Phyllodes tumours of the breast: a clinicopathological review of thirty-two cases

Metastatic Malignant Phyllodes Tumor of the Breast: An Aggressive Disease-Analysis of 7 Cases

Malignant phyllodes tumor (PT) of the breast behaves aggressively and the presentation of distant metastases is varied, ranging from synchronous or short interval commonly to a decade rarely. To assess the clinical and temporal pattern of distant metastases in malignant PTs. A retrospective analysis of patients with Phyllodes tumor of the breast from January, 2001 to November, 2014. There were a total of 167 patients with PT; 49 (29 %) were malignant PT out of which 7 developed distant metastases. Detailed analysis of these 7 patients showed that mean age was 36.71 years (range 28-53 years). Three of the seven patients had additional local recurrences post lumpectomy. The procedure performed were wide local excision with muscle reconstruction (n = 1), lumpectomy (n = 1) and mastectomy (n = 5). The distant metastases were synchronous (n = 2) and other 5 had metastases developing within 2 months to 13 years. The sites for distant metastases included lung, brain, adrenal, para-aortic nodes and bone. Six patients received palliative chemotherapy (CT) and 2 also had radiation therapy for brain metastasis. Only 1 patient is alive and receiving CT and all others succumbed to the disease. Patients with malignant PT of the breast with distant metastases behave aggressively and have a dismal outcome with rare exceptions. They need multimodality therapy and close follow up. Newer targeted therapies may have a role to improve the outcome.

Huge malignant phyllodes breast tumor: a real entity in a new era of early breast cancer

Phyllodes tumor is an extremely rare tumor of the breast. It occurs in females in the third and fourth decades. The difficulty in distinguishing between phyllodes tumors and benign fibroadenoma may lead to misdiagnosis. Lymph node involvement is rarely described in phyllodes tumors; for this reason, sentinel node biopsy may be warranted. We present a case of a 33-year-old woman affected by huge tumor of the right breast with ulceration in the skin with a rapid tumor growth and with omolateral axillary metastasis.

Effects of adjuvant radiotherapy on borderline and malignant phyllodes tumors: A systematic review and meta-analysis

The standard treatment for borderline and malignant phyllodes tumors is wide local excision (margins ≥1 cm), in the context of either breast-conserving surgery (BCS) or total mastectomy (TM). Due to the high risk of local recurrence (LR) following surgical intervention alone, the addition of adjuvant radiotherapy (RT) has been previously investigated; however, the conclusions have been inconsistent. This systematic review and meta-analysis was designed to assess the efficacy of adjuvant RT for borderline and malignant phyllodes tumors. Pubmed and Web of Science were systematically searched to identify relevant studies assessing the effect of adjuvant RT on borderline and malignant phyllodes tumors from the inception of this technique through May, 2014. A total of 8 studies were identified among 332 citations. In this meta-analysis, patients who received adjuvant RT had a lower relative risk of LR [hazard ratio (HR) = 0.43, 95% confidence interval (CI): 0.23-0.64]. The absolute risk difference was 10.1% (95% CI: 4.9-17.6), corresponding to a number needed to treat of 10. Our pooled meta-analysis clearly demonstrated a decreased risk of LR in patients with borderline and malignant phyllodes tumors who received RT following BCS (HR=0.31, 95% CI: -0.10-0.72). However, the combined HR for LR in the TM group did not demonstrate that adjuvant RT was superior to no RT (HR=0.68, 95% CI: -0.28-1.64). No significant differences were observed in overall survival (OS) or disease-free survival (DFS) between the two groups. Our analysis suggested that adjuvant RT for borderline and malignant phyllodes tumors decreased the LR rate in patients undergoing BCS. However, adjuvant RT was not found to exert an effect on OS or DFS.

Aggressive malignant phyllodes tumor

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Phyllodes tumor of breast could be either benign or malignant variety and they can grow into very large sizes and distort the breast.

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WHO classifies tumors into benign, borderline and malignant and it is the best methods to predict the local recurrence, distant metastasis or bath after resection.

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Borderline and malignant disease should have close follow up; as some of these tumors can rapidly change and metastasize.

Introduction

Originally described in 1838 by Muller, phyllodes tumor is a rare fibroepithelial neoplasm which represents roughly 0.3–0.9% of all breast cancers. Phyllodes tumor are divided into benign, borderline and malignant histologic categories. Malignant phyllodes tumor represent anywhere from 10–30% of all phyllodes tumors. This group has both the potential to recur locally and metastasize, however not all malignant phyllodes behave this way. The challenge lays in predicting which tumor will recur locally or metastasize. Distinguishing this subset of malignant phyllodes tumor is paramount.

Presentation of case

We present a case of malignant phyllodes which presented with metastatic disease. What is fascinating about this case is not only the initial presentation but also the aggressiveness of this variation of phyllodes tumor. The patient initially presented with a large mass which encompassed her whole right breast. On surgical pathology the mass measured roughly 31 cm in diameter and weighed over 10 kg. Within 5 weeks from surgery the patient had suffered brain metastases and also 6 local recurrent tumors. The patient passed roughly 11 weeks after her first visit to our office.

Conclusion

Despite biopsy proven malignant phyllodes tumor, it was near impossible to predict such a rapid course of disease progression in our patient. Our case illustrates the unpredictable nature of this disease in general and it possibly sheds light on a variant of the disease which had undergone an aggressive transformation.

