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Liu BL, Mehrotra M, Kowtha L, Guan M, Houldsworth J, Baskovich B, Harigopal M. Fibroepithelial Neoplasm with Hybrid Features of Benign Phyllodes Tumor, Juvenile Papillomatosis, and Juvenile Fibroadenoma: A Case Report. Int J Surg Pathol 2024:10668969241256112. [PMID: 38839253 DOI: 10.1177/10668969241256112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Phyllodes tumor is an uncommon breast fibroepithelial neoplasm mainly found in middle-aged patients, presenting a morphologic continuum from benign to malignant. Juvenile papillomatosis represents a rare benign proliferative breast tumor primarily affecting young individuals and carries a potential elevated risk of subsequent breast cancer development. Juvenile fibroadenoma is a well-circumscribed biphasic neoplasm that often occurs in adolescent girls, characterized by a pericanalicular growth pattern with usual-type epithelial hyperplasia and gynaecomastia-like micropapillary proliferation. Herein, we present an unusual example of a 26-year-old woman with a left breast outer lower quadrant palpable mass. Ultrasonography identified a 5.9 cm lobulated hypoechoic solid mass with scattered small cysts. The preoperative biopsy initially diagnosed a fibroepithelial lesion, considering giant cellular fibroadenoma and phyllodes tumor in the differential. Subsequent complete excision revealed areas of benign phyllodes tumor features closely admixed with distinctive elements such as prominent multiple cysts exhibiting apocrine and papillary apocrine metaplasia, duct papillomatosis, and duct stasis characteristic of juvenile papillomatosis, and hyperplastic ductal epithelium with micropapillary projections demonstrating a pericanalicular growth pattern indicative of juvenile fibroadenoma. The diagnosis was conclusively established as a fibroepithelial lesion with combined features of benign phyllodes tumor, juvenile papillomatosis, and juvenile fibroadenoma. Further investigation uncovered a family history of breast cancer. Molecular analysis revealed a pattern of unique and overlapping mutations within these distinct histopathological areas. This unusual presentation with hybrid features within a single tumor is described for the first time in the literature along with the molecular signature of the individual components.
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Affiliation(s)
- Bella Lingjia Liu
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Meenakshi Mehrotra
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Lakshmi Kowtha
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Michelle Guan
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jane Houldsworth
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brett Baskovich
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Malini Harigopal
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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Mon KS, Tang P. Fibroepithelial Lesions of the Breast: Update on Molecular Profile With Focus on Pediatric Population. Arch Pathol Lab Med 2023; 147:38-45. [PMID: 35776911 DOI: 10.5858/arpa.2022-0011-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 12/31/2022]
Abstract
CONTEXT.— This review article derives from the breast pathology lecture at the Eighth Princeton Integrated Pathology Symposium (PIPS VIII). OBJECTIVE.— To provide a literature review and update on fibroepithelial lesions of the breast with molecular findings and findings regarding the pediatric population. DATA SOURCES.— The sources include extensive literature review, personal research, and experience. CONCLUSIONS.— Given significant differences in prognosis and management of fibroepithelial lesions, we aim to provide readers with pertinent definitions, pathomorphology, molecular findings, and management for each diagnosis, with insights on the pediatric population.
