Surgical management of primary breast sarcoma

Primary sarcoma constitutes less than one per cent of breast malignancies. A retrospective review of this disease at our institution was undertaken to assess the effect of different treatment modalities on outcome. Over a 24-year period 28 patients were identified. Follow-up ranged from one to 228 months. Partial mastectomy was done in seven patients, whereas ten underwent total mastectomy and nine had modified radical mastectomy. Two refused surgery. All margins of resection were negative. In total ten axillary lymph node dissections were done with no positive nodes identified. Pathologic analysis of tumors revealed a variety of sarcomas including high-grade malignant cystosarcoma phyllodes in 13. Recurrence of disease occurred in two women, both with malignant cystosarcoma phyllodes. One was a local recurrence in a patient who had undergone partial mastectomy. This was successfully treated with a total mastectomy. The second recurrence involved a distant metastasis in a patient treated with modified radical mastectomy that eventually led to her death. For the entire group the disease-free survival was 75 per cent at 10 years whereas overall survival was 87.5 per cent. In conclusion an adequate margin of resection is the single most important determinant of long-term survival. Axillary lymph node dissection is not necessary for the treatment of these tumors.

Sonographic features of phyllodes tumors of the breast

OBJECTIVE

The aim of this study was to examine the sonographic features of phyllodes tumors of the breast.

METHODS

Retrospective analysis of prospectively recorded sonographic features was performed on 2268 patients with phyllodes tumors or fibroadenomas during 1995-98. Data from 110 phyllodes tumors (76 benign, 11 borderline, 23 malignant) and 2204 fibroadenomas were analyzed.

RESULTS

The patients with phyllodes tumors were older than the patients with fibroadenoma (mean +/- standard error, 39.7 +/- 1.1 years vs. 33.4 +/- 0.3 years; P < 0.0001). Sixty-four percent of patients with phyllodes tumors were aged 31-50 years, while 68.5% of those with fibroadenoma were aged 21-40 years. Phyllodes tumors were larger than fibroadenomas (5.90 +/- 0.43 cm vs. 1.95 +/- 0.03 cm; P < 0.0001). The ratio of length to anteroposterior diameter of phyllodes tumors was smaller than the ratio of length to anteroposterior diameter of fibroadenomas (1.72 +/- 0.06 vs. 1.89 +/- 0.02; P = 0.0105). Seventy-seven percent of phyllodes tumors were lobulated and 79.5% of fibroadenomas were oval. Lobulated shape of the tumor, heterogeneous echo pattern and absence of microcalcification are significant independent sonographic features in multiple logistic regression analysis to distinguish between phyllodes tumors and fibroadenoma. Benign, borderline and malignant phyllodes tumors displayed no significant differences in tumor size or the ratio of length to anteroposterior diameter.

CONCLUSIONS

There is a substantial overlap in the sonographic characteristics between phyllodes tumors and fibroadenoma of the breast. If lobulation and heterogeneous hypoechoic internal echoes are observed and calcifications are absent, a diagnosis of phyllodes tumors should be considered. Sonography cannot distinguish between malignant, borderline and benign phyllodes tumors.

Fine-needle aspiration cytology of phyllodes tumors

Breast lesions with a significant spindle cell or mesenchymal component are not commonly encountered in fine-needle aspiration (FNA) cytologic material and include a heterologous variety of benign and malignant conditions, with phyllodes tumors (PTs) being the foremost differential diagnostic consideration. This study comprises 28 tumors diagnosed histologically as PT in which FNAC material was available for review. Histological sections and cytological smears from these cases were retrieved and subjected to detailed morphological review. Cytological parameters assessed included ratio of stroma to epithelium, pattern characteristics and cytological characteristics of the stromal, and epithelial components and the background cells. Large and hypercellular stroma fragments, dissociated spindle and plump stromal cells, often accompanied by large, folded sheets of epithelium were cytological features that characterized PT. Smears from malignant PT showed predominantly or solely mesenchymal components. FNAC was a highly reliable procedure for the diagnosis of PT, giving an accuracy rate of 92.8%.

