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Elfgen C, Leo C, Kubik-Huch RA, Muenst S, Schmidt N, Quinn C, McNally S, van Diest PJ, Mann RM, Bago-Horvath Z, Bernathova M, Regitnig P, Fuchsjäger M, Schwegler-Guggemos D, Maranta M, Zehbe S, Tausch C, Güth U, Fallenberg EM, Schrading S, Kothari A, Sonnenschein M, Kampmann G, Kulka J, Tille JC, Körner M, Decker T, Lax SF, Daniaux M, Bjelic-Radisic V, Kacerovsky-Strobl S, Condorelli R, Gnant M, Varga Z. Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Virchows Arch 2023:10.1007/s00428-023-03566-x. [PMID: 37330436 DOI: 10.1007/s00428-023-03566-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/19/2023]
Abstract
The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.
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Affiliation(s)
- Constanze Elfgen
- Breast-Center Zurich, Zurich, Switzerland.
- University of Witten-Herdecke, Witten, Germany.
| | - Cornelia Leo
- Breast Center, Kantonsspital Baden, Baden, Switzerland
| | | | - Simone Muenst
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Noemi Schmidt
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Cecily Quinn
- Irish National Breast Screening Program & Department of Histopathology, St. Vincent's University Hospital Dublin and School of Medicine, University College Dublin, Dublin, Ireland
| | - Sorcha McNally
- Radiology Department, St. Vincent University Hospital, Dublin, Ireland
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ritse M Mann
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Maria Bernathova
- Department of Radiology and Nuclear Medicine, Medical University Vienna, Vienna, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | | | - Martina Maranta
- Department of Gynecology, County Hospital Chur, Chur, Switzerland
| | - Sabine Zehbe
- Radiology Section, Breast Center Stephanshorn, St. Gallen, Switzerland
| | | | - Uwe Güth
- Breast-Center Zurich, Zurich, Switzerland
| | - Eva Maria Fallenberg
- Department of Diagnostic and Interventional Radiology, School of Medicine & Klinikum Rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Simone Schrading
- Department of Radiology, County Hospital Lucerne, Lucerne, Switzerland
| | - Ashutosh Kothari
- Breast Surgery Unit, Guy's and St Thomas's NHS Foundation Trust, London, UK
| | | | - Gert Kampmann
- Centro di Radiologia e Senologia Luganese, Lugano, Switzerland
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University Budapest, Budapest, Hungary
| | | | | | - Thomas Decker
- Breast Pathology, Reference Centers Mammography Münster, University Hospital Münster, Münster, Germany
| | - Sigurd F Lax
- Department of Pathology, Hospital Graz II, Graz, and School of Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Martin Daniaux
- BrustGesundheitZentrum Tirol, University Hospital Innsbruck, Innsbruck, Austria
| | - Vesna Bjelic-Radisic
- University of Witten-Herdecke, Witten, Germany
- Breast Unit, Helios University Hospital, University Witten/Herdecke, Witten, Germany
| | | | | | - Michael Gnant
- Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria
| | - Zsuzsanna Varga
- Department of Pathology and Molecular Pathology, University Hospital Zürich, Zürich, Switzerland
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Muacevic A, Adler JR, Alattia L. Transformation of a Benign-Appearing Fibroepithelial Lesion to a Giant Malignant Phyllodes Tumor of the Breast. Cureus 2022; 14:e32881. [PMID: 36699789 PMCID: PMC9867914 DOI: 10.7759/cureus.32881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
This is a case of a woman who presented with a left breast mass that was initially diagnosed as fibroadenoma on core biopsy and, after three years without any surgical intervention, was found to be a malignant phyllodes tumor. Initially, a core needle biopsy of the mass showed probable fibroadenoma. Because of the initial benign seeming diagnosis and the need to treat her tongue cancer, the patient did not recognize the need for a recommended surgical consultation and excision. Three years later, she presented after the mass had enlarged to encompass nearly the whole left breast. Core needle biopsy revealed spindle cell proliferation with scattered benign-looking tubules. Due to the large size of the mass, she underwent a total mastectomy, and the final pathology demonstrated a malignant phyllodes tumor. This case demonstrates a case of progression of a benign-appearing fibroepithelial lesion to a malignant phyllodes tumor three years later.