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Affiliation(s)
- Khin Su Mon
- From the Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Ping Tang
- From the Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
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Tan BY, Fox SB, Lakhani SR, Tan PH. Survey of recurrent diagnostic challenges in breast phyllodes tumours. Histopathology 2023; 82:95-105. [PMID: 36468287 DOI: 10.1111/his.14730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/15/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Breast phyllodes tumours (PTs) are graded as benign, borderline, or malignant by analysis of multiple histological features. PT grading is often inconsistent, likely due to variation in the weighting of grading criteria by pathologists. DESIGN The hierarchy of use of diagnostic criteria was identified using a 20-question survey. RESULTS In all, 213 pathologists from 29 countries responded. 54% reported 10-50 PT cases per year. Criteria considered key to PT diagnosis were: increased stromal cellularity (84.3%), stromal overgrowth (76.6%), increased stromal mitoses (67.8%), stromal atypia (61.5%), stromal fronding (59.0%), periductal stromal condensation (58.0%), irregular tumour borders (46.3%), and/or lesional heterogeneity (33.7%). The importance of grading parameters were: mitotic activity (55.5%), stromal overgrowth (54.0%), stromal atypia (51.9%), increased stromal cellularity (41.7%), and nature of the tumour border (38.9%). 49% would diagnose malignant PT without a full array of adverse features. 89% used the term "cellular fibroepithelial lesion (FEL)" for difficult cases; 45% would diagnose an FEL with stromal fronding (but lacking other PT features) as fibroadenoma (FA), 35% FEL, and 17% PT. 59% deemed clinico-radiological findings diagnostically significant; 68% considered age (≥40 years) important in determining if an FEL was a FA or PT. In FELs from young patients, increased stromal cellularity (83%), fronding (52%), and mitoses (41%) were more common. 34% regarded differentiating cellular FA from PT as a specific challenge; 54% had issues assigning a borderline PT grade. CONCLUSION Criteria for grading PT lie on a spectrum, leading to interpretive variability. The survey highlights the criteria most used by pathologists, which do not completely align with WHO recommendations.
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Affiliation(s)
| | - Stephen B Fox
- Peter MacCallum Cancer Centre and University of Melbourne, Australia
| | - Sunil R Lakhani
- The University of Queensland and Pathology Queensland, Australia
| | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Singapore
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Seow DY, Tay TK, Tan PH. FIBROEPITHELIAL LESIONS OF THE BREAST: A REVIEW OF RECURRING DIAGNOSTIC ISSUES. Semin Diagn Pathol 2022; 39:333-343. [DOI: 10.1053/j.semdp.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022]
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5
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Tan PH. Fibroepithelial lesions revisited: implications for diagnosis and management. Mod Pathol 2021; 34:15-37. [PMID: 32461622 DOI: 10.1038/s41379-020-0583-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023]
Abstract
Fibroepithelial lesions of the breast, comprising the fibroadenoma and phyllodes tumour, are a unique group of neoplasms that share histological characteristics but possess different clinical behaviour. The fibroadenoma is the commonest benign breast tumour in women, while the phyllodes tumour is rare and may be associated with recurrences, grade progression and even metastasis. The diagnosis of fibroadenoma is usually straightforward, with recognised histological variants such as the cellular, complex, juvenile and myxoid forms. The phyllodes tumour comprises benign, borderline and malignant varieties, graded using a constellation of histological parameters based on stromal characteristics of hypercellularity, atypia, mitoses, overgrowth and the nature of tumour borders. While phyllodes tumour grade correlates with clinical behaviour, interobserver variability in assessing multiple parameters that are potentially of different biological weightage leads to significant challenges in accurate grade determination and consequently therapy. Differential diagnostic considerations along the spectrum of fibroepithelial tumours can be problematic in routine practice. Recent discoveries of the molecular underpinnings of these tumours may have diagnostic, prognostic and therapeutic implications.
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Affiliation(s)
- Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Academia, Diagnostics Tower Level 7, 20 College Road, Singapore, 169856, Singapore.
