Phyllodes Tumors of the Breast: A Literature Review

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.

Case report: The first case of concurrent breast myeloid sarcoma and borderline phyllodes tumor with malignant features

Background

Myeloid sarcoma (MS) is a rare hematological malignancy characterized by the formation of a solid mass of myeloblasts outside the bone marrow, such as in the lymph nodes, skin, or bone. MS may arise de novo or concurrently with acute myeloid leukemia (AML), myeloproliferative neoplasm (MPN), or myelodysplastic syndrome (MDS). MS accounts for less than 1% of extramedullary acute myeloid leukemia cases. Phyllodes tumors (PTs) are a rare fibroepithelial breast tumor that can be benign, malignant, or borderline, and account for less than 1% of all breast cancers.

Case presentation

We present a unique case of a 50-year-old woman with both breast MS and borderline PT with malignant features, which presented a diagnostic challenge. The patient initially presented with a mass in her right breast, and the initial fine-needle biopsy revealed the presence of immature myeloperoxidase (MPO)+ myeloid cells consistent with MS. Subsequent pathological analysis of tumor tissues after neoadjuvant radiotherapy and chemotherapy showed a borderline PT with malignant features. Following excision of the tumor, the patient experienced a local recurrence, which was also surgically removed. At 8 months post-surgery, the patient remains free of recurrence under close follow-up.

Conclusion

This case highlights the importance of considering the possibility of concurrent malignancies in the differential diagnosis of complex breast masses and underscores the challenges involved in diagnosing and managing such cases. Additionally, we also emphasize the value of neoadjuvant radiotherapy and chemotherapy in MS.

Metastatic and Malignant Phyllodes Tumors of the Breast: An Update for Current Management

Metastatic, malignant phyllodes tumor (PT) of the breast is a rare and aggressive neoplasm. Currently, there is no agreed upon consensus as to best management practices. A systematic review of literature was conducted investigating surgical, chemotherapeutic, and radiotherapeutic management for metastatic PT. Databases employed to identify articles included Embase, PubMed, and SAGE Journals. Diagnosis of metastatic PT has been of significant difficulty to radiologists as it is often confused with fibroadenomas. Surgically, metastatectomy has been correlated with increased overall survival (of 25.9 versus 9.9 months; P = .01). Radiotherapy has often been associated with palliation and pain control in metastatic, malignant neoplasia. However, one study showed that in malignant PT, radiation was associated with significantly lower rates of local recurrence (OR: 0.048 versus 0.209). Anthracycline containing chemotherapy regimens has been associated with improved overall survival (22.4 months versus 13.2 months; P = .040). Further research must be conducted into this rare malignancy to elucidate accurate diagnosis and care for patients with advanced metastatic or malignant phyllodes tumors.

Association between CD10 expression and phyllodes tumor: A retrospective case control study

The present study aimed to explore the association between immunohistochemical markers and phyllodes tumor (PT). The retrospective case control study included biopsies from patients with PT who underwent surgical treatment, and patients with fibronenoma (FA), diagnosed in our hospital from October 2014 to May 2021. Differences in microscopic histopathological characteristics and expressions of common immunohistochemical markers (CD10, cluster of differentiation 117 marker, cluster of differentiation 34 marker, tumor protein P53, cell proliferation antigen) for different grades of PT and FA were analyzed. A total of 69 patients were enrolled, of them 34 with PT (12 with benign PT, 13 with borderline PT, and 9 with malignant PT) and 35 with FA. With the increase of tumor malignancy, significant enlargement trend was noted; for FA, most tumor boundaries were well-defined, the stromal distribution was homogeneous, the stromal cellularity was small. In contrast for PT, as the degree of malignancy increased, tumor boundary gradually became ill-defined and the stromal distribution was heterogeneous; stromal cellularity and stromal overgrowth had increased significantly (All P < .05). Multivariate analysis showed that among other markers only CD10 expression (OR = 0.67, 95%CI: -0.88, 2.22, P < .05) was independently associated with PT. The study showed that in addition to histological features, CD10 expression was independently associated with PT and has a potential to be used as a differentiation marker.

