https://www.medicalnewstoday.com/articles/320930.php#detox
Saturday, November 30, 2019
I think what hurt me most was that I was made to feel as a predator and threat to you, when my only thoughts toward you were of caring and concern. I knew of how nice and sweet our relationship and people who had no clue of it, despoiled it and turned sweet into sour. They had the temerity to claim to know better than those involved and dared to speak for you and for myself and my intentions.
All I knew was that I found sheer joy in out meetings and a passion in seeing your happiness with each gift of appreciation I bestowed upon you.
Your happiness was/is my delight in life and hopefully will again, should I be so blessed, otherwise you will remain in my heart and mind as being from the period when life became beautiful and then, was gone, and life just became a waiting period for the end.
All I knew was that I found sheer joy in out meetings and a passion in seeing your happiness with each gift of appreciation I bestowed upon you.
Your happiness was/is my delight in life and hopefully will again, should I be so blessed, otherwise you will remain in my heart and mind as being from the period when life became beautiful and then, was gone, and life just became a waiting period for the end.
Friday, November 29, 2019
I would love to go to a place like a lookout with you and really get to know you and listen to your thoughts and opinions. It would be such a lovely, quality time. I guess it is only a dream.
I want you to know me, not the one who was smeared by people who wanted you to hate me. But, the thing is that you were always there for me as much as you were able. I so appreciated that and loved you so much for it. I always felt like you saw the best of me and I in you. I do understand you and I just feel like holding you and giving you happiness and soothing any pain. I want to see you again. I want to love you forever and I will. I will only be what you want. Only time has changed, not my feelings.
I want you to know me, not the one who was smeared by people who wanted you to hate me. But, the thing is that you were always there for me as much as you were able. I so appreciated that and loved you so much for it. I always felt like you saw the best of me and I in you. I do understand you and I just feel like holding you and giving you happiness and soothing any pain. I want to see you again. I want to love you forever and I will. I will only be what you want. Only time has changed, not my feelings.
Each day I go through such a wide range of emotions. It is weird when I only have myself with whom I have to reason things out. When I am down on myself, you hate me too, when I picture your kindness and sweet smile, I am hopeful again. It is a tiring battle, but I always end with how much I care about you and how much my heart feels lovely and at peace when it lands on you and your beautiful ways of devotion. I don't want it to ever leave.
Thursday, November 28, 2019
I would have been better off staying his patient. At least then I would have been able to see him once in awhile, instead of nothing and being tormented by jerks. Of course, they would have just come up with some accusation to make up against me anyway. They just wanted me gone. Everyone involved in this harm against me are criminals and I can prove it.
I may not even get the biopsy, if I cannot have someone observe.
I may not even get the biopsy, if I cannot have someone observe.
Wednesday, November 27, 2019
CEO TYSON ALLOWED TERRIBLE THINGS TO GO ON AT KAISER!
Mr. Tyson allowed their law firm of Buty & Curliano, with Mike C. Guasco as lead attorney, to attack certain patients with false restraining orders so they could "neutralize" them and put them in a bad light, BEFORE that patient could bring up a legal complaint against Kaiser, or perhaps if the patient was deemed to be putting a financial drain on Kaiser with their chronic illness. They would smear them and threaten them with jail. They make their employees put their names on the restraining orders and use actors in court to cry and make accusations against innocent patients who could not hire an attorney! TRO/RESTRAINING ORDERS are DIFFICULT TO FIGHT, ESPECIALLY W/O an attorney!
KAISER/their law firm, TREATS EMPLOYEES, INCLUDING DOCTORS, LIKE THEIR PROPERTY! They FORGED my doctor's signature and LIED in court docs and even used FALSE EVIDENCE! MR. GUASCO (Arrested twice and was married to a woman with many, many, many arrests for controlled substances) LIED IN COURT, HAD MY DOCTOR'S SIGNATURE FORGED, SAID MY DOCTOR WAS PRESENT IN COURT IN COURT FILED PAPERS, WHEN HE WAS NOT THERE (My adult son is a witness) and OUTSIDE COURT, MR. GUASCO SCREAMED IN MY FACE AND THREATENED ME! HE SAID HE COULD KEEP ME RESTRAINED FOREVER! I also believe that the Judge's signature was forged and by the same person who was deemed the one who forged my doctor's signature! It was looked over by an expert handwriting analyst: THEY DETERMINED IT TO BE KAISER PSYCHIATRIST, MARIJA M. PETROVIC from Serbia! She TERRORIZED ME with her devised plots and by making cruel and humiliating phone calls to me. She packed my chart with 5 false major mental illnesses, then harassed me with the cruel phone calls! I believe she wanted me to KILL myself and nearly succeeded. My doctor was my HERO! He must have sensed something bad was going on and he had many people call me and distract me.
