Malignant phylloides tumor in pregnancy

Malignant phylloides tumors are exceedingly rare with few cases being reported in pregnancy. We describe the first case ever reported of a malignant phylloides tumor presenting in the first trimester of pregnancy and provide insight into the complexities of management as well as a review of the known literature. An extensive PubMed literature search for "cystosarcoma," "phylloides," and "pregnancy" was performed. References of each citation were reviewed. Only six previous cases of phylloides tumor in pregnancy were found, none of which were in the first trimester. Medical records of a patient presenting to our institution at 9 weeks gestation with a malignant phylloides tumor were reviewed. We further provide a review of the current literature of the management of phylloides tumor in pregnancy. A 27-year-old white G2P0SA1 woman with no family history of breast cancer presented with a right breast mass at her first prenatal examination at 9 weeks of pregnancy. Ultrasound confirmed a solid mass measuring 24 mm. Core needle biopsy demonstrated a malignant phylloides tumor. She previously had a fibroadenoma removed from the same breast 7 years previously. The current tumor was excised to clear margins. Histopathological examination revealed a 4-cm fibroepithelial tumor with marked stromal cellularity and a high mitotic count (five to seven mitoses/high-power field), confirming the diagnosis of malignant phylloides tumor. The patient continued her pregnancy without complications. Six other cases of phylloides tumor presenting in pregnancy have been reported in the literature, one of which had bilateral disease. Of these, the average patient age was 32 years (range, 28 to 35 years). The majority of these patients presented in their third trimester (mean, 29 weeks; range, 20 to 36 weeks) and often had large tumors (mean, 15 cm; range, 5 to 21 cm). Four of the seven tumors (57%) required a mastectomy. Previous cases have shown phylloides tumors to present in the third trimester as large masses that require mastectomy. With early detection, malignant phylloides tumors can present in the first trimester of pregnancy at smaller sizes; in these patients, breast-conserving surgery is possible.

Phyllodes tumor of the breast; a case series

BACKGROUND

Phyllodes tumor (PT) is a rare neoplasm comprising less than 1% of all breast tumors. Its clinical spectrum ranges from a benign and locally recurrent form of behavior to malignant and metastatic forms. The aim of the study was to evaluate the clinical characteristics, treatment regimens, survival and late complications in patients with PT.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 10 women who were treated for PT in our center between 1998 and 2002. All cases were histologically examined by an experienced breast pathologist, and tumors were classified as benign, borderline malignant or malignant according to standard histological criteria.

RESULTS

The median age at diagnosis was 45.5 years (range: 21-69 years). Seven (70%) of 10 tumors were benign and 3 (30%) were malignant. The median tumor size was 29 mm (range: 12-80 mm). The least safe margin was 1 cm. Three of 10 patients had malignant PT and underwent simple mastectomy. Local recurrence was determined in no patients. Only one patient had lung metastasis. Median follow-up period was 62 months (range, 12-96 months). The patient with lung metastasis was treated with doxorubicine but died one year after the operation.

CONCLUSION

PT is a rare neoplasm of the breast. It resembles fibroadenoma. Local excision with appropriate surgical margins seems adequate in all patients (Tab. 1, Fig. 3, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Case report of a 30.8 pound cystosarcoma phyllodes of breast

This is a case report and literature review of a 30.8 pound cystosarcoma phyllodes tumor resected in a 54-year-old female. Starting at age 19, the patient had noted a small breast tumor that continued to grow over the years. Pathology reported a low-grade malignant phyllodes tumor with no nodal involvement. Surgical resection with clear margins still remains the main treatment for this tumor. Radiation may be helpful in those with positive margins, a tumor greater than 4 cm, and those with reoccurrence.

[Phyllodes tumor: institutional experience]

BACKGROUND

Phyllodes tumor represents one of the fibroepithelial breast neoplasms that accounts for 0.3% to 1% of the breast tumors.

OBJECTIVE

To describe a case series of patients with phyllodes tumor diagnosis.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of patients that had confirmed histological phyllodes tumor collected over a period of ten years.

RESULTS

The incidence was 0.8%, 12.5% of cases corresponded to malignant phyllodes. The average age was 35 years (range 14-50 years); the most frequent site of localization was the superior and external quadrant of the breast; the average tumoral size by image studies (ultrasound or mastography) and by direct measurement was 61 mm (13-150 mm) and 77 mm (30-300 mm), respectively. One case coexisted with pregnancy.

CONCLUSIONS

It is a rare neoplasm, andthe clinician must be aware of its timely diagnosis and treatment, if not some cases will develop breast deformity and some others will be borderline or malignant.

