Phyllodes tumor in ectopic breast tissue of the vulva

Ectopic mammary tissue in vulva: case report and systematic literature review

Objective

To report the case of a patient diagnosed with ectopic mammary tissue in the vulva, and to conduct a literature review of the diagnosis, treatment and prognosis of this condition in that location.

Materials and Methods

A 49-year-old patient who presented with a painful vulvar mass to a private intermediate complexity center in Bogotá, Colombia. The lesion was assessed on ultrasound and then surgically excised; histopathology showed ectopic mammary tissue with absence of malignancy. A search was conducted in the PubMed, Embase, Cochrane, LILACS and Scielo databases using the keywords “Vulva,” “Breast” and “Ectopic.” Case reports and case series of women with histopathology-confirmed mammary tissue in the vulva were included.

Results

Overall, 184 titles were identified and, of these, 94 were ultimately included, for a total of 126 cases, with 57.9% being benign tumors, 95% in women under 50 years of age, and 42.06% being malignant tumors, 92% in women over 50 years of age. Diagnosis was made on the basis of the clinical findings, with ancillary diagnostic imaging, tumor markers and immunohistochemistry in some cases. Local excision was performed in 91% of cases with benign pathology and in 43% of cases with malignant pathology, with the diagnostic method being therapeutic.

Conclusions

Ectopic mammary tissue in the vulva must be considered as part of the differential diagnosis of vulvar masses, prognosis being different in pre and postmenopausal women. Further studies are needed to enhance the characterization of this condition and define the ideal course of treatment in terms of relapse and survival.

Pregnancy-unrelated fibroadenoma in ectopic breast tissue in the axilla and vulva: A case report

Although ectopic breast tissue is rare in the general population, it is important to consider when investigating an axillary or vulvar mass. Ectopic breast tissue most commonly occurs postpartum but is not exclusive to that period. We report the case of a 29-year-old woman with ectopic breast tissue in multiple sites, including the axilla and vulva. The patient initially presented with a painless right axillary mass; it was excised and diagnosed as a fibroadenoma. She was then diagnosed with fibroadenoma of the vulva four years later. While ectopic breast tissue is most commonly found in the postpartum period it can occur outside of pregnancy. Therefore it should be included in the differential diagnoses for axillary or vulvar masses. Additionally, it is important to monitor women with ectopic breast tissue, particularly in the vulva, for recurrence.

A Giant Exulcerated Phyllodes Breast Tumor - A Case Report

Phyllodes tumors of the breast can be benign, malignant, or borderline. Benign and borderline tumors are rare tumor types that have a positive outlook and high survival rate, while the risk of recurrence is typical for malignant breast tumors. Giant phyllodes tumors are larger than 10 cm in diameter and demand a serious diagnostic and treatment approach.

In this study we present a case of a female patient treated for an exulcerated breast carcinoma- a giant borderline phyllodes tumor of the breast. The patient presented to the department for the right breast lump with ulcerated skin and nipple abnormalities. The core biopsy was performed and the patient was diagnosed with a benign tumor. Simple mastectomy was performed and final histopathological report revealed a borderline phyllodes tumor. Diagnosis and treatment of a giant phyllodes tumor remain a great challenge for the surgeons. Establishing the preoperative diagnosis based on histopathological findings is imperative to disease management. Surgery is the mainstay of treatment and mastectomy has been the traditional procedure; in cases where suspicious findings in the axilla are revealed, radical mastectomy is performed and the axilla is to be dissected.

Phyllodes tumour of the labia minora

A 33-year-old woman presented for a preoperative examination prior to an upcoming operative hysteroscopy. During the examination, a firm 1 cm mass in her right labia minora was noted. The mass was excised in the operating room without difficulty. Pathological examination revealed a benign phyllodes tumour of the vulva. Phyllodes tumours are uncommon fibroepithelial tumours primarily found in the breast although rarely may present as a vulvar lesion. Phyllodes tumours of the vulva are rarely reported in the literature, with only 17 previously reported cases. This case represents the first reported case of a phyllodes tumour occurring in the labia minora. While most of these tumours are benign, it is important to keep these and other rare tumours in the differential diagnosis of vulvar masses. Even with benign tumours, continued surveillance for recurrence should be performed.

