Cytodiagnosis of the primary breast lymphoma in a young woman
Identifieur interne : 002289 ( Pmc/Corpus ); précédent : 002288; suivant : 002290Cytodiagnosis of the primary breast lymphoma in a young woman
Auteurs : Shashikant C. U. Patne ; Mohan Kumar ; Rahul KhannaSource :
- Journal of Cytology / Indian Academy of Cytologists [ 0970-9371 ] ; 2013.
Abstract
Primary breast lymphoma (PBL) is a rare entity. It represents 0.4% of malignant breast lesions and 2% of extranodal lymphomas. A 23-year-old woman presented with a left breast lump followed by palpable left axillary lymphadenopathy. Fine-needle aspiration cytology (FNAC) and histopathology were diagnostic of non-Hodgkin lymphoma-large cell type. Immunohistochemistry was positive against leukocyte common antigen and CD20. Because PBLs are uncommon malignant lesions and they usually do not have characteristic clinical and imaging findings, FNAC may prove to be a simple, rapid, reliable, and cost-effective procedure for successful diagnosis of the PBL.
Url:
DOI: 10.4103/0970-9371.126674
PubMed: 24648678
PubMed Central: 3945635
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Cytodiagnosis of the primary breast lymphoma in a young woman</title><author><name sortKey="Patne, Shashikant C U" sort="Patne, Shashikant C U" uniqKey="Patne S" first="Shashikant C. U." last="Patne">Shashikant C. U. Patne</name><affiliation><nlm:aff id="aff1">Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author><author><name sortKey="Kumar, Mohan" sort="Kumar, Mohan" uniqKey="Kumar M" first="Mohan" last="Kumar">Mohan Kumar</name><affiliation><nlm:aff id="aff1">Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author><author><name sortKey="Khanna, Rahul" sort="Khanna, Rahul" uniqKey="Khanna R" first="Rahul" last="Khanna">Rahul Khanna</name><affiliation><nlm:aff id="aff2">Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24648678</idno><idno type="pmc">3945635</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945635</idno><idno type="RBID">PMC:3945635</idno><idno type="doi">10.4103/0970-9371.126674</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">002289</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002289</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Cytodiagnosis of the primary breast lymphoma in a young woman</title><author><name sortKey="Patne, Shashikant C U" sort="Patne, Shashikant C U" uniqKey="Patne S" first="Shashikant C. U." last="Patne">Shashikant C. U. Patne</name><affiliation><nlm:aff id="aff1">Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author><author><name sortKey="Kumar, Mohan" sort="Kumar, Mohan" uniqKey="Kumar M" first="Mohan" last="Kumar">Mohan Kumar</name><affiliation><nlm:aff id="aff1">Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author><author><name sortKey="Khanna, Rahul" sort="Khanna, Rahul" uniqKey="Khanna R" first="Rahul" last="Khanna">Rahul Khanna</name><affiliation><nlm:aff id="aff2">Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Cytology / Indian Academy of Cytologists</title><idno type="ISSN">0970-9371</idno><idno type="eISSN">0974-5165</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Primary breast lymphoma (PBL) is a rare entity. It represents 0.4% of malignant breast lesions and 2% of extranodal lymphomas. A 23-year-old woman presented with a left breast lump followed by palpable left axillary lymphadenopathy. Fine-needle aspiration cytology (FNAC) and histopathology were diagnostic of non-Hodgkin lymphoma-large cell type. Immunohistochemistry was positive against leukocyte common antigen and CD20. Because PBLs are uncommon malignant lesions and they usually do not have characteristic clinical and imaging findings, FNAC may prove to be a simple, rapid, reliable, and cost-effective procedure for successful diagnosis of the PBL.