I suppose it is all done to help Kaiser save the IMPORTANT bottom line: MONEY and reputation and to please someone (another Kaiser employee) I supposedly annoyed because of my doctor's kindness toward me!! I wrote MANY emails, tweets, etc to Mr. Tyson and he did NOTHING TO STOP IT FROM CONTINUING! Neither did exec VP MARK ZEMELMAN and I spoke twice with him on the phone!! They allowed me to be tortured and traumatized for 4 years! I DID NOTHING WRONG, YET I WAS SMEARED AND FALSELY ACCUSED!
THERE IS ANOTHER INNOCENT KAISER PATIENT SUFFERING NOW TOO! He has been going through Hell and has a son with a traumatic brain injury to care for 24-7, yet GUASCO threatens the poor man, the ONLY caretaker for his son, to be threatened with JAIL! The man's story is heartbreaking, yet GUASACO tells him how glad he is to hurt him!! How Guasco and law firm, BUTY & CURLIANO allow such horrible things to go on is DISGUSTING! I KEPT THEM APPRISED! What did they do? THEY MADE MR. GUASCO PARTNER!
THEY all DID THINGS TO TRY and MAKE ME FEEL LIKE DYING! None of my complaints to KAISER were EVER given ANY consideration! They got judges on their side and especially Judge Novak at San Mateo Superior Court! She harassed me, she mocked me, she had the courtroom cleared and she said terrible untrue things about me! Mr. Guasco of Kaiser hired law firm of Buty & Curliano, manufactured a TRO against me (which is his usual M.O. against innocent patients) and smeared my name and made it so no attorney would take my case. I had no real resources to fight my battle anyway. I was accused of giving my doctor unwanted gifts! REALLY! Then they added in some fake salacious accusation to make it seem dire, I guess. Another thing was, that I had not seen that doctor for 97 days prior to the TRO! BUT as soon as my doctor came to observe my gallbladder removal surgery at my request, a week later, MR. GUASCO had me served with a TRO! The TRO was in my doctor's name, but I believe he actually did it for another Kaiser employee who did not like my doctor's kindness toward me and wanted me out of the way, or as Kaiser security guard, Edward Souza (now in Kaiser SSF Janitorial as a supervisor, most likely as reward for all his cruel acts against me) said to me, "Marija Petrovic was hired back to Kaiser, SPECIFICALLY TO GET RID OF YOU!" I have a witness. Marija M. Petrovic VICIOUSLY BRUTALIZED ME AND ATTACKED ME! MR. TYSON, KAISER CEO, DID NOTHING TO HELP ME! THEIR LAW FIRM HAS TOO MUCH POWER/CONTROL! THEY ARE RUINING KAISER!
I am a senior widow, and former cancer patient and have some serious issues with my MS and MR GUASCO KNEW IT, so it is most likely why he had everyone connected with Kaiser and the case, YELL at me, so I would die of the MS brain lesion, or make my cancer come back! (I have a suspicious mass in my breast now) An attorney, Charles Smith IV (Redwood City, CA), pretended to be my attorney with the Private Defender Program and he screamed at me and kept me quiet and did NOTHING to help me! In fact, he served me up to Judge Novak on a platter and asked to have the courtroom cleared, so she could ream me out so badly that I know I passed out for a moment! In court, Judge Lisa Novak heckled me and called me "STALKER" as I walked past her to the witness stand. Then, she interrupted me and had everything I said stricken from the record! She gave me 5 days in JAIL, even though my doctor , whose name was USED (no doubt under lies and threats) on the restraining order, refuted the entire restraining order on the witness stand! Judge Novak ignored him!! They never brought him back to court!
