Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 2, 2011, pp. 253-255

Indian Journal of Cancer, Vol. 48, No. 2, April-June, 2011, pp. 253-255

Letter to Editor

Multifocal bilateral breast masses in HIV-positive status

K Vaishnav, S Shah, S Pandhi, Y Rathi

Department of Radiodiagnosis, The Gujarat Cancer Research Institute, Civil Hospital campus, Ahmedabad, Gujarat, India

Correspondence Address:K Vaishnav Department of Radiodiagnosis, The Gujarat Cancer Research Institute, Civil Hospital campus, Ahmedabad, Gujarat India kavitaradio@gmail.com

Code Number: cn11060

DOI: 10.4103/0019-509X.82878

Sir,

We present two rare cases of bilateral multifocal breast lesions in patients with human immunodeficiency virus (HIV) positive status. The masses were diagnosed with non-Hodgkin′s lymphoma (NHL) in the first case and carcinoma in the second.

A 47-year-old woman with HIV positive status on antiretroviral treatment since 3 years was recently operated for NHL of the right eyelid. She presented with complaints of swelling in the right eyelid and multiple painless lumps in both breasts. Mammography revealed multiple well-defined nodular soft tissue densities in both breasts [Figure - 1]a. Ultrasonography (USG) revealed well-defined discrete hypoechoic lesions with surrounding echogenic halo in both breasts, with more such lesions in the left breast [Figure - 1]b. Biopsy of the lesion showed the lesions to be NHL, and she was then initiated on chemotherapy.

A 38-year-old woman with HIV positive status presented with lumps in both breasts. On examination, multiple lumps were palpated in both breasts. Mammography revealed well-defined lobulated soft tissue densities in both breasts, with few coarse scattered calcifications [Figure - 2]a. The USG breast correlation revealed multiple well-defined hypoechoic lesions with lobulated margins. Colour Doppler study showed internal hypervascularity [Figure - 2]b. The patient was on antiretroviral treatment for 8 months. A biopsy of the breast lesion revealed high-grade ductal carcinoma. Screening of the abdomen revealed a small well-defined hypoechoic lesion in the body of pancreas [Figure - 2]c. A bone scan of the patient showed multiple areas of tracer uptake in the skull vault, both acetabulum, and proximal end of the right femur consistent with metastasis. The patient is currently on chemotherapy.

Both patients were initiated on nucleoside reverse transcriptase inhibitor (NRTI) and non-NRTI (NNRTI) group of antiretroviral treatment.

Common breast lesions occurring in patients with HIV positive status include tuberculous mastitis, enlargement of the intra-mammary lymph nodes, and lymphoma and breast involvement in Kaposi′s sarcoma.

Very few cases of breast masses in patients with HIV positive status have been reported. Of these, 38 cases are of breast cancer. ^[1] There is an increased propensity of lymphomatous involvement of the breast in patients with HIV positive status. Primary NHL of the breast is confined to the breast with ipsilateral lymphadenopathy and accounts for less than 0.7% of all NHLs. ^[2],[3]

HIV infections are associated with an increased risk of extra-nodal lymphomas. Furthermore, it has been speculated that the virus affects the breast parenchyma components by decreasing its ability to suppress growth of tumour cells. ^[4]

Although most patients present with palpable lumps, it is difficult to clinically distinguish it from the more common breast carcinoma. Differentiation between the two can only be made by fine needle aspiration cytology or core biopsy.

Breast cancer is not an acquired immunodeficiency syndrome (AIDS)-defining disease and its incidence does not increase in patients with HIV positive status. HIV-related immunocompromise does not have a direct tumorogenic role. ^[1] The rising incidence of HIV infection in women and the prolonged survival increases the risk of development of breast cancer in this population. ^[1]

However, aggressiveness of the disease is much more in patients with HIV positive status. It presents at a relatively early age, with an increased incidence of bilaterality of the disease. The disease also presents with atypical histology and early metastatic spread, with a poor outcome as in our reported case.

It is not clear whether the epidemiology, clinical scenario, pathology, and outcome of breast cancer are related, in any way, to HIV infection. Patients diagnosed with both breast cancer and HIV infection face multiple treatment dilemmas.

In conclusion, mammography of both patients described earlier showed multiple well-defined soft tissue density lesions with no typical features of malignant breast mass. On the radiological basis, it was not possible to differentiate between lymphomatous involvement and primary breast malignancy. Thus, breast mass in a woman with HIV positive status should be worked up thoroughly for the type of malignancy and then accordingly for appropriate treatment planning.

References

Copyright 2011 - Indian Journal of Cancer

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