GIANT INTRACANALICULAR MYXOMA OF THE BREAST

Surgical Management and System Therapy of the Most Giant Known Malignant Metastatic Breast Phyllodes Tumor: A Case Report and Review of the Literature

INTRODUCTION

Phyllodes tumors belong to uncommon fibroepithelial breast tumors with a range of biological behaviors. Phyllodes tumors are responsible for less than 1 percent of all neoplasms of the breast.

CASE PRESENTATION

A 66-year-old woman presented to our Breastcancer Unit in March 2021 because of a huge mass of her left breast with bleeding out of a tumor necrosis. Five years ago in 2016, a benign phyllodes tumor was diagnosed externally. When we started the treatment, the tumor had a weight of 18.6 kg.

CONCLUSION

We describe the surgical management and the systemic treatment of metastatic disease.

Refining the classification of breast phyllodes tumours

Phyllodes tumours of the breast are uncommon fibroepithelial neoplasms that pose recurrent classification challenges, in large part due to the multiple histological parameters of stromal hypercellularity and atypia, stromal mitotic count, stromal overgrowth and tumour borders, that are used for grading. While the World Health Organization (WHO) Classification of Breast Tumours provides recommendations on diagnostic features, defining criteria are not always applied in routine practice. Lack of concordance among pathologists in typing and grading further underscores the classification difficulties, especially in the borderline category. Although there has been significant molecular information on phyllodes tumours in recent years which has been diagnostically helpful, it has not been translated into daily clinical practice. In order to refine the classification of phyllodes tumours into one that is simple yet comprehensive, reproducible and prognostically precise, a multipronged approach is needed that leverages on global contributions of the International Fibroepithelial Consortium, support by the International Collaboration on Cancer Classification and Research (IC³ R) in amalgamating evidence translation, and guidance from the International Collaboration on Cancer Reporting (ICCR) for standardised reporting. It is hoped that the evidence generated can be used towards refining the classification of phyllodes tumours for the future.

Malignant phyllodes tumor of the breast with metastases to the lungs: A case report and literature review

Phyllodes tumors (PTs) are rare fibroepithelial neoplasms of the breasts. Approximately 10%-15% of PTs are malignant, and 9%-27% of patients with malignant PTs, develop metastatic disease. The lungs are the most common target organ for distant metastasis of PT. We report a case of 44-year-old female with a malignant PT. It had recurred locally 3 times, and 3 relapses occurred 13 months after the first diagnosis, presenting multiple metastases to the lungs by CT scan. The patient underwent radiation therapy, and palliative chemotherapy with doxorubicin was initiated. Two courses of doxorubicin therapy were administered, but the patient expired 16 months after PT diagnosis. We present a rare case of malignant PT with local recurrences, lung metastases, and poor patient outcome. Although malignant breast PTs have an unfavorable prognosis, adjuvant radiotherapy combined with margin-negative resection may be associated with decreased local recurrence and distant metastasis rates. Future research should include randomized clinical trials or well-designed prospective matched studies to clarify the effectiveness of treatments of PTs.

Malignant phyllodes tumor of the breast: a systematic review

Phyllodes tumors (PT) are fibroepithelial neoplasms of the breast showing a peculiar leaf-like appearance. They account for 0.3 to 1% of all primary breast tumors and 2.5% of all fibroepithelial breast tumors. PT are classified into benign, borderline and malignant based upon their stromal morphology with a distribution of 60%, 20%, and 20%, respectively. Malignant PT of the breast constitute an uncommon challenging group of fibroepithelial neoplasms. They have a relatively high tendency to recur, although distant metastasis is uncommon, and nearly exclusive to malignant PT. Adequate surgical resection remains the standard approach to achieve maximal local control. Giant malignant PT are rare and a pose a diagnostic dilemma for pathologists, especially when comprised of sarcomatous elements. This review highlights the morphological features of PT detected in cytology and histology specimens and discusses diagnostic pitfalls and differential diagnosis.