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Tummidi S, Kothari K, Agnihotri M, Naik L, Sood P. Fibroadenoma versus phyllodes tumor: a vexing problem revisited! BMC Cancer 2020; 20:648. [PMID: 32660435 PMCID: PMC7359567 DOI: 10.1186/s12885-020-07129-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibroepithelial lesions of the breast include fibroadenoma (FA) and phyllodes tumor (PT). Fibroadenomas are benign while phyllodes tumor range from benign, indolent neoplasms to malignant tumors capable of distant metastasis. Our study was to determine the select cytologic features that can accurately distinguish FA from PT. METHODS A retrospective review was performed of patients who had histopathology follow up of FA or PT and on whom a pre-operative fine needle aspiration was performed. Cytologic criteria i.e. epithelial component, stromal component and background cellularity were assessed. RESULTS 46 FA and 24 PT were specimens were reviewed. Median age and tumor size for FA and PT were 23.0 and 39.0 years, and 2.0 and 5.0 cm, respectively. Univariate analysis and regression models based on generalized estimating equations revealed that large opened out, folded epithelial sheets, frayed and irregular stromal fragment contours, spindle stromal cell nuclei, spindle cell nuclei in the background and background cell atypia are significant cytological predictors of PT. The GEE regression model achieved 78.9% diagnostic accuracy (p < 0.001) in identifying PT based on cytological features. Median epithelial: stromal ratio was 3.4 and 2.6 for FA and PT, respectively. CONCLUSION Presence of large, opened out, folded epithelial sheets, frayed and irregular stromal contours with spindle nuclei, background spindle cells and atypia can help distinguish PT from FA.
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Affiliation(s)
- Santosh Tummidi
- Department of Pathology, All India Institute of Medical Sciences, Mangalagiri, 522503 Andhra Pradesh India
| | - Kanchan Kothari
- Department of Pathology, Seth GSMC & KEMH, Parel, Mumbai, Maharashtra 400012 India
| | - Mona Agnihotri
- Department of Pathology, Seth GSMC & KEMH, Parel, Mumbai, Maharashtra 400012 India
| | - Leena Naik
- Department of Pathology, LTMMC & LTMGH, Sion, Mumbai, 400012 India
| | - Prashant Sood
- Department of Microbiology, All India Institute of Medical Sciences, Mangalagiri, 522503 Andhra Pradesh India
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Durakbaşa ÇU, Erkoç G, Çağlar Oskaylı M, Şeneldir H, Mutuş M, Aksu B, Pirim A. A retrospective evaluation of pediatric breast fibroadenomas with mid-term follow-up results. Breast J 2020; 26:1898-1899. [PMID: 32281202 DOI: 10.1111/tbj.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/15/2020] [Accepted: 03/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Çiğdem Ulukaya Durakbaşa
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Gürkan Erkoç
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Meltem Çağlar Oskaylı
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Hatice Şeneldir
- Department of Pathology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Murat Mutuş
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Burhan Aksu
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Pirim
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
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8
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Sun C, Zhang W, Ma H, Han N, Qi M, Li D, Wang X, Wang X, Yang J. Main Traits of Breast Fibroadenoma Among Adolescent Girls. Cancer Biother Radiopharm 2020; 35:271-276. [PMID: 32267738 DOI: 10.1089/cbr.2019.3209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: To investigate the clinicopathological features of breast fibroadenoma among female teenagers and provide some bases for its diagnosis and treatment, the authors conducted this study. Methods: Retrospective analysis on 80 female teenagers with fibroadenoma was carried out. The histological sections of H&E were reviewed, and immunohistochemical staining with ki67, CD34, and SMA were performed. The patients were followed up. Results: The age of included patients ranged from 12 to 18 years old, with a mean age of 17. Bilateral lesions occurred in 10% of the patients, and mean tumor diameter was 2.8 cm. Histologically, tumors in most cases showed clear boundary with no capsule. Also, 90% of the cases were confirmed to be pericanalicular mixed types, while about 20% had atypical foliation structure. The mean density of mesenchymal cells was 30%. The upper limit of mitotic figure was 2/10HPF in 80% of the cases, and the positive index of ki-67 was no more than 5% in 80% of cases. Sixteen percent of the cases also simultaneously suffered epithelial micropapillary hyperplasia. Six cases (6/39, 15%) faced relapse after tumor resection, with an average recurrence interval of 4.9 years after surgery. Tumor size, mitotic activity, ki67 positive index, and the density of mesenchymal cells were not associated with relapse. Conclusions: Adolescent fibroadenoma is a group of biphasic breast tumors with unique clinical and pathological features. Although fibroadenoma shows a local recurrence rate to a certain degree, its recurrent lesions grow slowly.