Next-Gen Sequencing Exposes Frequent MED12 Mutations and Actionable Therapeutic Targets in Phyllodes Tumors

Phyllodes tumors are rare fibroepithelial tumors with variable clinical behavior accounting for a small subset of all breast neoplasms, yet little is known about the genetic alterations that drive tumor initiation and/or progression. Here, targeted next-generation sequencing (NGS) was used to identify somatic alterations in formalin-fixed paraffin-embedded (FFPE) patient specimens from malignant, borderline, and benign cases. NGS revealed mutations in mediator complex subunit 12 (MED12) affecting the G44 hotspot residue in the majority (67%) of cases spanning all three histologic grades. In addition, loss-of-function mutations in p53 (TP53) as well as deleterious mutations in the tumor suppressors retinoblastoma (RB1) and neurofibromin 1 (NF1) were identified exclusively in malignant tumors. High-level copy-number alterations (CNA) were nearly exclusively confined to malignant tumors, including potentially clinically actionable gene amplifications in IGF1R and EGFR. Taken together, this study defines the genomic landscape underlying phyllodes tumor development, suggests potential molecular correlates to histologic grade, expands the spectrum of human tumors with frequent recurrent MED12 mutations, and identifies IGF1R and EGFR as potential therapeutic targets in malignant cases.

IMPLICATIONS

Integrated genomic sequencing and mutational profiling provides insight into the molecular origin of phyllodes tumors and indicates potential druggable targets in malignant disease. Visual Overview: http://mcr.aacrjournals.org/content/early/2015/04/02/1541-7786.MCR-14-0578/F1.large.jpg.

Phyllodes tumours of the breast: radiological presentation, management and follow-up

OBJECTIVE

Phyllodes tumours (PTs) are rare neoplasms accounting for <1% of breast lesions. With increased breast awareness and screening programmes, smaller PTs are being detected. The purpose of this study was to determine the clinical, radiological and pathological presentation of PTs and to evaluate the role of imaging follow-up, for which there are no specific guidelines.

METHODS

A retrospective study of all patients diagnosed with PT in a symptomatic unit between January 2006 and March 2013 was carried out. Patients were identified using breast care and electronic patient record databases.

RESULTS

53 patients with 54 lesions were diagnosed as having a PT. The median age was 27.5, 35.0 and 38.5 years for benign, borderline and malignant PT, respectively. Borderline and malignant PTs were larger than benign PTs, with mean sizes of 33 and 42 mm compared with 29 mm. 38% of PTs were labelled by the reporting radiologist as fibroadenomas, including two borderline PTs and one malignant PT. In 24% of cases, the radiologist raised the possibility of PT in the report. 17 patients (40%) developed a new fibroepithelial breast lesion during follow-up of which 4 were recurrent PTs.

CONCLUSION

Despite adequate surgical management, the development of further fibroepithelial lesions in the ipsilateral breast is common. 3-year clinical surveillance, with the addition of 6-monthly ultrasound is advised for females with initial borderline or malignant PT histology.

ADVANCES IN KNOWLEDGE

We propose a follow-up protocol with ultrasound based on the grade of the PT diagnosed for 3 years to detect recurrence.

Immediate implant breast reconstruction with acellular dermal matrix for treatment of a large recurrent malignant phyllodes tumor

Phyllodes tumors (PT) are rare fibroepithelial breast tumors representing less than 1 % of all breast malignancies. These tumors are unpredictable and fast growing with a high local recurrence rate, making this disease challenging to treat. Previous literature focused on surgical resection, and breast reconstruction following a mastectomy in patients with PT is rarely addressed. We report a case of a recurrent malignant PT treated with a nipple-sparing mastectomy followed by immediate single-stage silicone implant breast reconstruction. While PT is a rare breast malignancy that presents challenges with both surgical resection and reconstruction, we demonstrate that nipple-sparing mastectomy with immediate implant breast reconstruction with AlloMax is curative and can offer an appealing cosmetic option.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Phyllodes tumor metastasis to the tonsil with synchronous undifferentiated carcinoma

INTRODUCTION

Breast tumor metastasis to the tonsil is extremely rare.

PRESENTATION OF CASE

A 54-year-old woman underwent resection of a breast malignant phyllodes tumor and later presented with metastasis to the lung and the left tonsil. She underwent left lower lobectomy and resection of the left tonsillar tumor. She subsequently developed undifferentiated carcinoma of the right tonsil. She underwent resection of the right tonsillar tumor and chemotherapy was started. The central venous catheter became infected with methicillin-resistant Staphylococcus aureus. Finally, she died.

DISCUSSION

To the best of our knowledge, this is the first reported case of a phyllodes tumor metastasizing to the tonsil. Furthermore, morphological and immunohistochemical study revealed that the right tonsillar tumor was irrelevant to the phyllodes tumors.

CONCLUSION

We report a case of phyllodes tumor metastasis to the left tonsil which developed undifferentiated carcinoma in the other side of tonsil later. Breast tumor metastasis to the tonsil is rare but it should be considered as a possible diagnosis.