Clinical perspectives and outcomes of the giant breast phyllodes tumor and sarcoma: a real-world retrospective study

BACKGROUND

Giant breast malignant phyllodes tumor or sarcoma (GBPS) are rare entities with diameter larger than 10 cm and variously histological pleomorphisms. This disease poses a significant threat to the quality of life of individuals, and its prognosis remains unclear. This study aimed to explore the differential diagnosis, treatment, and prognosis of GBPS in a real-world retrospective cohort.

METHODS

We collected GBPS (diameter > 10 cm, n = 10) and BPS (diameter ≤ 10 cm, n = 126) from patients diagnosed with sarcoma or malignant phyllodes tumor between 2008 and 2022. We analyzed clinical characteristics, histological status, treatment, and local recurrence using the Fisher's exact test between GBPS (diameter > 10 cm) and BPS (diameter ≤ 10 cm) cohort. We described overall survival (OS) and disease-free survival (DFS) using Kaplan-Meier curves and identified risk factors for local recurrence using logistic regression. The tumor size, age at diagnosis, and differential immunohistochemistry markers of breast sarcoma or phyllodes tumor to determine the prognosis of GBPS.

RESULTS

In our retrospective analysis of breast malignancies, we identified 10 cases of GBPS and 126 cases of BPS, corresponding to a GBPS prevalence of 0.17% (10/6000). The median age was 38.5 years (inter-quartile range, IQR: 28.25-48.5 years). During the follow-up of period (median: 80.5 months, IQR: 36.75-122 months), the local recurrence (LR) rate was 40% and 20.6%, respectively. Clinical characteristics of young age (HR:2.799, 95%CI -00.09276-0.017, p < 0.05) and cytological characteristics of marked stromal atypia (HR:0.88, 95% CI 0.39-1.40, p < 0.05) were risk factors for the poor prognosis of GBPS by COX regression model analysis. The Kaplan-Meier curves of GBPS 5-year disease-free survival (DFS) and overall survival (OS) were 31.5 months and 40 months, respectively, and were not associated with adjuvant radiation or chemotherapy.

CONCLUSION

We recommend mastectomy with a clear surgical margin as the preferred treatment for GBPS. Age and stromal atypia are significantly associated with recurrence. Adjuvant radiation therapy is advised; however, there was no improvement in overall survival. There is no consensus on the effectiveness of adjuvant chemotherapy and genetic methods, highlighting the need for further research into this aggressive tumor. We recommend a multidisciplinary approach involving a dedicated team for the management of GBPS.

Breast development and disorders in children and adolescents

Breast masses are infrequently encountered in pediatric and adolescent populations. Most breast masses in children are benign entities arising from embryological defects which can be managed once breast development is complete. Diagnostic and management dilemmas arise when fibroepithelial lesions of the breast are seen in clinical practice. Differentiation between a fibroadenoma and a phyllodes tumor is important to guide management. Breast cancer in children under 18 years of age is extremely rare and invasive diagnostic testing and aggressive management is only recommended when clinical suspicion of malignancy is very high. Patient and caregiver counseling plays an important role in the management of these diseases. While adult-onset breast diseases have been studied very closely, there is a dearth of literature on pediatric breast anomalies. This review aims to provide a scoping overview of the available literature on benign, fibroepithelial, and malignant lesions of the breast in pediatric and adolescent populations to help guide physicians and surgeons with decision-making regarding the diagnosis and management of pediatric breast diseases.

Assessment of the Attitudes, Beliefs, and Potential Effects of Nutritional Phytoestrogenic Plant Consumption on Women's Health in Saudi Arabia

BACKGROUND AND OBJECTIVE

Phytoestrogens are plant-derived endocrine-disrupting chemicals known as estrogen-like compounds with health and preventive benefits. This study aimed to assess Saudi Arabian women's beliefs and attitudes toward phytoestrogen-rich plant consumption and its association with hormone-sensitive tumors and diseases.