[Anogenital mammary-like glands and related diseases. Part 2. Malignant tumors of the anogenital glands]

Mammary-like glands are a normal anatomical component of the anogenital region and can give rise to many benign and malignant tumors that morphologically mimic the similar diseases of the breast. The literature review is complemented by a description of 199 cases of malignant tumors of mammary-like glands. The paper presents the clinical and morphological characteristics of various malignant tumors of mammary-like glands, including extramammary Paget's disease, ductal, tubulolobular, adenoid cystic adenocarcinoma, low-grade phyllodes tumor, etc.

[Anogenital mammary-like glands and related lesions. Part 1. Benign tumors and tumor-like disorders]

Anogenital mammary-like glands represent a normal anatomic constituent of the anogenital area and may give rise to many benign and malignant tumors that morphologically mimic similar breast diseases. The literature review is complemented by a description of 286 cases of benign tumors and tumor-like processes in the mammary-like glands. The paper presents the clinical and morphological characteristics of papillary hidradenoma, fibroadenoma, benign phyllodes tumor, lactating adenoma, sclerosing adenosis, pseudoangiomatous stromal hyperplasia, etc.

A Giant Phyllodes Tumor of the Breast

Phyllodes tumors of the breast are rare, accounting for less than 1% of the breast tumors. They are mostly seen in women between 45 and 49 years old. These are fast growing tumors with a large spectrum of behavior (from benign to metastatic) and can resemble fibroadenomas. Correct diagnosis mostly through core needle biopsy is important to decide whether a surgical excision has to be done. Here we report a case of a 57-year-old woman with a fast growing, ulcerated tumor in the left breast. Core needle biopsy suggested a malignant phyllodes tumor with heterologous liposarcomatous differentiation. Treatment with total mastectomy and adjuvant radiotherapy followed. Primary treatment is always surgery, whether radiotherapy or chemotherapy has to follow remains uncertain. There is a high-recurrence rate, especially when the surgical margins are narrow.

Proliferative lesion of anogenital mammary-like glands in the setting of Cowden syndrome: case report and review of the literature

Mammary-like glands are normal appendages of anogenital skin and can give rise to epithelial and stromal tumors that closely resemble breast tumors. Cowden syndrome is an autosomal-dominant cancer-predisposition syndrome that is associated with increased risk of various benign and malignant tumors including breast cancers. Here, we report the first case of a proliferative lesion of mammary-like glands in the setting of Cowden syndrome. A 27-year-old female with Cowden syndrome (R130Q-PTEN mutation) presented with a 1-cm tender, polypoid perianal lesion. An excisional biopsy revealed a circumscribed, lobulated lesion with fibromyxoid stroma and epithelial hyperplasia with apocrine and columnar cell changes that was arranged in papillary, micropapillary and focal cribriform architecture. The features strikingly resembled proliferative changes commonly seen in the breast. Interestingly, the patient subsequently developed an atypical complex sclerosing lesion of the breast. Given the increased risk of breast neoplasia in Cowden syndrome, and the morphologic relationship between breast glands and mammary-like glands, this case raises the possibility of an increased risk of neoplasia arising in mammary-like glands in the setting of Cowden syndrome.

Benign Phyllodes Tumor of the Vulva: A Case Report and Literature Review

Phyllodes tumor is an uncommon breast lesion with characteristic histologic appearance when examined by hematoxylin and eosin staining: leaf-like fronds projecting into cystic spaces on low-power microscopy, and biphasic (epithelial and stromal) components on high-power microscopy. We report a rare primary case of this tumor arising within the vulva. A 34-year old African American female presented with a 3 cm slow-growing vulvar mass initially thought to be an inclusion cyst. The lesion was excised and histologic examination demonstrated this lesion to be a rare case of benign phyllodes tumor with morphologic features similar to those arising from breast tissue. Patient received no further treatment and did not exhibit any recurrence or metastasis. Nearly two years after excision, the patient died due to an unrelated medical cause. This rare tumor should be considered in the differential diagnosis for women presenting with a slow-growing vulvar mass.