Utility of Ki-67, CD10, CD34, p53, CD117, and Mast Cell Content in the Differential Diagnosis of Cellular Fibroadenomas and in the Classification of Phyllodes Tumors of the Breast

Adequate management of phyllodes tumors of the breast (PTB) remains a challenge because of the difficulty in correctly establishing preoperative diagnosis. The aim of this study was to evaluate the usefulness of Ki-67, CD10, CD34, p53, CD117, and of the number of mast cells in the differential diagnosis of benign PTB and cellular fibroadenomas (CFs) as well as in the grading of PTB. Fifty-one primary PTB and 14 CFs were examined by immunohistochemistry.When evaluating CD117 expression, higher epithelial expression was present in CF as well as an increased number of mast cells in benign PTB. Stromal expression of Ki-67, CD10, CD34, and p53 were relevant to PTB grading, of which the first 3 showed significance in the distinction of benign and borderline PTB, as well as between benign and malignant PTB. P53 was relevant only for the discrimination between benign and malign PTB. None of the markers showed significance in distinguishing between borderline and malign PTB.

In Situ Ductal Carcinoma Arising in Benign Phyllodes Tumor in 19-Year Old Patient: A Case Report

Phyllodes tumors are fibroepithelial lesions and malign forms are rare neoplasms with lower than 1% of all primary breast tumors. Malign forms are usually behaves like sarcomas because they occur in the stroma of the breast. Also proliferation of epithelium occurs and even it is less often, the epithelial component of phyllodes tumors can transform into malignancy too. This epithelial malignancies are usually in the form of infiltrative carcinomas and non-invasive tumors arising in benign phyllodes tumors are much rarer but can be seen. Literature include very few cases about this situation and cases are usually old woman. We report a 19-year old patient who was diagnosed with ductal carcinoma in situ arising in benign phyllodes tumor of the breast.

Utilization of radiotherapy for malignant phyllodes tumors: analysis of the National Cancer Data Base, 1998-2009

BACKGROUND

Malignant phyllodes tumors of the breast have traditionally been treated with surgical excision. Recently, the use of adjuvant radiotherapy has been advocated to reduce the risk of local recurrence; however, this recommendation is controversial in the absence of consistent outcome data. We hypothesize that there has been a trend toward increased utilization of adjuvant radiotherapy for malignant phyllodes tumors despite its uncertain effect on outcomes.

METHODS

Using the National Cancer Data Base, predictors of radiotherapy utilization were examined for women with malignant phyllodes from 1998 to 2009. Kaplan-Meier and Cox regression models were generated to determine the effect of radiotherapy on local recurrence (LR), disease-free survival (DFS), and overall survival (OS).

RESULTS

Of the 3,120 patients with malignant phyllodes, 57 % underwent breast conservation surgery and 42 % underwent mastectomy. Overall, 14.3 % of women received adjuvant radiotherapy. Utilization of radiotherapy doubled over the study period (9.5 % in 1998-1999 vs. 19.5 % in 2008-2009, p < 0.001). Women were significantly more likely to receive radiotherapy if they were diagnosed later in the study, were age 50-59 years old, had tumors >10 cm, or had lymph nodes removed. For the 1,774 patients with available recurrence data, overall recurrence was 14.1 %, and LR was 5.9 %. In adjusted models, adjuvant radiotherapy reduced LR (aHR 0.43, 95 % CI 0.19-0.95) but did not impact DFS or OS after 53 months' median follow-up.

CONCLUSIONS

Utilization of adjuvant radiotherapy for malignant phyllodes doubled from 1998 to 2009. Radiotherapy significantly reduced LR but had no effect on DFS or OS.

A subset of malignant phyllodes tumors harbors alterations in the Rb/p16 pathway

Breast phyllodes tumors are fibroepithelial neoplasms with variable risk of aggressive local recurrence and distant metastasis, and the molecular pathogenesis is unclear. Here, we systematically study p16 and Rb expression in 34 phyllodes tumors in relation to proliferation. Tissue microarrays were constructed from 10 benign, 10 borderline, and 14 malignant phyllodes (5 cores/tumor) and from 10 fibroadenomas (2 cores/tumor). Tissue microarrays were labeled by immunohistochemistry for p16, Rb, and Ki-67 and by in situ hybridization for high-risk human papillomavirus. Cytoplasmic and nuclear p16 were scored by percentage labeling (0%-100%, diffuse >95%) and intensity. Nuclear Rb was scored by percentage labeling (0%-100%, diffuse >75%) and intensity. p16 and Rb labeling were repeated on whole sections of cases with Rb loss on the tissue microarray. Twenty-nine percent (4/14) malignant phyllodes showed diffuse strong p16 labeling with Rb loss in malignant cells (diffuse p16+/Rb-), whereas 21% (3/14) malignant phyllodes showed the reverse pattern of p16 loss with diffuse strong Rb (p16-/diffuse Rb+). Results were consistent between tissue microarrays and whole sections. No borderline phyllodes, benign phyllodes, or fibroadenoma showed diffuse p16+/Rb- or p16-/diffuse Rb+ phenotypes. No cases contained high-risk human papillomavirus. Average Ki-67 proliferation indices were 15% in malignant phyllodes, 1.7% in borderline phyllodes, 0.5% in benign phyllodes, and 0% in fibroadenoma. Ki-67 was highest in malignant phyllodes with diffuse p16+/Rb- labeling. In summary, 50% malignant phyllodes display evidence of Rb/p16 pathway alterations, likely reflecting p16 or Rb inactivation. These and other mechanisms may contribute to the increased proliferation in malignant phyllodes relative to other fibroepithelial neoplasms.

Comprehensive characterization of malignant phyllodes tumor by whole genomic and proteomic analysis: biological implications for targeted therapy opportunities

Background

Phyllodes tumors are uncommon breast tumors that account for less than 0.5% of all breast malignancies. After metastases develop, the prognosis is poor, with very few patients living more than 1 year. The biology of this unusual cancer is not understood and, consequently, no potential targets for treatments are currently available. There has been an exponential increase in the number of commercially available tumor profiling services. Herein, we report a case of metastatic malignant phyllodes tumor for which a comprehensive molecular analysis was performed by using Clinical Laboratory Improvement Amendments (CLIA)-certified labs, providing new insights into the potential opportunities for molecularly targeted therapies for this extremely rare disease.

