Phyllodes tumor of the breast: an update

Hippo pathway effectors YAP, TAZ and TEAD are associated with EMT master regulators ZEB, Snail and with aggressive phenotype in phyllodes breast tumors

BACKGROUND

Phyllodes tumors (PTs) of the breast are uncommon fibroepithelial neoplasms that tend to recur locally and may have metastatic potential. Their pathogenesis is poorly understood. Hippo signaling pathway plays an essential role in organ size control, tumor suppression, tissue regeneration and stem cell self-renewal. Hippo signaling dysfunction has been implicated in cancer. Recent evidence suggests that there is cross-talk between the Hippo signaling key proteins YAP/TAZ and the epithelial-mesenchymal transition (EMT) master regulators Snail and ZEB. In this study we aimed to investigate the expression of Hippo signaling pathway components and EMT regulators in PTs, in relation to tumor grade.

METHODS

Expression of Hippo signaling effector proteins YAP, TAZ and their DNA binding partner TEAD was evaluated by immunohistochemistry in paraffin-embedded tissue specimens from 86 human phyllodes breast tumors (45 benign, 21 borderline, 20 malignant), in comparison with tumor grade and with the expression of EMT-related transcription factors ZEB and Snail.

RESULTS

Nuclear immunopositivity for YAP, TAZ and TEAD was detected in both stromal and epithelial cells in PTs and was significantly higher in high grade tumors. Interestingly, there was a significant correlation between the expression of YAP, TAZ, TEAD and the expression of ZEB and SNAIL.

CONCLUSIONS

Our results originally implicate Hippo signaling pathway in PTs pathogenesis and suggest that an interaction between Hippo signaling key components and EMT regulators may promote the malignant features of PTs.

Integrating single-cell and spatial transcriptomes reveals COL4A1/2 facilitates the spatial organisation of stromal cells differentiation in breast phyllodes tumours

BACKGROUND

Breast phyllodes tumours (PTs) are a unique type of fibroepithelial neoplasms with metastatic potential and recurrence tendency. However, the precise nature of heterogeneity in breast PTs remains poorly understood. This study aimed to elucidate the cell subpopulations composition and spatial structure and investigate diagnostic markers in the pathogenesis of PTs.

METHODS

We applied single-cell RNA sequencing and spatial transcriptomes on tumours and adjacent normal tissues for integration analysis. Immunofluorescence experiments were conducted to verify the tissue distribution of cells. Tumour cells from patients with PTs were cultured to validate the function of genes. To validate the heterogeneity, the epithelial and stromal components of tumour tissues were separated using laser capture microdissection, and microproteomics data were obtained using data-independent acquisition mass spectrometry. The diagnostic value of genes was assessed using immunohistochemistry staining.

RESULTS

Tumour stromal cells harboured seven subpopulations. Among them, a population of widely distributed cancer-associated fibroblast-like stroma cells exhibited strong communications with epithelial progenitors which underwent a mesenchymal transition. We identified two stromal subpopulations sharing epithelial progenitors and mesenchymal markers. They were inferred to further differentiate into transcriptionally active stromal subpopulations continuously expressing COL4A1/2. The binding of COL4A1/2 with ITGA1/B1 facilitated a growth pattern from the stroma towards the surrounding glands. Furthermore, we found consistent transcriptional changes between intratumoural heterogeneity and inter-patient heterogeneity by performing microproteomics studies on 30 samples from 11 PTs. The immunohistochemical assessment of 97 independent cohorts identified that COL4A1/2 and CSRP1 could aid in accurate diagnosis and grading.

CONCLUSIONS

Our study demonstrates that COL4A1/2 shapes the spatial structure of stromal cell differentiation and has important clinical implications for accurate diagnosis of breast PTs.

Borderline Phyllodes Tumor in a Child

Phyllodes tumor (PT) is considered a rare fibroepithelial tumor. Very few series have been reported in children and adolescents. Based on histopathological features, it can be classified as benign, borderline, or malignant, with the latter having a more aggressive clinical behavior. We report the case of a 10-year-old female who began with an asymptomatic mobile right breast mass. An initial fine needle biopsy (FNB) concluded fibroadenoma (FA). Months later, the mass kept growing, with the appearance of pain and nipple discharge. Benign PT was demonstrated in a new biopsy. A total mastectomy was performed. The post-surgical histopathological examination was compatible with a borderline PT. The patient is now symptom-free and with no signs of relapse. Not all breast masses in the pediatric or adolescent age bracket are FA. Attention is warranted when the clinical behavior does not follow the usual outline. PT has to be considered as a possible diagnosis and treated accordingly.

A Large Phyllodes Tumor With Axillary Lymph Node Involvement: A Case Report

Malignant phyllodes tumors of the breast are uncommon and complex to treat. This case involves a 39-year-old woman with a rapidly growing mass in her right breast measuring 32cm. The patient underwent a bilateral mastectomy with a right sentinel node biopsy and right chest wall reconstruction. The final pathology of the tumor revealed a malignant phyllodes tumor, with one of two right axillary lymph nodes positive for metastatic phyllodes tumor. Malignant phyllodes tumors should be taken into consideration in any rapidly growing breast mass. Further studies analyzing the treatment of malignant phyllodes tumors are necessary to reduce the risk of tumor recurrence and metastasis.