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Jennings, Wc" uniqKey="Jennings W">WC Jennings</name></author><author><name sortKey="Baker, Rs" uniqKey="Baker R">RS Baker</name></author><author><name sortKey="Murray, Ss" uniqKey="Murray S">SS Murray</name></author><author><name sortKey="Howard, Ca" uniqKey="Howard C">CA Howard</name></author><author><name sortKey="Parker, De" uniqKey="Parker D">DE Parker</name></author><author><name sortKey="Peabody, Lf" uniqKey="Peabody L">LF Peabody</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sabate, Jm" uniqKey="Sabate J">JM Sabaté</name></author><author><name sortKey="G Mez, A" uniqKey="G Mez A">A Gómez</name></author><author><name sortKey="Torrubia, S" uniqKey="Torrubia S">S Torrubia</name></author><author><name sortKey="Camins, A" uniqKey="Camins A">A Camins</name></author><author><name sortKey="Roson, N" uniqKey="Roson N">N Roson</name></author><author><name sortKey="De Las Heras, P" uniqKey="De Las Heras P">P De Las Heras</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Brogi, E" uniqKey="Brogi E">E Brogi</name></author><author><name sortKey="Harris, Nl" uniqKey="Harris N">NL Harris</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Watson, Ap" uniqKey="Watson A">AP Watson</name></author><author><name sortKey="Fraser, Se" uniqKey="Fraser S">SE Fraser</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hugh, Jc" uniqKey="Hugh J">JC Hugh</name></author><author><name sortKey="Jackson, Fi" uniqKey="Jackson F">FI Jackson</name></author><author><name sortKey="Hanson, J" uniqKey="Hanson J">J Hanson</name></author><author><name sortKey="Poppema, S" uniqKey="Poppema S">S Poppema</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wiseman, C" uniqKey="Wiseman C">C Wiseman</name></author><author><name sortKey="Liao, Kt" uniqKey="Liao K">KT Liao</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Cytol</journal-id><journal-id journal-id-type="iso-abbrev">J Cytol</journal-id><journal-id journal-id-type="publisher-id">JCytol</journal-id><journal-title-group><journal-title>Journal of Cytology / Indian Academy of Cytologists</journal-title></journal-title-group><issn pub-type="ppub">0970-9371</issn><issn pub-type="epub">0974-5165</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24648678</article-id><article-id pub-id-type="pmc">3945635</article-id><article-id pub-id-type="publisher-id">JCytol-30-284</article-id><article-id pub-id-type="doi">10.4103/0970-9371.126674</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Cytodiagnosis of the primary breast lymphoma in a young woman</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Patne</surname><given-names>Shashikant C.U.</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Kumar</surname><given-names>Mohan</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Khanna</surname><given-names>Rahul</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib></contrib-group><aff id="aff1">Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</aff><aff id="aff2"><label>1</label>Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Shashikant C.U. Patne, Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh, India. E-mail: <email xlink:href="scupatne@gmail.com">scupatne@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Oct-Dec</season><year>2013</year></pub-date><volume>30</volume><issue>4</issue><fpage>284</fpage><lpage>286</lpage><permissions><copyright-statement>Copyright: © Journal of Cytology</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Primary breast lymphoma (PBL) is a rare entity. It represents 0.4% of malignant breast lesions and 2% of extranodal lymphomas. A 23-year-old woman presented with a left breast lump followed by palpable left axillary lymphadenopathy. Fine-needle aspiration cytology (FNAC) and histopathology were diagnostic of non-Hodgkin lymphoma-large cell type. Immunohistochemistry was positive against leukocyte common antigen and CD20. Because PBLs are uncommon malignant lesions and they usually do not have characteristic clinical and imaging findings, FNAC may prove to be a simple, rapid, reliable, and cost-effective procedure for successful diagnosis of the PBL.</p></abstract><kwd-group><kwd>Breast lymphoma</kwd><kwd>FNAC</kwd><kwd>immunohistochemistry</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>Introduction</title><p>Primary breast lymphoma (PBL) is a rare neoplasm that accounts for 0.4% of malignant breast lesions and 2% of extranodal lymphomas.[<xref rid="ref1" ref-type="bibr">1</xref>] Diagnosis of PBL by fine-needle aspiration cytology (FNAC) is reported infrequently. We herein describe the rare cytodiagnosis of the PBL in a young lady.