Fatal outcome of malignant phyllodes tumor of the breast in pregnancy: a case and literature review

A case of phyllodes tumor with rapid growth during pregnancy and lactation period: a case report

BACKGROUND

The age of onset of the phyllodes tumor is generally in the late 40 s, and diagnosis and treatment during pregnancy and lactation are rare. We herein present a case of a phyllodes tumor that rapidly increased in size during the pregnancy and lactation period.

CASE PRESENTATION

A 39-year-old woman was referred to our hospital with a mass in the right breast that increased in size during the pregnancy and lactation period. On ultrasound (5 week postpartum), a well-defined lobulated mass with internal septations and fluid retention was observed. Magnetic resonance imaging of the breast at 8 week postpartum revealed a 70-mm-sized smooth-margin mass with multilocular cystic components. Marked proliferation of stromal cells with high cell density was observed in a biopsy specimen taken at the previous hospital. We diagnosed the mass as a phyllodes tumor of borderline malignancy and excised it at 13 week postpartum. The excised tumor was 85 mm in diameter and its interior was filled with a milk-like substance. Histologically, there was only a mild increase in stromal cell density but fibrosis with associated degeneration was prominent. The final diagnosis was benign phyllodes tumor with degeneration.

CONCLUSIONS

We report a case of a phyllodes tumor that rapidly increased in size during pregnancy and the lactation period. The accumulation of a milk-like substance was thought to be responsible for the rapid growth of the tumor.

Giant phyllodes tumor of the breast: A case report

Phyllodes tumors of the breast are rare fibroepithelial neoplasms that account for less than 1% of all breast tumors. They tend to affect middle-aged women, who present with a rapidly growing, palpable mass. Here we present a case of a 34-year-old female surrogate mother without any reported personal or family history of breast cancer who presented with a rapidly growing left breast mass, pathologically proven to be a phyllodes tumor. The patient was a G7P7 surrogate mother who received estrogen and progesterone injections for her twin surrogate pregnancy starting 4 months before embryo implantation, after which, she discovered a large palpable mass in the left breast at approximately week 7 gestational age. At the initial presentation, the patient was at week 23 gestational age. She underwent C-section delivery of the twins at this time and obtained further work-up of the mass. She had a core needle biopsy which yielded a benign fibroepithelial tumor. Due to the size of her breast mass and atypical morphology, including extension to the nipple, and skin ulceration, the patient subsequently underwent left mastectomy. At the time of mastectomy, which was 8 months after the initial work-up, the mass had grown to measure approximately 12 × 10 cm on physical examination and took up most of her left breast. It was completely resected and was pathologically determined to be a borderline phyllodes tumor. Only a few cases have been reported about the development of phyllodes tumor during pregnancy in the literature, and we believe this is the first case report of phyllodes tumor related to a surrogate pregnancy. Although the relationship between exogenous hormones and fibroepithelial tumors is not well understood, the case poses the clinical question if screening mammograms should be offered to patients undergoing exogenous hormonal therapy, regardless of age to establish a baseline and monitor for the development (if any) or growth of these tumors.

Clinical and radiological evaluation of a phyllodes tumor of the breast: a case report

Phyllodes tumors (PTs) are rare breast tumors characterized by varying biological behavior and heterogeneous clinical findings. As a result, accurately diagnosing PTs preoperatively is challenging, often leading to misdiagnosis. A 49-year-old patient presented with a steadily growing right breast mass that had persisted over a 10-year period. Breast mammography and ultrasonography results indicated the presence of a PT. Following a lumpectomy, the patient was diagnosed with a borderline PT. However, nearly 1 year later, she was readmitted due to the recurrence of a palpable mass at the site. Consequently, 1 year and 8 months after the initial operation, she underwent thoracoscopic lobectomy to address solitary lung metastases. Subsequently, the patient experienced brain metastasis and massive hemorrhage 14 months later. Long-term follow-up was recommended. This case study presents an instance of borderline PT with clinical and imaging features that are crucial for guiding clinical operations and evaluating patient prognosis.

Phyllodes Tumor of the Breast Complicated With Mastitis

One of the rarest fibro-epithelial neoplasms of the breast during pregnancy is the phyllodes tumor (PT). It is typically a painless, bi-phasic, and rapidly growing neoplasm that resembles fibroadenomas. It is still unclear if the neoplasm is hormone-dependent during pregnancy. It is often challenging to diagnose and treat PT. Herein, we report a case of a 30-year-old female at 31 weeks gestation who was diagnosed with a benign phyllodes tumor of her breast with concurrent mastitis. She was first seen during her third trimester where the neoplasm was around 5 cm as reported by the ultrasound (US) examination. Her biopsy report was suggestive of a PT and she was advised surgery with excision of the tumor margin, but she refused. Ten days after her delivery she presented to the emergency department with a fever and a hard, engorged, erythematous, and tender left breast. She was diagnosed with mastitis of the left breast. She then underwent incision and drainage of the left breast that drained purulent milk; additionally, large necrotic grape-like tissues were removed and were confirmed by the histopathology report as a benign phyllodes tumor of the breast.

Genomic characteristics of two breast malignant phyllodes tumors during pregnancy and lactation identified through whole-exome sequencing

Background

The genomic landscape of breast malignant phyllodes tumors (PTs) is not well defined, especially pregnancy-related malignant PTs. To clarify this topic, whole-exome next-generation sequencing (NGS) was performed on tumor samples and paired normal breast tissues from two pregnancy-related malignant PTs, followed by a functional analysis of the genetic alterations.