A giant malignant phyllodes tumor of breast post mastectomy with metastasis to stomach manifesting as anemia: a case report and review of literature

BACKGROUND

Phyllodes tumors (PTs) are well known for local recurrence and progression. Less than 10% of these tumors grow larger than 10 cm. Distant metastases have been reported in up to 22% of malignant PTs, with most metastases being discovered in the lungs. PTs of the breast rarely metastasize to the gastrointestinal tract, and reported cases are scarce. To date, a review of the English literature revealed only 3 cases, including our case, of PTs metastasis to stomach.

CASE PRESENTATION

An 82-year-old female patient had 10-year-duration of palpable huge tumor on left breast which was in rapid growth in recent months. Total mastectomy of left breast was performed thereafter, and pathology diagnosis was malignant phyllodes tumor. Adjuvant radiotherapy was suggested while she declined out of personal reasons initially. For PTs recurred locally on left chest wall 2 months later, and excision of the recurrent PTs was performed. She, at length, completed adjuvant radiation therapy since then. Six months later, she was diagnosed of metastasis to stomach due to severe anemia with symptom of melena. Gastrostomy with tumor excision was performed for uncontrollable tumor bleeding.

CONCLUSION

For PTs presenting as anemia without known etiologies, further studies are suggested to rule out possible gastrointestinal tract metastasis though such cases are extremely rare. Management of metastatic gastric tumor from PTs should be done on a case-to-case basis, surgical intervention may be needed if there is persistent active bleeding despite medical treatment. Adjuvant radiotherapy is recommended in borderline and malignant PTs with tumor-free margin < 1 cm and high-risk malignant tumors. Adjuvant chemotherapy or target therapy may be helpful for metastatic PTs. Molecular and genomic techniques may predict clinical outcomes of benign and borderline PTs more precisely.

Benign Phyllodes Tumor in Children: A Study of 8 Cases and Review of the Literature

Phyllodes tumor (PT) occurs predominantly in middle-aged women, and although its occurrence in young women, adolescents, and even children is documented, presentation in the pediatric population has been the least well studied because of its rarity. Incompletely defined in children with PT are recurrence rates and optimal surgical management. We retrospectively studied the pathology database of Hartford Hospital from 2010 to 2017 to find all cases of PT in patients 18 years of age or younger. A series of 8 children/adolescents with breast masses diagnosed as benign PT were identified. Patients were 14 to 16 years of age (mean 15.2 y) and tumor size ranged from 2.2 to 7.2 cm (mean 4.4 cm). Both breasts were equally affected. All patients were treated with excision, tantamount to simple enucleation in most cases, and positive or "tumor-abutting" margins were universal. Mean follow-up after surgery was 27.5 months, during which time a single recurrence (at 9 mo) became manifest, which was re-excised and again showed benign PT. There were no pathologic features (including marginal status) that could have predicted the sole recurrence. Despite positive margins, the local recurrence rate for pediatric benign PT appears acceptably low (1 in 8 cases) such that reflex re-excision is probably unnecessary.

Surgical Margins and Adjuvant Therapies in Malignant Phyllodes Tumors of the Breast: A Multicenter Retrospective Study

BACKGROUND

The optimal threshold of surgical margins for breast malignant phyllodes tumors (MPTs) and the impact of adjuvant chemotherapy and radiotherapy were investigated.

PATIENTS AND METHODS

We conducted a multicenter nationwide retrospective study of all MPT cases with central pathological review within the French Sarcoma Group. Endpoints were local recurrence-free survival (LRFS), metastasis-free survival (MFS), and overall survival (OS) rates.

RESULTS

Overall, 212 patients were included in the study. All non-metastatic patients underwent primary surgical treatment, including 58.6% of conservative surgeries. An R0 resection was achieved in 117 patients (59.4%: 26.9% of patients with 1-2 mm margins, 12.2% of patients with 3-7 mm margins, 20.3% of patients with ≥ 8 mm margins). Ninety-four patients (45%) underwent a second surgery (SS) to obtain R0 margins, with a final mastectomy rate of 72.6%. Radiotherapy and chemotherapy were performed in 91 (43.1%) and 23 patients (10.9%), respectively, but were not associated with better outcomes. Mastectomy was significantly associated with better LRFS (p < 0.001). Margins of 0, 1, or 2 mm with SS were associated with better MFS (hazard ratio [HR] 0.3, p = 0.005) and OS (HR 0.32, p = 0.005) compared with margins of 0-1-2 mm without SS. Wider margins (> 8 mm) were not superior to margins of 3-7 mm (3-7 mm vs. > 8 mm; HR 0.81, p = 0.69). Age (HR 2.14, p = 0.038) and tumor necrosis (HR 1.96, p = 0.047) were found to be poor prognostic factors and were associated with MFS.

