[Common benign breast tumors including fibroadenoma, phyllodes tumors, and papillary lesions: Guidelines]

[Rare tumours of the breast]

Breast tumours are the most common tumours in women but represent a very heterogeneous group. On the one hand, there are ductal and lobular carcinomas of the breast, representing 90% of tumours, whose clinicopathologic characteristics are well known. On the other hand, there are rare breast tumours, each of which represents less than 1% that limits their study through large cohorts. The objective of this work was to collect, update and synthesize knowledge on these rare tumours. A literature review was performed on the Medline and Google Scholar databases. We present here a selection of several rare tumours, providing updated data at the epidemiological, histopathological, genetic, clinical and radiographic, prognostic and therapeutic levels, taking into account the place of radiotherapy. Each tumour histology is unique and has its own characteristics, the management must therefore be adapted as much as possible and decided in a multidisciplinary meeting.

Fibroadenoma of the breast; incidence of malignancy and indicators for surgical intervention: An analysis of 1392 patients

BACKGROUND

Fibroadenomas are common among young females. The size of the lesion used to be an indication for further assessment or excision. With arising of the watch and see proponents, criteria for selecting patients are important to establish.

METHODS

This is a retrospective study of a prospectively maintained database where all patients having the clinical/radiological provisional diagnosis of fibroadenoma and attending our center - from January 2008 to March 2020 - were enrolled. The primary outcome was the incidence of malignancy and the secondary outcomes were the correlation of malignancy-risk with epidemiologic and radiologic criteria.

RESULTS

The study enrolled 1392 patients. The mean age of the patients was 35.7 + ∕- 13.1 years. The median of the longest diameter of the detected breast lesions was 25 mm. The incidence of malignancy was 188 (13.5%). The size of the lesion measured by largest diameter was insignificant (p = 0.99), while the patients' age, marital status, and imaging criteria as measured by BIRADS score were significant (<0.001).

CONCLUSION

Approaching patients with the age above 35 or with BIRADS 4 provisionally diagnosed with fibroadenomas should be cautious with biopsy and short-term follow-ups The size of the tumor alone should not be used as an indication for surgical intervention.

Management of postmenopausal women: Collège National des Gynécologues et Obstétriciens Français (CNGOF) and Groupe d'Etude sur la Ménopause et le Vieillissement (GEMVi) Clinical Practice Guidelines

AIM

The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT).

MATERIALS AND METHODS

Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence.

SUMMARY RECOMMENDATIONS

The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit-risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit-risk balance. Management of gynecological side-effects of MHT is also examined. These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).

[The HRT follow-up consultation. What to do in case of breast tumour (clinical or radiological) and microcalcifications. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

OBJECTIVE

The objective was to evaluate the diagnostic value of clinical examination and complementary imaging in the exploration of a breast lump or microcalcifications occurring in a postmenopausal woman taking hormonal replacement therapy (HRT), based on a systematic review of the literature in order to make recommendations for HRT management.

METHODS

A literature review was conducted using Medline, Cochrane Library data and international recommendations in French and English until 2020.

RESULTS

In the presence of a clinical breast mass in postmenopausal women, there is no clinical evidence to rule out cancer. A double evaluation by mammography and ultrasound is recommended and allows the imaging to be classified into 5 BI-RADS categories. The diagnostic management of masses classified BI-RADS 4 and 5 should be based on percutaneous sampling, with microbiopsy being the first step. A total of four situations may arise: 1. Clinical examination has detected a breast mass, but there is no imaging abnormality. In this case, the imaging NPV is high (>96%). If the clinical lesion increases in size, a tissue biopsy should be performed, while continued routine breast screening is recommended if the lesion remains stable and HRT can be continued. 2. Clinical examination, mammography, and ultrasound are in favour of a cyst. Simple cysts can be punctured if painful. There is no contraindication to continuing HRT in the case of simple cysts. Management options for complicated and complex cysts are no different from those offered to women without HRT. Continuation of HRT must consider their histological nature. 3. Clinical examination, mammography, and ultrasonography suggest a benign solid tumour. The management of these benign breast lesions (fibroadenoma…) is not different in women taking an HRT and there is no contraindication to continue the HRT. 4: Clinical examination, imaging and microbiopsy diagnose a malignant tumour. It is imperative that the HRT be stopped, whatever the hormonal dependence of the tumour and whether it is invasive or in situ. The management of the cancerous tumour must consider the updated breast cancer treatment guidelines. In the presence of microcalcifications, the course of action to be taken depends on the BI-RADS classification, established according to the morphology and arrangement of the calcifications. In case of suspicious microcalcifications (BI-RADS 4 or 5), a guided macrobiopsy should be performed. Diagnostic and therapeutic management in these patients is no different from that offered to women without HRT. Discontinuation of HRT is necessary in cases of malignancy (in situ or invasive cancer).

