Detailed DNA methylation characterisation of phyllodes tumours identifies a signature of malignancy and distinguishes phyllodes from metaplastic breast carcinoma

Phyllodes tumours (PTs) are rare fibroepithelial lesions of the breast that are classified as benign, borderline, or malignant. As little is known about the molecular underpinnings of PTs, current diagnosis relies on histological examination. However, accurate classification is often difficult, particularly for distinguishing borderline from malignant PTs. Furthermore, PTs can be misdiagnosed as other tumour types with shared histological features, such as fibroadenoma and metaplastic breast cancers. As DNA methylation is a recognised hallmark of many cancers, we hypothesised that DNA methylation could provide novel biomarkers for diagnosis and tumour stratification in PTs, whilst also allowing insight into the molecular aetiology of this otherwise understudied tumour. We generated whole-genome methylation data using the Illumina EPIC microarray in a novel PT cohort (n = 33) and curated methylation microarray data from published datasets including PTs and other potentially histopathologically similar tumours (total n = 817 samples). Analyses revealed that PTs have a unique methylome compared to normal breast tissue and to potentially histopathologically similar tumours (metaplastic breast cancer, fibroadenoma and sarcomas), with PT-specific methylation changes enriched in gene sets involved in KRAS signalling and epithelial-mesenchymal transition. Next, we identified 53 differentially methylated regions (DMRs) (false discovery rate < 0.05) that specifically delineated malignant from non-malignant PTs. The top DMR in both discovery and validation cohorts was hypermethylation at the HSD17B8 CpG island promoter. Matched PT single-cell expression data showed that HSD17B8 had minimal expression in fibroblast (putative tumour) cells. Finally, we created a methylation classifier to distinguish PTs from metaplastic breast cancer samples, where we revealed a likely misdiagnosis for two TCGA metaplastic breast cancer samples. In conclusion, DNA methylation alterations are associated with PT histopathology and hold the potential to improve our understanding of PT molecular aetiology, diagnostics, and risk stratification. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Stromal Ki67 Expression Might be a Useful Marker for Distinguishing Fibroadenoma From Benign Phyllodes Tumor of the Breast

Background. Fibroadenoma (FA) and benign phyllodes tumor (PT) of the breast often have similar appearances on imaging. While an exact diagnosis of biopsy specimens is required to choose adequate treatment, including surgical procedures, it is sometimes difficult to pathologically differentiate these 2 tumors due to histological resemblances. To elucidate markers for distinguishing FA from benign PT, we analyzed clinical samples immunohistochemically. Methods. We retrospectively investigated 80 breast fibroepithelial lesions. As a discovery set, 60 surgical excision samples (30 FA and 30 benign PT) were examined. Twenty biopsy samples (10 FA and 10 benign PT) were examined as a validation set. To determine targets for immunohistochemistry, we first tested some proteins based on previous reports. As a result, Ki67 was chosen for differentiating FA and PT; thus further examinations were conducted with this protein. Results. Among the proteins examined, stromal Ki67 was significantly higher in PT than in FA. Benign PT had significantly higher stromal Ki67 expression both at random and at hotspots (p < .001 and <.001, respectively). The receiver operating characteristic curve analysis identified 3.5% and 8.5% (at random spots and hotspots, respectively) as the optimal cutoff values of stromal Ki67 for distinguishing between these 2 tumors. In the validation cohort employing needle biopsy specimens, we confirmed that these 2 cutoff values properly classified these 2 tumors (p = .043 and .029, respectively). Conclusion.We revealed that stromal Ki67 might be a potential marker for distinguishing FA from benign PT.

Integrating single-cell and spatial transcriptomes reveals COL4A1/2 facilitates the spatial organisation of stromal cells differentiation in breast phyllodes tumours

BACKGROUND

Breast phyllodes tumours (PTs) are a unique type of fibroepithelial neoplasms with metastatic potential and recurrence tendency. However, the precise nature of heterogeneity in breast PTs remains poorly understood. This study aimed to elucidate the cell subpopulations composition and spatial structure and investigate diagnostic markers in the pathogenesis of PTs.