Organoid models derived from patients with malignant phyllodes tumor of the breast

PURPOSE

Phyllodes tumor of the breast is a kind of rare neoplasm, which accounts for less than 1% of all breast tumors. Malignant phyllodes tumor (MPT) is the highest risk subtype of phyllodes tumor, and is characterized by the tendency of local recurrence and distant metastasis. The prediction of prognosis and the individual therapy for MPT is still challenging. It's urgent to develop a new reliable in vitro preclinical model in order to understand this disease better and to explore appropriate anticancer drugs for individual patients.

METHODS

Two surgically resected MPT specimens were processed for organoid establishment. MPT organoids were subsequently subjected to H&E staining, immunohistochemical analysis and drug screening, respectively.

RESULTS

We successfully established two organoid lines from different patients with MPT. The MPT organoids can well retain the histological features and capture the marker expression in original tumor tissues, including p63, vimentin, Bcl-2, CD34, c-Kit, and Ki-67, even after a long-term culture. The dose titration tests of eight typical chemotherapeutic drugs (paclitaxel, docetaxel, vincristine, doxorubicin, cisplatin, gemcitabine, cyclophosphamide, ifosfamide) on the two MPT organoid lines showed patient-specific drug responses and varying IC₅₀ values. Of all the drugs, doxorubicin and gemcitabine showed the best anti-tumor effect on the two organoid lines.

CONCLUSION

Organoids derived from MPT may be a novel preclinical model for testing personalized therapies for patients with MPT.

A malignant transformation of borderline phyllodes tumor to fibrosarcoma breast: A rare case report

ABSTRACT

Phyllodes tumor of the breast with malignant transformation to fibrosarcoma of the breast is a rare entity. Breast fibrosarcoma is uncommon, accounting for less than 1% of all breast tumors. Prognosis of fibrosarcoma of the breast is poor. Due to its rarity, survival rates are not defined. A 23-year-old woman presented with a mass in the left breast, and another 48-year-old woman presented with right breast mass. Both patients underwent for surgery. The histological & immunohistochemical examination confirms the diagnosis of a malignant transformation from borderline phyllodes tumor to fibrosarcoma. We concluded that the phyllodes tumor is mostly benign but local recurrence is common. As the tumor progresses toward malignancy, due to the difficulty in the diagnosis of borderline phyllodes tumors, total mastectomy with axillary resection must be recommended.

Logistic regression analysis of ultrasound findings in predicting the malignant and benign phyllodes tumor of breast

OBJECTIVE

To evaluate ultrasound characteristics in the prediction of malignant and benign phyllodes tumor of the breast (PTB) by using Logistic regression analysis.

METHODS

79 lesions diagnosed as PTB by pathology were analyzed retrospectively. The ultrasound features of PTB were recorded and compared between benign and malignant tumors by using single factor and multiple stepwise Logistic regression analysis. Moreover, the Logistic regression model for malignancy prediction was also established.

RESULTS

There were 79 patients with PTB, including 39 benign PTBs and 40 malignant PTBs (33 borderline PTBs and 7 malignant PTBs by pathologic classification). The area under the ROC curve (AUC) of lesion size and age were 0.737 and 0.850 respectively. There were significant differences in age, lesion size, shape, internal echo, liquefaction, and blood flow between malignant and benign PTBs by using single-factor analysis (P<0.05). Age, internal echo, and liquefaction were significant features by using Logistic regression analysis. The corresponding regression equation In (p/(1 - p) = -3.676+2.919 internal echo +3.029 liquefaction +4.346 age).

CONCLUSION

Internal echo, age, and liquefaction are independent ultrasound characteristics in predicting the malignancy of PTBs.

Large borderline phyllodes breast tumor related to histopathology, diagnosis, and treatment management - case report

Breast phyllodes tumors (PTs) are uncommon tumors with a biphasic fibroepithelial component, characterized by rapid development in middle-aged women. A correct preoperative diagnosis after Tru-Cut biopsy allows for proper surgical planning. The treatment of choice remains surgery (wide local excision or mastectomy) with or without breast reconstruction, depending on the size and histopathological (HP) nature of the tumor. We reported a case of a 50-year-old woman with a large PT in her left breast, measuring 11/10 cm. Preoperative HP examination revealed biphasic proliferation, with the appearance of benign PT. The patient underwent a left mastectomy, with a favorable postoperative evolution. The final HP diagnosis was borderline PT, with areas of lipomatous metaplasia. After three months, breast reconstruction was performed. The therapeutic management of large PTs continues to be a challenge for pathologists and surgeons. Due to the increased frequency of local recurrence and HP progression to malignancies, the treatment of choice for these patients is mastectomy, without lymphadenectomy.

Quantitative proteome profiling stratifies fibroepithelial lesions of the breast

Breast fibroepithelial lesions (FELs) include heterogeneous pathological tumors, involving indolent fibroadenoma (FAD) to potentially aggressive phyllodes tumors (PTs). The current grading system remains unreliable in differentiating these tumors due to histological heterogeneity and lack of appropriate markers to monitor the sudden and unpredictable malignant transformation of PTs. Thus, there exists an imminent need for a marker-based diagnostic approach to augment the conventional histological platform that could lead to accurate diagnosis and distinction of FELs. The high- throughput quantitative proteomic analysis suggested that FAD and PTs form distinct clusters away from borderline and malignant though there exist marked differences between them. Interestingly, over-expression of extracellular matrices (ECM) related proteins and epithelial-mesenchymal transition (EMT) markers in borderline PTs led us to hypothesize a model of deposition and degradation leading to ECM remodeling and EMT acquisition triggering its malignant transformation. We also identified three candidate biomarkers such as MUCL1, HTRA1, and VEGDF uniquely expressed in FAD, borderline, and malignant PTs, respectively, which were further validated using immunohistochemistry. The present work shed light on a brief mechanistic framework of PTs aggressive nature and present potential biomarkers to differentiate overlapping FELs that would be of practical utility in augmenting existing diagnosis and disease management for this rare tumor.