[Benign phylloides tumor of the breast. Considerations on a clinical case]

Phyllodes tumors are unusual biphasic fibroepithelial neoplasms of the breast, accounting for < 1% of all breast tumors and raising issues of diagnosis and therapeutic choice. They can grow quickly and when the maximum diameter is greater than 10 cm. We talk about giant phyllodes tumors. Ultrasound, Mammography and FNA are not effective. A potentially useful diagnostic modality is MRI. Core tissue biopsy or incisional biopsy represent the preferred means of pre-operative diagnosis. Conservative treatment can be effective also in giant tumors depending upon the size of the tumor and the breast if a complete excision with an adequate margin of normal breast tissue can be achieved, so avoiding local recurrence often accompanied by worse histopathology. The Authors report the case of a giant benign phyllode tumor of the breast treated with conservative surgery, quadrantectomy and oncoplasty. No local recurrence at 4 years follow-up.

[Extraordinary case of malignant phylloid tumor of the breast: surgical reconstruction treatment]

Phyllode tumors of the breast are fibroepithelial tumors similar to fibroadenomas but with a predominant conjunctive tissue component. They are rare with an incidence of less than 1% of all breast neoplasms. They can be divided in three categories: benign, borderline, malignant. The Authors report the case of a 53 years old woman who presented an exceptional 6.5 kg phylloid tumor of the left mamma. The diagnostic strategies, the surgical total mastectomy procedure with anterior thoracic parietectomy and the surgical reconstructive treatment are described.

A large cystic phyllodes tumor of the prostate

We report a 65 year-old man with a large cystic phyllodes tumor of the prostate. The patient complained of abdominal discomfort and had a soft palpable mass. Computer tomography showed a solid and cystic mass in the pelvic fossa; the mass was adjacent only to the prostate. We excised the mass. Microscopic findings of the mass showed hyperplastic epithelium lined cysts with leaf-like intraluminal epithelia lined stromal projections, less than 2 mitotic counts/10 HPF, low-to-moderated cellularity, and mild-to-moderate cytoplasm atypia. The pathological findings were consistent with a phyllodes tumor of the prostate, a low-grade tumor. Twenty-eight months after the operation, the patient was well with no recurrence or metastases.

[Phyllodes tumour: a rare, rapidly growing breast tumour]

A 40-year-old woman presented at the breast outpatient clinic with a giant tumour of her left breast. The size, rapid growth and radiological characteristics of the lesion led us to suspect a phyllodes tumour. A histological examination of a needle biopsy confirmed this diagnosis. An additional CT scan revealed no signs of metastases. We performed a mastectomy during which a tumour measuring 48 x 33 x 25 cm was resected. Histological examination revealed a borderline phyllodes tumour. Phyllodes tumours are rare fibroepithelial neoplasms of the breast and pre-operatively these are often difficult to differentiate from fibroadenomas. Phyllodes tumours have a variable clinical course with the ability to metastasize and a propensity to recur locally. Complete excision with wide margins is essential to prevent local recurrence. In our case, the surgical margins were limited and our patient was therefore treated with postoperative radiation therapy.

[Analysis of the treatment and prognosis of recurrent breast phyllodes tumor]

OBJECTIVE

To explore the methods of diagnosis, treatment and prognosis for patients with recurrent breast phyllodes tumor.

METHODS

Clinicopathological data of 26 patients with pathologically proven recurrent phyllodes tumors treated from March 1972 to June 2006 were retrospectively analyzed.

RESULTS

The mean age of the 26 cases was 45 years, and the median follow-up duration was 83 months. The mean overall survival time of this series was 96 months. The primary breast phyllodes tumor was > or = 5 cm in 10 cases with a recurrence rate of 60.0% (6/10 cases); < 5 cm in 16 cases with a recurrence rate of 31.3% 5/16 cases). After surgical removal of the breast primary tumor, the recurrent tumor was > or = 5 cm in 14 cases with a re-recurrence rate of 35.7% (5/14 cases); < 5 cm was in 12 cases with are-recurrence rate of 50.0% (6/12 cases). There was no statistically significant relationship between the (primary and reccurent) tumor size and recurrence rate (P = 0.094, P = 0.383) or prognosis (P = 0.142, P = 0.486). The benign or malignant nature of the breast phyllodes tumor was significantly correlated with the rate of local re-recurrence (P = 0.046) and prognosis (P = 0.028).

CONCLUSION

The benign or malignant nature of the breast phyllodes tumor is significantly correlated with the local re-recurrence and prognosis, while the size of the primary breast phyllodes tumor has no significant effect on either re-recrruence or prognosis. The first rescue operation is most important in the treatment of recurrent breast phyllodes tumor. The resection margin should be wide enough. Active surgical treatment can still effectively save the life of the patients with a local re-recurrent tumor.

Surgical breast lesions in adolescent females

PURPOSE

Breast diseases in teenage girls are fortunately uncommon, with most presenting masses being benign. The aim of this study was to evaluate the histopathological results of breast lesions excised from adolescent females less than 19 years of age.