METHODS

A cross-sectional study was carried out between November 2022 and May 2023 in Saudi Arabia using an online self-administered questionnaire created via Google Forms (Appendix). The collected data were extracted, coded, and analyzed using the IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

RESULTS

The study included 702 females aged 18 years and older. 61.6% (n=432) of the participants consumed Trigonella foenum-graecum (fenugreek) and Foeniculum vulgare (fennel), whereas 45.7% (n=321) consumed soy products and flaxseeds. In addition, 44.7% (n=191) were diagnosed with breast tumors and other breast diseases. The association between the occurrence of breast conditions and the consumption of all the different types of phytoestrogen-rich plants in this study was significant, with a p-value of <0.001. (41.7%, n=187) diagnosed with uterine and ovarian-related conditions, the association with the consumption of fenugreek and fennel was significant with a p-value of <0.001, but for soy products and flaxseed consumption, the association was not significant with a p-value of 0.368. Regarding the consumer's attitudes and duration of consumption, most of them (41.0%, n=288) consume phytoestrogen-rich herbs and plants about every month during menstruation, and 55% (n=386) consumed phytoestrogen-rich plants a long time ago (for many years). About the purpose of consumption, 62.1% (n=436) answered to reduce pain and symptoms associated with menstruation. The majority of the participants (36.3%, n=255) have poor knowledge and don't know about the high estrogen levels' impact on their health.

CONCLUSION

The study showed that there is a possible association between the consumption of some types of phytoestrogen-rich plants and the occurrence of several hormone-related tumors and diseases. Further studies are needed to evaluate the possible effects in consideration of the co-founding factors.

Breast Phyllodes Tumor: A Tumor With Unpredictable Clinical Behavior

Phyllodes tumors are uncommon biphasic breast tumors with a wide range of clinical behaviors. The distinction between a phyllodes tumor and a fibroadenoma can be difficult. The diagnosis of phyllodes tumor should be suspected in all women who present with a rapidly growing breast lump. Based on the histological characteristics, the World Health Organization (WHO) classifies phyllodes tumors as benign, borderline, or malignant. The risk of recurrence and metastatic potential varies based on histological features. Wide excision or mastectomy is the standard of care ensuring histologically clear margins. Despite the grading criteria defined by the WHO, the management of phyllodes tumors continues to be a challenge. We report the case of a 48-year-old woman who presented to the emergency department with a large and ulcerated phyllodes tumor of the left breast. The tumor size did not allow conservative surgery. The final diagnosis of a borderline phyllodes tumor was made, and, in this case, the patient did not undergo adjuvant treatment.

Fibroepithelial Lesion Spectrum: A Case Report Documenting a Possible Transformation to a Malignant Phyllodes Tumor

We discuss the radiological-pathological aspects of a rare case of transformation of a presumed fibroadenoma (FA) to a malignant phyllodes tumor (PT) and review the literature. Phyllodes tumors often show heterogeneous histologic features with some areas indistinguishable on core needle biopsy. A core biopsy is often a small representation of a larger lesion. As such, a complete excisional biopsy is often needed for a definitive pathologic diagnosis. Careful clinical and imaging correlation and follow-up are necessary, even in a benign fibroepithelial lesion (FEL).

Osteosarcoma Originating From a Malignant Phyllodes Tumor: A Case Report of a Rare Malignancy

Fibroepithelial tumors are common in the breast; however, the frequency of malignancy is much less as compared to the epithelial counterpart. Malignant phyllodes are infrequent, and the proportion undergoing heterologous differentiation is very rare. Extensive sampling and astute examination are of utmost importance so as not to miss this lesion. The prognosis of these tumors is worse compared to cases where no heterologous transformation is seen.