The limited role of ultrasound in the surgical assessment of solid pediatric breast lesions

INTRODUCTION

Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P).

METHODS

A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS.

RESULTS

88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPØ) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPØ 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPØ 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPØ 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing.

CONCLUSION

US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE.

Malignant phyllodes tumor of the breast with rapid progression: a case report

BACKGROUND

Malignant phyllodes tumors (PTs) of the breast occur infrequently and are difficult to treat with adjuvant therapy. Here, we present a case of a female patient with a huge malignant PT with rapid progression in a short period.

CASE PRESENTATION

A 44-year-old woman presented to our hospital with a rapid growth mass in her right breast, measuring 20 cm. She was initially diagnosed as having a borderline phyllodes tumor by core needle biopsy and underwent total mastectomy and artificial dermis was grafted, 20 days later, latissimus dorsi muscle flap and free skin grafting were performed. Two courses of doxorubicin-ifosfamide therapy were administered because of recurrence, but the patient died 4 months after the mastectomy.

CONCLUSIONS

A standard therapeutic strategy for malignant PTs is needed in urgently to reduce the risk of tumor recurrence.

Characterizing excised breast masses in children and adolescents-Can a more aggressive pathology be predicted?

PURPOSE

Our aim was to characterize excised breast masses in children and adolescent and to identify factors associated with a more aggressive pathology.

METHODS

Retrospective review of all female patients <19 who underwent excision of breast masses at our institution between 1999 and 2018. Demographic, clinical, imaging, pathological and management data were collected. We assessed possible association of any of the variables with a more aggressive pathology (phyllodes tumor and malignancy). Correlation between core needle biopsy results and final pathology results was also calculated.

RESULTS

70 patients were included. Median age was 17 years (range: 11-19). Resected mass size was 4 cm (range: 2-16). Final pathology results were: fibroadenoma (49), juvenile fibroadenoma (7), hamartoma (5), benign phyllodes (7), malignant phyllodes (1) and sarcoma (1). Pathology was benign in 61 (87%) patients and more aggressive (phyllodes and sarcoma) in 9 (13%). None of the tested variables was associated with a more aggressive pathology. Presurgical core biopsy results matched final pathology in only 63.6%.

CONCLUSIONS

Excised breast masses in children and adolescents are sometimes of a more aggressive pathology, which cannot be predicted by presurgical factors, including a core needle biopsy. Prognosis study LEVEL OF EVIDENCE: III.

Ki67 and P53 Expression in Relation to Clinicopathological Features in Phyllodes Tumour of the Breast

OBJECTIVE

Phyllodes tumour (PT) is a rare fibroepithelial neoplasm of the breast that carries a risk of malignancy. Histopathological examination remains a gold standard for diagnosis. The usage of the immunohistochemical markers of Ki67 and p53 acts as a supplement method, particularly for the malignant PT. We aim here to study the expression of these markers in PT and to see their relation to the tumour grading.

METHODOLOGY

We conducted a retrospective cross-sectional study on 57 archived formalin-fixed paraffin-embedded tissue blocks of PT from the years 2015 to 2018 from two hospitals in East Coast Malaysia. The histopathological examination and immunohistochemical stain for Ki67 and p53 were analysed.

RESULTS

There was an association between clinical descriptive data of skin changes, lump size of more than 3 cm, cytological atypia, stromal hypercellularity, mitosis and immunohistochemistry with the clinical diagnosis of PT. Both marked expression of Ki67 and p53 were seen in borderline and malignant PT. Our study showed that in the presence of high mitotic figures, marked expression of Ki67 was only seen in cases of malignant PT.

CONCLUSION

We found a significant association of Ki67 and p53 expressions, high mitosis and other descriptive histopathological features in malignant PT. Further study with larger sample size is recommended to predict tumour grade and prognosis as well as the disease-free survival of the tumour. 
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Application of periareolar mastopexy technique for giant phyllodes tumor resection in an adolescent female with breast asymmetry: a case report and literature review

BACKGROUND

The phyllodes tumors are rare neoplastic disease which exhibits a benign behavior in adolescents female. After resection of a large benign breast tumor, insufficient breast contour may result with nipple areola complex malposition. As symmetry of the breast is psychologically extremely crucial, especially in adolescents, in such cases, an immediate mammoplasty-like breast reduction or mastopexy technique of the affected breast will be necessary to provide symmetry of the bilateral breasts at the initial surgery.

CASE PRESENTATION

A 16-year-old woman reported rapid enlargement of a large mass in her left breast over 12 months. The physical examination revealed a huge mass that occupied the lower quadrants of her left breast causing expansion of both the overlying skin and the nipple areolar complex. A biopsy was constant with a benign phyllodes tumor. We have applied a periareolar mastopexy technique to allow tumor resection through exposure incision at the lower half of the outer periareolar circular incision. At the same time, we reduced the expanded skin envelope and mobilized the nipple-areola complex to restore breast symmetry.

CONCLUSION

The periareolar mastopexy approach provides a wide surgical exposure, allows excision of benign giant breast tumor, and simultaneous restoration of the breast shape with favorable aesthetic results and minimal postoperative scarring.

A novel collision tumour of myofibroblastoma and low-grade adenosquamous carcinoma in breast

BACKGROUND

Myofibroblastoma (MFB) and low-grade adenosquamous carcinoma (LGASC) are rare tumours in the breast, respectively. However, a collision tumour of the two types has never been reported.

