Abstract

Abstract 5113

INTRODUCTION

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.

METHOD

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.

Table 1

Summary of DLBCL cases presented with primary breast swelling from 1st January 2009 till 30th June 2012 in Ampang Hospital

NoAge, ethnicMorphology, PI, genotypeStage by CTIPIExtranodal siteLymph node >1cm siteInduction regimeResponse after inductionSubsequent therapyOutcome on 30th June 2012Progression free survival time on 30th June 2012 (month)Survival time on 30th June 2012 (month)
47, M Ki-67 50%, * IV, A, H, S 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 
82, M * II, E, A, X 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 
42, M * I, E, A, X 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 
30, M * II, E, B 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 
34, Filipino Immunoblast, Ki-67 80%, * II, E 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 
35, Chinese Centroblastic, MIB-1 80%, ABC II, E, A, X 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 
NoAge, ethnicMorphology, PI, genotypeStage by CTIPIExtranodal siteLymph node >1cm siteInduction regimeResponse after inductionSubsequent therapyOutcome on 30th June 2012Progression free survival time on 30th June 2012 (month)Survival time on 30th June 2012 (month)
47, M Ki-67 50%, * IV, A, H, S 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 
82, M * II, E, A, X 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 
42, M * I, E, A, X 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 
30, M * II, E, B 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 
34, Filipino Immunoblast, Ki-67 80%, * II, E 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 
35, Chinese Centroblastic, MIB-1 80%, ABC II, E, A, X 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

CONCLUSION

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.

Disclosures:

No relevant conflicts of interest to declare.

Author notes

*

Asterisk with author names denotes non-ASH members.