Giant juvenile fibroadenoma in a 14-year old Chinese female: A case report

BACKGROUND

A giant juvenile fibroadenoma (GJF) is a rare, benign breast tumor that affects females < 18 years of age. GJFs are generally suspected based on a palpable mass. GJFs influence breast shape and mammary gland development via the pressure effect from their enormous size.

CASE SUMMARY

Herein we report a case involving a 14-year-old Chinese female with a GJF in the left breast. GJF is a rare, benign breast tumor that usually occurs between 9 and 18 years of age and accounts for 0.5%-4.0% of all fibroadenomas. In severe cases, breast deformation may occur. This disease is rarely reported in Chinese people and has a high clinical misdiagnosis rate due to the absence of specific imaging features. On July 25, 2022, a patient with a GJF was admitted to the First Affiliated Hospital of Dali University. The preoperative clinical examination and conventional ultrasound diagnosis needed further clarification. The mass was shown to be an atypical lobulated mass during the operation and confirmed to be a GJF based on pathologic examination.

CONCLUSION

GJF is also a rare, benign breast tumor in Chinese women. Evaluation of such masses consists of a physical examination, radiography, ultrasonography, computer tomography, and magnetic resonance imaging. GJFs are confirmed by histopathologic examination. Mastectomy is not selected when the patient benefits from a complete resection of the mass with breast reconstruction and an uneventful recovery.

Case report: Osteosarcomatous differentiation in the lung metastasis of a malignant phyllodes tumor

Malignant phyllodes tumor is a rare breast tumor, with distant metastases and heterologous differentiation in a few cases. We report a case of malignant phyllodes tumor with liposarcomatous differentiation in the primary tumor and osteosarcomatous differentiation in the lung metastatic tumor. A middle-aged female presented with a well-defined mass in the upper lobe of the right lung measuring 5.0 × 5.0 × 3.0 cm. The patient had a history of malignant phyllodes tumor in the breast. The patient underwent a right superior lobectomy. Histologically, the primary tumor was a typical malignant phyllodes tumor with pleomorphic liposarcomatous differentiation, while the lung metastasis showed osteosarcomatous differentiation without original biphasic features. The phyllodes tumor and heterologous components showed CD10 and p53 expression, and were negative for ER, PR, and CD34. Exome sequencing revealed TP53, TERT, EGFR, RARA, RB1, and GNAS mutations in all three components. Although the lung metastasis were morphologically different from the primary breast tumor, their common origin was demonstrated through immunohistochemical and molecular characterization. Cancer stem cells give rise to tumor heterogeneous cells, and heterologous components in malignant phyllodes tumors may indicate unfavorable prognosis and a greater risk of early recurrence and metastasis.

Surgery for phyllodes tumour of the breast. What should be surgical margins?

BACKGROUNDS

Optimal and tailored surgical treatment of phyllodes tumour(PT) of the breast is controversial. This study aims to determine the appropriate surgical margin in the treatment of PT.

METHODOLOGY

The data of 132 patients who underwent breast surgery with the diagnosis of PT at the Breast Unit of Istanbul Faculty of Medicine from 2000 to 2022 were retrospectively reviewed.

RESULTS

Median age was 38 and patients with benign PT were younger than others(median age was 34, 44, and 43 for benign, borderline, and malignant, respectively) (P = 0.001). Local recurrence was observed in 7 (5.3%) patients, systemic recurrence was observed in 3 (2.3%) patients, and disease-related death was observed in 2 (1.5%) patients. Local recurrence occurred in 1.4% (n = 1) of benign tumours, 8.3% (n = 2) of borderline tumours, and 10.3% (n = 4) of malignant tumours. All of the systemic recurrences and deaths were seen in the malignant group. The local recurrence rate was found to be higher in borderline and malignant tumours with surgical margins less than 10 mm (44.4% versus 3.7%, P = 0.003), and tumours larger than 5 cm (11.8% versus 1.3%, P = 0.015). In comparison, there was no correlation between the surgical margin proximity, tumour diameter, and local recurrence rates in benign PT (P > 0.05).

