Synchronous early-stage breast cancer and axillary follicular lymphoma diagnosed by core needle biopsy: A case report

Abstract

Synchronous double cancers are an infrequent finding. The focus of this study was a case of diagnosed synchronous double breast cancer (BC) and axillary (Ax) follicular lymphoma (FL). The patient was a 73-year-old woman who had been visiting her local doctor for follow-up of a fibroadenoma of the left breast, and was referred to our hospital after being diagnosed with invasive ductal carcinoma (IDC) of the left breast. Ultrasonography (US) revealed enlarged Ax lymph nodes (LNs) and US-guided core needle biopsy (CNB) was performed. CNB revealed no metastasis of IDC; however, a diagnosis of FL was made. Therefore, the patient was diagnosed with synchronous double BC and Ax FL and underwent partial surgical resection of the BC and close monitoring of the FL. To the best of our knowledge, this is the first case of malignant lymphoma diagnosed by CNB of Ax LNs during preoperative BC screening. CNB allows for a shorter waiting time for the examination, and it is considered to be minimally invasive, cost-effective and non-inferior to surgical resection in terms of specimen volume. Therefore, active preoperative evaluation of Ax LNs using US-guided CNB may contribute to BC staging, and may also help diagnose synchronous cancers.

Keywords: breast cancer; core needle biopsy; follicular lymphoma; invasive ductal carcinoma; synchronous double cancer.

Figure 1

Ultrasound images and histopathological images. (A) On ultrasound examination, a large (5.2x4.8 mm) irregular internal hypodense mass was found in the nipple areola-complex of the left breast, in the middle and immediately above the nipple. (B) H&E staining revealed invasive ductal carcinoma of the breast, histological grade I (tubule formation score 2, nuclear atypia score 2, mitotic count score 1). Scale bar, 100 µm. Immunohistochemical staining for (C) estrogen receptor (90%), (D) progesterone receptor (0%) and (E) HER2 (score).

Figure 2

Ultrasound imaging of the axillary lymph nodes. The level I axillary lymph node was enlarged to 16.8 mm with a loss of medullary structure. Ultrasound-guided core needle biopsy was performed.

Figure 3

Histopathological examination of the axillary lymph nodes. Immunostaining for (A) CD20; (B) CD3; (C) CD10; (D) Bcl-6; (E) Bcl-2; and (F) CD21. Most of the follicular component cells were positive for CD20, CD10, Bcl-2 and Bcl-6, and negative for CD3. CD21-positive dendritic cells that almost coincided with the follicles were identified, supporting the diagnosis of follicular lymphoma. Scale bar, 200 µm.

Figure 4

PET-CT examination. High fluorodeoxyglucose accumulation in the mediastinal, bilateral axillary (upper panel), abdominal para-aortic, iliac (middle panel), and bilateral inguinal (lower panel) lymph nodes can be observed.