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Affiliation(s)
- Chunjie Sun
- Department of Pathology and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China
| | - Wanlong Zhang
- Department of Pathology and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China.,Department of Traditional Chinese Medicine, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China
| | - Haihui Ma
- Department of Obstetrics, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
| | - Na Han
- Department of Obstetrics, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
| | - Menghu Qi
- Department of Pediatrics, and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
| | - Donglian Li
- Department of Pathology and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China
| | - Xiaojing Wang
- Department of Pathology and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China
| | - Xuehui Wang
- Department of Pathology and Tongzhou Maternal and Child Health Hospital of Beijing, Beijing , China
| | - Jie Yang
- Department of Information, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
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9
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Hasdemir S, Tolunay Ş, Özşen M, Gökgöz MŞ. Phyllodes Tumor of the Breast: A Clinicopathological Evaluation of 55 Cases. Eur J Breast Health 2020; 16:32-38. [PMID: 31912011 PMCID: PMC6939715 DOI: 10.5152/ejbh.2019.4709] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/21/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Phyllodes tumors are biphasic tumors consisting of epithelial and stromal components that account for less than 1% of all breast tumors. According to the World Health Organization (WHO) phyllodes tumors are classified into three categories as benign, borderline and malignant. It has been reported that these tumors are usually benign and both the stromal component and the epithelial component may progress to malignancy. In this descriptive study, it was aimed to present the cases of phyllodes tumor and to evaluate the clinicopathological features of these tumors in the light of the literature. MATERIALS AND METHODS In our study, 55 cases of phyllodes tumor diagnosed between 2005-2018 in the Department of Medical Pathology were retrospectively studied. A total of 55 cases were included in the study. RESULTS All cases were female with a mean age of 39.7+15.2 years. Fifty-seven tumors diagnosed in 55 cases were classed as benign in 20 cases (35.1%), borderline in 14 cases (24.6%) and malignant phyllodes tumors in 23 cases (40.3%). Ductal carcinoma in situ (solid and cribriform type) were detected in one case with malignant phyllodes tumor, whereas invasive ductal carcinoma was detected in one case. Bilateral ductal carcinoma in situ was present in the patient with invasive ductal carcinoma. CONCLUSION These tumors which rapidly grow into large masses can be clinically and pathologically confused with benign lesions, macroscopic and microscopic evaluation of concomitant in situ-invasive carcinomas should be considered. Phyllodes tumors have an important role in breast surgery and pathology.
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Affiliation(s)
- Seçil Hasdemir
- Department of Pathology, Uludağ University School of Medicine, Bursa, Turkey
| | - Şahsine Tolunay
- Department of Pathology, Uludağ University School of Medicine, Bursa, Turkey
| | - Mine Özşen
- Department of Pathology, Uludağ University School of Medicine, Bursa, Turkey
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Westfal ML, Chang DC, Kelleher CM. A population-based analysis of pediatric breast cancer. J Pediatr Surg 2019; 54:140-144. [PMID: 30352693 DOI: 10.1016/j.jpedsurg.2018.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this study was to evaluate trends in demographics and outcomes of pediatric breast cancer in a United States population-based cohort. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify all pediatric patients with malignant breast tumors between 1973 and 2014. Analysis was performed using Stata Statistical Software version 13.1. Associations between categorical variables were made using X2 test. Log-rank test was used for univariate survival analysis. Kaplan-Meier analysis investigated five-year survival rates across several variables. Adjusted analysis was performed using a Cox Proportional-Hazards regression. RESULTS 134 patients with breast malignancies were identified. Carcinoma was the most prevalent histology (48.5%), followed by fibroepithelial tumors (FETs) (35.1%), and sarcoma (14.2%). FETs were twice as common in black compared to nonblack patients (56.3% vs. 29.0%, p < 0.01). Analyzing histology by stage revealed that 100% of FETs were early stage disease (p < 0.0001). 46.7% of the tumors tested were ER/PR negative, more than twice as many compared to the published adult estimate of 20.0%. Unadjusted survival analysis revealed worse survival for patients with adenocarcinoma/sarcomas, advanced stage, and high grade disease, without a survival difference between races. CONCLUSION Breast cancer remains a rare malignancy among pediatric patients. Although black patients were found to have more noncarcinomatous tumors with less advanced disease, this did not confer a survival advantage. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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11