</p></sec><sec id="sec1-2"><title>Case Report</title><p>A 23-year-old non-lactating (para 2, gravida 0) lady came with a left breast lump and lymphedema of the left arm of 1-month duration. She recently had lumpectomy done in the same breast 1-month earlier at a peripheral hospital, which was diagnosed as breast abscess on histopathology. Her ultrasound examination previous to lumpectomy was available that showed an irregular hypoechoic mass of size 2.6 × 2.1 × 1.6 cm in the left breast having both solid and cystic components, perilesional inflammatory changes, and architectural distortion. The ultrasound findings of the left breast suggested focal mastitis with abscess formation. The right breast was normal and bilateral axillary lymphadenopathy was absent at this point of time. Her examination at the present visit revealed an irregular hard tender fixed mass of 6 × 4 cm in the outer lower and upper quadrants of the left breast. The skin overlying the mass was erythematous, nodular, and showed a surgical scar mark just above the areola [<xref ref-type="fig" rid="F1">Figure 1a</xref>]. The largest left axillary lymph node measured 4 × 2 cm. FNAC of the left breast mass and left axillary lymph nodes was done in Department of Pathology. Ethanol-fixed Papanicolaou-stained smears were prepared for cytological study. The breast mass FNAC showed richly cellular monomorphic population of loosely cohesive single lymphoid cells of two to three times the size of mature lymphocytes with moderate anisonucleosis, 1-3 prominent nucleoli and fragile cytoplasm [<xref ref-type="fig" rid="F1">Figure 1b</xref>]. The ductal epithelial cells of the breast were not seen in the cytology smears. Similar cytomorphologic features were also present in the aspirate from left axillary lymph nodes. A cytological diagnosis of non-Hodgkin lymphoma- large cell type was given. A tru-cut needle biopsy of the breast mass also showed features of non-Hodgkin lymphoma. Her formalin-fixed, paraffin-embedded blocks of the prior lumpectomy specimen was then retrieved from the peripheral laboratory and reviewed. Hematoxylin and eosin (H and E)-stained sections showed replacement of the breast parenchyma by diffuse sheets of monomorphic lymphoid cells [<xref ref-type="fig" rid="F1">Figure 1c</xref>]. On higher magnification, the lymphoid cells showed moderate anisokaryosis, clumped nuclear chromatin, prominent nucleoli, and minimal amount of eosinophilic cytoplasm on a background of lymphoglandular bodies [<xref ref-type="fig" rid="F1">Figure 1d</xref>]. Lymphoepithelial lesion was characterized by infiltration of lymphoma cells into the sparsely present duct epithelium of the breast [<xref ref-type="fig" rid="F2">Figure 2a</xref>]. Immunohistochemical studies were performed on formalin fixed, paraffin-embedded blocks of the lumpectomy specimen. Cytokeratin immunostaining showed strong cytoplasmic reactivity in the duct epithelium while the lymphoma cells stained negative [<xref ref-type="fig" rid="F2">Figure 2b</xref>]. In contrast, the lymphoma cells expressed diffuse strong membranous positivity with antibodies against leukocyte common antigen [<xref ref-type="fig" rid="F2">Figure 2c</xref>] and CD 20 [<xref ref-type="fig" rid="F2">Figure 2d</xref>] while negative for CD 15, CD 30, and CD 3. There was no primary elsewhere as evidenced by the absence of hepatosplenomegaly and the absence of any lymph node enlargement other than left axillary lymph nodes. The final diagnosis was primary diffuse large B-cell lymphoma of the breast, stage II. The patient was planned for chemotherapy, her baseline laboratory investigations and ultrasound examination of abdomen was normal. However, further management and follow up of the patient could not be done as she escaped from the hospital against the medical advice.