CASE PRESENTATION

A 42-year-old female presented with a palpable mass in diameter of about 2.5 cm in the left breast. Morphologically, the lesion was predominately composed of bland spindle cells admixed with some islands of mature adipocytes and a few epithelial elements dispersing in infiltrating way which formed both tubule and solid structures. The mass showed low positive index of Ki-67. The spindle cells were strongly and diffusely positive for CD34, SMA, desmin, ER and PR. The epithelial elements were positive for CK and EMA, and negative for ER and PR completely. CK5/6 and P63 were positive in the outer-layer of the tubules and nearly all the cells of the solid nests.

CONCLUSIONS

A collision tumour of MFB and LGASC in breast is extremely rare and either component is supposed to be not overlooked. Excision and close follow-up are advised.

Immunohistochemical expression of Ki-67, p53, and CD10 in phyllodes tumor and their correlation with its histological grade

CONTEXT:

Phyllodes tumors (PTs) are the fibroepithelial neoplasms of the breast. Histologically, PTs are divided into three subgroups according to their clinicopathological behavior: benign, borderline, and malignant. It is at times difficult to ascertain the grade of PT on morphological criteria alone, especially borderline PT may be at times difficult to distinguish from its benign or malignant counterparts.

AIMS:

This study was undertaken to evaluate an immunohistochemical panel of Ki-67, p53, and CD10 in PT and to determine their expression in PT in correlation with its grade.

SETTINGS AND DESIGN:

This was a retrospective study.

SUBJECTS AND METHODS:

The study included six malignant, six borderline, and twelve benign PT. Expressions of Ki-67, p53, and CD10 were evaluated on all the 12 cases and compared in these three categories.

STATISTICAL ANALYSIS USED:

Chi-square test was applied, and P < 0.05 was taken as statistically significant.

RESULTS:

Stromal expression of Ki-67 and p53 between the benign and borderline/malignant group showed a statistically significant difference. Neither CD10 expression nor epithelial expressions of Ki-67 and p53 were found significant. Periepithelial accentuation of Ki-67 and p53 immunostaining was noted in all positive cases.

CONCLUSIONS:

Ki-67 labeling index and p53 immunostaining can be a useful adjunct to determine the grade in difficult cases. However, no single immunomarker can reliably distinguish between benign and borderline phyllodes in all cases.

Benign phyllodes tumor with hemorrhagic cyst in a 14-year-old girl: A case report

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A rare phyllodes tumor in a 14-year-old girl.

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It increased rapidly due to bleeding and was accompanied by cyst formation.

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Needle biopsy is also important for differential diagnosis.

Introduction

The incidence of mammary phyllodes tumor is less than 0.3–0.5% of all breast tumors. Only a few pediatric cases have been reported. Here we report a benign phyllodes tumor that occurred in a 14-year-old girl.

Presentation of case

A left breast mass with a bleeding cyst of about 9 cm was resected after the tumor had rapidly increased in size over the course of 2 months. Imaging examinations suggested an intracystic tumor. Histopathological examination, however, revealed a benign phyllodes tumor without cytomorphism or mitotic figures. The tumor was accompanied by partial bleeding, which was considered to be the cause of the rapid increase in size of the hemorrhagic cyst. The patient remains under observation, and local recurrence has not occurred as of 3 years after surgery.

Conclusion

Due to the rarity of the condition in children and adolescents, an individualized, case-based approach is recommended.

Huge borderline phyllodes breast tumor with repeated recurrences and progression toward more malignant phenotype: a case report and literature review

Background

Phyllodes tumor (PT) is a rare breast fibroepithelial biphasic tumor composed of stromal and epithelial components. The patients suffering from this disease present with a large, round, mobile, fast-growing lump, and the giant PT of more than 10 cm in diameter is so uncommon. Surgery is regarded as the primary treatment, but curative efficiency of adjuvant chemotherapy and radiotherapy is so indefinite.

Case presentation

We reported one case of a middle-aged woman with a huge borderline PT in the right breast, over 20 cm in size. The pathology of needle core biopsy of the lump was suggestive of PT of the borderline subgroup, and then she underwent mastectomy of the right breast. The patient had recovered well without any postoperative treatment until a local recurrence occurred 1 year after operation. The tumor was removed with lumpectomy, which was pathologically diagnosed as malignant PT. We followed up her by telephone and heard about her postoperative adjuvant radiotherapy and chemotherapy, as well as her well recovery.

Conclusion

The pathology of PT with low incidence is mostly benign, but local recurrence is common, and the histopathology progresses toward worsen trend. Besides, due to the difficulty in precise diagnosis of the borderline PTs, it is recommended that this subtype of patients should undergo total mastectomy. Although the curative effect of postoperative treatment has not been recognized internationally, patients, especially those with huge tumors, may benefit from these treatments.

Breast Lesions in Children and Adolescents: Diagnosis and Management

Pediatric breast disease is uncommon, and primary breast carcinoma in children is extremely rare. Therefore, the approach used to address breast lesions in pediatric patients differs from that in adults in many ways. Knowledge of the normal imaging features at various stages of development and the characteristics of breast disease in the pediatric population can help the radiologist to make confident diagnoses and manage patients appropriately. Most breast diseases in children are benign or associated with breast development, suggesting a need for conservative treatment. Interventional procedures might affect the developing breast and are only indicated in a limited number of cases. Histologic examination should be performed in pediatric patients, taking into account the size of the lesion and clinical history together with the imaging findings. A core needle biopsy is useful for accurate diagnosis and avoidance of irreparable damage in pediatric patients. Biopsy should be considered in the event of abnormal imaging findings, such as non-circumscribed margins, complex solid and cystic components, posterior acoustic shadowing, size above 3 cm, or an increase in mass size. A clinical history that includes a risk factor for malignancy, such as prior chest irradiation, known concurrent cancer not involving the breast, or family history of breast cancer, should prompt consideration of biopsy even if the lesion has a probably benign appearance on ultrasonography.