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Slodkowska E, Nofech-Mozes S, Xu B, Parra-Herran C, Lu FI, Raphael S, Zubovits J, Hanna W. Fibroepithelial lesions of the breast: a comprehensive morphological and outcome analysis of a large series. Mod Pathol 2018; 31:1073-1084. [PMID: 29449684 DOI: 10.1038/s41379-018-0032-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 11/09/2022]
Abstract
Mammary fibroepithelial lesions encompass a wide spectrum of tumors ranging from an indolent fibroadenoma to potentially fatal malignant phyllodes tumor. The criteria used for their classification based on morphological assessment are often challenging to apply and there is no consensus as to what constitutes an adequate resection margin. We studied a retrospective cohort of 213 fibroepithelial lesions in 178 patients (80 fibroadenomas with unusual features and 133 phyllodes tumors: 63 benign, 41 borderline, and 29 malignant) in order to describe the spectrum of changes within each group, with special emphasis on margin evaluation. Outcome data were available for 153 fibroepithelial lesions in 139 patients (median 56 months, range 3-249 months). Positive final margin (tumor transected), age < 50 years and a predominantly myxoid stroma were statistically significant predictors of local recurrence, while age > 50, stromal overgrowth, diffuse marked atypia, necrosis and mitotic index of ≥ 10 per 10 HPF were predictive of distant metastases. Tumors with satellite/bulging nodules were at a significantly higher risk to have a final positive resection margin. Our findings highlight important aspects of the interpretation and reporting of fibroepithelial lesions: the amount of myxoid stroma and the presence of satellite nodules are clinically relevant and should be routinely assessed and reported; infiltrative border might not be a prerequisite for the diagnosis of malignant phyllodes tumor, while the presence of tumor necrosis, massive stromal overgrowth or mitotic index of ≥ 25 per 10 HPF is diagnostic of malignant phyllodes tumor. On the other hand, increased mitotic index outside of the range of the World Health Organization guidelines in the absence of other worrisome features should be treated with caution, as it can be found in benign tumors.
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Affiliation(s)
- Elzbieta Slodkowska
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
| | - Sharon Nofech-Mozes
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Bin Xu
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Carlos Parra-Herran
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Fang-I Lu
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Simon Raphael
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,North York General Hospital, Toronto, ON, Canada.,Markham Stouffville Hospital, Markham, ON, Canada
| | - Judit Zubovits
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Scarborough and Rouge Hospital, Scarborough, ON, Canada
| | - Wedad Hanna
- Departments of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment. J Pediatr Surg 2018; 53:1123-1128. [PMID: 29605260 DOI: 10.1016/j.jpedsurg.2018.02.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults. METHODS We queried the NCDB (2004-2014) for female patients with phyllodes tumor histology, excluding patients with missing age or survival data. Patients were stratified by age (pediatric <21, adult ≥21), and compared based on patient characteristics, treatment patterns, and survival. RESULTS We identified 2787 cases of phyllodes tumor (2725 adult, 62 pediatric). Median age was 17years in children and 52years in adults. Margin positivity rates and median tumor size were similar between adults and children. Treatment was discordant with NCCN guidelines in 28.6% of adults and 14.5% of children through use of axillary staging, chemotherapy, adjuvant endocrine therapy, and radiotherapy. Five-year and ten-year survival were comparable between both groups. CONCLUSION Children and adults present with similarly sized phyllodes tumors. Trends reveal high margin positivity rates, and overtreatment with regional axillary staging and systemic adjuvant therapies. Particularly in children, treatment decisions must consider risks of adjuvant therapy including radiation-related second primary cancers, given uncertain benefit. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Abstract
RATIONALE Most breast masses are benign and are rare in adolescent girls. The most frequent tumor is fibroadenoma. Juvenile fibroadenoma is a rare variant of fibroadenoma and is characterized by rapidly enlarging, painless, and unilateral masses occurring at ages between 10 and 18 years. PATIENT CONCERNS A 17-year-old girl who first presented to a hospital due to a left breast tumor. DIAGNOSES Juvenile fibroadenoma of the left breast. INTERVENTIONS She underwent fibroadenoma excision, but she complained of a mass that presented in her left breast 3 months after surgery. After 2 years of observation, the mass became tender and enlarged. We conducted a wide excision of the tumor. Recurrent juvenile fibroadenoma with hypercellular fibromyxoid stroma of the breast was noted. OUTCOMES The patient is in good general condition without tumor relapses during the 4 months of follow-up. LESSONS Recurrent fibroadenomas, particularly those of a large size with a rapid growth rate, in the same breast suggest a high possibility of transformation. We recommend wide tumor resection.