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Yu CY, Huang TW, Tam KW. Management of phyllodes tumor: A systematic review and meta-analysis of real-world evidence. Int J Surg 2022; 107:106969. [PMID: 36328344 DOI: 10.1016/j.ijsu.2022.106969] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/01/2022] [Accepted: 10/22/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Phyllodes tumor is rare but has a high recurrence rate. Treatment modalities and clinicopathological prognostic factors for recurrence remain unclear. The synthesis of real-world data can enable the integration of sufficient evidence on optimal treatment for this population. METHODS We searched PubMed, Embase, and Cochrane Library databases for studies focusing on the management of phyllodes tumor including the surgical margin, different clinicopathological prognostic factors, and postoperative adjuvant radiotherapy versus no radiotherapy. RESULTS Fifty-two studies were retrieved. The pooled estimated recurrence rates of benign, borderline, and malignant tumors were 7.1%, 16.7%, and 25.1%, respectively. Surgical margins of 1 mm (odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.27-0.61) and 1 cm (OR: 0.45, 95% CI: 0.15-0.85) resulted in significantly higher recurrence rates. Postoperative adjuvant radiotherapy significantly reduced the recurrence rate of malignant tumors relative to no radiotherapy (P = 0.034) but did not significantly reduce the recurrence rates of overall and borderline tumors. Regarding clinicopathological features, moderate or severe stromal atypia and hypercellularity, stromal overgrowth, mitotic number of 5, tumor necrosis, tumor border, and margin status were determined as independent prognostic factors for recurrence, except a tumor size of 5 cm. CONCLUSION The ideal surgical margin for phyllodes tumor incision should be at least 1 cm in width. Adjuvant radiotherapy reduced the recurrence of malignant tumor. By identifying patients with poor clinicopathological risk factors, surgeons may reduce the recurrence rate of phyllodes tumor.
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Affiliation(s)
- Chia-Yun Yu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
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Ofri A, Stuart KE, Chan B, Mak C, Warrier S, Bhadri V, Mander-Jones T, O'Toole S. Diagnosis and management of phyllodes tumours for the surgeon: An algorithm. Surgeon 2022; 20:e355-e365. [PMID: 35148937 DOI: 10.1016/j.surge.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 12/02/2021] [Accepted: 01/07/2022] [Indexed: 11/17/2022]
Abstract
A Phyllodes Tumour (PT) is an uncommon fibroepithelial lesion, with three histological grades - benign, borderline and malignant. PTs cause significant challenges in diagnosis, management and prognostication. Recent publications have clarified the definitions and prognostication of PTs. Contemporary data currently challenge international guidelines on PT management. We performed an in-depth literature review to develop a best-practice management algorithm for PTs. Diagnostic recommendations are that neither current imaging techniques, nor fine-needle biopsies, can reliably diagnose a PT. Core needle biopsy is the optimal diagnostic technique. Indeterminate or suspicious lesions are recommended to undergo an excisional biopsy due to the inherently heterogeneous nature of PTs. Management guidelines are that benign PTs should be completely excised, although an involved margin is acceptable in select situations. Borderline PTs should have a clear margin on excision due to their higher risk of recurrence, as well as the potential for a recurrence to progress to a malignant PT. In malignant PTs, a margin of 3 mm is acceptable as there is no reduction in recurrence risk if margins are >3 mm. Routine axillary surgery is not indicated in PTs, with axillary surgery only indicated in a histologically-confirmed positive axilla. Adjuvant treatment recommendations are that borderline and malignant PTs should be discussed at MDT, with radiotherapy considered in both. Chemotherapy should be discussed in malignant PT patients. In summary, we have developed an up-to-date simple algorithm to guide the surgeon's management of patients diagnosed with PTs and reduce excessive surgery.
