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by Biswajit Dubashi, MD, DM
A 69-year-old man with no comorbidities and a family history of cancer presented with a right breast lump of 1 month’s duration. On examination, a 3×2-cm right breast lump with ulceration, fixed to the pectoralis major muscle, was noted. A right axillary hard mobile lymph node was also found. Investigations revealed hemoglobin 8.2 g/dL and total leucocytes 63×109/L, with a differential count of neutrophils 13%, lymphocytes 2%, abnormal cells 85%, and platelets 75×109/L. Bone marrow aspiration and biopsy revealed cll with CD5+ and CD23+. Trucut biopsy from the breast lump revealed an infiltrating ductal carcinoma positive for the estrogen receptor and negative for the progesterone receptor. Staging work-up was normal. The patient had renal dysfunction (creatinine clearance: 30 mL/min) with 13% elevation in uric acid and normal serum calcium and potassium, suggestive of tumour lysis syndrome. The final diagnosis was synchronous primary with carcinoma right breast T4bN1M0 and cll Rai stage iv.
- What are the Malignancies associated with Chronic Lymphocytic Lymphoma?
- What are the various theories associated with development of second malignancies in patients?
- Which malignancy will you treat initially?
- Outline the management of breast cancer in the above patient.
- Outline the management of cll in the above patient.
1. In a retrospective analysis, it was found that in patients with CLL, the risk of all cancers was 3-fold, the risk of skin cancer was 8-fold, and the risk of all cancers, excluding skin cancer, was 2-fold higher than that for an age- and sex-matched control population. (Manusow D, Weinerman BH (1975) Subsequent Neoplasia in Chronic Lymphocytic Leukemia. JAMA 232:267-269) A study of 4,869 patients with CLL from a series in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI), patients with CLL were at increased risk of developing the following secondary cancers: malignant melanoma, soft-tissue sarcomas, and lung cancer.
i. Drug-induced – alkylating agents and nucleoside analogues
ii. Richter’s transformation
iii. Genetic predisposition
iv. Immunological defects
3. The patient has been diagnosed as CLL Stage IV and CA Breast T4BN1M0. The carcinoma breast in this patient has to be treated initially.
4. The advanced nature of the (untreated) CLL, combined with renal dysfunction, makes tolerance to an anthracycline and methotrexate regimen doubtful. Hence, this patient could be considered for neoadjuvant radiotherapy to the breast. As the patient is receiving neoadjuvant radiotherapy, patient could be started on treatment for CLL. Once the counts normalise, chemotherapy for breast cancer could be given. (Claude Jacquillat, MD, Marise Weil, MD. Results of neoadjuvant chemotherapy and radiation therapy in the breast–conserving treatment of 250 patients with all stages of infiltrative breast cancer. Cancer Volume 66, Issue 1, pages 119-129, July 1, 1990)
5. Patient can be considered for fludarabine or bendamustine based therapy. Protocols include fludarabine + cyclophosphamide + rituximab (FCR), bendamustine + rituximab (BR). Management of tumor lysis.