Methods

Next-generation sequencing was performed by using the FoundationOne™ platform (Foundation Medicine, Cambridge, MA). Whole-genome array-based comparative genomic hybridization (array CGH) was performed by using the DNAarray™ (CombiMatrix Diagnostics, Irvine, CA). Immunohistochemical and morphoproteomics analysis were performed at Consultative proteomics^®, The University of Texas, UT Health Medical School, Houston,TX (Robert E Brown Lab); Clarient Diagnostics, Aliso Viejo, CA; and Caris Life Sciences Target one, Irving, TX, USA.

Results

Next-generation sequencing showed 3 aberrant genes: activating mutation Q61L on NRAS; inactivating mutations Q504* and K740* on RB1; and TP53 loss. Whole-genome array-based comparative genomic hybridization (array CGH) revealed amplifications of chromosome (chr.) 1 (CKS1B gene), chr. 8 (MYC gene), and chr. 9 (CDKN2A gene) Deletions of chr. 17 (TP53), chr. 10 (GATA3), chr. 11 (FGF4 and CCND1 genes), and chr.22 (PDGFβ). Immunohistochemical analysis for relevant markers showed a positive staining for transducing-like enhancer of split (TLE) 3; secreted protein acidic and rich in cysteine (SPARC) was expressed at 2-3+ in the cytoplasm of the tumors cells, whereas mammalian target of rapamycin (mTOR) was expressed up to 2+ in the nuclei of the tumor cells.

Conclusions

We describe for the first time an NRAS mutation with concomitant activation of PI3K/Akt/mTOR in phyllodes tumor. We also found markers for sensitivity to taxane-based therapies, especially albumin-bound paclitaxel. Exploring the biology of rare malignancies by CLIA certified labs may be reasonable strategy for the development of targeted treatments.

Long-term follow-up result of benign phyllodes tumor of the breast diagnosed and excised by ultrasound-guided vacuum-assisted breast biopsy

Purpose

Percutaneous removal of benign breast tumors using ultrasound-guided vacuum-assisted breast biopsy (VABB) has been recently regarded as a feasible and safe method without serious complications. The aim of this study was to evaluate the efficacy and safety of the VABB in the treatment of benign phyllodes tumors, and to identify whether or not surgical re-excision is necessary for benign phyllodes tumors diagnosed and excised by VABB.

Methods

From January 2003 to December 2011, a total of 6,923 VABB were performed in 5,434 patients. Out of 6,923 lesions, 53 were benign phyllodes tumors. Among these, 31 lesions, with a follow-up period of longer than 24 months, were enrolled in this study. Ultrasonography follow-up was performed at 3 to 6 month intervals in order to assess recurrence. The mean follow-up period was 75.9±13.5 months (range, 24-94 months).

Results

The mean patient age at presentation was 31.6±9.4 years. The mean size of the lesion was 1.60±0.88 cm. The majority of lesions, 74.2% (23 cases), were palpable, and 25.8% (8 cases) were non-palpable. Twenty-two lesions (71.0%) were classified as Breast Imaging Reporting and Data System category 3, and nine lesions (29.0%) were classified as category 4a, by ultrasonography. During the follow-up period, local recurrence developed in one lesion, making the local recurrence rate 3.2%.

Conclusion

If a benign phyllodes tumor is diagnosed, and sufficiently excised by VABB, observing the clinical course may be considered as an alternative to performing immediate wide local excision; this is the case despite the fact that it would need to be observed for a prolonged period of time.

Anemia and jejunal intussusception: An unusual presentation for a metastatic phyllodes breast tumor

INTRODUCTION

Phyllodes tumor of the breast is a rare cause of breast cancer, accounting for less than 0.5% of breast cancers. These tumors are classified as benign, borderline, or malignant, with malignant tumors compromising nearly 25% of cases. Metastases occur in 20% of malignant tumors, lungs, bones, liver and brain being the frequent sites of metastases.

PRESENTATION OF CASE

We present a case of a metastatic phyllodes tumor to the small bowel causing jejunal intussusception, symptomatic anemia, and small bowel obstruction.

DISCUSSION

Patients with phyllodes tumor of the breast can develop disease recurrence even years after initial treatment. Phyllodes tumor metastasizing to the small bowel is extremely rare, with only three known previously described case reports in the literature.

CONCLUSION

High risk patients, with a past medical history of phyllodes breast cancer, should be monitored closely. Even years after breast cancer treatment, these patients may present with gastrointestinal complaints such as obstruction or bleeding, and therefore metastatic disease to the small bowel should be considered on the differential with subsequent abdominal imaging obtained.

Phyllodes tumors: race-related differences

BACKGROUND

Phyllodes tumors (PT) are rare breast malignancies accounting for 0.5% to 1% of all breast tumors. PT have unpredictable behavior, with recurrence rates as high as 40%. A dearth of information exists about racial differences; elucidation of these differences is the objective of this study.

STUDY DESIGN

A retrospective review of patients treated for PT at either Moffitt Cancer Center or University of Texas Health Science Center San Antonio from 1999 to 2010.