[A giant malignant tumour of the skull-Case report and differential diagnosis]

The case of a 72-year-old woman with a high-partially located tumor grown within a half year to a magnitude of 8.5 x 11 x 11 cm is reported. The patient remembered a mastectomy and axillary lymphadenectomy followed by chemotherapy and radiation 8 years ago. Therefore we assumed a skeletal metastasis of a breast cancer. After wide excision, an unusual morphology was found, allowing only a classification as a pleomorphic sarcoma. Searching for the pathohistological evaluation of the former breast tumor, a cystosarcoma phylloides malignum could be found out. The tumor described here can be identified as a metastasis of this rare neoplasm.

Effectiveness of fine-needle aspiration cytology of breast: analysis of 2,375 cases from northern Thailand

At the Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand, 2,375 cases of breast lesions were sampled by fine-needle aspiration (FNA) from 1994-1999. Cytologic diagnoses were: benign (48%), suspicious for malignancy (5%), malignant (15%), and unsatisfactory (32%). Comparison with histology was possible in 721 cases. The diagnoses obtained by FNA showed a sensitivity of 84.4%, specificity of 99.5%, positive predictive value of 99.8%, negative predictive value of 84.3%, false-negative rate of 16.7%, false-positive rate of 0.5%, and overall diagnostic accuracy of 91.3%. We conclude that, in experienced hands, FNA of breast masses is reliable for diagnosis. Assessment of samples at the time of aspiration can reduce the number of inadequate specimens to near zero. Correlation of FNA results with clinical and radiologic findings can identify false-negatives and false-positives, ensuring optimal patient management. Many centers now recommend needle core biopsy instead of FNA. For regions such as ours, the added cost of this test would make it unavailable to many patients, which could delay a diagnosis of breast cancer. We advocate keeping FNA as a first-line diagnostic procedure, at least in areas under economic restrictions, in order to maximize the availability of health care to women with breast disease.

Immunoreactivity of p53, Ki-67, and c-erbB-2 in phyllodes tumors of the breast in correlation with clinical and morphologic features

BACKGROUND AND OBJECTIVES

Phyllodes tumor (PT) is a biphasic tumor with unpredictable behavior. Our study aimed to evaluate clinicopathologic factors and biomarkers that may be helpful in predicting the outcome of these tumors.

METHODS

We evaluated immunoreactivity of p53, c-erbB-2, and Ki-67 in 23 PT treated over a 10-year period. The proliferative activity in PT and expression of p53 and c-erbB-2 were correlated with clinicopathologic features of the tumors and patients' outcome.

RESULTS

Positive stromal p53 immunoreactivity was found in PT with atypia, infiltrative borders, high cellularity, as well as in PT that displayed higher then average proliferation index, although none of these parameters reached statistical significance. There was a good correlation between proliferative stromal cell activity expressed Ki-67-labeling index and the malignant features of the tumors. Primary tumors that recurred displayed high proliferative activity. Three of four recurrent tumors showed a progression toward higher malignant phenotype with concomitant increase in proliferative stromal cell activity. c-erbB-2-positive tumors had no particular histologic features or association with either p53 positivity or higher proliferative indices.

CONCLUSIONS

p53 expression tends to be more frequent in PT with higher malignant potential but did not predict recurrence. Incompletely excised tumors that recurred displayed high proliferative activity in their primary tumors. Progression toward more malignant phenotype in the recurrent PT was accompanied with increase in stromal cell proliferative activity, suggesting the presence of biological continuity between benign, borderline, and malignant PT.

