Acute B-Cell Lymphoblastic Leukemia/Acute B-Cell Lymphoblastic Lymphoma Presenting as Bilateral Breast Masses

Aims: Metastases Discussion: In patients presenting with bilateral breast masses, considering that other tumors may metastasize to the breast, the details of this rare case may aid clinicians treating similar patients, and highlight the importance of this situation. Conclusion: This finding emphasizes the need to accurately identify these tumors as metastases in order to avoid unnecessary procedures and treatments in these patients.


INTRODUCTION
Metastases to the breast and axilla are rare and account for approximately 2% of all mammary malignancies [1,2]. The most common metastatic lesion to involve the breast is a metastasis from a contralateral mammary cancer [1,2]. If hematologic malignancies are also excluded, the number of non-mammary metastases drops to well below 1% [1][2][3]. Although most common extra mammarian metastases of breast is from hematopoetic system and melanomas, presenting of the patient with both breast involvement is very rare [4]. The present study reports the rare case of thirty-year-old female breast metastases with extra mammarian leukemia and lymphoma. Due to the rarity of the disease, the relevant literature was also reviewed.

CASE REPORT
Thirty-year-old woman with four month story of painless bilateral breast masses was presented to the Breast Unit of Istanbul Medical Faculty. The masses had rapidly increased their size in diameter according to the patient's story. Multiple masses were found with the largest being 4 cm on the right and 3 cm on the left breast. We detected multiple enlarged axillary and cervical lymph nodes on physical examination bilaterally. Bicytopenia on hemogram has made us to suspect hematologic diseases.
Bilateral mammography and ultrasonography were performed. Mammography has revealed BIRADS V lesions on both breasts. On ultrasonography, an intramamarian lymph node (IMLN) of 2,5x2 cm diameter located in the upper outer quadrant was detected. Fatty hilum of this node was undistinguishable with highly vascular appearance. Sonoelastographic value of IMNN was 129±26.2 kPa. Ultrasonography of the left breast was revealed several oval shaped and illdefined hypoechoic solid lesions with maximum diameter of 8.6 mm. In shear wave elastography, masses in left breast categorized as hard lesions (136.7±33.4 kPa). Normal breast parenchymal elastography value was 13.8±2.9 kPa for the left breast and 12.6±2.5 kPa for the right breast (Figs. 1-2). Shear wave sonoelastography provides quantitative elasticity measurements, thus adding complementary information that potentially could help in breast lesion characterization with B-mode US. With grayscale findings, as in our case, sometimes it can be challenging to distinguish pathologic tissue from normal breast tissue. In our case, we have measured the elasticity in the lesions higher than the normal tissue and classified them as hard. These values give us the opportunity to perform tru-cut biopsies for suspected lesions.
We additionally have performed a positron emission computed tomography to evaluate the patient and excluded further metastatic disease.

DISCUSSION
Intramammarian metastases in women were %92.2 and were metachronnous %84. In imaging commonly the presence of multiple, bilateral round tumors, superficial without the traditional signs of malignity which one meets with the primitive tumors, such as irregular margins, speculations, microcalsifications, posterior cone of shadows were evacuative diagnosis. The prevelance of primitive cancer were not alone responcable for intramamrian metastases. The seed and soil theory could explain, that tumor cells could grow selected organs, such as melanoma. The vascularty was also very important.
Hematologic metastases to the breast and axilla were rare occurrences. They usually develop in the fifth or sixth decade and the patients most often had a prior history of a malignant tumor with documented metastatic spread. A wide variety of malignancies from many different sites have been reported with the most common sites of origin reported as the lung, skin, stomach, colon, and ovary [5][6][7][8][9][10][11][12].
Breast metastases of leukemia and lymphoma remain as rare diseases however the occurrence was more frequent due to improved diagnostic techniques and increased awareness about the disease. As diagnostic criteria; obtaining adequate specimen for pathological evaluation, confirming the lymphoid infiltration of breast tissue, and the presence of ipsilateral axillary lymph node involvement was crucial [13]. Histopathological and immuno-hystochemical evaluation is very important, because this tumor was also the type most often misdiagnosed initially with a primary breast cancer. The literature shows that the lack of the clinician to provide the absence of a prior cancer history is resulted with the failure of the pathologist to recognize the metastatic nature of the lesion at the time of initial interpretation. A correct diagnosis is crucial so as to avoid unnecessary procedures and treatments in these patients. Holland solution should be used for fixation of the biopsy specimen in suspicion of hematopoetic malignancy. Additionally, Tdt, CD34, CD15, CD20, PAX5, CD2, CD3, CD5, CD10, pcl-6, bcl-1, and CD56 were useful for immunohystochemical evaluation of leukemia and lymphoma.

CONCLUSION
To date, no standard treatment for breast metastasis of leukemia and lymphoma has been identified. Mastectomy is not indicated and wide local excision is not required as these tumors are highly sensitive to radiotherapy and systemic chemotherapy [10]. For small localized tumors, adequate surgical resection may be effective, followed by chemotherapy or radiotherapy.

CONSTENT
All authors declare that 'written informed consent was obtained from the patient for publication of this case report and accompanying images

ETHICAL APPROVAL
It is not applicable.