Radiopathological characteristics and outcomes of phyllodes tumor of the breast in Malaysian women

Phyllodes tumor or cystosarcoma phyllodes is a rare fibroepithelial neoplasm which arises from the periductal stroma of the breast. They are classified as benign, borderline, and malignant based on the histologic features. However, all phyllodes tumor (PT) subtypes are regarded as having malignant potential and correct diagnosis is important for surgical management and optimal care. This study is a retrospective review of 76 women diagnosed as PT with highlights on the imaging characteristics, pathology, and surgical treatment over a 7-year period in a tertiary medical center of urban population in Malaysia. There were 45 benign, 16 borderline, and 15 malignant PT. The median age for benign PT was 43, borderline 48.5, and malignant 42 years. The Malay ethnic group constitute 52.6% of cases, with 27.6% and 18.4% in Chinese and Indian ethnic groups, respectively. On mammograms, most benign (64.3%) and 33.3% of malignant PT showed high-density lesions. Calcifications were only seen in 2 benign PT. On ultrasound, 86% of benign PT was well-circumscribed whilst 50.0% of malignant PT had irregular outline. Cystic spaces were seen in 40.0% of malignant and 9.5% of benign PT. 80% of malignant PT lesions were heterogenous. Malignant PT demonstrates tumor heterogeneity, cystic spaces, and posterior acoustic enhancement on ultrasound. Half of malignant PT showed regular borders on ultrasound and appear well circumscribed on mammogram. A total of 46 patients had wide local excision or excision biopsy whilst 30 underwent mastectomy as primary treatment. The majority of the borderline and malignant PTs in our study (75.0% and 85.7% respectively) and only 5 out of the 43 (11.6%) benign PT underwent mastectomy. There were 2 tumor recurrence in the benign PT group and 1 case in the borderline and malignant group respectively.

Inflamed Phylloides Tumour in a Girl: A Challenging Diagnosis in Paediatric Breast Lesions

Introduction: Phylloides tumours (PTs) are rare fibroepithelial neoplasms that account for 0.3⁻0.9% of all breast tumours. These tumours typically occur in women aged 30⁻70 years. The occurrence of these tumours in older children and adolescents poses particular diagnostic and therapeutic problems. However, early diagnosis is mandatory because although most of the cases of PTs in children are benign, the borderline and malignant cases with potential negative outcomes cannot be excluded. Case presentation: A 12-year-old girl presented at the Paediatric Emergency Department for hyperaemia and warmth of the left breast that occurred a few days prior without fever. The girl experienced menarche 8 months previously. She experienced no previous trauma and she had no family history of breast cancer. On physical examination, the left breast was painful, enlarged and tender. The overlying skin was erythematous and warm. A breast ultrasonography (US) revealed a large mass with features of an abscess, including a hyperechoic wall, scattered internal echoes and hypoechoic peripheral lacunae of apparent colliquative nature. After 4 days of unsuccessful antibiotic therapy, surgical drainage was performed due to the suspicion of a mammary abscess. At the surgical incision site, the lesion was not-well circumscribed and lacked a capsule. In addition, purulent material was not detected. Histological examination revealed that the tissue alterations were compatible with benign PT. With this diagnosis, the girl underwent definitive surgical removal of the lesion. The postoperative period passed without negative events. An US performed 6 months later revealed that no new mass was present at this time, suggesting no recurrence of the tumour. Conclusion: This case shows that in the presence of a clinical picture suggesting the inflammation of the breast in adolescent females, PT should be considered as a possible diagnosis and US-guided core biopsy should be considered to confirm this suspicion. Thereafter, when surgical excision is performed, particular attention must be paid to both the preservation of all the normal breast parenchyma and future aesthetic problems.

Expression of EMT markers and mode of surgery are prognostic in phyllodes tumors of the breast

Phyllodes tumors of the breast are rare neoplasms that account for <1% of all mammary tumors and 2-3% of fibro-epithelial neoplasms of the breast. We evaluated the clinicopathological characteristics of a cohort of 246 Chinese patients in relation to the expression of epithelial-to-mesenchymal (EMT) markers in benign, borderline and malignant tumors and the prognostic value of different surgical regimens. We observed that survival outcomes correlated with the mode of surgical management in the three patient groups. Expression of E-cadherin, Snail, Slug and Twist were higher in epithelial cells from borderline and malignant tumors than those in benign tumors, whereas the expression of N-cadherin was opposite. Levels of the EMT markers Snail and Slug in the stromal compartment increased with the advancing tumor grade. Expression of mesenchymal stem cell markers contributed to the inherent heterogeneity in the malignant tumors. Based on Cox models, surgical management emerged as an independent predictor for disease-free survival, whereas a history of recent growth and tumor grade were independent predictors for overall survival. These findings show that expression of EMT markers, the mode of surgical management, and a history of recent tumor growth had prognostic potential for patients with phyllodes tumors of the breast.

Phyllodes Tumor of the Breast: Ultrasound-Pathology Correlation

OBJECTIVE

The purpose of this study is to evaluate the sonographic and histopathologic features distinguishing benign from borderline and malignant phyllodes tumors.