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Affiliation(s)
| | - Pei-Chen Li
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and Tzu Chi University
| | - Dah-Ching Ding
- School of Medicine, Tzu Chi University, Hualien
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and Tzu Chi University
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan, Republic of China
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Abstract
Fibroepithelial breast lesions encompass a heterogeneous group of neoplasms that range from benign to malignant, each exhibiting differing degrees of stromal proliferation in relation to the epithelial compartment. Fibroadenomas are common benign neoplasms that may be treated conservatively. Phyllodes tumors are relatively rare lesions, and classified as benign, borderline, or malignant based on histologic evaluation of various parameters. The diagnostic interpretation of "gray-zone" fibroepithelial lesions often imposes formidable demands on a pathologist's skills. This article offers practical recommendations for the diagnostic workup of these lesions, including the appropriate utilization of ancillary investigations and the approach to core needle biopsies.
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Abstract
Fibroepithelial lesions of the breast comprise a morphologically and biologically heterogeneous group of biphasic tumors with epithelial and stromal components that demonstrate widely variable clinical behavior. Fibroadenomas are common benign tumors with a number of histologic variants, most of which pose no diagnostic challenge. Cellular and juvenile fibroadenomas can have overlapping features with phyllodes tumors and should be recognized. Phyllodes tumors constitute a spectrum of lesions with varying clinical behavior and are graded as benign, borderline or malignant based on a set of histologic features according to recommendations by the World Health Organization (WHO). Recent developments have significantly expanded our understanding of the pathogenesis of fibroepithelial lesions, highlighting fibroadenomas as true neoplasms and underscoring a commonality with phyllodes tumors in the form of recurrent MED12 exon 2 mutations. In addition, sequencing studies have elucidated pathways associated with phyllodes tumor progression. Accurate diagnosis and grading of phyllodes tumors are important for patient management and prognosis, as grade broadly correlates with increasing local recurrence risk, and essentially only malignant tumors metastasize. However, classification of fibroepithelial lesions in many cases remains challenging on both core biopsy and excision specimens. A commonly encountered problem at the benign end of the spectrum is the distinction of benign phyllodes tumor from cellular fibroadenoma, which is largely due to the subjective nature of histologic features used in diagnosis and histologic overlap between lesions. Grading is further complicated by the requirement to integrate multiple subjective and ill-defined parameters. On the opposite end of the histologic spectrum, malignant phyllodes tumors must be distinguished from more common metaplastic carcinomas and from primary or metastatic sarcomas, which can be especially difficult in core biopsies. Immunohistochemistry can be useful in the differential diagnosis but should be interpreted with attention to caveats. This review provides an overview and update on the spectrum of fibroepithelial lesions, with special emphasis on common problems and practical issues in diagnosis.