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Affiliation(s)
- Adam Ofri
- Department of Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW 2052, Australia.
| | - Kirsty E Stuart
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, 166-174 Hawkesbury Rd, Westmead, NSW 2145, Australia; Westmead Breast Cancer Institute, Block F/189 Cnr Hawkesbury & Darcy Rd, Westmead, NSW 2145, Australia; Western Clinical School, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Belinda Chan
- Department of Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia; Strathfield Private Hospital, 3 Everton Rd, Strathfield, NSW 2135, Australia
| | - Cindy Mak
- Department of Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia; Royal Prince Alfred Hospital Institute of Academic Surgery, Camperdown, NSW 2050, Australia; Mater Hospital, 25 Rocklands Rd, North Sydney, NSW 2060, Australia
| | - Sanjay Warrier
- Department of Surgery, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia; Royal Prince Alfred Hospital Institute of Academic Surgery, Camperdown, NSW 2050, Australia
| | - Vivek Bhadri
- Department of Medical Oncology, Chris O'Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia
| | - Tim Mander-Jones
- Department of Radiology, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW 2139, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
| | - Sandra O'Toole
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW 2052, Australia; The Kinghorn Cancer Centre and Cancer Research Division, Garvan Institute of Medical Research, 370 Victoria St, Darlinghurst, NSW 2010, Australia; Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Johns Hopkins Dr, Camperdown, NSW 2050, Australia; Western Sydney University, Campbelltown, NSW 2560, Australia
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Khalid IB, Parvaiz MA, Sarwar A, Shaikh OS, Javed N, Fatima A. A leafy surprise: Case report of male breast malignant phyllodes. Int J Surg Case Rep 2021; 88:106536. [PMID: 34715464 PMCID: PMC8577468 DOI: 10.1016/j.ijscr.2021.106536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Phyllodes tumor is a biphasic fibroepithelial tumor which accounts for less than 1% of all breast neoplasms. We aim to raise awareness among clinicians that a male breast lump may be indicative of underlying sinister pathology and therefore, should be investigated thoroughly. CASE PRESENTATION A 62 year old male presented in clinic with right beast lump for the last 6 weeks. A preoperative diagnosis of spindle cell tumor was made on core needle biopsy. Neoadjuvant chemotherapy was administered in order to downsize the tumor as it was inseparable from underlying muscle. A post-operative diagnosis of malignant phyllodes was made following mastectomy. As the tumor was 1 mm from the deep margin, adjuvant radiotherapy was administered. CLINICAL DISCUSSION Differential diagnoses of malignant phyllodes include metaplastic carcinomas metastatic/primary sarcomas and fibroadenomas. Metaplastic carcinomas are morphologically heterogeneous and include adenosquamous carcinoma, squamous cell carcinoma and spindle cell carcinoma. In some malignant phyllodes, extensive stromal proliferation can make detection of epithelial component very difficult. This highlights the limitation of core biopsy in establishing an accurate preoperative diagnosis. The standard treatment for phyllodes treatment is surgical resection with margins of 1 cm or more. Adjuvant radiotherapy is used in cases with threatened margins. CONCLUSION Malignant phyllodes tumor of breast can exist in men, and its accurate pre-operative diagnosis is difficult given the limitations of core biopsy. This case report draws attention to the challenges associated with the diagnosis of this rare condition and highlights the role of different treatment modalities in its management.
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Affiliation(s)
- Ibtissam Bin Khalid
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan.
| | - Muhammad Asad Parvaiz
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan
| | - Albash Sarwar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan.
| | - Omair Shahid Shaikh
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan.