[Phyllodes tumor. The experience of the 4th Obstetrics-Gynecology Department]

The experience of the IVth Obstretrics Gynecology Department. Between the 1st of January 1994 and the 1st of November 2001 587 operations have been performed as treatment of breast tumors in the IVth Obstetrics and Gynecology Department. The phyllodes tumor has been diagnosed in 11 cases (1.8% of the benign breast masses). The genesis is unknown. Local trauma, pregnancy, lactation, high estrogenic levels have been suggested to have an influence upon the tumoral development. The most common aspect is a round, hard, unpainful breast mass. The diameter is variable (1 to 45 cm). The mammogram shows a well defined, high density, smooth contour opacity. A four degree classification has been described. Specific evolution features may involve local recurrences and metastasis. The surgical treatment is mandatory but radiotherapy, chemotherapy and endocrine treatment protocols have been brought up.

[Phyllodes tumor of the prostate: a case report]

Prostatic phyllodes tumor is an unusual lesion for which there are only occasional reports in the literature. We encountered a phyllodes tumor of the prostate in a 36-year-old man who had complained of urinary frequency and dysuria for one month. In October 1998, he visited our hospital and had a transurethral resection of the prostate (TUR-P) for obstructive symptoms. He experienced recurrent same symptoms in September 1999 and underwent another TUR-P. The pathologic examination at this time revealed phyllodes tumor. In the tumor, despite its regular alternating growth of ducts and stroma, the stromal element appeared histologically malignant, showing marked atypia and rhabdomyosarcoma-like components. Consequently, in December 1999, the patient underwent radical prostatectomy with lymph node dissection. The resection margins and pelvic lymph nodes were free of tumor. The patient remains alive and well after 14 months.

p53 and Ki-67 expression as prognostic factors in cystosarcoma phyllodes

We have reviewed the histopathological, clinical outcome and immunohistochemical status in 21 women with cystosarcoma phyllodes (CSP) tumors of the breast. We assessed 12 tumors as histopathologically benign and 9 tumors as malignant. The median patient ages in benign and malignant CSP tumors were 39.6 and 45.4 years of age, respectively. The stromal cellularity, stromal cellular atypism, high mitotic activity, atypic mitoses, stromal overgrowth, infiltrative tumor contour, and heterologous stromal elements were significant features of the malignant CSP tumors. Benign CSP tumors were predominantly of fibroadenomatous architecture with cellular stroma (mild or moderate) and some distortion and elongation of glandular elements. Five malignant CSP tumors were stained positively with p53, and 6 malignant CSP tumors were stained immunohistochemically with Ki-67. All benign CSP tumors were negatively stained for p53 and Ki-67. The patients with benign CSP tumors were treated with local excision ( n=11) and with subcutaneous mastectomy ( n=1). Malignant CSP tumors were treated with wide local excision ( n=1), partial mastectomy ( n=1), simple mastectomy ( n=2), and modified radical mastectomy ( n=5). Two patients with a high mitotic rate and high values of p53 and Ki-67 received additional radiotherapy and chemotherapy. One case had liver metastasis. This tumor had high mitotic figures, stromal overgrowth, severe stromal cellularity, and 20% Ki-67 and mild p53 positivity. We suggest that p53 and Ki-67 can play an important role in predicting prognosis and yielding additional therapy besides conventional prognostic factors in the treatment of the CSP patients.

Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phyllodes tumours of the breast

AIM

High-grade malignant phyllodes tumour (MPT) is a rare but aggressive breast malignancy and forms approximately 25% of all phyllodes tumours. The aim of the study was to determine parameters that influence outcome in high-grade MPT.

METHODS

This study consisted of 48 women diagnosed with high-grade MPT. All patients were treated primarily with surgery by local excision (LE, margins <1 cm), wide local excision (WLE, margins > or =1 cm) or mastectomy. Cox's regression was used for multivariate analysis of the data.

RESULTS

The mean patient age was 47 (range 21-85) years and the average tumour size was 7.8 (range 1.5-20) cm. Ten patients were treated with LE, 14 with WLE and 24 with mastectomy. The median follow-up was 9 years (range 5 months-28 years). Local recurrence (LR) occurred in 19 patients (40%) at mean time of 28 (range 5-84) months after primary treatment. Distant metastasis (DM) occurred in 13 (27%) patients at average time of 25.6 (range 6-120) months. LR, subsequent metastatic spread and survival following treatment of MPT were related to tumour size and excision margins, but not to other clinical or histopathological characteristics.