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Affiliation(s)
- Gregor Krings
- Department of Pathology, University of California San Francisco (UCSF), San Francisco, CA, USA.
| | - Gregory R Bean
- Department of Pathology, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Yunn-Yi Chen
- Department of Pathology, University of California San Francisco (UCSF), San Francisco, CA, USA
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16
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Ross DS, Giri DD, Akram MM, Catalano JP, Olcese C, Van Zee KJ, Brogi E. Fibroepithelial Lesions in the Breast of Adolescent Females: A Clinicopathological Study of 54 Cases. Breast J 2017; 23:182-192. [PMID: 28299887 PMCID: PMC5356480 DOI: 10.1111/tbj.12706] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fibroepithelial lesions (FELs) are the most frequent breast tumors in adolescent females. The pubertal hormonal surge could impact the growth and microscopic appearance of FELs in this age group. In this study, we evaluate the morphology and clinical behavior of FELs in adolescents. We searched the 1992-2012 pathology data base for FELs in females 18 years old or younger (F ≤18 years). Seven FELs from 1975 to 1983 were also included. Three pathologists reviewed all available material. Patient (pt) characteristics and follow-up information were obtained from electronic medical records. Forty-eight F ≤18 years had 54 FELs with available slides. Thirty (67%) pts were Caucasian, 12 (27%) African-American, two (4%) Hispanic, one (2%) Asian; three were of unknown race/ethnicity. Median age at diagnosis was 16 years. Median age at menarche was 12 years; most (96%) FELs occurred after menarche (median interval 48 months). All patients underwent lumpectomy; one required subsequent mastectomy. The FELs were 34 fibroadenomas (FAs) (11 usual, 23 juvenile), and 20 phyllodes tumors (PTs) (16 benign, one borderline and three malignant). Eight (35%) juvenile FAs showed slight intratumoral heterogeneity. The mean mitotic rate was 1.3 mitoses/10 high-power fields (HPFs) (range, 0-6) in usual FAs, 1.8/10 HPFs in juvenile FAs, 3.1/10 HPFs in benign PTs, 10/10 HPFs in the borderline PT and 17/10 HPFs in malignant PTs. The mean follow-up for 29 pts with 33 FELs was 44 months. Two (10%) PTs recurred locally (a benign PT at 18 months, and a borderline PT at 11 months). Both recurrent PTs had microscopic margins <1 mm. Mitotic activity in FAs from adolescents can be substantial and this finding should be interpreted cautiously. Awareness of the morphologic features of FELs in adolescents is important to avoid overdiagnosis of PTs, which can lead to additional unnecessary and potentially disfiguring surgery.
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Affiliation(s)
- Dara S. Ross
- Department of Pathology, Memorial Sloan Kettering Cancer Center
| | - Dilip D. Giri
- Department of Pathology, Memorial Sloan Kettering Cancer Center
| | | | | | - Cristina Olcese
- Department of Surgery, Memorial Sloan Kettering Cancer Center
| | | | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center
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17
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Zhang Y, Kleer CG. Phyllodes Tumor of the Breast: Histopathologic Features, Differential Diagnosis, and Molecular/Genetic Updates. Arch Pathol Lab Med 2017; 140:665-71. [PMID: 27362571 DOI: 10.5858/arpa.2016-0042-ra] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Phyllodes tumor (PT) of the breast is a rare fibroepithelial neoplasm with risks of local recurrence and uncommon metastases. The classification proposed by the World Health Organization for PTs into benign, borderline, and malignant is based on a combination of several histologic features. The differential diagnosis between PT and fibroadenoma and the histologic grading of PT remain challenging. In addition, the molecular pathogenesis of PT is largely unknown. OBJECTIVE -To provide an updated overview of pathologic features, diagnostic terminology, and molecular alterations of PT. DATA SOURCES -Current English literature related to PT of the breast. CONCLUSIONS -Phyllodes tumor shows a wide spectrum of morphology. There are no clearly distinct boundaries between PT and fibroadenoma. Strict histologic assessment of a combination of histologic features with classification can help to achieve the correct diagnosis and provide useful clinical information. The genomic landscapes of PT generated from genomic sequencing provide insights into the molecular pathogenesis of PT and help to improve diagnostic accuracy and identify potential drug targets in malignant PT.
