The use of staging imaging modalities with increased sensitivity has led to an increase in the incidence of detection of simultaneous malignancies. These cases require careful evaluation and discussion in a multidisciplinary setting to establish a treatment plan that optimizes the outcome with respect to each malignancy, particularly when treatment modalities overlap. We report a case of a patient diagnosed with axillary nodal diffuse large B-cell lymphoma (DLBCL) in a community hospital where staging workup also revealed synchronous bilateral breast carcinomas. To our knowledge, this is only the second case report of a patient with three synchronous primary malignancies: bilateral breast carcinomas and axillary DLBCL. The only other similar case report had no role for radiation or chemotherapy in the management of the indolent follicular lymphoma. 1. Introduction Breast cancer constitutes approximately 14% of all primary cancers in women, accounting for more than 207,000 cases per year [1], but only a small fraction (2.2–4.3% in retrospective reviews) of these presented as bilateral breast cancer [2–4]. For early-stage disease, primary treatment involves surgical resection via modified radical mastectomy or breast conservation therapy with lumpectomy and sentinel lymph node biopsy. Adjuvant chemotherapy and hormonal therapy are often considered as well as completion of breast conservation therapy with radiation therapy to the involved breast and, if indicated, the regional lymph nodes [5]. Conversely, non-Hodgkin lymphoma constitutes only 4% of all primary cancers in women. Primary treatment for limited stage diffuse large B-cell lymphoma (DLBCL) involves systemic chemotherapy with or without consolidative radiation therapy, while late stage is treated primarily with systemic chemotherapy alone with radiation therapy considered for areas of original bulky disease [6]. Herein, we report a case of a patient diagnosed with axillary nodal DLBCL in a community hospital where staging workup also revealed synchronous bilateral breast carcinomas. A review of the relevant literature is also discussed. 2. Case Report The patient was a 64-year-old woman who presented to her local community hospital emergency department with a complaint of rapidly increasing edema to the right arm. She was noted to have significant right axillary adenopathy and although she denied fevers or night sweats, she had lost over 25 pounds (>10% of her body weight) in the three months prior to presentation. A computed tomography (CT) scan of the chest demonstrated multiple right axillary
References
[1]
A. Jemal, R. Siegel, E. Ward, Y. Hao, J. Xu, and M. J. Thun, “Cancer statistics, 2009,” CA: Cancer Journal for Clinicians, vol. 59, no. 4, pp. 225–249, 2009.
[2]
L. Schwentner, R. Wolters, M. Wischnewsky, et al., “Survival of patients with bilateral versus unilateral breast cancer and impact of guideline adherent adjuvant treatment: a multi-centre cohort study of 5292 patients,” Breast, vol. 21, no. 2, pp. 171–177, 2012.
[3]
W. Setz-Pels, L. E. M. Duijm, J. H. Groenewoud et al., “Patient and tumor characteristics of bilateral breast cancer at screening mammography in the Netherlands, a population-based study,” Breast Cancer Research and Treatment, vol. 129, no. 3, pp. 955–961, 2011.
[4]
R. Díaz, B. Munárriz, A. Santaballa, L. Palomar, and J. Montalar, “Synchronous and metachronous bilateral breast cancer: a long-term single-institution experience,” Medical Oncology, vol. 29, no. 1, pp. 16–24, 2010.
[5]
R. W. Carlson, D. C. Allred, B. O. Anderson, et al., “Breast cancer: clinical practice guidelines in oncology,” Journal of the National Comprehensive Cancer Network, vol. 7, pp. 122–192, 2009.
[6]
A. D. Zelenetz, J. S. Abramson, R. H. Advani, et al., “NCCN clinical practice guidelines in oncology: non-Hodgkin's lymphomas,” Journal of the National Comprehensive Cancer Network, vol. 8, pp. 288–334, 2010.
[7]
B. Fisher, J. Dignam, N. Wolmark et al., “Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B- 17,” Journal of Clinical Oncology, vol. 16, no. 2, pp. 441–452, 1998.
[8]
T. Papajík, M. Myslive?ek, Z. S?edová et al., “Synchronous second primary neoplasms detected by initial staging F-18 FDG PET/CT examination in patients with non-Hodgkin lymphoma,” Clinical Nuclear Medicine, vol. 36, no. 7, pp. 509–512, 2011.
[9]
M. D. Laudenschlager, K. L. Tyler, M. C. Geis, M. R. Koch, and D. B. Graham, “A rare case of synchronous invasive ductal carcinoma of the breast and follicular lymphoma,” South Dakota Medicine, vol. 63, no. 4, pp. 123–125, 2010.
[10]
K. E. Cuff, A. J. Dettrick, and B. Chern, “Synchronous breast cancer and lymphoma: a case series and a review of the literature,” Journal of Clinical Pathology, vol. 63, no. 6, pp. 555–557, 2010.
[11]
J. Cox, L. Lunt, and L. Webb, “Synchronous presentation of breast carcinoma and lymphoma in the axillary nodes,” Breast, vol. 15, no. 2, pp. 246–252, 2006.
[12]
D. Wahner-Roedler, C. Reynolds, and J. Boughey, “Collision tumors with synchronous presentation of breast carcinoma and lymphoproliferative disorders in the axillary nodes of patients with newly diagnosed breast cancer: a case series,” Clinical Breast Cancer, vol. 11, no. 1, pp. 61–66, 2011.
[13]
N. K. Garg, N. B. Bagul, G. Rubin, and E. F. Shah, “Primary lymphoma of the breast involving both axillae with bilateral breast carcinoma,” World Journal of Surgical Oncology, vol. 6, article 52, 2008.
[14]
B. Susnik, J. J. Rowe, P. N. Redlich, C. Chitambar, C. C. Chang, and B. Kampalath, “A unique collision tumor in breast: invasive ductal carcinoma and mucosa-associated lymphoid tissue lymphoma,” Archives of Pathology and Laboratory Medicine, vol. 128, no. 1, pp. 99–101, 2004.
[15]
J. M. Quilon, T. A. Gaskin, A. S. Ludwig, and C. Alley, “Collision tumor: invasive ductal carcinoma in association with mucosa-associated lymphoid tissue (MALT) lymphoma in the same breast,” Southern Medical Journal, vol. 99, no. 2, pp. 164–167, 2006.
[16]
F. A. Siddiqui, V. Maheshwari, K. Alam, et al., “Coexistent non-Hodgkins lymphoma and ductal carcinoma breast: diagnosis on fine needle aspiration cytology,” Diagnostic Cytopathology, vol. 39, no. 10, pp. 767–769, 2011.
[17]
S. Broco, N. Bonito, P. Jacinto, G. Sousa, and H. Gervásio, “Primary non-Hodgkin lymphoma and invasive ductal carcinoma in the same breast: a rare case report,” Clinical and Translational Oncology, vol. 11, no. 3, pp. 186–188, 2009.