| | - Nida Javed
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan
| | - Arooj Fatima
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R-3, M.A. Johar Town, Lahore, Pakistan
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Latif M, Loya A, Hameed M, Hassan U, Mushtaq S, Hussain M. Diagnosis on Excision Biopsy of Breast Tissues Labeled As Fibroepithelial Tumors on Trucut Samples in a Developing Country. Cureus 2021; 13:e18111. [PMID: 34692322 PMCID: PMC8527186 DOI: 10.7759/cureus.18111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Fibroadenomas (FAs) and phyllodes tumors (PTs) are less prevalent but allied to have malignant transformation in many instances. It is a challenge to diagnose the phyllodes by conventional trucut biopsy technique. Objective: To evaluate the histological characteristics of tumors labeled as fibroepithelial lesions of breast tissues on trucut biopsy and compare with a diagnosis on excision biopsy. Methods and materials: It was a descriptive cross-sectional study that was carried out in Shaukat Khanum Memorial Hospital and Research Centre within six years from January 2015 to January 2021. In trucut samples, stromal cellularity, stromal cell nuclear atypia, mitotic count, stromal overgrowth, the enhancement of stromal cellularity adjacent to epithelium were scrutinized. In each category, the activity was seen as absent, mild, moderate, or severe. Mitotic activity was graded as 0-1, 0-5, 5-10, >10. Results: A total of 125 patients were registered for the study. The mean age of patients in our study was 33.86 ± 9.95 years. The mean size was 41.02 ± 27.38 mm with a mean lump duration of 7.52 ± 5.34 months. In the FA group, the trucut sampling report showed the stromal cellularity as mild in 62 (69.7%) and stromal cell nuclear atypia as absent in 68 (76.4%) cases. But in the phyllodes tumor group, the stromal cellularity was severe in 10 (27.8%) patients and stromal cell nuclear atypia was severe in five (13.9%). The ultimate outcome showed that 89 (71.2%) patients had FA and 36 (28.8%) had PT at excision. Conclusion: Assessment of tumor size, stromal cellularity, mitoses, and enhancement of stromal cellularity adjacent to epithelium are useful markers for diagnosing the PT in trucut needle biopsy.
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Affiliation(s)
- Maliha Latif
- Histopathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Asif Loya
- Histopathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Maryam Hameed
- Pathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Usman Hassan
- Pathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Sajid Mushtaq
- Pathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Mudassar Hussain
- Histopathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
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Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study. J Surg Res 2021; 264:309-315. [PMID: 33845414 DOI: 10.1016/j.jss.2021.01.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/18/2020] [Accepted: 01/18/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. MATERIALS AND METHODS A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. RESULTS Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. CONCLUSIONS Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.
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Mihai R, Callagy G, Qassid OL, Loughlin MO, Al-Hilfi L, Abbas A, Campora M, Hodi Z, Ellis I, Lee AHS, Rakha EA. Correlations of morphological features and surgical management with clinical outcome in a multicentre study of 241 phyllodes tumours of the breast. Histopathology 2021; 78:871-881. [PMID: 33325544 DOI: 10.1111/his.14316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/12/2020] [Indexed: 12/27/2022]
Abstract
AIMS Phyllodes tumours (PTs) represent an unusual but complex group of breast lesions with a tendency to recur locally and, less commonly, metastasise. On core biopsies, their appearances can be difficult to discriminate from those of other fibroepithelial lesions, which may compromise their surgical management. The aims of this study were to assess the preoperative diagnosis of PTs and to evaluate the impacts of surgical management and morphological features on their behaviour. METHODS AND RESULTS We combined datasets from three centres over two decades, including core biopsies, excision specimens, and follow-up. Core biopsy results were compared with final excision specimens. The relationships of surgical procedure and morphological features with local recurrence (LR) and metastasis were assessed. Two hundred and forty-one PTs were studied. Core biopsy resulted in a diagnosis of possible or definite PT in 76% of cases. Malignant tumours were more likely to be larger, occurred at an older age, and were surgically more challenging, with difficulties being encountered in achieving negative margins. There were 12 cases (5%) that showed LR alone, and another six cases (2.5%) that had distant metastases. Morphological features associated with adverse outcome were grade of PT, increased mitotic counts, necrosis, infiltrative margins, stromal atypia, and heterologous components. Both LR and metastatic behaviour correlated with larger size and distance to margins. CONCLUSIONS Our results suggest that excision margins have a significant impact on LR of PT, whereas metastatic behaviour is influenced by tumour biology. We add to the evidence base on histological features of tumours that contribute to long-term outcomes of PT patients.