CONCLUSION

According to our findings, negative surgical margins seem to be sufficient in the treatment of benign phyllodes tumours. Furthermore at least 1 cm negative surgical margins must be achieved for malignant and borderline phyllodes tumours to avoid local recurrence.

Contrast-enhanced spectral mammographic findings of phyllodes tumor of the breast

Background

Phyllodes tumors of breast are rare fibroepithelial neoplasms. They have similar radiological findings with fibroadenomas. While fibroadenomas are benign lesions, phyllodes tumors may have malignant potential. Therefore, any imaging findings to differentiate fibroadenoma from phyllodes tumor are valuable.

Case presentation

A 51-year-old female patient was admitted to our clinic with the complaint of a palpable mass. Tru-Cut biopsy resulted as phyllodes tumor, and excision was recommended. However, the patient neglected herself during the COVID-19 pandemic, and 20 months later, she presented with a huge and complex mass. On CESM imaging, cystic areas and clefts were identified. The case was diagnosed as borderline phyllodes tumor.

Conclusions

Although MRI findings of phyllodes tumor are well known and reported many times, there is no information about CESM findings of this tumor in literature. Bubbly appearance on CESM is useful finding in the diagnosis of phyllodes tumor of breast.

Synchronous Luminal A Ductal Carcinoma In Situ in a Recurrent Benign Phyllodes Tumor Diagnosed Preoperatively: An Unusual Presentation of a Rare Neoplasm

Phyllodes tumor (PT) is a rare benign tumor of the breast with a propensity to recur and metastasize. Ductal carcinoma in situ (DCIS) within PT is an extremely rare finding and is usually diagnosed postoperatively. We present a case of a 36-year-old female with a recurrent lump in her left breast diagnosed as a benign PT. Preoperatively, aspiration cytology revealed DCIS within the known case of recurrent PT. Emergency left modified radical mastectomy was performed due to an uncontrolled sudden hemorrhage from the tumor. Postoperatively, hormonal therapy was started based on immuno-histopathological findings.

DCIS in PT is not encountered frequently and hence no standard management protocol exists for such cases, but when detected by histopathology, the clinical management and prognosis have to undergo a complete change. Preoperative diagnosis and proper individualized management by a multidisciplinary team that ensures clear surgical margins and planned adjuvant therapy play a crucial role in preventing the recurrence of DCIS within PT.

The Enigma of Giant Phyllodes Tumour

Phyllodes tumours are an uncommon type of biphasic fibroepithelial neoplasm of the breast. We present a case of a 28-year-old, para one lady with no risk of breast cancer presented with painless left breast swelling for three months. Over one month, the swelling suddenly increased in size and became painful with skin changes associated with pus discharge. On physical examination, a huge swelling measuring about 25cm x 30cm occupies the central and lateral aspect of the left breast with surrounding erythema. We proceeded for a tru-cut biopsy, and the histopathological examination (HPE) showed a stromal proliferation with myxoid changes consistent with phyllodes tumour of benign type. The patient underwent a left simple mastectomy, and the histopathological examination (HPE) confirmed the diagnosis of borderline phyllodes tumour with clear margins without lymph nodes involvement. The patient was subsequently referred to the oncology team and was subjected to 40 Gy in 15 fractions of radiotherapy. Given the rarity of the disease and based on current studies, simple mastectomy with negative margins is recommended for giant benign phyllodes tumours

Immediate Breast Reconstruction in an 11-year-old Girl with a Large Malignant Phyllodes Tumor

Phyllodes tumors are rare fibroepithelial breast tumors representing less than 1% of all breast malignancies, with an extremely uncommon presence in the pediatric population.¹ Although prognosis is favorable following excision given their indolent course, they often grow rapidly and frequently recur. As such, they can present unique oncologic and reconstructive challenges. Herein we present a case of a malignant phyllodes tumor in an 11-year-old girl treated with total skin-sparing mastectomy and adjustable saline implant, and explore the reconstructive challenges of this unique case.

