Singhal Manish, Raina Vinod, Gupta Ritu, Das Prasenjit
Department of Medical Oncology, Institute Rotary Cancer Hospital (IRCH), All India Institute of Medical Sciences (AIIMS), New Delhi, India.
Cases J. 2010 Jan 4;3:4. doi: 10.1186/1757-1626-3-4.
Therapy related second malignancy of the hematological system is small but real risk after adjuvant chemotherapy for breast cancer. It includes acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS); however T-cell prolymphocytic leukemia (T-PLL) has not been described earlier in relation to breast cancer and its therapy. T-PLL is a rare chronic T-cell lymphoproliferative disease with a mature post-thymic T-cell immunophenotype and aggressive clinical course.
A 45 year old Indian female of Nordic origin presented 5 years back with a lump in the right breast and the axilla. She underwent modified radical mastectomy. Histophotomicrograph of the excised breast lesion showed a 2.1 cm duct carcinoma, positive for ER and PR with 1 out of 25 lymph nodes positive for metastasis. She received 6 cycles of chemotherapy with cyclophosphamide, epirubicin, and 5-fluorouracil. This was followed by tamoxifen 20 mg per day for five years. She was doing well on follow up until the completion of fifth year of her disease, when she presented with complaints of mild fever and weakness. Examination revealed generalized lymph node enlargement along with hepatomegaly. Hemogram showed mild anemia, normal platelet count and a leukocyte count of 1.2 x 10(11)/L. Peripheral blood examination revealed medium sized lymphoid cells, constituting almost 75% of total nucleated cell population. Immunophenotying, established a diagnosis of post thymic T-cell prolymphocytic leukemia. Contrast-enhanced computed tomography of the chest and abdomen was done which revealed an anterior mediastinal mass with destruction of sternum along with multiple small nodular shadows in bilateral lung fields suggestive of lung metastasis. Fine needle aspiration cytology of the mass showed atypical ductal cells with nuclear pleomorphism, which were positive for ER, PR and Her2neu protein. This confirmed a co-existent metastatic breast carcinoma. She was started on chemotherapy for T-PLL along with hormonal therapy with aromatase inhibitor. Unfortunately, both her malignancies progressed after an initial stable disease of two months.
Our case describes the potential of breast chemotherapy to cause grave second hematological malignancies of the T-cell lymphoid lineage, not described earlier. Such events highlight the importance to identify those patients of breast cancer in whom chemotherapy can safely be avoided.
乳腺癌辅助化疗后发生血液系统治疗相关的第二原发性恶性肿瘤的风险虽小但确实存在。它包括急性髓系白血病（AML）和骨髓增生异常综合征（MDS）；然而，此前尚未有关于乳腺癌及其治疗与T细胞幼淋巴细胞白血病（T-PLL）相关的报道。T-PLL是一种罕见的慢性T细胞淋巴增殖性疾病，具有成熟的胸腺后T细胞免疫表型和侵袭性临床病程。
一名45岁具有北欧血统的印度女性5年前因右乳及腋窝肿块就诊。她接受了改良根治性乳房切除术。切除的乳腺病变组织学显微照片显示为2.1厘米的导管癌，雌激素受体（ER）和孕激素受体（PR）呈阳性，25个淋巴结中有1个有转移。她接受了6个周期的环磷酰胺、表柔比星和5-氟尿嘧啶化疗。随后每天服用20毫克他莫昔芬，持续五年。在疾病的第五年结束前随访期间她情况良好，之后她出现低热和乏力症状。检查发现全身淋巴结肿大及肝肿大。血常规显示轻度贫血、血小板计数正常，白细胞计数为1.2×10¹¹/L。外周血检查发现中等大小的淋巴细胞，几乎占总核细胞群的75%。免疫表型分析确诊为胸腺后T细胞幼淋巴细胞白血病。胸部和腹部增强计算机断层扫描显示前纵隔肿块伴胸骨破坏，双侧肺野有多个小结节阴影，提示肺转移。肿块的细针穿刺细胞学检查显示非典型导管细胞，核异型性，ER、PR和人表皮生长因子受体2（Her2neu）蛋白呈阳性。这证实同时存在转移性乳腺癌。她开始接受T-PLL化疗及芳香化酶抑制剂激素治疗。不幸的是，在最初两个月病情稳定后，她的两种恶性肿瘤均进展。
我们的病例描述了乳腺癌化疗导致严重的T细胞淋巴系第二血液系统恶性肿瘤的可能性，此前未被报道。此类事件凸显了识别那些可安全避免化疗的乳腺癌患者的重要性。