RESULTS

Of the 124 patients, 71 (57%) were treated at Moffitt Cancer Center and 53 (42%) at University of Texas Health Science Center San Antonio. Mean age at diagnosis was 44 years (15 to 70 years). Thirty-three patients required mastectomy. Combining both cohorts, 42% of the patients were Caucasian, 43% were Hispanic, and 12% were black. Tumors were benign in 49% patients, borderline in 35%, and malignant in 16%, with a higher percentage of borderline and malignant tumors in Hispanic patients (p < 0.01). Hispanic patients tended to have larger tumors and higher mitotic rates (p = 0.01; p = 0.03). At a median follow-up time of 13 months, the local recurrence rate (6.4%) was associated with tumor size, tumor grade, mitotic rate, and close margin status (<2 mm) (p <0.01; p = 0.01; p = 0.01; p = 0.04). However, these findings did not translate into a survival difference by race.

CONCLUSIONS

In this multi-institutional review of PT we found substantial pathologic differences by race with higher-grade tumors present more often in Hispanic patients. These differences did not substantially affect outcomes at short-term follow-up. Further investigation into additional molecular, biologic factors, geographic impact, and socioeconomic factors is needed to more clearly delineate this finding.

Osseous differentiation in cystosarcoma phyllodes - diagnosed by fine needle aspiration cytology

Osseous differentiation within a phyllodes tumor is extremely rare. Cytological and histological findings of a case of malignant phyllodes tumor with osseous differentiation are presented. A 45-year-old female had a malignant phyllodes tumor with osseous stroma diagnosed by fine needle aspiration cytology. The cytological findings were representative of the histological features. The diagnosis of these tumors preoperatively is important in planning the most appropriate treatment. It is also important to follow up these patients postoperatively for long periods for recurrence and metastasis.

CD34, CD117, and Ki-67 Expression in Phyllodes Tumor of the Breast: An Immunohistochemical Study of 33 Cases

Phyllodes tumors (PTs) of the breast are biphasic lesions, comprising an epithelial component set within a neoplastic spindle-celled stroma. These tumors have been classified as benign, borderline, and malignant based on a combination of histological criteria, including stromal cellularity, nuclear pleomorphism, mitotic rate, stromal overgrowth, and margin appearance. The aim of this study was to evaluate the expression of CD34, CD117 (c-kit), and Ki-67 in PT of the breast and attempt to correlate the staining pattern with tumor grade by morphology. Immunohistochemical expression of CD117, CD34, and Ki-67 was studied on formalin-fixed, paraffin-embedded archival tissue material from 33 cases of PT. Histologically, there were 21 benign, 6 borderline, and 6 malignant (high-grade) tumors. All 6 histologically malignant PTs were positive for CD117 (100%), but only 1 marked with CD34 (16.7%). Borderline PTs frequently coexpressed CD34 and CD117 (66.7%). The benign PTs, on the other hand, most commonly (52.4%) showed a CD34(+)/CD117(-) immunoprofile with 33.3% cases coexpressing the markers: that is, CD34(+)/CD117(+). Although most benign PTs (80.6%) showed a Ki-67 of <2%, a few cases showed slightly higher proliferation indices. This study indicates that CD34 and CD117 are differentially expressed in benign and malignant PTs. These markers, therefore, in combination, may be used as an adjunct to morphology in the subclassification of PTs.

Phyllodes Tumors of the Breast: A Review of 26 Cases

Background

Phyllodes tumors of the breast are rare and locally aggressive neoplasms. Our study aimed to report the experience of the Farhat Hached Hospital (Sousse, Tunisia) acquired during a 7-year period and to give an additional review of the available literature.

Methods

The authors analyzed retrospectively clinical, radiological, histopathological and therapeutic features as well as outcome in a series of 26 cases diagnosed as phyllodes tumors of the breast at the Pathology Department of Farhat Hached Hospital, Sousse, Tunisia, from 2003 to 2009. The slides were reviewed in order to classify the tumors into benign, borderline and malignant on the basis of the criteria proposed by the World Health Organization.

Results

All the cases occurred in women. The analysis of this series showed the following characteristics: mean age at diagnosis was 40 years (19 - 66), tumor size was 1.5 - 40 cm (mean: 7.8 cm); the chief complaint was a mammary mass; the right breast was affected in 14 cases, the upper outer quadrant was the most commonly involved site (42.3%); surgical treatment was used in all cases, 21 patients (80.8%) were treated conservatively (13 benign, 6 borderline, and 2 malignant) and 5 (19.2%) by radical surgery (1 borderline and 4 malignant); seven patients underwent post-operative radiotherapy; in 14/19 cases (73.7%), a good correlation was observed between intraoperative frozen section analysis and definitive histology; the tumor was classed as benign in 13 cases (50%), borderline in 7 cases (27%) and malignant in 6 cases (23%); follow-up data was available in 22 cases; the rate of recurrence was 23% (1 benign, 3 borderline, and 2 malignant) after a mean follow-up of 13.6 months; all the recurrent tumors were initially treated by lumpectomy and were close to margin at the initial pathologic examination; the treatment of recurrences consisted of simple mastectomy in 5 cases, and local excision in one case; three patients developed metastases, one of whom after recurrence; three patients have died.

Conclusions

This is a substantial single institution experience of a rare tumor. Phyllodes tumors of the breast have an unpredictable outcome, thus a wide local excision, with an adequate margin of normal breast tissue, is the preferred initial therapy.