METHODS

The authors reviewed the medical and pathology records at the University Hospital of Vienna, Department of Obstetrics and Gynaecology, between 1993 and 2006, retrospectively. All data included the patient age, age of menarche, pregnancy, hormonal contraception, family history of breast cancer, size of the breast lesion and its histopathology following surgery.

RESULTS

Thirty-seven female patients with an average age of 16 years (ranging 12-18 years) were operated on for breast tumor and/or discharge. All tumors were palpable. Six patients had bilateral breast masses; thus, 43 breast lesions were evaluated following surgical excision. Surprisingly, breast cancer was found in two cases. Both patients were diagnosed with a noninvasive ductal carcinoma in situ (DCIS) within a fibroadenoma at the age of 16. These are the first reported cases of DCIS found in this young age group. As breast neoplasm was found in two cases, a malignancy rate of 4.7% was observed. The most common histologies were fibroadenoma (n=27) and fibrocystic disease (n=4).

CONCLUSION

The incidence of primary breast cancer in adolescent women is low. However, our experience shows the need for compulsory excision of all breast masses and highlighting the importance of histopathological evaluation of all breast tumors including adolescents.

[Bilateral phylloid cystosarcoma of the breast: a case report and review of the literature]

Phylloides tumours are unusual neoplasms, accounting for less than 0.5% of breast tumours and approximately 2.5% of fibro-epithelial tumours. They usually present as fast-growing, painless masses, with a high local recurrence rate. Grading and an adequate surgical resection with tumour-free margins are the most important factors predictive of recurrence. The treatment is based on surgery, with poor results reported for chemo- and radiotherapy, but controversy still exists as to whether the best surgical approach consists in radical or conservative procedures, depending upon tumour size at diagnosis. The authors report the case of a patient affected by a metachronous bilateral malignant phylloid tumour of the breast, involving regional nodes and with a single pulmonary metastasis. The patient was treated with radical surgery including a bilateral mastectomy, an axillary dissection and a right inferior pulmonary lobectomy. Unfortunately, even this substantially aggressive management was unable to change the final outcome of the disease. The review of the literature on the subject is consistent with a preferably conservative surgical treatment also in advanced stages of the disease.

[Phyllodes tumor in a pediatric patient. Case report and literature review]

BACKGROUND

Phyllodes tumors occur with a frequency of 0.3- 0.9% and are rare in young women. Their clinical presentation is unilateral and behavior and management are unclear. We present a phyllodes tumor in an 11-year-old female and we reviewed the literature regarding this pathology.

CASE REPORT

We present the case of an 11-year-old female with a diagnosis of phyllodes tumor. Her disease began 4 months previously. We made an incision biopsy followed by simple mastectomy. Histological report demonstrated benign phyllodes tumor. The patient is currently disease free after 1 year.

CONCLUSIONS

Small phyllodes tumors can be excised with a 1-cm surgical border, whereas larger phyllodes tumors are treated with simple mastectomy. Precise pathological evaluation is necessary to plan a better surgical approach and to determine recurrence possibility.

Ductal carcinoma in situ arising in a benign phyllodes tumor: report of a case

Malignant epithelial change within a phyllodes tumor (PT) is a rare event. To our knowledge, only six cases of ductal carcinoma in situ arising in a PT have been reported in English. We report a case of PT with an intraductal carcinoma component, which grew rapidly to a huge size in 3 months. Histologically, the stromal element showed mild to moderate cellularity with few mitoses and mild nuclear atypia. The epithelial element consisted of irregularly dilated ducts with a phyllodes structure that had moderate to severe epithelial hyperplasia, and foci of cribriform ductal carcinoma in situ with comedo necrosis.

Astonishingly rapid growth of malignant cystosarcoma phyllodes tumor in a pregnant woman--a case report

There are very few reports concerning the presence of malignant cystosarcoma phyllodes (CSP) in breasts of pregnant women. In the hereby described case, a 28-year-old woman presented in our department with huge (18 x 11 x 8 cm) tumor of left breast, 2 weeks after labor. The patient discovered a tumor in 34th week of pregnancy, 6 weeks before labor. Histopatholgic examination of excised tumor revealed the presence of malignant CSP tumor. Simple mastectomy was proposed to patient as a best treatment modality. However, the patient refused. She underwent excision of tumor bed (2-cm tumor-free margin was achieved). Despite insufficient treatment, she remains free of disease 20 months after the wide excision of breast malignancy. It is not known how pregnancy influences prognosis of patients with malignant CSP. Lack of such information prompted us to describe the clinical course of our patient.