CONCLUSION

Tumour size and surgical margins were found to be the principal determinants of LR and DM. Complete surgical excision, by mastectomy if necessary, is important in the primary surgical treatment of high-grade MPT.

Malignant phyllodes tumor

The study aims to evaluate the survival and prognosis of patients with malignant phyllodes tumor. Between 1982 and 1998, 37 women with malignant phyllodes tumor were treated at the Regional Cancer Center, Trivandrum. Twelve patients were recurrent. Survival was estimated using the Kaplan-Meier method. Patient, disease, and treatment factors were compared using log-rank test. The Cox-proportional hazard model was employed to identify the prognostic factors. Thirty-six patients had surgery. Twenty-five patients received postoperative radiotherapy, and 2 received chemotherapy in addition. The median follow-up was 43 months (range 1-170 months). Eight patients failed locally, and 7 of these were successfully salvaged by surgery. The 5-year overall survival was 74.2% (95% CI, 0.44 to 0.89), whereas 5-year disease-free survival was 59.6% (95% CI, 0.39 to 0.7). The margin of surgical excision was found to be the only independent prognostic factor (p=0.003). However, patients with tumor size more than 5 cm (hazard ratio 2.9) were found to have increased hazard, whereas those receiving adjuvant radiotherapy (hazard ratio 0.6), married women (hazard ratio 0.4), and those women over the age of 35 years (hazard ratio 0.7) showed a decreased hazards. Cystosarcoma phyllodes is a rare malignancy of the female breast. Surgery with adequate margins is the primary treatment. Adjuvant radiotherapy appears to improve the disease-free survival.

Rare case of biphasic tumor of the breast with prominent CD34-positive spindle cells

We report an unusual case of biphasic tumor of the breast with prominent CD34-positive spindle cells. A 53-year-old woman presented with a mass in her right breast. Following an incisional biopsy, a partial mastectomy was done. Histologically, the tumor was a biphasic variant of a malignant spindle cell tumor of the breast. The lack of a leaf-like structure, together with the apparent myoid features of the spindle-shaped tumor cells, made it difficult to distinguish from malignant phyllodes tumor and from myoepithelial carcinoma. Immunohistochemistry revealed the spindle-shaped tumor cells to be myofibroblastic, but not myoepithelial in nature, ultimately categorizing this tumor as a malignant phyllodes tumor with prominent myofibroblastic differentiation.

Benign breast disease

Benign breast disorders (BBD), classified by the ANDI system (aberrations of normal development and involution), constitute the major workload in breast clinics. Breast pain (mastalgia) is classified as cyclical, and non-cyclical extramammary causes such as ribircage pain have to be identified. Most patients need reassurance alone but those with moderate/severe pain present for > 6 months may need treatment: randomised trials have shown danazol, bromocriptine and tamoxifen to be effective. Fibroadenoma is the commonest benign solid lump in women aged 15-30 years. The diagnosis must be confirmed by triple assessment. Cysts occur usually in women of middle to late reproductive life. After ultrasound has confirmed the lump as cystic, it can be aspirated. Nipple discharge should be tested for the presence of haemoglobin (Hb). Those with HB+ discharge may require microdochectomy for treatment and diagnosis, common causes being duct papilloma and duct ectasia. Breast abscesses may occur during lactation or in women with duct ectasia and are treated by incision or aspiration together with antibiotics.