METHODS

We applied single-cell RNA sequencing and spatial transcriptomes on tumours and adjacent normal tissues for integration analysis. Immunofluorescence experiments were conducted to verify the tissue distribution of cells. Tumour cells from patients with PTs were cultured to validate the function of genes. To validate the heterogeneity, the epithelial and stromal components of tumour tissues were separated using laser capture microdissection, and microproteomics data were obtained using data-independent acquisition mass spectrometry. The diagnostic value of genes was assessed using immunohistochemistry staining.

RESULTS

Tumour stromal cells harboured seven subpopulations. Among them, a population of widely distributed cancer-associated fibroblast-like stroma cells exhibited strong communications with epithelial progenitors which underwent a mesenchymal transition. We identified two stromal subpopulations sharing epithelial progenitors and mesenchymal markers. They were inferred to further differentiate into transcriptionally active stromal subpopulations continuously expressing COL4A1/2. The binding of COL4A1/2 with ITGA1/B1 facilitated a growth pattern from the stroma towards the surrounding glands. Furthermore, we found consistent transcriptional changes between intratumoural heterogeneity and inter-patient heterogeneity by performing microproteomics studies on 30 samples from 11 PTs. The immunohistochemical assessment of 97 independent cohorts identified that COL4A1/2 and CSRP1 could aid in accurate diagnosis and grading.

CONCLUSIONS

Our study demonstrates that COL4A1/2 shapes the spatial structure of stromal cell differentiation and has important clinical implications for accurate diagnosis of breast PTs.

Surgical Management and System Therapy of the Most Giant Known Malignant Metastatic Breast Phyllodes Tumor: A Case Report and Review of the Literature

INTRODUCTION

Phyllodes tumors belong to uncommon fibroepithelial breast tumors with a range of biological behaviors. Phyllodes tumors are responsible for less than 1 percent of all neoplasms of the breast.

CASE PRESENTATION

A 66-year-old woman presented to our Breastcancer Unit in March 2021 because of a huge mass of her left breast with bleeding out of a tumor necrosis. Five years ago in 2016, a benign phyllodes tumor was diagnosed externally. When we started the treatment, the tumor had a weight of 18.6 kg.

CONCLUSION

We describe the surgical management and the systemic treatment of metastatic disease.

Malignant Phyllodes Tumor in a Pubertal Girl: A Report of a Case

BACKGROUND

Malignant phyllodes tumor (MPT) is a rare breast disease that is extremely rare in children. A few cases of pediatric malignant phyllodes tumors have been reported, including some with a poor prognosis.

CASE

A 14-year-old girl presented with a growing lump on her right breast. On the basis of imaging tests and a core needle biopsy, MPT was diagnosed, and right mastectomy was performed. The postoperative course was uneventful.

SUMMARY AND CONCLUSION

MPT is an infrequent disease in adult females and is extremely rare in pubertal females. It occasionally shows rapid growth, metastasis, and recurrence with a poor prognosis. Early surgical resection is necessary to obtain a cure. When a rapidly growing breast tumor is observed in pubertal females, MPT should be considered.

Adenomyoepithelial adenosis mimicking phylloides: A diagnostic dilemma

Benign proliferative breast diseases are well recognized in young females. Benign biphasic proliferation of epithelial and myoepithelial cells has been observed, among which adeno-myoepithelial adenosis is one of the rare morphologies published in the literature with the tendency to recur and poses a risk for low-grade malignant transformation. Here, we report a case of a young female who had a history of recurrent breast lump mimicking phyllodes tumor and eventually diagnosed as adeno-myoepithelial adenosis on histopathological examination. Benign proliferative breast diseases are well recognized in young females. Benign biphasic proliferation of epithelial and myoepithelial cells has been observed, among which adeno-myoepithelial adenosis is one of the rare morphologies published in the literature with the tendency to recur and poses a risk for low-grade malignant transformation. Here, we report a case of a young female who had a history of recurrent breast lump mimicking phyllodes tumor and eventually diagnosed as adeno-myoepithelial adenosis on histopathological examination.

Malignant phyllodes tumour with lymph node metastasis: a diagnostic conundrum resolved by next generation DNA sequencing

A malignant neoplasm with spindle cell and chondroid differentiation in the breast, metastatic to lymph node. In this context, a metaplastic carcinoma is typically favored given the exceptional nature of lymph node metastases in malignant phyllodes tumors (MPT). However, we demonstrate pathognomonic hotspot mutations in MED12 and the promoter of the TERT gene by targeted next-generation DNA sequencing, supporting a diagnosis of MPT.