Kaiser is obviously spending a ton of money on my case and has hurt me like mad, all because my doctor was kind to me! His life has been made inconvenienced, to say the least and had to go through the humiliation of giving a restraining order to his own patient, for his being kind to her! Guasco was wrong to take a case of this nature, but worse for trying to harm me, and for lying to the court! He is supposed to be an officer of the court yet he spits on it and shows complete disdain to their rules and protocol! Because I have seen what he has done with all the lies, forgeries and false evidence, I feel no regret in calling Mike C Guasco and his law firm of Buty & Curliano: CRIMINALS! I feel the same about Marija M. Petrovic! KAISER HAS BEEN A PLACE OF TORTURE THROUGH THEM BOTH! IT NEEDS TO STOP BEFORE PEOPLE DIE, OR STILL....
I DESERVE COMPENSATION. I frankly think my doctor does too, he has gone through a lot through this travesty!
Cheryl Petrovich
- I do not feel super confident about a surgeon who talks to a patient while holding his hair with his hands in a ponytail above his head. I also don't want him to arbitrarily put a piece of metal in my breast, when it is not determined to be necessary. I am not even sure if I can trust needles there. They do not seem to like me even Dr. Z seemed somewhat cold and did not follow up on the breast pain and masses. Why just give up, even if he did not think it was cancer.
countessprague@gmail.com
To Kaiser
I was told by your representative, Lily, that bad things are written about me at the beginning of my chart. She told me to look at it, but I said that not being able to see my chart was the problem. I was cut off by a temporary Kaiser employee who used Dr. Koa's name (radiology). He knew nothing about it, but didn't know what to do, so he left it as was. It has been at least since 2017 that I had been denied access to my online account, and it was never justified. I did nothing wrong, but that temporary employee thought it was amusing to do it to me. She did not want me to see what bad things she had done to my chart. Now that she is gone, I think her lie should be reversed. I did nothing wrong and I am not getting the full benefit of the membership. I think it is wrong to smear me in my chart. That is not nice. I have not been given a chance to refute the unfair lies put in it, because they must be lies, since I did nothing wrong, but the person who put them there DID do something wrong and she was hiding it, by blocking me from seeing them to prove it. She put false diagnoses in my chart and laughed about them. She did not like that I denied her romantic advances toward me and she wanted revenge, so she did what she could to make me feel bad. I have not had my online account since 2017, or so. I don't blame Kaiser, I blame the temp. I am glad she is gone.
To Kaiser
I was told by your representative, Lily, that bad things are written about me at the beginning of my chart. She told me to look at it, but I said that not being able to see my chart was the problem. I was cut off by a temporary Kaiser employee who used Dr. Koa's name (radiology). He knew nothing about it, but didn't know what to do, so he left it as was. It has been at least since 2017 that I had been denied access to my online account, and it was never justified. I did nothing wrong, but that temporary employee thought it was amusing to do it to me. She did not want me to see what bad things she had done to my chart. Now that she is gone, I think her lie should be reversed. I did nothing wrong and I am not getting the full benefit of the membership. I think it is wrong to smear me in my chart. That is not nice. I have not been given a chance to refute the unfair lies put in it, because they must be lies, since I did nothing wrong, but the person who put them there DID do something wrong and she was hiding it, by blocking me from seeing them to prove it. She put false diagnoses in my chart and laughed about them. She did not like that I denied her romantic advances toward me and she wanted revenge, so she did what she could to make me feel bad. I have not had my online account since 2017, or so. I don't blame Kaiser, I blame the temp. I am glad she is gone.
I don't want to make your life bad, so just forget I exist. I could never forget you, because you are lovely. I hate that people act like I am a monster. That is not me. I can't live being thought of that way and you deserve better than to be connected with someone who is thought of in that way. I guess I won't seek treatment. You are the only one I trust, so I guess I will do nothing. Just have them drop the court stuff. I don't want to put you through that. I am so sad and confused. It is too bad that those with selfish agendas got involved.