CONCLUSION

A rigorous multidisciplinary approach is necessary for the exploration of a breast mass or microcalcifications in a postmenopausal woman.

Value of conventional magnetic resonance imaging texture analysis in the differential diagnosis of benign and borderline/malignant phyllodes tumors of the breast

BACKGROUND

The purpose of this study was to determine the potential value of magnetic resonance imaging (MRI) texture analysis (TA) in differentiating between benign and borderline/malignant phyllodes tumors of the breast.

METHODS

The preoperative MRI data of 25 patients with benign phyllodes tumors (BPTs) and 19 patients with borderline/malignant phyllodes tumors (BMPTs) were retrospectively analyzed. A gray-level histogram and gray-level cooccurrence matrix (GLCM) were used for TA with fat-suppressed T2-weighted imaging (FS-T2WI), diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) images, and 2- and 7-min postcontrast T1W images on dynamic contrast-enhanced MRI (DCE-T1WI_2min and DCE-T1WI_7min) between BPTs and BMPTs. Independent sample t-test and Mann-Whitney U test were performed for intergroup comparison. A regression model was established by using binary logistic regression analysis, and receiver operating characteristic (ROC) curve analysis was carried out to evaluate diagnostic efficiency.

RESULTS

For ADC images, the texture parameters angular second moment (ASM), correlation, contrast, entropy and the minimum gray values of ADC images (ADC_Minimum) showed significant differences between the BPT group and BMPT group (all p<0.05). The parameter entropy of FS-T2WI and the maximum gray values and kurtosis of the tumor solid region of DCE-T1WI_7min also showed significant differences between these two groups. Except for ADC_Minimum, angular second moment of FS-T2WI (FS-T2WI_ASM), and the maximum gray values of DCE-T1WI_7min (DCE-T1WI_7min-Maximum) of the tumor solid region, the AUC values of other positive texture parameters mentioned above were greater than 0.75. Binary logistic regression analysis demonstrated that the contrast of ADC images (ADC_Contrast) and entropy of FS-T2WI (FS-T2WI_Entropy) could be considered independent texture variables for the differential diagnosis of BPTs and BMPTs. Combined, the AUC of these parameters was 0.891 (95% CI: 0.793-0.988), with a sensitivity of 84.2% and a specificity of up to 89.0%.

CONCLUSION

Texture analysis could be helpful in improving the diagnostic efficacy of conventional MR images in differentiating BPTs and BMPTs.

Time to revise classification of phyllodes tumors of breast? Results of a French multicentric study

OBJECTIVE

To assess prognostic factors of recurrence of phyllodes tumors (PT) of the breast.

METHODS

We performed a retrospective, multicentric cohort study, including all patients who underwent breast surgery for grade 1 (benign), 2 (borderline) or 3 (malignant) PT between 2000 and 2016 in five tertiary University hospitals, diagnosed according to World Health Organisation classification.

RESULTS

230 patients were included: 144 (63%), 60 (26%) and 26 (11%) with grade 1, 2 and 3 PT, respectively. Recurrence occurred in 10 (7%), 7 (12%) and 5 (19%) patients with grade 1, 2 and 3 PT, respectively. In univariate analysis, moderate to severe nuclear stromal pleomorphism (HR 8.00 [95% CI: 1.65-38.73], p < 0.009) was correlated with recurrence in all groups including grade 1 (HR 14.3 [95% CI: 1.29-160], p = 0.031). In multivariate analysis, surgical margin >5 mm, (HR 0.20 [95% CI: 0.06-0.63], p = 0.013) were significantly correlated with less recurrence in all PT grades. For grade 1 PT, there was also significantly less recurrence with surgical margin >5 mm, (HR 0.09 [95% CI: 0.01-0.85], p = 0.047) in multivariate analysis.

CONCLUSION

The surgical margin should be at least 5 mm whatever the grade of PT. Moderate to severe nuclear stromal pleomorphism identified a subgroup of grade 1 PT with a higher rate of recurrence. This suggests that the WHO classification could be revised with the introduction of nuclear stromal pleomorphism to tailor PT management.