Methods

DNA from malignant PT samples and matched normal breast tissues of both patients were subjected to molecular profiling. NGS of the whole-exome was performed in a commercial molecular pathology laboratory. Predictive tools were used to estimate genetic variation in somatic and germline genes.

Results

In total, 29 somatic genomic alterations and 18 germline alterations were found in both patients. In Patient 1, 12 aberrations were identified in the tumor tissue, and 9 alterations were identified in matched normal breast tissue. One pathogenic variant in tumor suppressor genes (TP53) was detected in patient 1. In Patient 2, 18 and 10 variants were found in the tumor and matched normal breast tissue, respectively. In Patient 2, pathogenic alterations were identified in two tumor suppressor genes (PTEN and TP53). PTEN and TP53 may be potential drug targets. The functional predictive tools showed that genes of unknown significance for PTs, including FCHO1 in Patient 1, and LRP12 and PKM in Patient 2, were pathogenic. Several genes, including FCHO1, LRP12 and PKM, were shown for the first time to be altered in malignant PTs. A potentially pathogenic germline variant in PRF1, was detected in Patient 1.

Conclusion

Our study first demonstrated somatic and germline gene alterations in two malignant PTs during pregnancy and lactation. These two PTs shared major genetic events, including TP53 mutation, which commonly occurs in malignant PTs; additionally, we identified two potential genes for targeted therapy, TP53 and PTEN. One germline mutation in PRF1 was also detected. These results provide clues regarding tumor pathogenesis and precision therapy development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02537-w.

Malignant Phyllodes Tumor of the Breast and Pregnancy: A Rare Case Report and Literature Review

Phyllodes Tumor (PT) is a rare fibroepithelial breast tumor that can behave differently depending on its biologic features. Traditionally, PTs are classified by their histologic features into benign, borderline, and malignant. In most cases that were reported, all PTs may recur, but only the borderline and malignant PT can metastasize. PT usually occurs as a breast lump or accidental finding on ultrasound (US) examination. The clinical features include a well-defined breast mass, regular or lobulated. The diagnosis is based on the integration of morphology features, but remains challenging, particularly in the distinction from fibroadenomas. We report a case of a 36-year-old patient who presented for a voluminous breast mass, rapidly growing in the past 3–4 months. At presentation, the patient was 19 weeks pregnant. The breast tumor had the clinical and US aspect of PT. A core needle biopsy was obtained, confirming a benign PT, and local excision was performed with no postoperative complications. The final pathology report showed a borderline PT with close resection margins of 1 mm. Immunohistochemistry (IHC) established the diagnosis of malignant PT with heterologous sarcomatous differentiation. The case was discussed in the multidisciplinary tumor board (MDT) and mastectomy was recommended. The patient fully consented but refused surgery at 25 weeks’ gestation, fearing premature delivery. The right breast was closely monitored by US, and at 9 weeks after the first surgery, signs of local recurrence were detected. At 35 weeks’ gestation, right mastectomy was performed, with no perioperative complications. The pregnancy was closely followed up and no complication were found. The final pathology report describes multiples PT recurrences with heterologous sarcomatous differentiation. The pregnancy outcome was uneventful, and the patient delivered a healthy child vaginally at term with no peripartum complication. Postpartum, a computer tomography (CT) examination of the head, thorax, abdomen and pelvis was performed, with no evidence of metastases. Adjuvant chemotherapy and radiotherapy completed the treatment. The follow-up and CT scan showed no metastases or further recurrence 4 years after diagnosis. In conclusion, diagnosis of PT can be difficult, especially because of the easy confusion with fibroadenoma of the breast. There are rare cases when a pathology exam needs further assessment and IHC is recommended for accurate diagnosis. Although malignant PT is rare and accounts for <1% of all breast cancers, the diagnosis and treatment that are recommended are based on the reported cases. Moreover, when complete surgical excision is achieved, the rates of recurrence and distant metastases are low, and adjuvant therapy might not be necessary.

Diagnostic challenges of benign breast phyllodes tumour: A rapid-growing tumour during pregnancy caused breast loss. A case report

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Phyllodes tumours are rare breast neoplasms.

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Inadequate treatment of phyllodes tumour can result to tumour recurrence, growth or metastatic spread, when tumour has malignant potential.

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In suitable cases, skin-sparing mastectomy with immediate silicone implant reconstruction might be a treatment option.

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The patients with microscopically radical removed benign phyllodes tumours can be followed up with annual surveillance.

Introduction

Phyllodes tumours are rare breast neoplasms. It is especially rare in pregnancy.

Presentation of case

We report a case of a 37-year-old woman with left breast benign phyllodes tumour, which started to grow very fast during pregnancy. The tumour was too big for breast-conserving surgery and it was necessary to remove the whole left breast. Patient underwent successful nipple-skin-sparing mastectomy with immediate silicone implant reconstruction.

Conclusion

Breast phyllodes are classified as benign, borderline, and malignant. Standard treatment of breast phyllodes is surgery. The choice of surgery type depends on the tumour factors and breast size.

We highlight that, inadequate treatment of phyllodes tumour can result to recurrence, growth, or even metastatic spread, when tumour has malignant potential.