MATERIALS AND METHODS

The ultrasound examinations of women with pathologically proven phyllodes tumors from 2004 to 2011 were retrospectively reviewed. The sonographic features of benign, borderline, and malignant phyllodes tumors were compared and analyzed using the American College of Radiology's BI-RADS ultrasound lexicon. Fisher exact test and Wilcoxon rank sum test were used for statistical analysis.

RESULTS

Fifty-nine women were included in the study; 28 benign (47%), 19 malignant (32%), and 12 borderline (20%) phyllodes tumors were identified. Significant univariate predictors of increased risk of borderline or malignant phyllodes tumors were patient age greater than 55 years (p = 0.014), irregular lesion shape (p = 0.011), and longest lesion dimension greater than 7 cm (p = 0.0022) at sonography. No significant differences were observed in lesion margins, boundaries, echo patterns, or posterior acoustic features.

CONCLUSION

There is substantial overlap in the sonographic features of benign and borderline or malignant phyllodes tumors. Understanding the clinical and sonographic features of phyllodes tumors may aid the radiologist in predicting biological behavior, including the likelihood of benign versus borderline or malignant phyllodes tumors at pathologic analysis.

Breast malignant phyllodes tumor with rare pelvic metastases and long-term overall survival: A case report and literature review

BACKGROUND

Malignant phyllodes tumor (PT) is a rare fibro epithelial neoplasm of the breast, which is poor prognosis due to high risk of recurrence and distant metastasis.

METHODS

We report a case of malignant PT. It had recurred locally five times, and the sixth relapse was occurred 54 months after first diagnosis, presenting a huge pelvic mass (14 cm × 11 cm) by CT scan. Histopathological examination has demonstrated a metastatic phyllodes tumor. After postoperative chemotherapy treatment, a longer survival has been achieved, which is more than 72 months.

RESULTS

Our case report describes a breast PT with several local recurrences and a rare metastasis (pelvic cavity), but long-term overall survival was achieved after surgery and chemotherapy.

CONCLUSION

We conclude that trustworthy prognosticators that identify patients with excessive potential of aggressive clinical course should be explored. Moreover, proper treatment could prolong overall survival of metastatic PT patients.

Treatment of Patients with Distant Metastases from Phyllodes Tumor of the Breast

Background

Here, the treatment methods and results of patients with phyllodes tumor of the breast (PT) with distant metastases at a single institution are presented.

Methods

A retrospective analysis was performed on a group of 295 patients with PT treated from 1952 to 2010.

Results

Distant metastases developed in 37 (12.5 %) patients; 3/160 (1.9 %) patients had benign PT, 6/36 (16.7 %) were considered borderline, and 28/99 (28.3 %) had malignant PT. Most frequently, the metastases were located in the lungs; 28 (75.7 %), bone 7 (18.9 %), brain 4 (10.8 %), and liver 2 (5.4 %). Metastases occurred on overage 21 months (2–57) after surgery. Patients with lung metastases were generally treated with monochemotherapy or polychemotherapy. In one patient Testosterone and in two patients resection of metastases combined with Doxorubicin were used. Patients with bones or brain metastases were treated with palliative radiotherapy only or combined with Doxorubicin. The mean survival (MS) from diagnosis of distant metastases (DM) was 7 months (2–17). The longest mean survival in patients with bones metastases was 11.8 months, the worst survival was for patients with brain metastases—2.8 months. Hormone therapy appeared to have low efficacy (MS: 2 months) as well as monochemotherapy (MS: 3–5 months). Improved MS was obtained using Doxorubicin (7 months) and Doxorubicin with Cisplatin, Cyclophosphamide, or Ifosfamide (9 months).

Conclusion

The prognosis of patients with DM from PT is poor. The role of surgery and irradiation of such patients is very limited. There appears to be no role for the use of hormone therapy. This study showed that polychemotherapy with Doxorubicin and Ifosfamide suggest that it might be more effective than once thought.

First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The purpose of this study is to obtain a consensus for the therapy of B3 lesions. The first International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions) including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), benign phyllodes tumors (PT), and radial scars (RS) took place in January 2016 in Zurich, Switzerland organized by the International Breast Ultrasound School and the Swiss Minimally Invasive Breast Biopsy group-a subgroup of the Swiss Society of Senology. Consensus recommendations for the management and follow-up surveillance of these B3 lesions were developed and areas of research priorities were identified. The consensus recommendation for FEA, LN, PL, and RS diagnosed on core needle biopsy or vacuum-assisted biopsy (VAB) is to therapeutically excise the lesion seen on imaging by VAB and no longer by open surgery, with follow-up surveillance imaging for 5 years. The consensus recommendation for ADH and PT is, with some exceptions, therapeutic first-line open surgical excision. Minimally invasive management of selected B3 lesions with therapeutic VAB is acceptable as an alternative to first-line surgical excision.

Fibroadenoma versus phyllodes tumor: distinguishing factors in patients diagnosed with fibroepithelial lesions after a core needle biopsy

PURPOSE

We aimed to identify factors that might help differentiate phyllodes tumors from fibroadenomas among cases in which a fibroepithelial breast lesion was diagnosed from core needle biopsy (CNB) under imaging guidance.

MATERIALS AND METHODS

A retrospective review was performed on 213 lesions in 200 patients who had undergone both CNB and excisional biopsy during a four-year period between 2008 and 2011. The final pathology revealed 173 fibroadenomas and 40 phyllodes tumors. The data, including patient characteristics, clinical presentation, and mammography, ultrasonography (US), and pathology findings were analyzed.