[Malignant phyllodes tumor of the breast with osteoclast-like giant cells: a case report]

Breast tumors, particularly of stromal origin, containing multinucleated osteoclast-like giant cells (OLGC) are rarely reported in the literature. We report here the first case of a malignant phyllodes tumor associated with OLGC occurring in a 43 year-old African woman who presented with a painful palpable mass of the outer upper quadrant of the right breast. After surgical excision, histological examination showed a malignant phyllodes tumor in which the stromal component displayed evident sarcomatous changes and was densely populated with benign multinucleated OLGC. These cells expressed the CD68 histiocytic marker. No evidence of osseous or cartilaginous differentiation was seen throughout the lesion. This lesion ressembles giant cell tumor of bone. However, the nature of the OLGC is not well precised yet.

[Giant phyllodes tumor of the prostate]

A 55 year-old man complained dysuria and visited to our hospital. Physical examination showed firm large mass occupying whole abdomen. Computed tomography (CT) demonstrated a huge retroperitoneal tumor which compressed intestine, liver, kidney, and urinary bladder. We performed extirpation of the tumor (8.6 kg, largest diameter 60 cm) which was composed of myxoid stromal region associated with cystic pattern. Histological examination revealed that the epithelium of the cystic region was positive for prostate specific antigen (PSA) immunostaining. The tumor was diagnosed phyllodes tumor of the prostate (prostatic stromal proliferation of uncertain malignancy, PSTUMP). Serum PSA was declined 3.9 ng/ml to 0.9 ng/ml; however, magnetic resonance imaging (MRI) demonstrated a residual (recurrent?) tumor in the pelvis one month after the operation. We carried out total prostatectomy and residual tumor resection. Phyllodes tumor of the prostate is histologically characterized with biphasic pattern of hyperplastic epithelial cysts and variably cellular spindle stroma. The tumor is considered to have malignant potential and several histological factors including cellularity, atypia, etc. are utilized to assess it. However diagnostic criteria and subsequent treatment modalities are not established thus far. Previous reports showed efficacy of total surgical removal rather than partial resection and that we performed radical extirpation of the entire tumor. Close follow up is needed against this frequently recurrent disease.

Ultrasonography and core needle biopsy in the differential diagnosis of fibroadenoma and tumor phyllodes

BACKGROUND

The diagnosis of phyllodes tumors of the breast is challenging due to many similarities with common fibroadenomas.

PURPOSE

To determine the diagnostic accuracy of core needle biopsy in diagnosing phyllodes tumors and to analyze the ultrasonographic (US) features of phyllodes tumors and fibroadenomas.

MATERIAL AND METHODS

From 1999 to 2003, 1010 breast lesions underwent imaging-guided core needle biopsy. Of these, 57 fibroadenomas and 12 phyllodes tumors were removed surgically. The US and needle biopsy results of a total of 64 lesions (52 fibroadenomas and 12 phyllodes tumors) were further analyzed, compared, and correlated with surgical histological results.

RESULTS

The median sonographic sizes of the phyllodes tumors and the fibroadenomas were 3.2 cm and 1.6 cm, respectively. At US, 58% of the phyllodes tumors (7/12) were classified as equivocal or suspicious of malignancy and 42% (5/12) as probably benign, while 54% of the fibroadenomas (28/52) were classified as probably benign and 46% (24/52) as equivocal. The sensitivity, specificity, and positive and negative predictive values of core needle biopsy histology regarding tumor phyllodes were 83%, 92%, 71%, and 96%, respectively.

CONCLUSION

Imaging-guided core needle biopsy was accurate in differentiating between fibroadenomas and phyllodes tumors. US classification was unreliable due to considerable overlap in the findings. Combined use of US feature analysis and needle biopsy may help to avoid the misinterpretation of phyllodes as fibroadenoma.

Management of benign tumors of the adolescent breast

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the differential diagnosis of breast tumors in adolescent girls. 2. Compare and contrast surgical options for the management of adolescent breast tumors. 3. Recognize the utility of a reduction mammaplasty technique when resecting these larger tumors in adolescents.

SUMMARY

Although 99 percent of breast lesions in female adolescents are benign tumors, surgical intervention is commonly required. This article reviews the differential diagnosis, evaluation, and management of these benign tumors. A modified surgical technique for resection of large fibroadenomas and reconstruction of the remaining breast is described. The authors review the approach to five specific breast lesions: fibroadenomas, phyllodes tumors, juvenile hypertrophy, inflammatory processes, and premature breast development.

Low-grade phyllodes tumor of the seminal vesicle treated with laparoscopic excision

BACKGROUND

A 43-year-old man presented with a 2-year history of hematospermia and dull ache in the left testis. On physical examination he had left epididymal tenderness and a normal digital rectal examination.

INVESTIGATIONS

Transrectal ultrasonography and MRI.

DIAGNOSIS

Low-grade phyllodes tumor of the left seminal vesicle.

MANAGEMENT

Laparoscopic excision of the left seminal vesicle.