CONCLUSIONS

This study suggests that 3 mm margins are necessary and sufficient for surgical management of MPTs, and emphasizes the importance of SS to obtain clear margins in case of 0-1-2 mm margins. No impact of adjuvant chemotherapy or radiotherapy was detected in this study.

Surgical excision and oncoplastic breast surgery in 32 patients with benign phyllodes tumors

Background

The purpose of this study was to assess the effectiveness and safety in patients with benign phyllodes after performing local excision and following with intra-operative breast flap reconstruction.

Methods

Patients (n = 32) with eligible breast cystosarcoma phyllodes underwent wide local excision followed by intra-operative breast flap reconstruction. Primary outcome measures included average operative time, length of in-hospital stay, postoperative recurrence, and intra-operative and postoperative complications.

Results

Thirty-two patients who underwent surgical excision and oncoplastic breast surgery were evaluated using the BCCT.core software. A satisfactory symmetrical breast shape was achieved. The average operative time was 56.3 ± 8.2 min. The average postoperative duration of hospitalization was 3.7 ± 1.2 days. While there was no breast disease recurred during the 1 to 8-year follow-up period.

Conclusions

Wide local excision accompanied by intra-operative breast flap reconstruction could be adopted for removing benign phyllodes tumors while retaining the basic shape of the breast.

Metastasis of Mammary Gland Malignant Phyllodes Tumor to the Mandibular Region: A Case Report and Review of the Literature

Phyllodes tumor is a rare breast tumor described by Müller (1938) as a lesion comprising leaflike stromal fibrous components and narrow cysts. The frequency of distant metastasis from this entity is reportedly approximately 20%, and no effective therapy has been established, so the prognosis is poor. This report describes the case of a 60-year-old woman with a history of left lung resection who showed metastasis of a mammary gland malignant phyllodes tumor to the oral cavity. Intraoral examination showed an elastic, hard mass measuring 28 × 27 mm in the gingiva around the left mandibular second molar. Biopsy examination showed growth of giant cells and roughly circular cells showing positivity for S-100, p63, and vimentin on immunohistochemical staining. The authors diagnosed metastasis of the mammary gland malignant phyllodes tumor to the left mandible and performed cyber knife irradiation (44 Gy in 5 fractions) of the left mandible. The mass in the oral cavity disappeared after cyber knife irradiation, but the patient died of direct invasion to the spine.

A Rare Case of Phyllodes Tumor Metastasis to the Stomach Presenting as Anemia

Metastasis of a phyllodes tumor to the stomach is an extremely rare condition with important clinical implications. A 44-year-old woman was initially diagnosed with a phyllodes tumor in her right breast in 2008, and subsequently presented to an outpatient clinic with dizziness on December 16, 2013. We found that she had severe anemia (hemoglobin levels, 6.7 g/dL), and we quickly performed esophagogastroduodenoscopy to identify the cause. This procedure revealed large ulcerofungating masses with active bleeding in the stomach. Histopathological examination revealed that the masses were consistent with phyllodes tumor metastases. In patients with a metastatic phyllodes tumor presenting as anemia, gastric metastasis should be considered as one of the differential diagnoses because overlooking the possibility might have dire consequences if cytotoxic chemotherapy were administered.