Phyllodes tumor of the breast metastasizing to the vulva

Phyllodes tumors of the breast are rare breast tumors that resemble fibroadenoma. They are composed of two types of tissues: stromal and glandular tissues. Unlike fibroadenoma, they are commonly found in the third decade of life and they tend to grow more rapidly. Depending on the relative components of the cells and mitotic activity, they are classified into benign, borderline, and malignant. They are usually present as a lump in the breast. Phyllodes tumors are usually managed by wide excision. The excision should be wide enough to ensure a tumor-free margin. Recurrence rate is very high and most recurrences are usually local. Metastasis to the vulva has not been reported.

Phyllodes Tumor of Vulva: A Brief Diagnostic Review

Phyllodes tumors of the vulva are rare proliferations that share morphologic similarities with breast neoplasms. Their histogenetic origin is elusive and may be associated with specialized mammary-like glands of the vulva. Because of their rarity, the clinical and pathologic features, classification, and therapy are not well defined, and their biologic behavior is difficult to predict by histology alone. Immunohistochemical expression of estrogen and progesterone receptors and breast markers provide further support for a common origin. Surgical resection is the current mainstay of therapy and is definitive in most cases.

Cystic benign phyllodes tumor in the inguinal region

The present lesion was the first reported case of a benign intracystic phyllodes tumor in the inguinal region. We report the case of a 51-year-old female patient who presented with an inguinal mass. A clinical diagnosis of malignant lymphoma was considered in this case. The resected tumor was well-circumscribed and showed numerous papillary nodular protrusions into a central cystic cavity (3.5×2.5 cm). The microscopic findings showed hyperplastic epithelium-lined cysts with leaf-like intraluminal epithelium-lined bland stromal projections. The epithelial cell linings were strongly positive for estrogen and progesterone receptors.

Hidradenoma papilliferum with mixed histopathologic features of syringocystadenoma papilliferum and anogenital mammary-like glands: report of a case and review of the literature

Hidradenoma papilliferum of the anogenital region was previously believed to originate from apocrine glands but has recently been accepted as originating from anogenital mammary-like glands. We describe a case of hidradenoma papilliferum with mixed features of syringocystadenoma papilliferum and mammary-like glands from the left labia majora of a 25-year-old woman. Histopathologically, the lesion showed an epithelial lining with apocrine secretion, and like syringocystadenoma papilliferum, the lesion extended from the epithelium as invaginations into the dermis. Adjacent to this lesion were ductal and glandular structures resembling normal mammary tissue. This review of the literature highlights the heterogeneity and complexity of lesions arising from anogenital mammary-like glands, and this case serves as further documentation of the association between anogenital mammary-like glands and hidradenoma papilliferum.

Lesions of anogenital mammary-like glands: an update

Long considered to be ectopic breast tissue representing the caudal remnants of the milk ridges, anogenital mammary-like glands are nowadays thought to represent a normal constituent of the anogenital area. Lesions involving these glands, benign or malignant, epithelial or stromal manifest a striking similarity to their mammary counterparts. This review addresses the recent literature on lesions of anogenital mammary-like glands and our personal experience with various lesions related to these structures. Discussed are the normal anatomy and histology of these glands as well as the clinical presentation, histopathological and immunohistochemical features, molecular biological aspects, and differential diagnosis of various lesions involving anogenital mammary-like glands, including lactating adenoma, hidradenoma papilliferum, hidradenocarcinoma papilliferum, fibroadenomas, phyllodes tumor, pseudoangiomatous stromal hyperplasia, extramammary Paget disease, and other carcinomas. In addition, "nonspecific" epithelial or stromal changes some of which can be likened to similar changes occurring in a range of benign breast disease, including sclerosing adenosis, columnar cell lesions, ductal lesions and various metaplastic changes affecting epithelium and myoepithelium are discussed. Although lesions of anogenital mammary-like glands are often discussed in many dermatopathology textbooks in the context of cutaneous adnexal neoplasms we advocate that the best approach to the diagnosis of these lesions is to relate them to analogous well recognized lesions occurring in the breast, that is, through the eyes of a breast pathologist. This will enable their recognition, precise classification and should introduce greater uniformity in how they are reported in the literature so that more meaningful clinicopathological comparisons and correlations may be made.