Being a good person was all I had, now I am treated like a monster. I would rather die than be thought that way. Some Kaiser woman said I should see what it says in my chart about me. She sounded disgusted. That isn't fair. I did nothing wrong, but they say bad things in my chart? Why? I have been so sad. I hate this.
I canceled my biopsy. Maybe it would just be better to die. I hate my life. People act like they hate me and that is killing me too, so what is the difference? I am only visible if someone thinks I have done something wrong. At least dying will make some people happy. I used to be considered a nice person, then I did something nice back to my doctor for his kindness and I was suddenly a monster. How could people do that to someone, then allow it to keep going? I know my sadness caused my illness, so I will just stop fighting it. Life is not worth it any longer if I cannot see you. I am so tired.
Tuesday, November 26, 2019
I don't understand. I am sad from so many directions. I am in physical and mental pain. When will it end? Do what makes you happy. I am a supernumerary. I have been so alone and so tormented, I have not died; that makes them unhappy. But, maybe my health will do it for them. I love you, but I am not attractive, I don't expect you to feel love back. Just please help me and I will be gone.
Could it be lymphoma? It could be from my past cancer treatment.
Corresponding author.
Lymphoma Affecting the Breast: A Pictorial Review of Multimodal Imaging Findings
Euddeum Shim, Sung Eun Song, [...], and Gil Soo Son
Abstract
Hematological malignancies rarely affect the breast, and the majority of those that do are lymphomas. In this review, we describe the clinical aspects and multimodal imaging findings of breast lymphoma. We also illustrate the key clinical and radiological findings that allow it to be distinguished from various other malignant and benign diseases of the breast. Breast lymphoma manifests as a breast mass, a change in the subcutaneous tissue or the skin, or enlargement of the associated lymph node on radiological examination. Radiological findings associated with other breast malignancies, such as calcifications, spiculations, or architectural distortions are extremely rare. Skin and subcutaneous changes frequently accompany T-cell lymphoma. Multimodal breast imaging characteristics may aid in the diagnosis of breast lymphoma.
Keywords: Breast, Computed tomography, Lymphoma, Magnetic resonance imaging, Ultrasonography
INTRODUCTION
Hematological malignancies include lymphoid, myeloid, and histiocytic/dendritic neoplasms as defined in the most recent World Health Organization classification, updated in 2008 [1]. Lymphoma is the most common hematological malignancy affecting the breast. However, breast lymphoma accounts for only approximately 0.04% to 0.7% of all breast cancer cases [2,3], and this rarity may be related to the fact that the breast contains very little lymphoid tissue [4,5]. In these cases, it is often difficult to determine the relationship between the breast lesion and the hematological malignancy. Although several previous studies have addressed the imaging features of breast lymphoma, these findings are generally nonspecific and are typically presented as a list that was insufficient to guide clinical practice. As a result, clinicians may misinterpret the imaging findings associated with this lesion and consequently miss its significance. However, unlike a breast carcinoma, a mass of lymphoma cells in the breast does not require excision. To avoid unnecessary treatment, clinicians and radiologists need to know the characteristic imaging features of breast lymphoma.
The purpose of this pictorial review is to illustrate the clinical aspects and multimodal imaging findings of lymphoma affecting the breast. We also described the key radiological and clinical findings that allow it to be distinguished from other breast malignancies and inflammations. We identified articles that concerned breast lymphoma, were published in English between 1983 and 2012, and were indexed on PubMed. In addition, we evaluated the radiological, pathological, and clinical findings of 10 patients who had lymphoma affecting the breast and who underwent multimodal breast imaging studies in our institute between January 2003 and March 2012. The multimodal imaging consisted of mammography, ultrasonography (US), dynamic low-dose computed tomography (CT), and dynamic magnetic resonance imaging (MRI). The protocol for breast low-dose CT differs from that of conventional chest CT, as the former is performed in a prone position to spread the whole breast parenchyma and lower radiation dose settings (120 kVP and 50 mA) are used. The American College of Radiology recommends an average glandular dose of ≤3 mGy for standard screening mammography, and thus, the effective radiation dose should be 6 mGy or less for routine, two-view mammography [6]. When measured radiation doses administered to a CT phantom at 120 kVp and 50 mA were compared with the recommended dose for mammography, a CTDI100 of ≤6 mGy was obtained (2.01-4.08 mGy) [7]. We have already published both the phantom and patient results of the breast CT scan using this protocol and demonstrated satisfactory image quality and radiation doses [7-9]. The radiological findings were evaluated using a modified version of the Breast Imaging Reporting and Data System lexicon [10]. Because this lexicon does not include breast CT, we described CT findings using MRI descriptions, and the density of a breast lesion on a CT scan was compared with that of the pectoralis muscles. Thus, for example, if a lesion was of identical density to the pectoralis muscle, it was described as "isodense."