Metastatic phyllodes tumor causing small-bowel obstruction

Cystosarcoma phyllodes is an important but relatively uncommon fibroepithelial breast neoplasm that accounts for 0.5%-1.0% of female breast carcinomas. Malignant forms comprise nearly 25% of cases. These usually metastasize to the lung, pleura, bone, and liver. Metastases to the small intestine are extremely rare, with only 1 case of metastatic spread to the duodenum reported in the literature. No previous reports of metastatic spread to the ileum have been published. This report highlights a unique case of a metastatic phyllodes breast tumor leading to small bowel obstruction. Phyllodes tumors are generally classified into histologic subtypes of benign, intermediate, and malignant, using agreed classification systems. The tumor characteristics that can lead to the dedifferentiation of a relatively benign phenotype to an overt malignant process are discussed. Chemotherapeutic regimens that might be effective treatments are discussed, and the importance of regular clinical and radiologic follow-up in patients with poor prognostic factors is outlined.

Update on Fibroepithelial Lesions of the Breast

This article focuses on current issues relating to fibroepithelial lesions, predominantly those with cellular stroma, and covers key pathologic features, differential diagnosis, and pitfalls. Phyllodes tumors are emphasized, including the histologic categorization and prognostic features of these lesions. The management of fibroepithelial lesions on needle core biopsy is reviewed.

Recurrent challenges in the evaluation of fibroepithelial lesions

CONTEXT

The morphologic spectrum of mammary fibroepithelial lesions ranges from fibroadenoma, a common benign neoplasm, to phyllodes tumor, an uncommon lesion that can sometimes recur and metastasize.

OBJECTIVE

To focus on problems encountered in the diagnostic evaluation of fibroepithelial tumors, highlighting the diagnostically relevant morphologic features and providing an update on the immunohistochemical profile and genetic alterations of these rare neoplasms.

DATA SOURCES

A PubMed search of the English-language literature identified published reports on fibroepithelial lesions, with a special focus on phyllodes tumor. The results and conclusions of these studies form the basis of this review.

CONCLUSIONS

The distinction between fibroadenoma and phyllodes tumor is usually not problematic, especially in excision specimens. In some cases, however, the diagnostic evaluation of fibroepithelial lesions can be challenging, especially if only limited material is available. Morphologic predictors of local recurrence of phyllodes tumor include cellularity and cytologic atypia, mitotic activity, positive margins, infiltrative borders, fibroproliferative satellite nodules, and past history of fibroadenoma. Predictors of distant metastasis include size, tumor necrosis, and stromal overgrowth. None of these parameters, however, constitutes a definite marker of malignancy. Presently, molecular and immunohistochemical techniques play a limited role in the diagnosis of fibroepithelial lesions.

Phyllodes tumor of the breast: an update

Phyllodes tumor is an uncommon biphasic breast tumor, with the ability to recur and metastasize, and it behaves biologically like a stromal neoplasm. Traditionally, phyllodes tumors are graded by the use of a set of histologic data into benign, borderline, and malignant. In most series, all phyllodes tumors may recur, but only the borderline and malignant phyllodes tumors metastasize. On the basis of histologic features, prediction of behavior is difficult. The expression of many biological markers, including p53, hormone receptors, proliferation markers, angiogenesis group of markers, c-kit, CD10 and epidermal growth factor receptor have been explored, and many have been shown to be variably expressed, depending on the grade of the tumor. These markers are, however, of limited value in predicting the behavior of the tumor. Recently investigators have reported a plethora of genetic changes in phyllodes tumors, the most consistent of which seems to be 1q gain by comparative genomic hybridization. Some candidate genes have been mapped to various sites, and preliminary data suggest that some of these changes may be related to recurrence. It is foreseeable that more exciting data will be generated to help us to understand the etiology and pathogenesis of phyllodes tumor.

A prospective, multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumors

BACKGROUND

Malignant phyllodes tumors of the breast are unusual neoplasms, with an incidence of approximately 500 cases annually in the United States. Published local recurrence rates after margin-negative breast-conserving resections of borderline malignant and malignant phyllodes tumors are unacceptably high, at 24 and 20%, respectively. It is uncertain whether radiotherapy after resection of phyllodes tumors is beneficial.

METHODS

We prospectively enrolled patients who were treated with a margin-negative breast-conserving resection of borderline malignant or malignant phyllodes tumors to adjuvant radiotherapy. The primary endpoint was local recurrence.

RESULTS

Forty-six women were treated at 30 different institutions. The mean patient age was 49 years (range, 18-76 years). Thirty patients (65%) had malignant phyllodes tumors; the rest were borderline malignant. The mean tumor diameter was 3.7 cm (range, .8-11 cm). Eighteen patients had a negative margin on the first excision. The median size of the negative margin was .35 cm (range, <.1-2 cm). Twenty-eight patients underwent a re-excision because of positive margins in the initial resection. Two patients died of metastatic phyllodes tumor. During a median follow-up of 56 months (range, 12-129 months), none of the 46 patients developed a local recurrence (local recurrence rate, 0%; 95% confidence interval, 0-8).

CONCLUSIONS

Margin-negative resection combined with adjuvant radiotherapy is very effective therapy for local control of borderline and malignant phyllodes tumors. The local recurrence rate with adjuvant radiotherapy was significantly less than that observed in reported patients treated with margin-negative resection alone.