Phyllodes tumor of the vulva: Report of a rare case and review of the literature

Phyllodes tumor occurring in the vulva is extremely rare; only 6 cases have been previously reported in the literature. The histogenetic origin of this tumor is controversial as it is being debated whether such lesions evolve from ectopic breast tissue, cutaneous apocrine glands, and most recently, anogenital mammary-like gland. We report an 18-year-old Kuwaiti girl who presented with a painless mass in the left labium majus, which was subsequently excised. Microscopic examination revealed morphologic pattern characteristic of benign phyllodes tumor. Immunostaining demonstrated the presence of estrogen receptors and progesterone receptors in the epithelial component. We present this case to emphasize the importance of recognizing this uncommon lesion occurring at an extremely unusual site. We also discuss the histogenesis of phyllodes tumor and related lesions occurring in the anogenital region in light of the current literature along with a brief review of the previously reported cases of vulvar phyllodes tumor.

Bilateral aberrant axillary breast tissue mimicking lipomas: report of a case and review of the literature

A 31 year old Indian woman presented with bilateral axillary masses that became noticeable with the onset of puberty. The masses exhibited similar consistency to the adjacent normal breast tissue but lacked an associated nipple complex. The clinical impression was lipoma; however, mammography, ultrasonography and skin biopsy revealed ectopic breast tissue. These findings were consistent with the diagnosis of aberrant breast tissue. A subset of ectopic mammary tissue, aberrant breast tissue may constitute a diagnostic challenge and is often misdiagnosed as lipoma, hidradenitis, follicular cyst, or lymphadenopathy. In addition, some studies have suggested that aberrant breast tissue may be at higher risk of malignant degeneration. Therefore, it's important that physicians be familiar with this condition as this may contribute to the early detection of ectopic breast cancer.

Mammary-type fibroepithelial neoplasms of the vulva: a case report and review of the literature

Mammary-type fibroepithelial neoplasms of the vulva are rare lesions of uncertain histogenesis. Origin from ectopic breast tissue and from anogenital glandular tissue that shares similar histologic homology with breast tissue has been postulated. We report the case of a 45-year-old woman who presented with a vulvar mass of several years duration. Excision of the lesion and subsequent histologic examination showed a mammary-type fibroadenoma with apocrine change. No ectopic breast tissue was identified outside the lesion. The theories of histogenesis of these neoplasms and additional cases of mammary-type lesions of the vulva reported in the medical literature are reviewed.

Human Papillomavirus in Lesions of Anogenital Mammary-Like Glands

Long considered as ectopic breast tissue, anogenital mammary-like glands (MLGs) have recently been suggested to represent distinctive structures located in the anogenital area. We studied 16 neoplasms of anogenital MLG for human papillomavirus (HPV) DNA using INNO-line probe assay (LiPA) HPV Genotyping kit, GP5+/6+, CP(SGB), and FAP 6085-6319 primer sets. The lesions included 3 fibroadenomas, 2 adenosis tumors, 1 invasive ductal carcinoma, 1 tubulolobular carcinoma, 2 hidradenoma papilliferum with prominent cystic change rendering a cystadenoma appearance and oxyphilic metaplasia, and 7 cases of extramammary Paget disease. All 3 fibroadenomas, both adenosis tumors, both hidradenoma papilliferum, and the tubulolobular carcinoma proved negative for HPV DNA. HPV-31 was detected by LiPA in the case of invasive ductal carcinoma. In 2 of the 7 patients with extramammary Paget disease, there was HPV DNA present in the lesional tissue, typed as HPV-6 (LiPA) and a type which was closely related to HPV-21 and HPV-24 (FAP 6085-6319), whereas the remaining 5 cases tested negative. These results coupled with those obtained from literature review suggest that HPV plays no causative role in lesions of anogenital MLG.