CLINICAL ASPECTS
Epidemiology
Breast lymphoma may occur as either a primary or a secondary lesion. Wiseman and Liao [11] proposed that, for a diagnosis of primary breast lymphoma, the breast should be the site of the first or major manifestation of the lymphoma and that there should be no evidence of lymphoma elsewhere, except at the ipsilateral axillary node. Primary breast lymphoma accounts for 0.85% to 2.2% of all extranodal malignant lymphomas, and secondary breast lymphoma is more common [12]. The age distribution of reported cases is wide (16-93 years at the time of diagnosis) and the reported median age ranges from 55 to 65 years [13,14], which is similar to the median age of extramammary lymphoma patients [15,16]. Of the 10 cases we described, six (60%) were primary breast lymphomas and the remaining four were secondary lymphomas (Table 1). The median age of the patients was 49.5 years (range, 21-65 years) and all of the patients were women.
Patients characteristics
Clinical findings
The most common symptom of breast lymphoma is a painless, palpable mass. Nipple retraction or discharge and skin change can also occur, but are rare [12,17]. Most B-cell lymphomas of the breast are present as palpable masses, whereas skin changes, edema, and local pain are more commonly associated with T-cell lymphoma [18]. Ipsilateral axillary lymphadenopathy has been reported in 13% to 50% of cases [19]. In our study, all patients had clinical symptoms. These were painless palpable masses in the breast and/or axilla in seven cases (70%), tender subcutaneous nodules in two cases (20%), and breast swelling in one case (10%) (Table 1). Three patients (30%) complained of skin thickening. Both patients (100%) with subcutaneous nodules and two of the three patients (67%) with skin thickening were found to have T-cell lymphoma on pathological examination. Therefore, skin or subcutaneous changes were more common in T-cell lymphoma, which is consistent with the findings of the previous study [18].
Pathophysiology
Most breast lymphomas are of the B-cell type. In a recent study by Surov et al. [12], 94% of breast lymphomas were found to be of the B-cell type and only 6% were of the T-cell type. However, some forms of T-cell lymphoma are more common in Asia than in Western countries [20], most notably peripheral T-cell, nasal T-cell, and natural killer (NK)/T-cell lymphomas. In the breast, T-cell lymphoma occurs only rarely and is reported on a case-by-case basis [21-24]. Included in these reports are lymphoblastic lymphoma, peripheral T-cell lymphoma, multilobated T-cell lymphoma, NK/T-cell lymphoma, cutaneous T-cell lymphoma, and anaplastic large cell lymphoma.
Of growing concern is a possible association between anaplastic large cell lymphoma and breast implants [22,23,25-28]. Previously regarded as chemically inert, silicone has been shown to induce inflammatory T-cell reactions [29]. If implants are causally related to lymphoma, the incidence of T-cell lymphoma in the breast may soon increase. In our study, six patients (60%) had diffuse large B-cell lymphomas and the remaining four (40%) had various T-cell lymphomas: two cases of peripheral T-cell lymphoma and a single case each of NK/T-cell lymphoma and precursor T-lymphoblastic lymphoma (Table 1). We included lymphoma patients who had breast involvement in this study and excluded patients who had only lymph node enlargement, and as a result, T-cell lymphoma manifesting as breast parenchymal or subcutaneous nodules might have been more common in study.
