Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 47, Num. 4, 2010, pp. 477-479

Indian Journal of Cancer, Vol. 47, No. 4, October-December, 2010, pp. 477-479

Letter to Editor

Synchronous carcinoma breast with chronic myelogenous leukemia: A rare presentation

A Bahl, A Dhiman, V Talwar, DC Doval

Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi - 110 085, India

Correspondence Address:
A Bahl
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi - 110 085
India
drankurbahl@gmail.com

Code Number: cn10115

PMID: 21131771

DOI: 10.4103/0019-509X.73558

Sir,

A 45-year-old woman was diagnosed as a case of carcinoma (CA) left breast. She had a 5-cm lump in left breast; fine-needle aspiration cytology revealed infiltrating ductal carcinoma. On investigation, she was found to have leukocytosis of 105 Χ 10 ⁹ /L with shift to left and blast 5%, peripheral smear was suggestive of myeloproliferative disorder. Further investigation by bone marrow aspiration was suggestive of chronic myelogenous leukemia (CML) [Figure - 1], BCR-ABL by real-time reverse transcriptase polymerase chain reaction (RT-PCR) quantitative assay was positive, with 81.9% on fluorescence in situ hybridization analysis. She was finally diagnosed as synchronous CML and carcinoma breast [Figure - 1].

Subsequently, before surgery, cytoreduction was done with hydroxyurea followed by imatinib in the dose of 400 mg/d. Left modified radical mastectomy was performed and on HPE, the tumor was invasive ductal carcinoma grade II [Figure - 2], pT2N3M0 with 21/26 lymph node positives at levels I-III with extracapsular extension. Breast prognostic profile was estrogen receptor 100% and progesterone receptor 80%, and HER2/neu score was not overexpressed [Figure - 2].

She was planned for adjuvant chemotherapy for intraductal breast concurrently with imatinib. She was continued on imatinib 400 mg once a day. TAC regimen (docetaxel, adriamycin, cyclophosphamide) was instituted and supported with granulocyte colony-stimulating factor, whenever required.

Imatinib was withheld whenever neutropenia was encountered, and G-CSF support was given. Chemotherapy was completed over a period of 22 weeks with an inadvertent delay of 4 weeks.

Subsequently, the patient was planned for adjuvant hormonal manipulation with tamoxifen 20 mg daily and radiation therapy while continuing with imatinib 400 mg once daily. After 6 months on imatinib, BCR-ABL was 3.01% with RT-PCR method. During the treatment duration, imatinib was withheld 3 times because of neutropenia and 1 episode of febrile neutropenia. BCR-ABL done after 12 months and 18 months with RT-PCR method was 0.0% and 0.03%, respectively. She has now completed 2 years of follow-up and is presently on imatinib and tamoxifen.

Although a number of case reports are in literature that leukemia either CML, acute lymphocytic leukemia, chronic myelomonocytic leukemia occurred after anthracycline-based therapy of CA breast or synchronously with adenocarcinoma stomach/hairy cell leukemia but simultaneous occurrence of CML and CA breast has not been reported in the literature.^[1]

In general, a person with one malignancy is at an increased risk of developing another malignancy. Nineteen cases of second malignancies (CA prostate-4 cases, CA breast-1 case, adenocarcinoma stomach-1 case, lymphoma-1 case, CA ovary-2 cases, CA cervix 1 case, small cell lung cancer -1 case, CA rectum-1 case, basal cell cancer skin-1 case) in CML patients have been reported but only 1 case of synchronous CML with gastric adenocarcinoma. ^[2] Moertal et al reported 17 cases of CML occurring in association with a second malignancy. In one study with age- and sex-matched controls, patients who were 40-60 years old when CML was diagnosed had an approximately 10-fold higher frequency of other malignancies than did age-matched controls. Patients younger than 40 years did not have a second malignancy.^[3]

Studies have shown that in CML, mutation at the stem level, that is, in ph chromosome, occurs around 6 years before the presentation of the disease, whereas carcinoma breast occurs many years prior to its presentation.^[4]

In summary, our case of CA breast with CML is a rare presentation and it appears to be more of a coincidence than any association.

References

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