Expression of the breast differentiation antigen NY-BR-1 in a phyllodes tumor of the vulva

We describe a phyllodes tumor of borderline malignancy in the labium majus of a 49-year-old woman. The histogenetic origin of phyllodes tumors in the vulva is controversial. Strong immunoreactivity for NY-BR-1, a novel breast differentiation antigen, was demonstrated within the epithelial components of the phyllodes tumor. A similar expression pattern was observed in mammary-like glands of the vulva. These findings provide further evidence that phyllodes tumors of the vulva might derive from mammary-like glands in the labium majus or from ectopic breast tissue.

Primary ectopic breast cancer presenting as a vulvar mass

Ectopic breast tissue is found along the primitive embryonic milk lines, which extend from the axilla to the groin. Rarely, its occurrence has been described in the vulva. We report a patient who developed primary adenocarcinoma of ectopic breast tissue in such a location and present a review of the pertinent medical literature. The predominant pathology is that of invasive ductal carcinoma; however, other tumor types have also been reported in accessory breast tissue. Its treatment usually entails surgical resection with lymph node dissection. Adjuvant therapy should be guided by the same principles as in orthotopic breast carcinoma.

Mammary Type Tubulolobular Carcinoma of the Anogenital Area: Report of a Case of a Unique Tumor Presumably Originating in Anogenital Mammarylike Glands

We present a case of an unusual tumor that occurred in the perianal area of a 64-year-old woman. Clinical investigation revealed no tumor elsewhere. The lesion was removed and the patient is alive without signs of metastasis or recurrence 5.5 years after surgery. Histopathologically, the neoplasm was composed of single-cell cords of uniform round to ovoid cells intermixed with round to elongated tubules showing decapitation secretion at the luminal border. The tubules were mainly composed of a single cell layer, but focally multilayered epithelium (without evidence of myoepithelial cell differentiation) was seen as well as discrete cribriform structures and intraluminal bridges. Overall, the cell cord component slightly dominated over the tubular component, and the two were intermixed. A vague targetoid arrangement of the cell cords was seen focally. Immunohistochemically, the tumor cells in both components reacted positively for E-cadherin, 34betaE12, estrogen receptors and progesterone receptor and were negative for HER2/neu (c-erbB-2). There was no evidence of myoepithelial cell differentiation with calponin. We believe that the present case is best classified as mammary type tubulolobular carcinoma and, given the location, the origin in anogenital mammary-like glands most likely.

Phyllodes tumors of the breast: a case series of 106 patients

BACKGROUND

Phyllodes tumors (PTs) of the breast are rare, and their prognosis and treatment are still subject of discussion. The purpose of this study is to clarify therapeutic aspects and prognostic factors of this disease.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 106 patients who had histologically confirmed PTs collected over a period of 10 years.

RESULTS

The mean age was 39.5 years (14-71 years). The mean tumoral size was 83 mm (15-250). According to criteria of Azzopardi and Salvadori, tumors were classified into 3 groups: benign (62 cases, 58.4%), borderline (16 cases, 15%), and malignant (28 cases, 26.4%). Eighty-two patients (77.4%) were treated conservatively (62 benign, 11 borderline, and 9 malignant) and 24 (22.6%) by radical surgery (5 borderline and 19 malignant). For malignant PTs treated by enucleation or local excision with or without reexcision of the tumor bed, the 5-year overall and disease-free survivals were 28.5% and 15.6% versus 72.7% and 73.6% when the surgery was radical (mastectomy with or without axillary dissection) (P = .12 and P = .0022). For the other histotypes, this difference disappeared. The rate of recurrence was 12.2% (13) after a mean follow-up of 39 months (5 benign, 2 borderline, and 5 malignant). The treatment of recurrences consisted of radical mastectomy (8 cases), simple mastectomy (2 cases), and local excision in 3 cases. Eight patients developed metastases, 2 of whom after recurrences. The 5-year overall and disease-free survivals were 86.54% and 78%, respectively. In univariate analysis, age and recurrences are not of prognostic value for survival, whereas tumor size, histotype, necrosis, cytonuclear atypia, tumor margins, and number of mitosis were significant prognostic factors for survival. In a multivariate study, only cytonuclear atypia remained an independent predictor for survival.