RESULTS

Upon univariable analysis, the factors that significantly helped to identify phyllodes tumors consisted of the presenting symptoms (palpable mass or breast pain), increased size on clinical examination, hyperdense mass on mammogram, and the following three US features: heterogeneous echo, presence of round cysts within the mass, and presence of clefts within the mass. The pathologist's suggestion of a phyllodes tumor was also helpful. The factors that remained statistically significant upon multivariable analysis consisted of symptoms of breast pain, the presence of clefts on US, the presence of round cysts on US and the pathologist's favoring of phyllodes tumors from a CNB specimen.

CONCLUSION

A multidisciplinary approach was needed to distinguish phyllodes tumors from fibroadenomas in patients who had undergone CNB. US findings (clefts and round cysts), suggestive pathological diagnoses, and clinical symptoms were all useful for the decision to surgically remove the fibroepithelial lesions diagnosed from CNB.

Biomarkers distinguishing mammary fibroepithelial neoplasms: a tissue microarray study

AIM

To determine whether any markers in biopsy specimens were useful for distinguishing (1) fibroadenoma (FA) from benign phyllodes tumors (PTs); and (2) from benign borderline PTs of the breast.

MATERIALS AND METHODS

Specimens of 80 breast tumors (20 FA, 38 benign, 12 borderline, and 10 malignant PTs) diagnosed at Tri-Service General Hospital from 1986 to 2006 and 10 normal breast tissue were investigated immunohistochemically for the expression of 11 biomarkers including p53, Ki-67, topoisomerase IIα, p16, retinoblastoma protein (pRb), fascin-1, estrogen receptor-β, CD117, osteopontin, hypoxia-inducible factor-1α, and cyclooxygenase-2. The binary logistic regression method was used to generate functions that discriminate between benign and borderline PT and also between FA and benign PT.

RESULTS

On the basis of the most active area of stained stromal cells, the staining intensity, and the immunoscore, the expression of Ki-67, topoisomerase IIα, p16, and pRb was significantly higher in borderline or malignant PTs than in benign PTs. Ki-67 could discriminate benign from borderline PTs singly with a high sensitivity (91.7%), specificity (100%), and accuracy (98%). In addition, expression of Ki-67, p16, and pRb was significantly higher in benign PT than in FA. Binary logistic regression identified p16 and pRb as the only marker combination capable of distinguishing FA from benign PTs with sensitivity (94.7%), specificity (75%), and accuracy (87.9%).

CONCLUSION

Ki-67 may be a useful marker for discriminating benign from borderline PTs, and p16 and pRb may be a useful combination of markers for distinguishing FA from benign PTs in core biopsy specimen.

Five-Year Disease-Free Follow-Up of a Borderline Breast Phyllodes Tumor in a 15-year-old Patient

Phyllodes tumors are large breast tumors representing only 1% of breast neoplasms and are rarely seen in young women. Histologically, phyllodes tumors are classified as benign, borderline, or malignant based on the characteristics of the stroma. Although wide local excision is recommended for the treatment modality, the reoccurrence rate after surgical excision varies between 36% and 65%, with recurrence more likely in those with the tumor at the margins of excision. Our aim was to report -a case in a 15-year-old girl with a 115-mm borderline phyllodes tumor in her left breast mimicking a juvenile fibroadenoma. We presented a 5-year disease-free follow-up after wide local excision with negative margins.

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.

A pulmonary metastasis of a cystosarcoma phyllodes of the breast detected by 18F-FDG PET/CT

We describe a pulmonary metastasis of a cystosarcoma phyllodes of the breast (CPB) detected by F-FDG PET/CT. A 65-year-old female patient previously operated on for a cystosarcoma phyllodes of the left breast underwent F-FDG PET/CT for restaging. F-FDG PET/CT showed an area of increased F-FDG uptake corresponding to a 2-cm right pulmonary nodule. Histology suggested the presence of a pulmonary metastasis of CPB.

Breast-conserving surgery is contraindicated for recurrent giant multifocal phyllodes tumours of breast

Background

The controversy between breast conserving surgery and simple mastectomy for phyllodes tumours of the breast remains because of the unpredictable nature of the disease. Although some benign tumours may show an unusually aggressive behaviour, modified radical surgery for phyllodes tumours offers no survival advantage, and recently more conservative surgical approaches have been deployed.

Case presentation

A 30-year-old woman with a giant multifocal tumour of the breast underwent breast-conserving surgery that made use of the well- circumscribed feature of the tumour. The case demonstrates the safety, and cosmetic benefit of the breast-conserving approach for multifocal phyllodes tumours except for the high recurrence rate.

Conclusions

Large size, multifocality, and borderline or malignant histology are contraindications for breast-conserving surgery.

Malignant phyllodes tumors of the breast: a study in clinical practice

Malignant phyllodes tumors are an uncommon breast tumor in clinical practice of surgery. The study population consisted of five consecutive patients. Each patient had complete clinical follow-up with annual mammograms and physical examination in a specialized breast clinic. They were surgically treated for with malignant phyllodes tumor of the breast. All patients are alive and well with a complete follow-up. The first 2 patients had a fine needle aspiration cytology and were surgically treated by a simple mastectomy. The remaining 3 patients were preoperatively diagnosed with core needle biopsy. These 3 patients were treated with a wide excision of the phyllodes tumor with at least a 1-cm margin of normal breast tissue. Mammography was 100% accurate in demonstrating a dense breast mass. In each patient ultrasound suggested heterogeneous internal echoes present in each malignant phyllodes tumor. Fine needle aspiration cytology was of no value in the diagnosis of a phyllodes tumor. Core needle biopsy is highly reliable in establishing a preoperative diagnosis. The most helpful clinical observation of a malignant phyllodes tumor was rapid growth and enlargement, which is frequently noted by the patient.