An 11 kg Phyllodes tumor of the breast in combination with other multiple chronic diseases: Case report and review of the literature

Phyllodes tumors (PTs) of the breast are a rare type of tumor that account for <1% of breast tumors in females and usually present as a large lump of 3–5 cm in size. Surgery is the first line of treatment for PTs, and chemotherapy and irradiation may be useful in certain patients but not all. In the present study, the case of a 63-year-old female patient with a huge PT in the left breast is described. On physical examination, the patient presented with a huge mass of ∼45 cm in diameter, weighing ∼11 kg, and a composite of multiple chronic diseases. The breast and pectoris major and minor were excised. Post-operatively, the patient recovered well and to date there has been no evidence of local recurrence or distant metastasis.

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.

Temporomandibular region metastasis from cystosarcoma phyllodes: a case report and review of the literature

A rare breast tumour (Cystosarcoma phyllodes) in a 58-year-old female metastasizing to the temporomandibular region and infra-temporal fossa, presenting as temporomandibular pain dysfunction syndrome is reported, along with a literature review.

Cystosarcoma Phyllodes Metastatic to the Mandible: Report of a Rare Case and Literature Review

Cystosarcoma phyllodes is a rare breast tumor with variable malignant potential. Metastasis has been reported in a small percentage of cases. We describe the case of a 52-year-old woman who developed a large facial tumor 1 year after she had undergone a mastectomy fora rapidly enlarging breast neoplasm. The facial lesion was found to be a malignant cystosarcoma phyllodes metastatic to the mandible, and the patient died shortly after diagnosis. To our knowledge, this patient represents only the third reported case of a phyllodes tumor metastatic to the mandible.

Phylloides tumor of the breast: a report of 14 cases

The objective of this retrospective study is to determine the role of radiation therapy in the management of benign phylloides tumors. Fourteen patients with a diagnosis of benign phylloides tumor (PT) and registered at the Princess Margaret Hospital are included in the study. Definitive surgery consisted of either lumpectomy in seven patients or mastectomy in the other seven patients. One patient died of her disease, and the remaining patients had no evidence of disease at last follow-up (median 38.4 months). Among these 13 patients, 4 had at least one recurrence and the recurrence rate was higher for the group who underwent lumpectomy (43% compared with 28%). One patient was treated by lumpectomy and adjuvant radiation therapy, and had no subsequent recurrence (follow-up time 35.5 months). The role for radiation therapy in the management of this disease remains unclear.

The coexistence of lobular carcinoma in a fibroadenoma with a malignant phyllodes tumor in the opposite breast: report of a case

It is very unusual for a carcinoma of the breast to coexist with a phyllodes tumor, or for a carcinoma to arise within a fibroadenoma. We present herein an extremely rare case of lobular carcinoma in situ arising in a fibroadenoma, associated with a malignant phyllodes tumor in the opposite breast. A 49-year-old woman was admitted to our hospital with a large mass in the right breast and a small mass in the left breast. Microscopic examination of biopsy materials revealed a malignant phyllodes tumor in the right breast and a fibroadenoma in the left breast, for which a right standard radical mastectomy and left lumpectomy were performed. Microscopic findings of the material excised from the left breast showed the presence of multiple lobular carcinoma in situ within the tumor mass of the fibroadenoma. However, histological examination did not detect any metastasis to the bilateral axillary lymph nodes. To our knowledge this is the only such case ever to be reported in Japan.

Bilateral malignant phyllodes tumours

We report a rare example of bilateral primary malignant phyllodes tumours. The diagnosis was supported by the identification of a benign epithelial element in each lesion. The case illustrates the typical dimorphic features of malignant phyllodes tumours. A contralateral tumour should not be regarded as metastatic without histological confirmation.

Cultured breast cystosarcoma phylloides cells and applications to patient therapy

Malignant cystosarcoma phylloides (CP) is a relatively rare cancer of the breast. A CP tumor was processed as part of a tumor acquisition, propagation, and preservation program in patient biotherapy. Two tissue culture cell lines were developed from this tumor, one directly from the biopsy, another from a xenograft tumor grown in athymic mice. The two cell lines were similar in character. There was strong immunochemical reactivity with antibodies to vimentin, type I collagen, and type III collagen. There was no reactivity with antibodies to cytokeratin and epithelial membrane antigen. Both cell lines were aneuploid, clonogenic in soft agar, and tumorigenic in nude mice. 5 alpha-dihydrotestosterone and thyroxine added to the culture medium stimulated growth, while testosterone, 17 beta-estradiol, and 4-hydroxytamoxifen were without effect. Dexamethasone and cortisol were inhibitory at high doses (10(-6) M). Dibutyryl cyclic AMP, theophylline, and vitamin C were all inhibitory. The biopsy contained tumor-infiltrating lymphocytes which proliferated in cultures containing interleukin 2. The expanded lymphocytes were activated T cells which had the capacity to lyse tumor cells. These results suggest possibilities in the therapy of cystosarcoma phylloides involving vitamin C, certain hormones, and tumor-infiltrating lymphocytes.