CONCLUSION

According to our results, we recommend for malignant PT a simple mastectomy, whereas for borderline and benign PT, treatment is based rather on wide excision passing in healthy tissue.

Unusual Hyperplasia of Anogenital Mammary-Like Glands

Anogenital mammary-like glands, although known to exist (as ectopic breast tissue) as early as 1872, have only recently been thoroughly studied and suggested to be the possible origin for various neoplastic (benign and malignant) and reactive conditions that show a striking homology with lesions in the breast. Reported herein is an unusual benign lesion involving anogenital mammary-like glands in the perineal area of a 41-year-old woman. The lesion is unique in that it does not fully fit into any of the previously recognized conditions affecting anogenital mammary-like glands nor has it an apparent well-defined mammary counterpart. Microscopically, at first glance the lesion appeared as a cluster of extended anogenital mammary-like glands of variable complexity and a lobular architecture, which probably resulted from a compact proliferation of closely situated ducts with small, round lumens (when cut transversally). When cut longitudinally, some of these tiny ducts appeared to bud from larger ductal structures, resembling so-called satellitosis in the breast and this gave a fibroadenomatous appearance to the areas. In addition, there were adenosis-like areas. This lesion extends the spectrum of changes seen in anogenital mammary-like glands.

Pseudoangiomatous Stromal Hyperplasia in Lesions Involving Anogenital Mammary-Like Glands

Pseudoangiomatous stromal hyperplasia (PASH), first reported in 1986, is nowadays a well-recognized change in the breast. We present three cases of lesions involving anogenital mammary-like glands demonstrating this feature. All patients were females (ages, 42, 43, and 53 years). Each presented with a solitary, 1.5- to 2-cm asymptomatic nodule. Locations included the perianal area, perineum, and labium majus. Histopathologically, one lesion was classified as low-grade phyllodes tumor, another as fibroadenoma, and in the remaining case PASH was found in the background of mild hyperplasia of anogenital mammary-like glands and substantial lipomatous metaplasia. In all lesions, PASH had an identical appearance to that in the breast, that is open, slit-like, often anastomosing channels devoid of erythrocytes and lined by discontinuous, often attenuated, inconspicuous cells without atypia or mitotic activity set in a hyalinized collagenous stroma. Quantitatively, PASH ranged in the above cases, forming a relatively small focus in the fibroadenoma and being quite extensive in the remaining two cases. In the phyllodes tumor, PASH areas exhibited focal hypercellularity and presence of myoid cells. In none of the cases were there cells with intranuclear inclusions or multinucleated cells. The lesions were surgically excised. Two patients with follow-up were disease-free at one and three years after the operation. As to our knowledge, PASH has not been previously described in the anogenital area, this feature seems to have been either overlooked or is genuinely rare in this location. It may occur in a preexisting lesion of anogenital mammary-like glands or may apparently by itself produce a clinically detectable lesion. The clinicopathologic features of PASH in the anogenital area seem to be identical to those in the breast.

Phyllodes tumor arising in ectopic breast tissue of the axilla

We examined a 31-year-old woman with a solid mass in her left axilla. Physical examination and ultrasonography confirmed a 2 cm well-defined mass. Fine needle aspiration biopsy suggested fibroadenoma of breast. Excisional biopsy revealed benign phyllodes tumor of the ectopic breast tissue. Phyllodes tumor in ectopic breast tissue is an extremely rare occurrence. Only nine cases have been reported, including tumors of the vulva, inguinal region and axilla. This is the second case in the axillary region.