Multinucleated stromal giant cells in mammary phyllodes tumours

Mammary phyllodes tumour (PT) is an uncommon fibroepithelial neoplasm with a prominent stromal component. We report five cases of PT (one benign, three borderline, one malignant) with giant cells in the stroma. All occurred in adults and ranged from 1.8 to 4.0 cm in size. The overall cellularity, stromal cell pleomorphism and mitotic count was higher for the malignant and borderline than the benign PT. The giant cell number ranged from 18 to 35 cells per 10 high power fields, but there was no relationship between this number and the grade of the PT. Most giant cells were subepithelial, with multiple nuclei arranged in a linear or irregular pattern, and moderate amount of cytoplasm. The immunohistochemical profile of the giant cells was similar to the stromal cells. In all cases, both giant cells and stromal cells expressed vimentin strongly but not desmin; in two cases, both cell populations expressed actin weakly. The respective percentage of giant cells and stromal cells expressing MIB1 was also similar. This suggests that these giant cells do not represent a different, more active stromal population, despite the more bizarre appearance. In view of the small number of cases, the significance of such giant cells on the prognosis of PT remains uncertain.

Phyllodes tumors of the breast

Phyllodes tumor is a rare fibroepithelial neoplasm of the breast with a very variable, but usually benign, course. Formerly known as cystosarcoma phyllodes, the designation "phyllodes tumor" with appropriate qualification regarding malignant potential based on pathologic features is now the agreed-upon term. The most important diagnostic distinction is from fibroadenoma--phyllodes tumors require complete excision with free margins even when pathologic features suggest benignity because of a proclivity to local recurrence. The most important component of therapy is wide surgical excision, and mastectomy is necessary only when free margins cannot be achieved without it. Involvement of axillary nodes is rare, and axillary dissection is not indicated. The role of radiation therapy and chemotherapy is not established and has not been studied in randomized trials due to the rarity of the tumor. At present, there is no consensus that patients with high-grade phyllodes tumors of the breast will benefit from either of these modalities.

Pseudoangiomatous hyperplasia of mammary stroma: a case of pure type after removal of fibroadenoma

A case of pure pseudoangiomatous hyperplasia of the mammary stroma after removal of a fibroadenoma is described. The lesion, which was found in the right breast of a 40-year-old woman, was a well-circumscribed non-encapsulated, rubbery, lobulated mass measuring 40x40x35 mm. Histologically, it consisted predominantly of a proliferation of spindle cells with interanastomosing vascular-like arrangements in the interlobular or interductal stroma. Neither cytological atypia nor mitotic figures were observed. The stroma contained abundant collagen with focal hyalinization. Focally, epithelial elements showed mild ductal hyperplasia. There was no fibroadenoma. Immunohistochemically, the spindle cells were positive for vimentin, CD34, alpha-smooth muscle actin, muscle actin, CD34, calponin, and progesterone receptors. Ultrastructurally, many spindle cells had thin elongated cytoplasmic processes, which enveloped pseudovascular spaces containing a few collagenous fibrils, indicating fibroblastic cells. This lesion should be distinguished from other mammary fibrous and vascular lesions with which it may be confused.

Phyllodes tumor in ectopic breast tissue of the vulva

Phyllodes tumor arising from ectopic breast tissue of the vulva is an extremely rare occurrence. A case is reported in a 34-year-old nulligravida woman, presenting as a nodule on the left labium majus. A simple excision was carried out, and no recurrence has been detected after 18 months of follow-up.

Bilateral cystosarcoma phyllodes of the breast: a case report of malignant form with contralateral benign form

Bilateral cystosarcoma phyllode is uncommon; bilateral tumors, either synchronous or metachronous, are generally either benign or malignant. We report one case of bilateral synchronous cystosarcoma phyllode in a 32-year-old pregnant woman. The left breast mass, measuring 21 x 17 x 10 cm, was classified as malignant cystosarcoma phyllode (high cellularity, stromal overgrowth, marked nuclear atypia, necrosis, mitotic rate = 4 mitoses/10 high power field, infiltrative margin). The right 9 x 9 cm mass was a benign cystosarcoma phyllode tumor (low to moderate cellularity, discrete nuclear atypia, mitotic rate = 1 mitoses/10 high power field, no necrosis, pushing margin). The patient had a left-sided mastectomy and a complete local excision with clear margin of the right breast mass. The patient is free of disease with a 17-month follow-up.