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Affiliation(s)
- Raluca Mihai
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Grace Callagy
- Discipline of Pathology, NUI Galway, Lambe Institute for Translational Research, Galway, Ireland
| | | | - Mark O Loughlin
- Discipline of Pathology, NUI Galway, Lambe Institute for Translational Research, Galway, Ireland
| | | | - Areeg Abbas
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Michela Campora
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Zsolt Hodi
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Ian Ellis
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Andrew H S Lee
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Emad A Rakha
- Department of Histopathology, The University of Nottingham and the Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
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Limberg J, Barker K, Hoda S, Simmons R, Michaels A, Marti JL. Fibroepithelial Lesions (FELs) of the Breast: Is Routine Excision Always Necessary? World J Surg 2021; 44:1552-1558. [PMID: 31974650 DOI: 10.1007/s00268-020-05385-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND When needle core biopsies (NCBs) of the breast reveal fibroepithelial lesions (FELs), excision is often performed to rule out a phyllodes tumor (PT), despite low malignancy rates. Consequently, the natural history of observed FELs is not well described. We analyzed the malignancy risk in excised FELs and the natural history of FELs undergoing active surveillance (AS). METHODS We retrospectively studied the pathology and imaging records of 215 patients with FELs (n = 252) diagnosed on NCB. Incidence of growth was determined by Kaplan-Meier method. RESULTS Of 252 FELs, 80% were immediately excised and 20% underwent AS. Of the excised FELs, 198 (98%) were benign: fibroadenoma (FA) or benign breast tissue in 137 (68%), benign PT in 59 (29%), or LCIS in 2 (1%). Borderline PT or malignant lesions were found in 4 (2%). On ultrasound, malignant and borderline PTs were larger than benign lesions [median 3.9 vs 1.3 cm, p = 0.006]. Fifty FELs underwent AS, with a median follow-up of 17 (range 2-79) months. The majority remained stable or decreased in size: at 2 years, only 35% increased in volume by ≥ 50%. Of those tumors undergoing AS that were later excised (n = 4), all were benign. CONCLUSIONS Almost all FELs (98%) were benign on surgical excision, and the majority undergoing AS remained stable, with benign pathology if later excised. Most FELs on NCB can be safely followed with US, with surgery reserved for patients with FELs that are large, symptomatic, or growing. This could spare most women with FELs unnecessary surgery.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 420 East 70th St, Room 251, New York, NY, 10021, USA
| | - Kelly Barker
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 420 East 70th St, Room 251, New York, NY, 10021, USA
| | - Syed Hoda
- Department of Pathology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Rache Simmons
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 420 East 70th St, Room 251, New York, NY, 10021, USA
| | - Aya Michaels
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jennifer L Marti
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 420 East 70th St, Room 251, New York, NY, 10021, USA.
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Reis YN, Maesaka JY, Shimizu C, Soares-Júnior JM, Baracat EC, Filassi JR. Core needle biopsy in fibroepithelial tumors: predicting factors for phyllodes tumors. Clinics (Sao Paulo) 2021; 76:e2806. [PMID: 33886790 PMCID: PMC8024926 DOI: 10.6061/clinics/2021/e2806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/15/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the clinical and imaging predictive factors for the diagnosis of phyllodes tumors in patients with inconclusive results from core needle biopsy (fibroepithelial lesions). METHODS We retrospectively analyzed data of patients who underwent surgical excision of breast lesions previously diagnosed as fibroepithelial lesions. Numeric variables were analyzed using the Shapiro-Wilk and t-tests, and categorical variables were analyzed using the chi-square and Fisher's exact tests. Multivariate logistic regression was performed to calculate odds ratios and detect predictive factors for the diagnosis of PT. RESULTS A total of 89 biopsy samples were obtained from 77 patients, of which 43 were confirmed as fibroadenomas, 43 as phyllodes tumors, and 3 as other benign, non-fibroepithelial breast lesions. The mean tumor size was 3.61 cm (range, 0.8-10 cm) for phyllodes tumors and 2.4 cm (range, 0.8-7.9 cm) for fibroadenomas. The predictive factor for phyllodes tumor diagnosis was lesion size >3 cm (p<0.001). CONCLUSION Our data indicate that fibroepithelial lesions of the breast larger than 3 cm are more likely to be phyllodes tumors.