Periductal Stromal Tumor of the Breast with a TERT Promoter Mutation: First Case Report with Comprehensive Molecular Analysis

The molecular pathogenesis of breast fibroepithelial tumors continues to be elucidated. Recently, highly recurrent MED12 mutations arising in exon 2 at codon 44 were discovered in fibroadenomas and phyllodes tumors. In addition, a high prevalence of TERT promoter mutations in two hotspots (124 and 126 bp upstream from the translation start site) was discovered in up to 65% of phyllodes tumors. Breast periductal stromal tumors are a potentially distinct category of fibroepithelial lesions that are exceptionally rare with controversial classification and pathogenesis. Herein, we report the first comprehensive molecular genetic workup of a breast periductal stromal tumor that harbored a TERT promoter -124C > T mutation, supporting a relation to phyllodes tumors.

[A Case of a Malignant Phyllodes Tumor of the Breast with Osteogenic Sarcoma Which Repeated Local Recurrence]

The patient is a 39-year-old woman. At the age of 34, she recognized a 22 mm sized mass in the upper outer quadrant of her right breast, which was diagnosed as a fibroadenoma. 5 years later, the mass increased to 45 mm. We performed lumpectomy which led to a diagnosis of a malignant phyllodes tumor with osteogenic sarcoma. Since the resection margins were positive, we performed mastectomy in addition. Nine months after surgery, a 23 mm large mass appeared on the right fifth costal. Recurrence of malignant phyllodes was suspicious from cytological diagnosis and since thoracoabdominal CT showed no metastasis to other organs, we performed resection. Histological results were the same as the primary tumor. Two months more later, an 11 mm large mass revealed in the right anterior thoracic region. We performed resection again, which showed the same histological features as the primary tumor. Since malignant phyllodes tumors often recur in the early postoperative period, a close follow-up is recommended.

A case report of a patient with ductal carcinoma and a malignant phyllodes tumor in situ in 2 separate breasts

RATIONALE

Breast malignant phyllodes tumors (MPT) are quite uncommon. It is rarely reported that they occur in conjunction with breast cancer. We detailed a case in which an MPT and ductal carcinoma in situ carcinoma occurred simultaneously in 2 different breasts.

PATIENT CONCERNS

A 79-year-old female patient was seen for a rapidly growing lump in the upper left quadrant of her breast. The lump was described as huge, hard, irregular, and palpable. MRI of the breasts revealed a big mass in the left breast and a smaller lump in the right.

DIAGNOSIS

Ductal carcinoma in situ with breast MPT.

INTERVENTIONS

We performed a double mastectomy. Post-operative endocrine treatment was suggested.

OUTCOMES

During the 18-month follow-up period, no signs of recurrence or metastasis were seen. The ultrasound examination of the chest wall showed no abnormality. Bilateral axillary and supraclavicular ultrasonography showed no lymphadenectasis and a CT scan of the lungs showed no suspicious cancer nodules.

LESSONS

It is possible for MPT and ductal carcinoma in situ to occur simultaneously in different breasts. Surgeons need to integrate clinical observations, imaging tools, and patient history to make an early diagnosis. Before undergoing surgery, a thorough examination of both breasts is required.

Precise diagnosis of breast phyllodes tumors using Raman spectroscopy: Biochemical fingerprint, tumor metabolism and possible mechanism

BACKGROUND

Breast fibroadenomas and phyllodes tumors are both fibroepithelial tumors with comparable histological characteristics. However, rapid and precise differential diagnosis is a tough point in clinical pathology. Given the tendency of phyllodes tumors to recur, the difficulty in differential diagnosis with fibroadenomas leads to the difficulty in optimal management for these patients.

METHOD

In this study, we used Raman spectroscopy to differentiate phyllodes tumors from breast fibroadenomas based on the biochemical and metabolic composition and develop a classification model. The model was validated by 5-fold cross-validation in the training set and tested in an independent test set. The potential metabolic differences between the two types of tumors observed in Raman spectroscopy were confirmed by targeted metabolomic analysis using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