[Treatment of fibroadenomas by high-intensity focused ultrasound: What results? Review]

OBJECTIVES

To assess benefits and adverse effects of high-intensity focused ultrasound (HIFU) as a treatment for fibroadenomas (FA).

METHODS

To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this review. We searched MEDLINE from inception to May 2017, without any restriction.

KEYWORDS

fibroadenoma, focused ultrasound, HIFU and fibroadenomata were used. Data were extracted and the results were compared. Two reviewers independently extracted study characteristics and outcome data.

RESULTS

Of 20 identified abstracts, 5 primary studies met inclusion criteria. All studies reported a reduction in the size of FA treated with an increasing effect over time. Pain tolerance was most often assessed as moderate. Adverse effects of HIFU were not severe in all studies.

CONCLUSIONS

HIFU appears to be a promising technique in the treatment of fibroadenomas with a volume decrease of approximately 50 % at 6 months of therapy.

[Pleural and lung metastasis from degenerated multiple adenofibromas: about a case]

Multiple adenofibromas or adenofibromatosis is characterized by the presence of at least 3 mono- or bilateral adenofibromas increasing significantly in size, causing trophic disorders. We report the case of a 46-year old female patient who had been followed up since she was 30 years old for bilateral adenofibromatosis that required 4 surgical procedures. Patient's medical data were collected in the Department of Respiratory Diseases at the Ibn Rochd University Hospital Center, Casablanca. Basing on preoperative assessment before bilateral mastectomy, the patient underwent chest X-ray that showed opaque right hemithorax exerting compression on the mediastinum. Clinical examination showed effusion syndrome in the right hemithorax and left supraclavicular cervical adenopathy. Pleural puncture biopsy confirmed the presence of poorly differentiated invasive carcinoma in the pleura, supporting breast origin. Bronchoscopy after pleural puncture objectified infiltration of the whole bronchial tree; biopsies confirmed the anatomopathological results. The recommended treatment strategy was based on multidrug chemotherapy. Patient's evolution was marked by the occurrence of hepatic metastases. This study shows that adenofibromas require regular monitoring given the risk of trasformation to breast cancer, which is a frequent cause of pleuropulmonary metastases.

Advantages of the modified double ring areolar incision over the traditional areolar incision in multicentric breast fibroadenoma surgery

BACKGROUND

This study was conducted to investigate the clinical advantages of modified double ring areola incision (MDRAI) compared to ordinary areola incision (OAI) in multicentric breast fibroadenoma in women.

METHODS

Sixty cases of multicentric benign breast tumor were recruited from the First Affiliated Hospital of Bengbu Medical College from January to December 2016. The cases were divided into two groups according to surgical approach: MDRAI (n = 20) and OAI (n = 40). The operation duration, intraoperative blood loss, drainage time, and postoperative recurrence rate in the first six months were compared.

RESULTS

The mean age and tumor locations were not statistically different between the groups (P > 0.05). However, more lesions and larger tumor diameter were found in the MDRAI group than in the OAI group, with statistical difference (P < 0.05). The operation duration and drainage time of the two groups were not statistically different for unilateral or bilateral lesions (P > 0.05). However, the intraoperative blood loss was statistically different between the two groups (P < 0.05). All 60 cases received six months of follow-up. Eight recurrent cases were found in the OAI group, but none in the MDRAI group. The recurrence rate was significantly different (χ²  = 4.62, P < 0.05).

CONCLUSION

Compared with OAI, MDRAI offers greater advantages in the aspects of blood loss and recurrence for the treatment of breast benign tumor, especially for multicentric larger lesions.

Laser interstitial thermotherapy application for breast surgery: Current situation and new trends

While breast specialists debate on therapeutic de-escalation in breast cancer, the treatment of benign lesions is also discussed in relation to new percutaneous ablation techniques. The purpose of these innovations is to minimize potential morbidity. Laser Interstitial ThermoTherapy (LITT) is an option for the ablation of targeted nodules. This review evaluated the scientific publications investigating the LITT approach in malignant and benign breast disease. Three preclinical studies and eight clinical studies (2 studies including fibroadenomas and 6 studies including breast cancers) were reviewed. Although the feasibility and safety of LITT have been confirmed in a phase I trial, heterogeneous inclusion criteria and methods seem to be the main reason for LITT not being yet an extensively used treatment option. In conclusion, further development is necessary before this technique can be used in daily practice.