A 47-year-old female patient, residing in Western part of rural India presented with chief complaints of lump in right breast involving all quadrants for 3 months. Lump was initially small in size and pain in thelump was present for last 1 month. Patient also noticed sudden increase in size of left breast for last 1 month which was associated with low grade fever and chills without rigor. There was no history of nipple discharge, trauma or insect bite. Patient visited private hospital and underwent truecut biopsy and was diagnosed to have granulomatous mastitis for which she took anti-tuberculous 4 drug treatment for 2 months. Local Examination of Right breast revealed redness and swelling over right breast, with peau de orange appearance and normal appearing nipple areola complex. Palpation showed raised local temperature and tenderness present in whole breast with diffuse lump of approximately 10x10 cm sized involving whole breast with firm to hard consistency, fixed to the skin but not fixed to the chest wall. Left breast on inspection did not reveal any lump or redness or peau de orange appearance but on palpation approximately 5x6x2 cm sized lump was present in upper outer quadrant, well defined, firm to hard in consistency, mobile and not fixed to the skin and chest wall. Anterior axillary lymph nodes were palpable on both sides, multiple, firm to hard in consistency and freely mobile.
Investigations:
Her complete blood count reve4 Hemoglobin of 10 gm/dl with normal white cell and platelet counts.
Mammography revealed few prominent ducts present in upper outer quadrant. Pathological nodes in right axilla and metastatic lymph nodes in right supraclavicular and infraclavicular region, BIRADS II in right breast while left breast showed well defined soft tissue opacities in upper outer quadrant which on ultrasonography showed few dilated ducts with hypoechoeic area
True Cut Biopsy had revealed changes of chronic mastitis.
Breast MRI showed diffuse altered signal intensity noted in bilateral breast (Right > Left) with relative sparing of lower and outer quadrant of left breast. Right Breast was noted to be comparatively larger. Multiple enlarged heterogeneously enhancing lymph nodes were noted in bilateral axillary region (Level I and ll), largest measuring approximately 33*16 mm on right side. Due to diagnostic uncertainty incisional biopsy on right side with excisional biopsy on left side was taken which showed bilateral breast involvement by follicular lymphoma with right axillary lymph nodes showing follicular lymphoma grade 2. Hematoxylin and eosin stained section of breast tissue showed sheets of pleomorphic cells with vesicular nucleoli resembling lyphoid cells thus clinching the diagnosis.
Management:
Currently, a combination of chemotherapy and radiation therapy are used, which was done in our case [4]. Patient was given three cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP regimen) followed by Involved Field Radiation Therapy (IFRT). Similar to the treatment of breast carcinoma, lumpectomy with radiation therapy is often performed in patients with low grade breast lymphoma. Role of mastectomy in PBL is controversial, with many patients undergoing mastectomy due to diagnostic difficulty before the surgery, but its usefulness is similar to combination of chemotherapy and radiotherapy [5]. Prognosis is dependent on lymphoma type, grade and stage.SBL demonstrates a poor prognosis when compared with that of PBL and breast carcinoma.