Treatment and prognosis
The optimal treatment for B-cell lymphoma is a multiagent regimen consisting of anthracycline-based chemotherapy with rituximab, possibly also combined with radiation. In patients with an indolent lymphoma such as lymphoplasmacytic lymphoma, mucosa-associated lymphoid tissue lymphoma, low-grade follicular lymphoma, or small lymphocytic lymphoma, radiation therapy is potentially curative. Central nervous system relapse occurs more frequently (3%-27%) in primary breast lymphoma cases than in those involving extramammary lymphoma, and thus, cranial radiation therapy or intrathecal chemotherapy may be performed prophylactically [15]. Treatment for T-cell lymphoma varies widely because there are so many different types. Standard lymphoma therapies including chemotherapy, radiation, bone marrow transplantation, and surgery may be effective in some cases, and ultraviolet light therapy or electron beam radiation is effective for T-cell lymphoma with skin involvement. With appropriate management, a high rate of locoregional control can be achieved for primary breast lymphoma, although there is often systemic relapse. The 5-year overall survival for diffuse large B-cell lymphoma in the breast has been reported to range from 60% to 65% [30-32]. Of the 10 cases included in our study, two patients underwent excision with chemotherapy, three received radiation therapy with chemotherapy, and the remaining five received only chemotherapy (Table 1). Radiation therapy was administered in 75% of the T-cell lymphoma cases. Seven of our 10 patients (70%) had complete remission after treatment, two patients (20%) underwent salvage treatment due to tumor recurrence after complete remission, and the remaining patient (10%) achieved a partial remission.
MULTIMODAL BREAST IMAGING FINDINGS
Lymphoma affecting the breast manifests as a breast mass, a change in the subcutaneous tissue or the skin, or enlargement of the associated lymph node on radiological examination.
Breast mass
On mammography, breast lymphoma appears as a solitary, noncalcified, circumscribed, or indistinctly delineated, oval or round mass that can vary in density (Figures 1--3)3) [33,34]. Calcifications, spiculations, and architectural distortion are distinctively absent [17,33,34]. For B-cell lymphoma, diffuse or ill-defined increases in breast density representing irregular infiltrating processes may be observed. Mammography is limited in its capacity to detect lymphomas that present as a diffuse infiltration or a small mass (Figure 4). For these lesions, which may be associated with skin thickening or breast edema, US is often more informative (Figures 4, ,5),5), as breast lymphoma usually appears as a hypoechoic solid mass with circumscribed or indistinct margins (Figures 1--4)4) [28,29,33-36]. Heterogeneous echo patterns, hypoechogenicity, and hyperechogenicity are also seen frequently in breast lymphoma, and were present in 23% of cases in a study by Yang et al. (Figures 6--8)8) [13]. Posterior acoustic enhancement is another common feature, as is an echogenic rim or onion peel-like rim surrounding the mass that may represent lymphedema (Figure 2). The value of MRI of breast lymphoma is not firmly established, but inhomogeneous enhancement is seen in most cases on T1-weighted images after the administration of contrast media (Figure 2) [12,37,38]. Kinetic analysis on MRI shows that most breast lymphomas exhibit a rapid initial enhancement and plateau or a washout delayed phase enhancement (Figure 2) [12,13]. On CT, most lymphomas present as a circumscribed round or oval mass with various degrees of enhancement (Figures 2--4)4) [12].
A 61-year-old woman with diffuse large B-cell lymphoma. (A) Both craniocaudal mammograms show multiple circumscribed oval or round masses (arrows) in both breasts. On (B) right and (C) left breast ultrasonography, the masses (arrows) are circumscribed ...
A 43-year-old woman with diffuse large B-cell lymphoma. (A) Both craniocaudal and mediolateral oblique mammograms demonstrate bilateral indistinct oval or round masses (arrows) and axillary lymph node enlargements (white arrowheads). (B) Ultrasonography ...
A 46-year-old woman with diffuse large B-cell lymphoma. (A) Both craniocaudal and mediolateral oblique mammograms are negative. (B) Ultrasonography scans of the right breast show multiple circumscribed oval hypoechoic masses (arrows). (C) Enhanced breast ...
A 52-year-old woman with precursor T-lymphoblastic lymphoma. (A) Right mediolateral oblique mammogram shows a circumscribed and partially obscured marginated round hyperdense mass (arrows). (B) Ultrasonography scan of the right breast demonstrates a circumscribed ...
