CASE REPORT Open Access F-18 fluorodeoxyglucose positron emission tomography and/or computed tomography findings of an unusual breast lymphoma case and concurrent cervical cancer: a case report

Introduction: Breast lymphoma accounts for less than 1% of all non-Hodgkin’s lymphomas and approximately 0.1% of all breast neoplasms. Most breast lymphomas are classified as diffuse large B-cell lymphomas or as mucosa associated lymphoid tissue lymphomas. Concurrent cases of breast lymphoma and cervical cancer are extremely rare. Case presentation: We report a case of a 46-year-old woman of unknown ethnic origin diagnosed with concurrent diffuse large B-cell lymphoma of the breast and squamous cell cancer of the cervix that was detected and followed with F-18 fluorodeoxyglucose (FDG) positron emission tomography and/or computed tomography (PET/CT). The metastatic pattern of this case of breast lymphoma is similar to that of a typical metastatic breast carcinoma. These findings have never been described in the literature. PET/CT also demonstrated an incidentally intense FDG focus in the uterine cervix ultimately leading to the pathologic diagnosis of squamous cell carcinoma of the uterine cervix. An appropriate staging of breast lymphoma and cervical cancer with FDG PET/CT is important because of therapeutic consequence. This case report and review of the literature highlights the role of FDG PET/CT in staging and restaging of both breast lymphoma and cervical cancer. Conclusions: We report a case of a breast lymphoma with a metastatic pattern similar to that of typical metastatic breast carcinoma. The FDG PET/CT scan also diagnosed a rare case of concurrent breast lymphoma and cervical cancer. This concurrence has not been reported previously in the medical literature. Introduction Breast lymphoma accounts for less than 1% of all cases of patients with non-Hodgkin’s lymphomas (NHL) [1] and approximately 0.1% of all cases of patients with breast neoplasms [2]. Most breast lymphomas are either classified as diffuse large B-cell (DLBC) lymphomas (as with the case of our patient) or as mucosa associated lymphoid tissue (MALT) lymphomas. The prevalence of breast lymphoma is much less compared to that of cervical cancer. In the USA, there were an estimated 11,070 new cases of invasive cervical cancer in 2008. As a result, 3870 cancer-related deaths are expected. This represents approximately 1% of cancer deaths in women [3]. 18-Fluorodeoxyglucose (FDG) positron emission tomography and/or computed tomography (PET/CT) has been shown to be useful in the diagnosis, staging and restaging of various cancers with accuracies ranging from 80% to 90% [4]. We describe the staging and restaging findings of FDG PET/CT scans in a patient with synchronous breast lymphoma and cervical cancer and highlight this rare clinical occurrence. To the best of our knowledge, concurrent breast lymphoma and cervical cancer have not been reported in the literature. Case presentation A 46-year-old woman of unknown ethnic origin presented to her primary doctor with a one-month history * Correspondence: [email protected] Department of Radiology, Division of Nuclear Medicine, Saint Louis University, 3635 Vista Avenue (at Grand Avenue), Saint Louis, MO, 63110, USA Full list of author information is available at the end of the article Nguyen et al. Journal of Medical Case Reports 2010, 4:282 http://www.jmedicalcasereports.com/content/4/1/282 JOURNAL OF MEDICAL CASE REPORTS © 2010 Nguyen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. of a painless left breast lump without associated nipple discharge that was noticed by the doctor on examination. She was otherwise healthy with no other relevant history. Physical examination revealed a large, non-tender, freely movable mass in the left breast and multiple enlarged lymph nodes in the left axilla. Our patient reported no systemic B symptoms such as fever or weight loss. A biopsy of her left breast mass revealed a DLBC lymphoma. Our patient was then referred for staging with F-18 FDG PET/CT that was acquired from base of skull to upper thigh with the CT being low-dose and unenhanced. The PET/CT scan revealed a 8 × 10 cm hyperdense and intensely FDG-avid mass occupying almost the entire left breast with maximum standard uptake value (SUV) of 21 (Figure 1). In addition, several left axillary lymph nodes measuring up to 5 cm in size and several left sub-centimeter internal mammary lymph nodes showed intense FDG avidity (Figure 2), with SUV values of 33 and 3.3. However, PET/CT findings were suggestive a breast carcinoma rather than a lymphoma, based on the location and distribution of the lesion. Because of the rarity of breast lymphoma, it would be unusual to consider metastatic breast lymphoma in the differential diagnosis of breast tumors. As a result, it would have been impossible to distinguish breast lymphoma from breast carcinoma through PET/ CT. An incidental finding of intense FDG uptake in the uterine cervix, SUV of 8, led to the subsequent pathologic diagnosis of a previously unsuspected squamous cell carcinoma (Figure 3). The lesion appeared to involve the proximal third of the vagina and the corpus uterine, but a tumor extension to the parametrial soft tissue was not noticed. Our patient underwent chemotherapy for NHL of the breast and cervical cancer as well as afterloading brachytherapy to the uterine cervix. A repeat FDG PET/CT three months after completion of therapy showed resolved FDG avidity of all previously described lesions (Figures 1, 2, 3).