[Phyllodes tumor of the breast. Personal contribution of 21 cases]

The study is based on the observation of 21 cases of phyllodes tumour of the breast. The mean age of patients was 43 years (range 18-60 years). In all the cases the tumour was monolateral, more common in the right breast (66.7% vs. 33.3%) and in external quadrants. Clinical features and diagnostic investigations were able to make a preoperative diagnosis in 6 out of 21 cases, while frozen sections and histological examination allowed to diagnose in the others. FNAB was not performed in any case. In this way 18 benign and 3 "borderline" tumours were discovered. No malignant lesion was observed. Local recurrence rate was 14.6%. Local recurrence was not associated with age of patients, tumor size and histological type. In neither case axillary nodal involvement was found. The study and the review of the literature suggest that wide local excision is the treatment of choice and adjuvant therapies have no place in the routine management of phyllodes tumours.

Primary treatment of cystosarcoma phyllodes of the breast

BACKGROUND

Cystosarcoma phyllodes is a rare sarcoma of the breast. Although surgical removal is the mainstay of treatment, the extent of surgery required (excision vs. mastectomy) and the need for additional local therapy, such as radiotherapy, are unclear. The current study evaluated the rate of local and distant failure, as well as potential prognostic factors, to better define appropriate treatment strategies.

METHODS

One hundred one patients treated primarily for cystosarcoma phyllodes of the breast were evaluated. These tumors were classified histologically into benign (58%), indeterminate (12%), and malignant (30%) based on well defined criteria. Stromal overgrowth (29%) was considered separately. Surgery was comprised of local excision with breast conservation (47%) or mastectomy (53%). Microscopic surgical margins were negative in 99% of cases. Six patients received adjuvant radiotherapy.

RESULTS

Overall survival for the 101 patients was 88%, 79%, and 62% at 5, 10, and 15 years, respectively. For patients with nonmalignant (benign or indeterminate) and malignant cystosarcoma phyllodes, the overall survival was 91% and 82%, respectively, at 5 years, and 79% and 42%, respectively, at 10 years. Similar rates were observed based on the presence or absence of stromal overgrowth. Local recurrence occurred in 4 patients, with an actuarial 10-year rate of 8%. Eight patients developed distant metastases, with an actuarial 10-year rate of 13%. Multivariate analysis using Cox proportional hazards regression revealed stromal overgrowth to be the only independent predictor of distant failure.

CONCLUSIONS

Local failure in this group of largely margin negative patients with cystosarcoma phyllodes of the breast was low, showing that breast-conserving surgery with appropriate margins is the preferred primary therapy. The current study data do not support the use of adjuvant radiotherapy for patients with adequately resected disease. Patients with stromal overgrowth, particularly when the tumor size was > 5 cm, were found to have a high rate of distant failure; such patients merit consideration of a trial that examines the efficacy of systemic therapy.

Malignant phyllodes tumor with liposarcomatous components: a case report with cytological presentation

Cytological and histological findings of a rare case of a malignant phyllodes tumor (with liposarcomatous components) of the breast are presented. The atypia of the stromal cells and naked nuclei in a lesion considered benign clinically and on imaging alerted us to the possibility of a phyllodes tumor, despite the low cellularity of the preoperative fine-needle aspiration smears. The excisional biopsy was histologically diagnosed as malignant phyllodes tumor with liposarcomatous components. Peculiar atypical cells with large, pale, transparent cytoplasm, or with intranuclear chromatolytic areas similar to intranuclear cytoplasmic inclusions, in addition to atypical lipoblasts revealed in imprint smears from the excised tumor, may be important for cytopathologists to achieve a definitive cytological diagnosis, and also to observe patients over long periods for recurrences and metastasis after surgery for this rare breast tumor.