Primary non-Hodgkin lymphoma of the breast. Is it possible to avoid mastectomy?

Primary lymphoma of the breast is a rare disease that has been estimated to represent from 0.05% to 0.53% of all malignant breast tumors and approximately 2.2% of all extranodal lymphomas. The aim of this study is to review all cases of primary lymphoma of the breast at the Institute of Oncology and Radiology of Serbia from 1984 to 1996 in order to determine the incidence, patterns of clinical presentation, radiological features, histopathology, mode of therapy and outcome of the disease. The criteria for inclusion in this retrospective study corresponded to a revision of the original criteria suggested by Wiseman and Liao. The clinical histories of ten patients with breast lymphomas were reviewed. Clinical follow-up was obtained through a review of the patients hospital chart or by direct contact with the patients. Ten cases of primary lymphoma of the breast have been identified during the 12-yr period, presenting 0.05% of all patients with malignant breast disease. All patients were female, median age at diagnosis 58 years (range 49-69), all presented with breast lumps (3 right, 7 left) of median size 5 cm (range 3.5-8 cm). Mammography and breast echography were unable to bring a suspicion of lymphoma. Histologically, 6 cases were diffuse large cell, 3 of which with features consistent with immunoblastic lymphoma; 2 were diffuse mixed cells and 2 had small lymphocytic morphology. In 4 out of 5 patients, in the clinical stage corresponding to the "operable breast cancer" category, the ex tempore histological analysis could not differentiate lymphoma from cancer, so that all of them had mastectomy with axillary dissection. Those corresponding to the "locally advanced breast cancer" category, escaped mastectomy and a classical biopsy was performed, anticipating eventual neoadjuvant procedures. Thus, four patients underwent radical mastectomy, 1 wide local excision and 5 diagnostic biopsies. Further treatment included chemotherapy for 8 patients. The projected probability of a 10-years survival was 0,60. The rarity of this disease, and uneven treatment modalities make prognosis of breast lymphoma difficult. It seems that cooperation between the surgeon and the pathologist is necessary in order to reach the correct diagnosis during ex tempore analysis. With the limitations of available diagnostic procedures, it appears that most patients with breast lymphoma, in the stage corresponding to the "operable breast cancer" category, will unnecessarily undergo mastectomy and axillary dissection as primary treatment approach.