Composite primary breast diffuse large B-cell lymphoma and T lymphoblastic leukemia/lymphoma: report of a case and review of literature

Abstract

We reported a rare case of composite diffuse large B-cell lymphoma and T lymphoblastic leukemia/lymphoma (T-LBL) in a 46-year-old woman with progressive enlargement of the breast lump. The patient initially sought care at a local hospital with a single left breast lump without any other physical examination findings. Histopathological analysis of which revealed a diffuse infiltration of tumor cells that were rich in cytoplasm with vesicular chromatin and prominent nucleoli. Further analysis of immunohistochemistry showed a cluster of neoplastic cells which express B-cell markers: CD19, CD20 (weak), CD79a, PAX5 and BCL-2, but negative for T-cell markers such as CD2, CD3, CD5 and CD7. PET-CT showed evidence of lymphadenopathy and splenomegaly, which may indicate lymphoma infiltration. Then a biopsy of bone marrow showed typical features of T-LBL. The aberrant terminal deoxynucleotidyl transferase (TDT) and cCD3 positive T-cell population that lack surface CD10 and CD19 were identified by flow cytometric immunophenotyping. Polymerase chain reaction analysis of the T-cell receptor gamma gene and IgH gene revealed a clonal rearrangement and confirming T-cell clonality. Fluorescence in-situ hybridization (FISH) revealed a deletion of the P53 gene in these T-neoplastic cells may indicate a bad outcome of such disease. Neither the large B-cells nor T-cells were positive for Epstein-Barr virus encoded RNA.

Keywords: Composite lymphoma; T-lyphoblastic leukimia/lymphoma; primary breast diffuse large B-cell lymphoma.

Figure 1

HE staining and immunohistochemistry pictures of the breast mass (×400). HE staining picture revealed a diffuse infiltration of tumor cells that were rich in plasma, and possessed vesicular chromatin accompanied prominent nucleoli (A). The tumor tissue strongly expressed CD79a (F), PAX5 (G), Ki-67 (J), and BCL-2 (K), but was negative for CD3 (B), CD4 (C), CD10 (D), CD30 (E), TDT (L) and MPO (H). Weak expression of CD20 (I) was observed.

Figure 2

Morphology of the neoplastic cells from bone marrow sample. Picture (A) represent the initial status of the patient; Picture (B) was rechecked after accept the chemotherapy of VDP regimen.

Figure 3

Immunophenotypic analysis of T lymphoblastic leukemia/lymphoma by 4-color flow cytometry. The neoplastic T-cells were cCD3+, CD33+, CD71+, TDT+ (B), and partially positive for CD34 but CD13-, CD14-, CD19, MPO-, HLA-DR- (A) and CD79a- (B).

Figure 4

DNA extracted from patient’s bone marrow samples and amplified by polymerase chain reaction with primers for the DH region of the immunoglobulin heavy chain (IgH) (A) and the T-cell receptor (TCRÝ) (B). Monoclonal patterns of TCR Ý (131.96 bp, arrow B) and IgH rearrangements (170.4 bp, arrow A) were detected by polymerase chain reaction and electropherogram in the same specimen.

Figure 5

Neoplactic cells in the T-LBL component was detected by Fluorescence in-situ hybridization (FISH) revealed a deletion of P53 gene while in same tumor cells there was no evidence of translocation of the IGH and BCL-2 and expression of BCL-6 and C-MYC gene.