Preoperative embolization of a giant benign phyllodes tumor: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Phyllodes tumors (PT) account for less than 1% of all breast tumors. Giant PTs can lead to breast disfigurement, tumoral ulceration, and bleeding. Outright surgical excision can be challenging or unsafe. Preoperative transarterial embolization (TAE) has a role but data on its use in the management of PT is limited.

CASE PRESENTATION

A 43-year-old female presented with a 28 cm fungating, necrotic, benign PT on her left breast that eventually developed tumoral bleeding leading to hemodynamic instability. Preoperative TAE controlled the bleeding and allowed the safe performance of mastectomy. A literature review of preoperative TAE of PTs is also presented including the addition of a chemotherapeutic agent in malignant types.

CLINICAL DISCUSSION

PTs are rare and comprise only 2.5% of all fibroepithelial breast lesions. Tumoral bleeding causing severe anemia is one of the most common presentations of massive (≥20 cm) PTs, especially when neglected. Indications for preoperative TAE include (1) to halt rapid tumor growth, (2) to control active/persistent tumoral bleeding, and (3) to shrink the tumor size and allow successful resection with negative margins, and avoidance of skin grafting. Post-TAE side effects include fever, chest pain, gradual/expanding tumor necrosis, decrease in tumor weight, and diminished tumoral abscess/discharge, and loss of tumoral vessel elasticity.

CONCLUSION

Neglected PTs can reach an alarming size. Preoperative TAE is a safe and effective method of controlling life-threatening tumoral hemorrhage and decreasing the size of PTs thereby allowing definitive resection while avoiding skin grafting and/or flap reconstruction.

Large borderline phyllodes breast tumor related to histopathology, diagnosis, and treatment management - case report

Breast phyllodes tumors (PTs) are uncommon tumors with a biphasic fibroepithelial component, characterized by rapid development in middle-aged women. A correct preoperative diagnosis after Tru-Cut biopsy allows for proper surgical planning. The treatment of choice remains surgery (wide local excision or mastectomy) with or without breast reconstruction, depending on the size and histopathological (HP) nature of the tumor. We reported a case of a 50-year-old woman with a large PT in her left breast, measuring 11/10 cm. Preoperative HP examination revealed biphasic proliferation, with the appearance of benign PT. The patient underwent a left mastectomy, with a favorable postoperative evolution. The final HP diagnosis was borderline PT, with areas of lipomatous metaplasia. After three months, breast reconstruction was performed. The therapeutic management of large PTs continues to be a challenge for pathologists and surgeons. Due to the increased frequency of local recurrence and HP progression to malignancies, the treatment of choice for these patients is mastectomy, without lymphadenectomy.

Malignant Phyllodes Breast Tumor: A Rare Case of Metastasis in Skeletal Muscle Detected on 18-Fluorodeoxyglucose Positron Emission Tomography

Rapidly growing cystosarcoma phyllodes tumor (PT) of the breast are rarely encountered. Distant metastases are not uncommon in malignant PTs; however, rare sites of metastases are sometimes observed. Here, we present the case of a rapidly metastasizing malignant PT in which skeletal muscle metastasis was identified on 18F-fluorodeoxyglucose-based positron emission tomography-computed tomography reflecting its aggressive course and poor prognosis.

Imaging features of myopericytoma of the breast: A case report and review of the literature

Myopericytoma is a rare perivascular tumor commonly arising in the superficial soft tissue and subcutaneous tissue of the distal extremities. We report the first case of myopericytoma occurring in the breast, focusing on the imaging and histopathological characteristics of the tumor. From an imaging perspective, myopericytoma presents a well-circumscribed, marked hypervascularity, and intense enhancement after injection of contrast material. Imaging examinations, such as ultrasonography and magnetic resonance imaging, can contribute to the detection of tumor invasion to adjacent structures or distant metastases, and provide evidence for a treatment plan.