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Affiliation(s)
- Yanhong Zhang
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, Sacramento (Dr Zhang); and the Department of Pathology, University of Michigan, Ann Arbor (Dr Kleer)
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18
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Tan BY, Acs G, Apple SK, Badve S, Bleiweiss IJ, Brogi E, Calvo JP, Dabbs DJ, Ellis IO, Eusebi V, Farshid G, Fox SB, Ichihara S, Lakhani SR, Rakha EA, Reis-Filho JS, Richardson AL, Sahin A, Schmitt FC, Schnitt SJ, Siziopikou KP, Soares FA, Tse GM, Vincent-Salomon A, Tan PH. Phyllodes tumours of the breast: a consensus review. Histopathology 2016; 68:5-21. [PMID: 26768026 PMCID: PMC5027876 DOI: 10.1111/his.12876] [Citation(s) in RCA: 258] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Phyllodes tumours constitute an uncommon but complex group of mammary fibroepithelial lesions. Accurate and reproducible grading of these tumours has long been challenging, owing to the need to assess multiple stratified histological parameters, which may be weighted differently by individual pathologists. Distinction of benign phyllodes tumours from cellular fibroadenomas is fraught with difficulty, due to overlapping microscopic features. Similarly, separation of the malignant phyllodes tumour from spindle cell metaplastic carcinoma and primary breast sarcoma can be problematic. Phyllodes tumours are treated by surgical excision. However, there is no consensus on the definition of an appropriate surgical margin to ensure completeness of excision and reduction of recurrence risk. Interpretive subjectivity, overlapping histological diagnostic criteria, suboptimal correlation between histological classification and clinical behaviour and the lack of robust molecular predictors of outcome make further investigation of the pathogenesis of these fascinating tumours a matter of active research. This review consolidates the current understanding of their pathobiology and clinical behaviour, and includes proposals for a rational approach to the classification and management of phyllodes tumours.
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Affiliation(s)
- Benjamin Y Tan
- Department of Pathology, Singapore General Hospital, Singapore
| | - Geza Acs
- Women's Pathology Consultants, Ruffolo Hooper & Associates, Tampa, FL, USA
| | - Sophia K Apple
- Department of Pathology, UCLA Medical Center, Santa Monica, CA, USA
| | - Sunil Badve
- Departments of Pathology and Internal Medicine, Clarian Pathology Laboratory of Indiana University, Indianapolis, IN, USA
| | - Ira J Bleiweiss
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - José P Calvo
- Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - David J Dabbs
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ian O Ellis
- Department of Histopathology, Nottingham City Hospital NHS Trust, Nottingham University, Nottingham, UK
| | - Vincenzo Eusebi
- Sezione Anatomia e Istologia Patologica, 'M. Malpighi' Università di Bologna, Bologna, Italy
| | - Gelareh Farshid
- BreastScreen SA, Discipline of Medicine, Adelaide University and Directorate of Surgical Pathology, SA Pathology, Adelaide, South Australia
| | - Stephen B Fox
- Pathology Department, Peter MacCallum Cancer Centre, St Andrews Place, East Melbourne, Vic., Australia
| | - Shu Ichihara
- Department of Pathology, Nagoya Medical Center, Nagoya, Japan
| | - Sunil R Lakhani
- School of Medicine and Pathology Queensland, The Royal Brisbane & Women's Hospital, University of Queensland Centre for Clinical Research, Brisbane, Qld, Australia
| | - Emad A Rakha
- Department of Histopathology, Nottingham City Hospital NHS Trust, Nottingham University, Nottingham, UK
| | - Jorge S Reis-Filho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L Richardson
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aysegul Sahin
- Department of Pathology, Division of Pathology/Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Stuart J Schnitt
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Kalliopi P Siziopikou
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Fernando A Soares
- Department of Anatomic Pathology, A. C. Camargo Cancer Centre, São Paulo, Brazil
| | - Gary M Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Puay Hoon Tan
- Department of Pathology, Singapore General Hospital, Singapore
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