A total of 204 patients with formalin-fixed paraffin-embedded (FFPE) tissue samples, including 100 fibroadenomas and 104 phyllodes tumors were recruited from April 2014 to August 2021. All patients were randomly divided into the training cohort (n = 153) and the test cohort (n = 51). The Raman classification model could differentiate phyllodes tumor versus fibroadenoma with cross-validation accuracy, sensitivity, precision, and area under curve (AUC) of 85.58 % ± 1.77 %, 83.82 % ± 1.01 %, 87.65 % ± 4.22 %, and 93.18 % ± 1.98 %, respectively. When tested in the independent test set, it performed well with the test accuracy, sensitivity, specificity, and AUC of 83.50 %, 86.54 %, 80.39 %, and 90.71 %. Furthermore, the AUC was significantly higher for the Raman model than that for ultrasound (P = 0.0017) and frozen section diagnosis (P < 0.0001). When it came to much more difficult diagnosis between fibroadenoma and benign or small-size phyllodes tumor for pathological examination, the Raman model was capable of differentiating with AUC up to 97.45 % and 95.61 %, respectively. On the other hand, targeted metabolomic analysis, based on fresh-frozen tissue samples, confirmed the differential metabolites (including thymine, dihydrothymine, trans-4-hydroxy-l-proline, etc.) identified from Raman spectra between phyllodes tumor and fibroadenoma.

SIGNIFICANCE AND NOVELTY

In this study, we obtained the molecular information map of breast phyllodes tumors provided by Raman spectroscopy for the first time. We identified a novel Raman fingerprint signature with the potential to precisely characterize and distinguish phyllodes tumors from fibroadenoma as a quick and accurate diagnostic tool. Raman spectroscopy is expected to further guide the precise diagnosis and optimal treatment of breast fibroepithelial tumors in the future.

[Invasive Ductal Carcinoma within a Borderline Malignancy Phyllodes Tumor-A Case Report]

Phyllodes tumors are uncommon breast neoplasms that constitute 1-2% of breast malignancies. Invasive ductal carcinoma in the epithelial component of phyllodes tumor is very rare. When carcinoma is detected within the specimen, the management of treatment changes completely. We report a rare case of invasive ductal carcinoma arising in a giant borderline malignancy phyllodes tumor in a 51-year-old female patient. A painful 20 cm mass was found in her right breast, and a needle biopsy revealed fibroadenoma or benign phyllodes tumor, and a total mastectomy was performed. Pathological results showed that a borderline malignant phyllodes tumor coexisted with invasive ductal carcinoma. We explained that axillary surgery was necessary because invasive cancer was diagnosed after surgery, but the patient requested follow-up using images. Endocrine therapy was performed as postoperative adjuvant therapy, and the follow-up is underway without recurrence.

[A Case of Giant Phyllodes Tumor Treated with Breast Reconstruction]

A 62-year-old woman was diagnosed with right breast tumor 2 years ago, which she refused to undergo surgery. The patient experienced a rapid enlargement of the mass over the past 1 month, and visited hospital. The patient was diagnosed with a borderline phyllodes tumor by needle biopsy. Her right breast was occupied by an 18 cm mass. We conducted tumor resection and immediate reconstruction with DIEAP flap. The pathological diagnosis was a malignant phyllodes tumor, and the postoperative radiation to the chest wall was performed. During a year and a half follow up, she has no recurrence and highly satisfied with the reconstructed breast. Phyllodes tumors may recur locally regardless of whether they are benign or malignant, and we need strict follow-up.

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.

Epithelial Carcinomas Arising within Phyllodes Tumours of the Breast: A Review of Their Pathological Characteristics

Epithelial proliferation is a common feature of phyllodes tumours (PTs), but epithelial malignancy is rare. This review seeks to further our understanding of epithelial malignancy within PTs by analysing their histopathological characteristics in previously reported cases and providing an overview of studies on their pathological features. PubMed and DeepDyve were searched for case reports, case series, and literature reviews of in situ and invasive carcinoma within PTs. Only cases where the carcinoma was within the PT were included. Cases of synchronous carcinoma in the ipsilateral or contralateral breast were excluded. Ninety-eight cases of in situ or invasive carcinoma within a PT were identified. Across the grades of PTs, there was a similar proportion of invasive carcinomas compared to in situ lesions. Malignant PT correlates with a higher likelihood of epithelial malignancy, and molecular studies support a possible causal pathophysiological relationship. This higher likelihood may suggest interactions between malignant stroma and the transforming epithelium that could potentially play a significant role in the phenomenon, which remains to be elucidated. Encasement within a PT likely improves the prognosis of breast carcinoma due to earlier detection. The presence of carcinoma within a malignant PT has uncertain prognostic implications. Thorough sampling of all PTs is recommended for appropriate prognostication and management.