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Affiliation(s)
- Yedda Nunes Reis
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Jonathan Yugo Maesaka
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carlos Shimizu
- Departamento de Radiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Maria Soares-Júnior
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Edmund Chada Baracat
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Roberto Filassi
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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11
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Rosa M, Agosto-Arroyo E. Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry. Ann Diagn Pathol 2019; 43:151407. [PMID: 31634810 DOI: 10.1016/j.anndiagpath.2019.151407] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/22/2019] [Accepted: 09/02/2019] [Indexed: 12/11/2022]
Abstract
Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.
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Affiliation(s)
- Marilin Rosa
- Department of Anatomic Pathology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States of America.
| | - Emmanuel Agosto-Arroyo
- Department of Anatomic Pathology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States of America.
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12
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Management of Palpable Pediatric Breast Masses With Ultrasound Characteristics of Fibroadenoma: A More Conservative Approach. AJR Am J Roentgenol 2019; 212:450-455. [DOI: 10.2214/ajr.17.19482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Rageth CJ, O'Flynn EAM, Pinker K, Kubik-Huch RA, Mundinger A, Decker T, Tausch C, Dammann F, Baltzer PA, Fallenberg EM, Foschini MP, Dellas S, Knauer M, Malhaire C, Sonnenschein M, Boos A, Morris E, Varga Z. Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat 2018; 174:279-296. [PMID: 30506111 PMCID: PMC6538569 DOI: 10.1007/s10549-018-05071-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022]
Abstract
Purpose The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations. Methods This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy. Results In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)]. Conclusions Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.
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Affiliation(s)
- Christoph J Rageth
- Département de Gynécologie et d'Obstétrique, Centre du sein, Hôpitaux Universitaires de Genève, Bd de la Cluse 30, 1211, Geneva 14, Switzerland. .,, Ringlikerstrasse 53, 8142, Uitikon Waldegg, Switzerland.
| | - Elizabeth A M O'Flynn
- The Rose Centre, St George's University Hospitals NHS Foundation Trust, Perimeter Road, London, SW17 0QT, UK
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Rahel A Kubik-Huch
- Department of Medical Services, Institute of Radiology, Kantonsspital Baden, im Ergel, 5404, Baden, Switzerland
| | - Alexander Mundinger
- Zentrum Radiologie der Niels-Stensen-Kliniken; Marienhospital Osnabrück, Bischofsstraße 1, 49074, Osnabrück, Germany
| | - Thomas Decker
- Institut für Pathologie am Dietrich-Bonhoeffer-Klinikum, Salvador-Allende-Straße 30, 17036, Neubrandenburg, Germany
| | - Christoph Tausch
- Brust-Zentrum Zürich, Seefeldstr. 214, 8008, Zurich, Switzerland
| | - Florian Dammann
- Interventional and Pediatric Radiology, Department of Diagnostic, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Pascal A Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Allgemeines Krankenhaus, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eva Maria Fallenberg
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria P Foschini
- Department of Biomedical and Neuromotor Sciences, Unit of Anatomic Pathology at Bellaria Hospital, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Sophie Dellas
- Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michael Knauer
- Breast Center St. Gallen, Cantonal Hospital St. Gallen, Rorschacher Str. 95, 9007, St. Gallen, Switzerland
| | - Caroline Malhaire