Rare breast lesions: correlation of imaging and histologic features with WHO classification

Mammographers occasionally are surprised by the diagnosis of a rare lesion at breast biopsy. The imaging features of some breast lesions are unfamiliar because they are rarely seen in routine mammographic practice and they are not well described or well documented in the radiologic literature. Moreover, there may be wide variation in the appearances of rare breast lesions at mammography and ultrasonography (US). In addition, although a few rare breast lesions have a typical imaging appearance, most have mammographic and US features similar to those of breast carcinomas, and a needle biopsy is almost always necessary to obtain a diagnosis. However, even when a rare breast lesion is diagnosed on the basis of a needle biopsy, knowledge of the imaging features of such lesions may help the radiologist decide whether the results of pathologic analysis concur with the imaging findings and whether surgical excision is necessary. It is therefore important that radiologists be familiar with the broad spectrum of imaging features of rare breast lesions as well as with the correlation between their histopathologic features and their current classification according to the World Health Organization classification system.

Recent developments in the histological diagnosis of spindle cell carcinoma, fibromatosis and phyllodes tumour of the breast

This article reviews recent advances in the diagnosis of these three unusual tumours of the breast. Spindle cell carcinoma needs to be considered in the differential diagnosis of many mammary spindle cell lesions: it is important to be aware of the wide range of appearances, including the recently described fibromatosis-like variant. Immunohistochemistry using a broad panel of cytokeratin antibodies is needed to exclude spindle cell carcinoma; there is frequent expression of basal cytokeratins and p63. CD34 is often expressed by the stroma of phyllodes tumours, but does not appear to be expressed by spindle cell carcinoma or fibromatosis. Nuclear beta-catenin is found in about 80% of fibromatoses, but can also be seen in spindle cell carcinomas and phyllodes tumours. Two recent studies have described features useful in the distinction of phyllodes tumour and fibroadenoma on core biopsy, including increased cellularity, mitoses and overgrowth of the stroma, adipose tissue in the stroma and fragmentation of the biopsy specimen. Periductal stromal tumour is a recently described biphasic tumour composed of spindle cells around open tubules or ducts (but no leaf-like architecture) with frequent CD34 expression. The overlap of morphology with phyllodes tumour suggests that it may be best regarded as a variant of phyllodes tumour.

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.

Immediate breast reconstruction for phyllodes tumors

Phyllodes tumors are rare breast tumors. Surgery is the mainstay of treatment and mastectomy has been the traditional procedure adopted for these tumors. Although wide excision with adequate margins gives equivalent results, mastectomy may still be required if the tumors are very large. There are very few reports on the use of breast reconstruction after mastectomy for phyllodes tumors. We present a series of 7 patients with phyllodes tumors who were treated with mastectomy and immediate breast reconstruction. Mastectomy was conventional in 4 patients and skin sparing in 3. Reconstruction was performed with latissimus dorsi (LD) musculocutaneous flap in 4 patients and transverse rectus abdominis musculocutaneous (TRAM) flap in 3 patients. The mean follow-up was 40.1 months. One patient developed recurrence, 1 year after the surgery, which was treated with excision and radiotherapy. The cosmetic results were acceptable to all patients. Skin sparing mastectomy was associated with better cosmetic results.

Quantification of the Morphologic Features of Fibroepithelial Tumors of the Breast

Context.—Phyllodes tumors of the breast are uncommon, comprising 0.3% to 0.9% of female primary breast tumors. Owing in part to their rarity, definitive, objective, reproducible morphologic criteria that reliably distinguish benign from low-grade malignant or malignant phyllodes tumors have yet to be established.

Objective.—To use image analysis to quantitate and compare morphologic features of different groups of fibroepithelial tumors (FETs) of the breast.

Design.—Hematoxylin-eosin–stained sections of 41 FETs previously identified as fibroadenoma, benign phyllodes, low-grade malignant phyllodes, or high-grade malignant phyllodes were blinded and studied using a Leica DMRA2 microscope and OpenLab Image Analysis software. Features measured included mitotic rate per 10 high-power fields, stromal cellularity, nuclear size, stromal overgrowth, and the largest and smallest stromal-epithelial surface area ratios. Epithelial appearance was measured on a semiquantitative basis. Features of each case including tumor size, margin status, and the presence of necrosis or heterologous elements were also considered; these data were retrieved from surgical pathology reports.

Results.—Quantitative measures of stromal cellularity, stromal-epithelial ratio, mitotic rate, stromal overgrowth, and mean nuclear diameter were developed and found to stratify a population of FETs by the current classification system of fibroadenoma, benign, and low-grade or high-grade malignant phyllodes tumor.

Conclusions.—Quantitative morphologic features of FETs can be used to stratify these tumors by subtype. Use of these quantitative criteria could reduce interrater variability in histologically identifying FETs by subclass.

Phyllodes tumour of the breast: clinical follow-up of 33 cases of this rare disease

OBJECTIVE

The "cystosarcoma phyllodes" of the breast is a rare entity which accounts for 0.5% of all breast neoplasms. The aim of our study was to analyse the clinical management with respect to patient outcome.

STUDY DESIGN

The data of 5270 patients with primary breast neoplasms treated in our department between 1984 and 2005 were retrospectively analysed for the histopathologic diagnosis of a cystosarcoma phyllodes. The clinical data was analysed with respect to tumour grading and size, treatment and prognosis.