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>(a) Clinical photograph of the patient. (b) FNAC showing dispersed large non-cleaved lymphoma cells aspirated from the breast lump (Pap, x400). (c) Diffuse infiltration of the lymphoma cells resulting in destruction and fibrosis of breast parenchyma (H and E, x200). (d) Magnified view of lymphoma cells against a background of lymphoglandular bodies (H and E, x400)</p></caption><graphic xlink:href="JCytol-30-284-g001"></graphic></fig><fig id="F2" position="float"><label>Figure 2</label><caption><p>(a) Lymphoepithelial lesion demonstrating invasion of ductal epithelium of the breast by lymphoma cells (H and E, x200). (b) Cytokeratin immunostaining strongly positive in ductal epithelium, negative in surrounding lymphoma cells (IHC, x200). (c) Diffuse strong LCA positive immunostaining in tumour cells (IHC, x400). (d) Lymphoma cells showing diffuse strong positivity against CD 20 (IHC, x400)</p></caption><graphic xlink:href="JCytol-30-284-g002"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>Discussion</title><p>This case report highlights the usefulness of FNAC in correct diagnosis of the PBL. The deceptive benign appearance on clinical and ultrasound examinations was diagnosed as non-Hodgkin Lymphoma. FNAC provided the earliest clue to diagnosis of PBL which was later confirmed by histology and immunohistochemistry in this case. Because breast lymphoma is a rare condition, it is not usually considered when a patient presents with the breast lump. However, clinician should be aware of the deceiving benign appearance of PBL in contrast to much more commonly seen breast carcinoma.[<xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref>] On physical examination, PBL often appears as a rapidly growing single palpable nodule of mean size 3.5 cm that is mobile and non-tender.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref4" ref-type="bibr">4</xref>] This probably results from the relatively rapid growth of these lesions in comparison to breast carcinomas, especially in the younger patients.[<xref rid="ref4" ref-type="bibr">4</xref>] Ipsilateral axillary lymph nodes are palpable in 30% to 70% cases.[<xref rid="ref1" ref-type="bibr">1</xref>] Clinical signs of advanced breast malignancy are rare, such as inflammatory changes, nipple retraction, puckering of the skin or tumor fixation.[<xref rid="ref5" ref-type="bibr">5</xref>] Breast lymphoma can occasionally present as a diffuse rapid breast enlargement in the younger age group, or as breast skin thickening due to lymphatic blockage by lymphoma resulting in retrograde edema.[<xref rid="ref4" ref-type="bibr">4</xref>] On diagnostic mammography, PBL often appears as a well-defined mass with smooth margins and homogeneous appearance. Again, signs of breast malignancy such as microcalcification, spiculation, and distortion of surrounding tissue are usually absent.[<xref rid="ref1" ref-type="bibr">1</xref>] Lymphomas in the body when imaged with ultrasound generally appear as hypoechoic masses.[<xref rid="ref4" ref-type="bibr">4</xref>] Likewise PBL will most often demonstrate a well-defined hypoechoic lesion without enhancement suggesting a wrong notion of benignity.</p><p>The specific criteria for diagnosis of PBL were first defined by Wiseman and Liao in 1972.[<xref rid="ref6" ref-type="bibr">6</xref>] These are: (a) the clinical site of appearance is the breast; (b) a history of prior lymphoma or evidence of widespread disease are absent at diagnosis; (c) demonstration of lymphoma in proximity to breast tissue; and (d) involvement of ipsilateral lymph nodes may be present if they develop simultaneously with the primary breast tumor.[<xref rid="ref1" ref-type="bibr">1</xref>] The entire criteria for diagnosis of PBL are satisfactorily present in our case.</p><p>At the time of initial lumpectomy, patient had stage I disease with the tumor limited to the breast only. However, when patient came to us she had significant enlargement of the ipsilateral axillary lymph nodes in association with the recurring breast lump (Stage II disease). This offers evidence that excision biopsy alone is not curative in patients with PBL; rather such a procedure may upstage the disease process in these patients. Thus, if a young patient presents with a rapidly growing breast tumor, lymphoma should be considered before undertaking any surgical intervention. In such cases, a meticulously performed FNAC is vital for an accurate preoperative diagnosis of the breast lymphoma.