Phyllodes Tumors of the Breast: Canadian National Consensus Document Using Modified Delphi Methodology

PURPOSE

Phyllodes tumors are rare breast neoplasms with limited prospective data to guide treatment, leading to heterogeneous management of this disease. We developed National consensus statements using modified Delphi methodology including patients and practitioners across Canada.

METHODS

Statements were developed based on a literature review. Two iterations of surveys were distributed with a planned virtual consensus meeting. Panelists were invited from surgery, radiation oncology, medical oncology, pathology, radiology, and plastic surgery.

RESULTS

Twenty-three participants attended the virtual conference. One hundred statements regarding diagnostics, pathology, surgical planning, adjuvant therapies, recurrence, surveillance, and patient support were approved with an a priori defined consensus of ≥ 80%. Two tables on locoregional management were developed and approved. The management of borderline phyllodes tumors was a source of uncertainty, and recommendations reflect the lack of evidence in this rare presentation.

CONCLUSION

A consensus document containing all approved statements for the care and management of phyllodes tumors was developed to help guide practice and future research.

Phyllodes Tumor of the Bladder in a 2-Year-Old Boy - An Exceptional Finding

Background: Breast phyllodes tumor has a distinct histologic appearance. There are no pediatric phyllodes tumors of the bladder in English literature reported. Case report: A 2-year-old boy presented with a urinary infection and obstructive urinary symptoms. A 3-cm slow-growing bladder mass revealed by repeated transabdominal ultrasonography was initially considered a ureterocele. Cystoscopic and laparoscopic exploration using pneumovesicum confirmed the diagnosis of a bladder neck tumor. Histologically, the features were of a benign phyllodes tumor, morphologically similar to those seen in breast tissue. The patient received no further treatment and showed no recurrence or metastasis. Conclusion: Phyllodes tumor can cause a pediatric bladder tumor.

Disseminated malignant phyllodes: Presentation after a decade

Phyllodes tumors are rare biphasic fibroepithelial lesions of the breast and account for 0.3%-0.5% of primary breast tumors. Malignant phyllodes tumor has a 10%-26% risk of distant metastasis. The most common site of metastasis is lungs followed by bone and soft tissue. This is a rare case of a 42-year-old female with a previous history of malignant phyllodes tumor breast. She presented after 10 years with metastases to multiple sites including lung, abdominal wall, retroperitoneum, bone, and brain. These tumors have a poor overall survival. Accurate diagnosis and aggressive management of malignant phyllodes tumors can help in effective treatment at diagnosis and for close follow-up of the patients.

Benign Biphasic Tumors of the Mullerian Tract - a Mimic of Phyllodes Tumor. A Clinical-Pathologic Description of 21 Cases

OBJECTIVE

A review of the clinical-pathologic characteristics and outcomes of biphasic polyps occurring in the female genital tract, not meeting the diagnostic criteria of Mullerian Adenosarcoma (MA).

METHODS

An archival database search was run, after IRB approval, between 2001 and 2019, using terminology such as "Mullerian adenofibroma," "atypical Mullerian adenofibroma," "polypoid adenofibroma," and "atypical polyp with increased stromal cellularity." Two pathologists (JW and MRQ) reviewed all the retrieved cases and documented the morphologic features with particular emphasis on the presence of any features of Mullerian adenosarcoma. Follow-up data were also abstracted.

RESULTS

Twenty-one cases, 12 cervical and 9 endometrial lesions, constituted the study cohort. Patients ranged from 26 to 64 years (median 49 years). On review, 20 of 21 of those cases showed Phyllodes-like architectural patterns. However, only one case showed all four features of MA, all of which were focal and inconspicuous. Follow-up (median duration of 5 years) did not document any recurrences in any of the 21 cases after excision.

CONCLUSION

This series adds to the growing body of literature affirming the existence of benign biphasic Mullerian polyps encountered in the endometrium and cervix that fall short of the Mullerian adenosarcoma diagnosis.

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.