A 43-year-old woman with diffuse large B-cell lymphoma. (A) Left mediolateral oblique mammogram shows axillary lymphadenopathy (arrows) and trabecular thickening (arrowheads). (B) Ultrasonography (US) scans of the left breast show skin thickening (arrows) ...
A 65-year-old woman with diffuse large B-cell lymphoma. (A) Ultrasonography (US) scan of the right breast shows an indistinct oval hyperechoic mass (arrows) in the subcutaneous fat layer. (B) US scan of the right axilla shows enlarged lymph nodes with ...
A 62-year-old woman with peripheral T-cell lymphoma. (A) Ultrasonography (US) scans of the right breast show multiple oval or round masses (arrows) in skin and subcutaneous fat layers. (B) Enhanced computed tomography scan of right breast shows multiple ...
Subcutaneous or skin change
US, CT, and MRI facilitate the evaluation of diffuse infiltrative lesions, tiny nodules, or superficial lesions involving the skin or subcutis in breast tissue (Figures 3--8).8). Radiological reports of T-cell lymphoma in the breast are extremely rare compared to those of B-cell lymphoma, although T-cell lymphoma, especially subcutaneous panniculitis-like T-cell or peripheral T-cell lymphoma, preferentially infiltrate the subcutaneous tissues (Figures 6--8)8) [21,39,40]. US shows indistinct and irregular hyperechoic masses in the subcutis, and the hyperechoic areas may contain internal tubular branching hypoechogenicity (Figures 6, ,7)7) [40,41]. Hyperechogenicity in breast lymphoma probably reflects the cellularity of these tumors [42]. On MRI, irregular masses with a rim or heterogeneous enhancement in the subcutis may be present. No characteristic CT findings of breast T-cell lymphoma have been reported to date, although in our study, we observed circumscribed or indistinct isodense masses with skin thickening on dynamic CT scans (Figures 6--88).
A 21-year-old woman with NK/T-cell lymphoma. (A) Ultrasonography (US) scan of the right breast shows an indistinct oval hyperechoic mass (arrows) with internal tubular hypoechogenicities and thickening of overlying skin. (B) US scan of the left breast ...
Lymphadenopathy
Routine breast imaging does not usually help to distinguish between primary and secondary lymphoma, although bilateral axillary lymphadenopathy or breast edema could indicate a secondary lymphoma. US, CT, and MRI are all more useful techniques than mammography for the evaluation of enlarging lymph nodes (Figures 4--6),6), and CT may be useful for the evaluation of intrathoracic and extrathoracic lymphadenopathy and involvement of the chest wall or lung in lymphoma patients (Figure 4).
DIFFERENTIAL DIAGNOSIS FROM OTHER BREAST MALIGNANCIES AND INFLAMMATORY BREAST DISEASES
It is difficult to distinguish breast lymphoma from various benign or malignant breast diseases on the basis of clinical and radiological findings. However, it is important to distinguish between breast lymphoma and other malignant diseases (for example, invasive breast carcinoma), inflammatory breast carcinoma, or metastasis, so that the appropriate treatment can be selected. The diagnostic strategy for lymphoma affecting the breast is determined by the presence or absence of known systemic lymphoma. If a patient is known to have systemic lymphoma, changes in the breasts must raise the possibility of a lymphomatous involvement [43]. However, in cases where lymphoma is not otherwise suspected, lymphoma of the breast is usually only suggested as one possibility in the differential diagnosis.