</p><p>In summary, PBL is a rare entity that accounts for only a small fraction of the breast malignancies. As none of the clinical or imaging features of the disease is characteristic, a rapidly growing breast lump in a young female should warn the attending clinician of this rare possibility. FNAC is very useful, simple, rapid, reliable, and cost-effective procedure for an accurate diagnosis of the lesion.</p></sec></body><back><ack><title>Acknowledgement</title><p>Authors are thankful to Mr. Kanhaiya Lal and Mr. Vikash Agrawal for providing excellent technical assistance in immunohistochemistry.</p></ack><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> Revolving fund of Department of Pathology, IMS, BHU, Varanasi</p></fn><fn fn-type="conflict"><p><bold>Conflict of Interest:</bold> None declared.</p></fn></fn-group><ref-list><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jennings</surname><given-names>WC</given-names></name><name><surname>Baker</surname><given-names>RS</given-names></name><name><surname>Murray</surname><given-names>SS</given-names></name><name><surname>Howard</surname><given-names>CA</given-names></name><name><surname>Parker</surname><given-names>DE</given-names></name><name><surname>Peabody</surname><given-names>LF</given-names></name><etal></etal></person-group><article-title>Primary breast lymphoma: The role of mastectomy and the importance of lymph node status</article-title><source>Ann Surg</source><year>2007</year><volume>245</volume><fpage>784</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">17457172</pub-id></element-citation></ref><ref id="ref2"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sabaté</surname><given-names>JM</given-names></name><name><surname>Gómez</surname><given-names>A</given-names></name><name><surname>Torrubia</surname><given-names>S</given-names></name><name><surname>Camins</surname><given-names>A</given-names></name><name><surname>Roson</surname><given-names>N</given-names></name><name><surname>De Las Heras</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Lymphoma of the breast clinical and radiologic features with pathologic correlation in 28 patients</article-title><source>Breast J</source><year>2002</year><volume>8</volume><fpage>294</fpage><lpage>304</lpage><pub-id pub-id-type="pmid">12199758</pub-id></element-citation></ref><ref id="ref3"><label>3</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Brogi</surname><given-names>E</given-names></name><name><surname>Harris</surname><given-names>NL</given-names></name></person-group><article-title>Lymphomas of the breast: Pathology and clinical behavior</article-title><source>Semin Oncol</source><year>1999</year><volume>26</volume><fpage>357</fpage><lpage>64</lpage><pub-id pub-id-type="pmid">10375092</pub-id></element-citation></ref><ref id="ref4"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Watson</surname><given-names>AP</given-names></name><name><surname>Fraser</surname><given-names>SE</given-names></name></person-group><article-title>Primary lymphoma of the breast</article-title><source>Australas Radiol</source><year>2000</year><volume>44</volume><fpage>234</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">10849995</pub-id></element-citation></ref><ref id="ref5"><label>5</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hugh</surname><given-names>JC</given-names></name><name><surname>Jackson</surname><given-names>FI</given-names></name><name><surname>Hanson</surname><given-names>J</given-names></name><name><surname>Poppema</surname><given-names>S</given-names></name></person-group><article-title>Primary breast lymphoma</article-title><source>Cancer</source><year>1990</year><volume>66</volume><fpage>2602</fpage><lpage>11</lpage><pub-id pub-id-type="pmid">2249200</pub-id></element-citation></ref><ref id="ref6"><label>6</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wiseman</surname><given-names>C</given-names></name><name><surname>Liao</surname><given-names>KT</given-names></name></person-group><article-title>Primary lymphoma of the breast</article-title><source>Cancer</source><year>1972</year><volume>29</volume><fpage>1705</fpage><lpage>12</lpage><pub-id pub-id-type="pmid">4555557</pub-id></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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