RESULTS

Retrospective analysis of 5270 patients with primary breast neoplasms revealed 33 patients. In the histopathological analysis, tumour grade was classified as benign in 40%, borderline in 27% and malignant in 33% of patients. Breast conserving surgery was conducted in 58% of the patients, mastectomy in 42%. Only one patient was treated with adjuvant radiotherapy after primary surgery. Mean tumour size was 6.9 cm, and no lymph node infiltration was found in the 10 patients who received axillary lymph node dissection. Local recurrence occurred in eight patients (26%). The local recurrence rate was 50% in malignant, 20% in borderline and only 8% in benign tumours. Distant metastases were seen in three patients (9%) with malignant phyllodes tumours. Neither regarding age at primary diagnosis nor in tumour size there was a significant difference between patients with local recurrence or metastatic spread and those without (p=0.284 tumour size; p=0.739 for age; Mann-Whitney U-test).

CONCLUSION

Histopathological classification appears to be the strongest prognostic factor in this disease.

Spindle cell lesions of the breast--the pathologic differential diagnosis

Spindle cell lesions of the breast represent an interesting diagnostic problem, as the differential diagnoses are wide. Diagnosing this is particularly problematic but important when encountered in a needle core biopsy, as treatments of different entities are different. In the histologic assessment of spindle cell lesions, the simplified approach is to evaluate the spindle cells and the accompanying epithelial cells. In the biphasic lesions with predominance of spindle cells with benign epithelial component, fibroepithelial lesions including fibroadenomas and phyllodes tumors are the most common, followed by pseudoangiomatous stromal hyperplasia, hamartoma and adenomyoepithelioma. For biphasic lesions with predominance of spindle cells with malignant epithelial component, the biphasic metaplastic carcinoma is likely. For monophasic lesions with pure pleomorphic spindle cell only, the monophasic metaplastic carcinoma is more common than the rare primary sarcomas like malignant fibrous histiocytoma, angiosarcoma, and other high grade sarcomas. In monophasic lesions with pure bland spindle cells only, the possible lesions include fibromatosis, fibromatosis like metaplastic carcinoma and other unusual conditions like dermatofibrosarcoma protuberance. By careful searching for the accompanying epithelial element, and with the aid of appropriate clinical input and judicious use of immunohistochemistry, many of these lesions can be confidently diagnosed in the needle core biopsy, thus facilitating appropriate treatments.

Phyllodes tumors of the breast segregate in two groups according to genetic criteria

Phyllodes tumors are rare fibroepithelial tumors of the breast. The pathologic grading of phyllodes tumors based on the aspect of the stromal component, is divided into 2 or 3 grades according to the system used. To determine whether genetic markers could be of use for improving the classification of phyllodes tumors and to provide a better knowledge of the genetic alterations in these tumors, we analyzed chromosomal changes detected by comparative genomic hybridization (CGH) in comparison with histological data, in a series of 30 cases. Recurrent chromosome imbalances were observed in 55, 91 and 100% of benign, borderline and malignant phyllodes tumors, respectively. The mean number of chromosome changes was one in benign, six in borderline, and six in malignant phyllodes tumors. Most frequent genetic imbalances were +1q (12/30), -13q (7/30), -6q (9/30), +5 (9/30) and -10p (8/30). Gains of 1q, present in only one of nine benign tumors, were found in 11/21 (51%) borderline or malignant tumors. Losses of 13q have 13q14.2 as smallest region of overlap, suggesting that the RB1 gene could be the target of deletions. Amplifications of 12q14, involving the MDM2 locus, and of 8p24, involving the MYC gene, were observed in one case each. Borderline and malignant phyllodes tumors could not be differentiated on the basis of their genomic imbalances (presence and number of chromosomal changes, presence of 1q gain and/or 13q loss). Conversely, benign tumors could be significantly differentiated from the group composed of borderline and malignant tumors (P<0.01). This study reveals two distinct patterns of genomic imbalance in phyllodes tumors: benign, with none or a few chromosome changes and malignant, with numerous recurrent chromosomal changes, in particular 1q gain and 13q loss. Helpful additional pathological criteria for differentiating the two genetic groups of phyllodes tumors are the nuclear size and the mitotic rate.

Phyllodes Tumors of the Breast – Diagnostic and Therapeutic Dilemmas

BACKGROUND

This article compares experiences in the diagnosis and treatment of phyllodes tumors from 2 regional institutions with the relevant literature.

PATIENTS AND METHODS

From 1991 to 2005, 2,848 breast cancer patients were treated in our institutions, 36 (1.44%) for phyllodes tumors. The average tumor size was 5.1 cm (range 1.4-19.6). Triple assessment was the standard diagnostic algorithm. Wide excision with tumor-free margins was carried out in 29 (80.5%) cases and mastectomy in 7 (19.4%) cases. Axillary lymphadenectomy was performed in patients with positive lymph nodes.

RESULTS

Histology showed the phyllodes tumors to be benign in 27 (75.0%), malignant in 6 (16.6%), and borderline in 3 (8.3%) cases. Follow-up was from 5 months to 16 years. In this period, recurrences of 3 (8.3%) malignant and 2 (5.6%) benign phyllodes tumors were diagnosed and treated. 10 (27.7%) patients treated with wide local excision showed deformities in the form of scarring. The steroid receptor status was of no prognostic value in our patients, and chemotherapy was used in only 1 (2.7%) patient. 5-year survival was 86.2%.

CONCLUSION

Our study shows that tumor size, margin infiltration, mitotic activity and degree of cellular atypia are important prognostic factors. Problems in diagnosing this condition arise from its similarity to fibroadenoma. Although wide local excision is usually the treatment of choice, tumor recurrence is common. Axillary lymphadenectomy in malignant phyllodes tumors is, in our opinion, still controversial.