- Imaging Department, Institut Curie, PSL Research University, Paris, France
| | - Martin Sonnenschein
- Division of Radiology, Breast Center Bern (Brustzentrum Bern), Klinik Engeried, Lindenhofgruppe AG, Riedweg 15, 3012, Bern, Switzerland
| | - Andreas Boos
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland
| | - Elisabeth Morris
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY, 10065, USA
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland Schmelzbergstrasse 12., 8091, Zurich, Switzerland
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14
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Yii N, Read T, Tan CC, Ng SL, Bennett I. Diagnosing phyllodes tumours of the breast: how successful are our current preoperative assessment modalities? ANZ J Surg 2018; 88:988-992. [DOI: 10.1111/ans.14815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/11/2018] [Accepted: 07/14/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Nathan Yii
- Department of Surgery, Princess Alexandra Hospital; The University of Queensland; Brisbane Queensland Australia
| | - Tavis Read
- Department of Surgery, Princess Alexandra Hospital; The University of Queensland; Brisbane Queensland Australia
| | - Chuan Chien Tan
- Department of Surgery, Princess Alexandra Hospital; The University of Queensland; Brisbane Queensland Australia
| | - Suat Li Ng
- Department of Surgery, Princess Alexandra Hospital; The University of Queensland; Brisbane Queensland Australia
| | - Ian Bennett
- Department of Surgery, Princess Alexandra Hospital; The University of Queensland; Brisbane Queensland Australia
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15
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McLaughlin CM, Gonzalez-Hernandez J, Bennett M, Piper HG. Pediatric breast masses: an argument for observation. J Surg Res 2018; 228:247-252. [DOI: 10.1016/j.jss.2018.03.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/24/2018] [Accepted: 03/21/2018] [Indexed: 10/17/2022]
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16
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Zhou Z, Wang C, Sun X, Yang Z, Chen X, Shao Z, Yu X, Guo X. Prognostic factors in breast phyllodes tumors: a nomogram based on a retrospective cohort study of 404 patients. Cancer Med 2018; 7:1030-1042. [PMID: 29479819 PMCID: PMC5911599 DOI: 10.1002/cam4.1327] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to explore the independent prognostic factors related to postoperative recurrence-free survival (RFS) in patients with breast phyllodes tumors (PTBs). A retrospective analysis was conducted in Fudan University Shanghai Cancer Center. According to histological type, patients with benign PTBs were classified as a low-risk group, while borderline and malignant PTBs were classified as a high-risk group. The Cox regression model was adopted to identify factors affecting postoperative RFS in the two groups, and a nomogram was generated to predict recurrence-free survival at 1, 3, and 5 years. Among the 404 patients, 168 (41.6%) patients had benign PTB, 184 (45.5%) had borderline PTB, and 52 (12.9%) had malignant PTB. Fifty-five patients experienced postoperative local recurrence, including six benign cases, 26 borderline cases, and 22 malignant cases; the three histological types of PTB had local recurrence rates of 3.6%, 14.1%, and 42.3%, respectively. Stromal cell atypia was an independent prognostic factor for RFS in the low-risk group, while the surgical approach and tumor border were independent prognostic factors for RFS in the high-risk group, and patients receiving simple excision with an infiltrative tumor border had a higher recurrence rate. A nomogram developed based on clinicopathologic features and surgical approaches could predict recurrence-free survival at 1, 3, and 5 years. For high-risk patients, this predictive nomogram based on tumor border, tumor residue, mitotic activity, degree of stromal cell hyperplasia, and atypia can be applied for patient counseling and clinical management. The efficacy of adjuvant radiotherapy remains uncertain.