Changes in the clinical characteristics, treatment options, and therapy outcomes in patients with phyllodes tumor of the breast during 55 years of experience

Background

Data from the literature suggests that the clinical picture of phyllodes tumor (PT) of the breast, as well as treatment options and perhaps therapy outcomes, have significantly changed. The aim of this work was to review these changes by analysis of consecutive patients with PT over a 55-year period at a single institution.

Material/Methods

From 1952 to 2007, 280 women with PT were treated surgically at the Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Center in Cracow. Age, size of breast tumor, microscopic type, extent of surgery, and therapy outcomes were compared between 2 groups: 190 patients treated from 1952 to 1991 vs 90 patients treated from 1992 to 2007.

Results

The results show that the 1992–2007 group compared to the 1952–1991 included more patients <50 years of age, with tumor <5 cm in diameter, undergoing breast-conserving therapy, as well as no evidence of disease at 5-year survival had increased and this change was statistically significant. In addition, malignant PT cases had decreased in frequency.

Conclusions

The results of this study show that patients with PT are increasingly younger, the breast tumors at diagnosis are smaller, malignant PT is becoming less frequent, and BCT is now the treatment of choice. Most importantly, the general treatment outcomes are significantly better.

Phyllodes tumor of the breast: a retrospective study of the impact of histopathological factors in local recurrence and distant metastasis

BACKGROUND AND OBJECTIVES

The challenging issue for the breast surgeons is local recurrence of phyllodes tumor. The histological criteria to predict local recurrence has been a controversial issue. The objective of this study was to determine pathological parameters and surgical margins that influence outcome of local recurrence and distant metastasis in phyllodes tumor (PT).

DESIGN AND SETTING

Retrospective review between January 2003 to August 2008 at King Hussein Cancer Center-Jordan.

PATIENTS AND METHODS

Forty-two female patients diagnosed as having PT were classified to benign, borderline and malignant. The medical records were reviewed in relation to the surgical management, recurrence, follow-up, the histological features of the tumor and grading of tumors based on the following histological parameters: mitotic count, stromal cellularity, stromal overgrowth, cellular pleomorphism, nuclear grade, tumor necrosis, tumor margin, and surgical margin status. All patients underwent wide local excision of the tumor or mastectomy.

RESULTS

Forty-two patients with PT (16 benign, 9 borderline, 17 malignant PT) were followed up for 30 months. The mean age was 39.8 years, and the average tumor size was 6.6 cm. The recurrence rate of PT in our study was 21% at a mean time of 11 months. Nine patients had local recurrence; 2 benign, 6 malignant and 1 borderline. Cellular pleomorphism had correlation with recurrence rate (P=.045). We had six patients (14%) with distant metastasis. All had malignant PT. Metastasis in PT has a relationship with histological grade (P=.02).

CONCLUSIONS

We conclude that patients with moderate and severe cellular pleomorphism had higher local recurrence, while metastatic PT occur more in patients with high nuclear grade.

Giant malignant phyllodes tumor: a case report

We present a case of a 57-year-old woman with a giant malignant phyllodes tumor (PT) in her right breast, with maximum diameter of 20 cm. The core-needle and excisional biopsy specimens were diagnosed as suspicious for low-grade myofibroblastic sarcoma (LGMS). The subsequent total mastectomy with partial resection of the pectoral muscles showed predominance of stromal hypercellularity without an epithelial component. However, we diagnosed this as a malignant PT because focal areas showed a leaf-like pattern. In the case of large malignant PTs that exhibit stromal predominance, it can be difficult to distinguish between a pure sarcoma and malignant PT. It is important to thoroughly examine multiple sections from the view point of residual epithelial structure in morphological diagnosis.

Invasive cribriform carcinoma arising in malignant phyllodes tumor of breast: a case report

Phyllodes tumor is an uncommon fibroepithelial neoplasm of the breast. And it is characterized by expanded stroma with increased cellularity and elongated epithelium-lined clefts. Mammary carcinomas within phyllodes tumors have been rarely reported. To date, however, no reports have described the invasive cribriform carcinoma arising in malignant phyllodes tumor. Here, we report a 62-year-old woman who presented with a large breast mass. Microscopically, the mass was a typical malignant phyllodes tumor showing well developed leaf-like architecture and stromal overgrowth with high cellularity and nuclear pleomorphism. In a portion of the tumor, however, the epithelial component showed a cribriform pattern of proliferation in the absence of myoepithelial cells, suggestive of the invasive cribriform carcinoma. To our knowledge, this is rare and it is difficult to make a differential diagnosis of it. Here, we report our case with a review of literatures.

Spontaneous regression of pulmonary metastases from a malignant phyllodes tumor

We report a case of spontaneous regression of pulmonary metastases from a malignant phyllodes tumor. A 50-year-old woman was diagnosed with a breast phyllodes tumor. Computed tomography and positron emission tomography revealed multiple lung metastases. She underwent a mastectomy to control the pain of the enlarging breast mass. Histopathologic examination diagnosed a malignant phyllodes tumor. Without the administration of any adjuvant therapy, the follow-up chest computed tomography scan and positron emission tomography scan showed disappearance of the lung metastases 2 months after surgery.