An evaluation of the preoperative diagnosis and management of cystosarcoma phyllodes

Cystosarcoma phyllodes is a rare tumour of the breast which is notoriously difficult to diagnose accurately preoperatively. In this review we report the clinical, imaging and histopathological features of 20 patients who have presented in our Centre over a 10-year period.

Cystosarcoma phyllodes metastatic to the mandible

Cystosarcoma phyllodes of the breast appears to encompass a diverse group of tumors with variable clinical behaviors. Although the tumor can behave in a malignant fashion, metastases to the head and neck region are distinctly uncommon. A case is presented of a solitary metastasis to the mandible appearing 1 year after mastectomy and in the absence of widespread disease. The metastatic potential of this neoplasm is discussed and involvement of the head and neck region is reviewed.

Malignant cystosarcoma phyllodes of the breast metastatic to the oral cavity: report of a case and review of the literature

A case report involving an oral lesion that was found to be histologically identical to the stromal component of malignant metastatic cystosarcoma phyllodes of the breast is described. This represents the first reported histologically confirmed oral manifestation of an extremely rare breast tumor. The literature regarding oral manifestations of metastatic disease in general and of cystosarcoma phyllodes in particular is reviewed.

An unusual case of malignant cystosarcoma phyllodes of the breast

A unusually large tumor of the left breast diagnosed as a cystosarcoma phyllodes with multiple malignant sarcomatous changes of the stroma, consisting of liposarcoma, myxoid fibrosarcoma, anaplastic, and giant cell sarcoma is described. The weight of 6200 g (13.5 lb) seems to be the largest so far presented in the literature reviewed by the authors.

A malignant cystosarcoma phyllodes with positive estrogen receptor and its heterotransplantation into nude mice

We detected cytosol estrogen receptors in a malignant cystosarcoma phyllodes and succeeded in serial transplantations into athymic nude mice. The tumors of this transplantable strain (MC-3-JCK) have the same histologic features as the original tumors, and retain significant amounts of cytosol estrogen receptors. This strain appears to provide a useful experimental model for the study of biologic and therapeutic aspects of human cystosarcoma phyllodes of the breast.

Cystosarcoma phyllodes of the mammary gland--Müller's tumor. For the 180th birthday of Johannes Müller

For the last 150 years, cystosarcoma phyllodes of the mammary gland has had 62 different synonyms. At the present time, the most logical name for it seems to be tumor phyllodes. The result of the histological analysis of every single tumor should contain information about the degree of its maturity. The classical description of cystosarcoma phyllodes given by Johannes Müller (1838) is still considered the basis for understanding the clinical and histogenetical aspects of this neoplasm.

Cystosarcoma phylloides in the adolescent female

Two cases of cystosarcoma phylloides in the adolescent female are presented and the literature reviewed. This lesion is usually benign. Even when malignant, simple excision has been curative in 2 or 3 cases. Therapy recommended is local excision with a small margin of normal tissue.

Recurrent cystosarcoma phylloides

Images

Giant intracanalicular fibroadenoma. With report of five cases

Five cases of giant intracanalicular fibroadenoma ("cystosarcoma phylloides") were observed at one hospital in a period of three years. In a search of the literature, additional reports of breast tumors of this kind, not included in previous reviews, were noted. As there is record of 229 cases, it would appear that this rapidly growing benign tumor should be kept in mind in the diagnosis of masses in the breast. If removal is incomplete, there may be recurrence. Simple mastectomy is the treatment of choice. Radical mastectomy should be avoided.