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Affiliation(s)
- Zhi‐Rui Zhou
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
| | - Chen‐Chen Wang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
| | - Xiang‐Jie Sun
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
- Department of PathologyFudan University Shanghai Cancer CenterShanghai 200032China
| | - Zhao‐Zhi Yang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
| | - Xing‐Xing Chen
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
| | - Zhi‐Ming Shao
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
- Department of Breast SurgeryFudan University Shanghai Cancer CenterShanghai 200032China
| | - Xiao‐Li Yu
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
| | - Xiao‐Mao Guo
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghai 200032China
- Department of OncologyShanghai Medical CollegeFudan UniversityShanghai 200032China
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17
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Efared B, Ebang GA, Tahiri L, Sidibé IS, Erregad F, Hammas N, Melhouf MA, Banani A, Chbani L, Fatemi HE. Phyllodes tumors of the breast: clinicopathological analysis of 106 cases from a single institution. Breast Dis 2018; 37:139-145. [PMID: 29332027 DOI: 10.3233/bd-170297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Phyllodes tumors (PT) are uncommon biphasic tumors, accounting for less than 1% of all breast primary neoplasms. They form a wide variety of tumors ranging from benign to malignant. Several histological features are used to grade PT into 3 categories: benign (grade I), borderline (grade II) and malignant (grade III) tumors. The aim of our study was to analyse histolopathological, radiological and clinical features of PT from an experience of a single center. METHODS It was a retrospective study including 106 patients diagnosed with phyllodes tumors on surgical specimens at the department of pathology, of Hassan II university hospital (Fez, Morocco), from 2009 to 2016. RESULTS The mean age was 33.81 years (range of 13-66 years), and the mean age increases with the tumor grade (mean ages of 32.32, 32.87 and 33.65 years respectively for grade I, II and III PT) (p = 0.023); 78 patients (73.58%) had benign PT, 20 (18.86%) had borderline PT and 8 (7.54%) patients were diagnosed with malignant PT. Mostly, the tumor size was <5 cm (63.2%), with BI-RADS 3 (51 patients, 48.11%). The tumor size and the radiological suspicion (ACR/BI-RADS) increased with the tumor grade (p < 0.001). Mitosis count, cellular atypia and stromal cellularity increased with the tumor grade (p < 0.001). Also, the presence of necrosis is associated with malignant PT (p < 0.001). Before surgery, patients had undergone core needle biopsies (CNB) for diagnostic purpose, and the overral sensitivity of this diagnostic procedure was 71.83%. The sentivity of the CNB decreased from grade I PT to grade III PT (from 56.81% to 37.5%), however its specificity increased from grade I to grade III PT (from 59.25% to 100%). CONCLUSION Phyllodes tumors of the breast are rare neoplasms with a wide range of clinicopathologic presentations. The core needle biopsy has a good diagnostic sensitivity compared to definitive diagnosis on surgical specimens. There was a statistically significant association between the histological grade of PT and tumor size, radiological suspicion, mitotic count, cellular atypia, stromal cellularity, and tumor necrosis.
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Affiliation(s)
- Boubacar Efared
- Department of pathology, Hassan II university hospital, Fez, Morocco
| | | | - Layla Tahiri
- Department of pathology, Hassan II university hospital, Fez, Morocco
| | - Ibrahim S Sidibé
- Department of pathology, Hassan II university hospital, Fez, Morocco
| | | | - Nawal Hammas
- Department of pathology, Hassan II university hospital, Fez, Morocco
- Laboratory of biological and translational research, Faculty of medicine and pharmacology, Sidi Mohamed Ben Abdellah university Fez, Morocco
| | - Moulay Abdelilah Melhouf
- Department of obstetrics and gynecology, Hassan II university hospital, Fez, Morocco
- Faculty of medicine and pharmacology, Sidi Mohamed Ben Abdellah university, Fez, Morocco
| | - Abdelaziz Banani
- Department of obstetrics and gynecology, Hassan II university hospital, Fez, Morocco
- Faculty of medicine and pharmacology, Sidi Mohamed Ben Abdellah university, Fez, Morocco
| | - Laila Chbani
- Department of pathology, Hassan II university hospital, Fez, Morocco
- Laboratory of biological and translational research, Faculty of medicine and pharmacology, Sidi Mohamed Ben Abdellah university Fez, Morocco
| | - Hinde El Fatemi
- Department of pathology, Hassan II university hospital, Fez, Morocco
- Laboratory of biological and translational research, Faculty of medicine and pharmacology, Sidi Mohamed Ben Abdellah university Fez, Morocco
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