The most common symptom of breast malignancy is a painless palpable lump. Local pain, edema, or subcutaneous or skin nodules are frequent in lymphoma, especially the T-cell type, whereas nipple retraction or discharge is extremely rare [12,17,18]. With respect to radiological findings, the characteristic features of more common breast carcinomas, including calcifications, spiculations, or architectural distortion, are distinctively absent in lymphoma [17,33,34]. Inflammatory breast carcinoma manifests as breast edema with a mass on breast imaging that is usually of irregular shape and has indistinct margins or is spiculated, characteristics that are somewhat different from those of breast lymphoma. Metastasis to the breast manifests as a localized lesion or diffuse infiltration [43]. The former presents as a circumscribed oval or round mass and the latter appears as breast edema with dilated dermal lymphatics on breast imaging. These are very similar findings to those of lymphoma affecting the breast. There are currently no reliable criteria for distinguishing breast lymphoma from metastasis, although a history of a known metastasis or lymphoma in another organ is important in the diagnosis of a breast lesion. The findings of our study revealed that because a subcutaneous breast mass or nodule on radiological examination is rare in invasive breast carcinoma, inflammatory breast carcinoma, or metastasis, a change in the subcutis might aid in the diagnosis of breast lymphoma. Although there are some indicative clinical and radiological features of breast lymphoma, imaging-guided core needle biopsy or excisional biopsy should be performed for confirmative diagnosis. If a patient has a skin or subcutaneous lesion, a full thickness excisional skin biopsy should be performed in order to differentiate breast lymphoma from diffuse infiltrative metastasis and inflammatory carcinoma.
Differentiating breast lymphoma from inflammatory diseases is challenging, especially in patients with a painful breast lump, erythema, or skin thickening [44,45]. Inflammatory breast diseases include infectious mastitis, abscess, or idiopathic granulomatous lobular mastitis. Mammography and US often reveal unilateral breast edema, possibly with accompanying masses, in both breast lymphoma and inflammatory diseases. However, on breast US, the echo pattern of masses and associated findings differ between lymphoma and inflammation. In the latter, the masses are complicated cysts that have movable echoes or sedimentations, complex cysts, which have cystic and solid contents or are hypoechoic [43]. Dilated ducts or fistulous tracts to the skin are also often associated with inflammatory disease [43]. Conversely, a complex cyst is extremely rare and dilated ducts or fistulas are never associated with breast lymphoma. If a breast lesion is located in the subcutis, breast lymphoma needs to be distinguished from panniculitis or fat necrosis. Subcutaneous panniculitis, like T-cell lymphoma of the breast, is indistinguishable from inflammatory panniculitis and fat necrosis because of their clinical and pathological similarities [21,40], as both present as solitary or multiple subcutaneous nodules. Fat lobules in the subcutaneous layer are surrounded by neoplastic T-cells in cases of subcutaneous panniculitis like T-cell lymphoma, and inflammatory cells and some atypical cells are present in inflammatory panniculitis and fat necrosis on pathological examination, resulting in radiologically similar features. Clinically, inflammatory panniculitis spontaneously regresses without treatment within 1 to 4 weeks and frequently occurs in the lower extremities [46]. For the diagnosis of fat necrosis, it is important know the history of breast surgery, trauma, and biopsy [47].
CONCLUSION
Here we have described the clinical aspects and multimodal imaging findings of lymphoma affecting the breast. Breast lymphoma manifests as a breast mass, changes in the subcutaneous tissue or the skin, or enlargement of the associated lymph node on radiological examination. We also have illustrated the key clinical and radiological findings that can distinguish breast lymphoma from various breast malignancies and benign diseases. In breast lymphoma, usual malignant radiological features such as calcifications, spiculations, or architectural distortions are extremely rare, and skin and subcutaneous changes frequently accompany T-cell lymphoma. Multimodal breast imaging characteristics may aid the diagnosis of breast lymphoma.
Footnotes
The authors declare that they have no competing interests.
Article information
J Breast Cancer. 2013 Sep; 16(3): 254–265.
Published online 2013 Sep 30. doi: 10.4048/jbc.2013.16.3.254
PMCID: PMC3800721
PMID: 24155754
Department of Radiology, Korea University Ansan Hospital, Ansan, Korea.
1Department of Pathology, Korea University Ansan Hospital, Ansan, Korea.
2Department of General Surgery, Korea University Ansan Hospital, Ansan, Korea.
Corresponding author.
Correspondence to: Bo Kyoung Seo. Department of Radiology, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, Korea. Tel: +82-31-412-5228, Fax: +82-31-412-5224, rk.ca.aerok@ykoboes
*These authors contributed equaly to this work.
Received 2013 May 4; Accepted 2013 Sep 6.
This article has been cited by other articles in PMC.
Articles from Journal of Breast Cancer are provided here courtesy of Korean Breast Cancer Society
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