three patients (patients 9-11 from , male = 1) had primary breast sarcomas () with an average age of 50.7 years (range 29-65 years). All patients presented to our symptomatic breast clinic with either a lump (n = 2) and/or mastalgia (n = 2) (left = 2, right = 1). The mean duration of symptoms was 192 days (range 31-365 days). Patients 9 and 10 had palpable masses whereas patient 11 had minimal localised thickening only. Patients 9 and 10 had positive mammograms (M4 = 2) while patients 10 (U4) and 11 (U1) had ultrasound assessments. Fine needle aspiration was positive in patient 9 (C5) but insufficient in patient 11 (C1). Patient 9 underwent simple mastectomy and axillary node clearance for a primary rhabdomyosarcoma where immunohistochemical labeling was positive for actin (smooth muscle) and negative for epithelial markers. Despite adjuvant chemo- and radiotherapy, she died 553-days post-surgery. Patient 10 had a simple mastectomy for dermatofibrosarcoma protruberans and remains well 380-days later. Although ultrasound, magnetic resonance imaging (MRI) and FNA cytology investigations were normal patient 11, further investigation was arranged due to a persistent clinical suspicion of a possible lesion. A subsequent ultrasound-guided excisional biopsy demonstrated an angiosarcoma. She proceeded to simple mastectomy with adjuvant radiotherapy followed by delayed breast reconstruction one-year later. She remains well 1415 days following her initial breast surgery.
Breast sarcoma (H&E × 200). This field shows large spindle shaped cells with nuclear pleomorphism and eosinophilic cytoplasm. There is no differentiation which would indicate the cell of origin.
Two female patients (patients 12-13 from ), aged 69 and 61, were diagnosed with metastatic sarcomas from distant primary neoplasms. Patient 12 had a previous primary thigh liposarcoma resection while patient 13 had a previous excision of a primary retroperitoneal leiomyosarcoma. Both of these patients presented with painless lumps in the left breast. The mean duration of symptoms was 5 days (range 3-7 days). Patient 12 had a positive mammogram (M4) and FNA (C5) with confirmation of sarcoma following core biopsy with vimentin positive immunohistochemical labeling while other epithelial, neural (S100) and muscle (actin and desmin) markers were negative. She was treated with palliative chemo- and radiotherapy and died 679 days later. Patient 12 had a positive mammogram (M4) and FNA (C5) with confirmation of sarcoma following core biopsy. Patient 12 did not undergo surgery as staging investigations had shown widespread metastatic disease. She was treated with palliative chemo- and radiotherapy and died 679 days later. Patient 13 proceeded directly to lumpectomy. She refused adjuvant therapy and remains well 2980-days following lumpectomy and has had further surgery for abdominal wall recurrences in the interim.
Three patients (patients 14-16 from , male = 1) had a malignant melanoma with an average age of 54.3 years (25-70 years). These patients presented with an enlarging naevus on the right breast (patient 14), a superficial nodule on the left breast (patient 15) and a right-sided breast lump (patient 16). The mean duration of symptoms was 699 days (range 93-1825 days). Patient 14 had palpable axillary nodes and proceeded directly to excision biopsy with ANC. A mastectomy was subsequently required due to involved breast margins from deeper infiltration of the primary melanoma. Although further adjuvant treatment was declined, the patient remains disease-free. Patient 15 had been treated 3-years earlier for metastatic melanoma with lung involvement from a separate lesion on the left arm but was thought to be in remission. In view of the history she proceeded straight to excisional biopsy of the left breast nodule and pathology showed malignant melanoma. She received adjuvant chemotherapy and immunotherapy but developed lung metastases 3-years later. Following further oncological therapy the patient has been disease free for the last 9-years. Patient 16 had been treated with chemotherapy 8-years previously for a cutaneous malignant melanoma of her left lower limb and was also thought to be in remission. She had both USS and mammogram investigations (U = 4, M = 4). Subsequent FNA and core biopsy confirmed malignant melanoma (). Despite palliative radiotherapy, this patient died 7-weeks later from metastatic disease.
Breast melanoma (H&E × 200) (Inset - Hmb45 immunohistochemistry stain for melanoma). This field shows melanoma cells some of which are producing brown melanin pigment. The cells are HMB45 positive.
Metastatic multiple myeloma
Patient 17 (F, 71) presented with a 28-day history of a right-sided breast lump. She had a history of multiple myeloma and left mastectomy 4-years earlier for a metastatic myelomatous deposit. Although mammography was indeterminate (M = 3), ultrasound imaging was suspicious of malignancy (U = 4). Subsequent FNA and core biopsy investigations were indeterminate. Excisional biopsy confirmed metastatic multiple myeloma which was treated with adjuvant chemotherapy (melphalan in combination with prednisolone and allopurinol) (). The patient died from metastatic disease 342 days later.
Multiple myeloma deposit right breast (H&E × 200). This field shows large atypical plasma cells many of which are showing immunoblastic differentiation with large central nucleoli.
Metastatic carcinoid tumour
Patient 18 (F, 52) was referred from the breast-screening department with an abnormality in the right breast. USS and FNA investigations were equivocal and suggested fibroadenosis. Core biopsy suggested invasive ductal carcinoma and she proceeded to WLE and ANC. Histopathology analysis confirmed a grade-1 carcinoid tumour without nodal involvement. She proceeded to a simple mastectomy and was subsequently referred to the regional neuroendocrine department. Although she had no clinical evidence of carcinoid syndrome, she was commenced on the somatostatin analogue lanreotide. She was subsequently referred for gastrointestinal screening where a primary carcinoid tumour was detected in the distal small bowel 9-months following her initial breast surgery. A small bowel resection was then performed and she remains well on lanreotide with no evidence of carcinoid syndrome.
Metastatic renal cell carcinoma
Patient 19 (F, 63) presented with a seven-day history of a right-sided breast lump. Past medical history included left nephrectomy for renal cell carcinoma 4-years previously and she had known bony metastases. Mammogram and USS were suspicious of malignancy (M = 4, U = 4). FNA showed malignant cells and core biopsy confirmed metastatic renal cell carcinoma (). Wide local excision and ANC was performed and the patient received chemotherapy. A subsequent CT scan revealed widespread metastases. She died 1128 days later.