Malignant Phyllodes Tumour with Osteoclast-type Giant Cells in Young Females: A Rare Histology and Differential Diagnoses

Phyllodes tumour (PT) is a biphasic fibroepithelial tumour of the breast that accounts for 0.3-1% of all primary breast neoplasms. It is subdivided into benign, borderline, and malignant categories based on histologic features including stromal overgrowth, stromal hypercellularity, mitotic count, degree of atypia, and type of margins. Malignant PT (MPT) is characterised by infiltrative margins, marked stromal overgrowth, increased stromal hypercellularity, greater than 10 mitoses/10 high-power fields (HPFs), and moderate to severe atypia. It shows aggressive behaviour with a high risk of local recurrence and metastasis. Surgery with adequate margins is the recommended treatment. Heterologous differentiation is not an uncommon phenomenon in MPT. In addition to classic phyllodes histology, the tumour shows areas of benign/malignant mesenchymal differentiation. MPT containing multinucleated osteoclast-type giant cells (OGCs) is extremely rare. We herein report cases of MPT with OGCs in two young females who had a history of swelling in unilateral breast for two-three years. Histologic examination revealed classic phyllodes areas admixed with a sarcomatous stromal component with OGCs. Key Words: Malignant phyllodes tumour, Breast, Osteoclast-type giant cells.

A malignant transformation of borderline phyllodes tumor to fibrosarcoma breast: A rare case report

ABSTRACT

Phyllodes tumor of the breast with malignant transformation to fibrosarcoma of the breast is a rare entity. Breast fibrosarcoma is uncommon, accounting for less than 1% of all breast tumors. Prognosis of fibrosarcoma of the breast is poor. Due to its rarity, survival rates are not defined. A 23-year-old woman presented with a mass in the left breast, and another 48-year-old woman presented with right breast mass. Both patients underwent for surgery. The histological & immunohistochemical examination confirms the diagnosis of a malignant transformation from borderline phyllodes tumor to fibrosarcoma. We concluded that the phyllodes tumor is mostly benign but local recurrence is common. As the tumor progresses toward malignancy, due to the difficulty in the diagnosis of borderline phyllodes tumors, total mastectomy with axillary resection must be recommended.

High-Grade Spindle Cell Lesions of the Breast: Key Pathologic and Clinical Updates

Most of the high-grade spindle cell lesions of the breast are malignant phyllodes tumors (MPTs), spindle cell carcinomas (SpCCs), and matrix-producing metaplastic breast carcinomas (MP-MBCs). MPTs have neoplastic spindle stromal cells and a classic leaf-like architecture with subepithelial stromal condensation. MPTs are often positive for CD34, CD117, and bcl-2 and are associated with MED12, TERT, and RARA mutations. SpCCs and MP-MBCs are high-grade metaplastic carcinomas, whereas neoplastic epithelial cells become spindled or show heterologous mesenchymal differentiation, respectively. The expression of epithelial markers must be evaluated to make a diagnosis. SAS, or rare metastatic spindle cell tumors, are seen in the breast, and clinical history is the best supporting evidence. Surgical resection is the standard of care.

Diagnosis and management of phyllodes tumours for the surgeon: An algorithm

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.

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.

The giant phyllodes tumor of the breast - a case report

Phyllodes tumors are rare tumors of the breast, which are often misdiagnosed as fibroadenomas and difficult to treat with adjuvant therapy. Here, we present a case of a female patient with giant phyllodes tumor of the breast.

Expression of cancer stem cell markers in breast phyllodes tumor

BACKGROUND

Phyllodes tumor (PT) is a rare tumor showing various malignant potential. The histological grade of PT is related to clinical outcome, but its relationship between gaining of malignant potential and underlying mechanism including cancer stem cell factor was not understood yet.

OBJECTIVE

The main purpose of this study was to determine the expression pattern of cancer stem cell marker in PT and to understand its clinical and pathological implications.

METHODS

CD44, CD166, ALDH1, and Ki-67 immunohistochemistry were performed on a tissue microarray from 185 cases of PT specimens (138 benign, 32 borderline, 15 malignant). The immunohistochemistry result and clinicopathological parameter of each cases were compared to analyze the implications of cancer stem cell markers on PT.

RESULTS

Borderline/malignant PT showed higher CD44 expression of the stromal component than benign PT (p< 0.001). In lower histologic grade PT, CD166 showed increased expression in the epithelial component (p= 0.019), but decreased in the stromal component (p< 0.001). Stromal overgrowth was rarely observed as the number of positive cancer stem cell markers increased in the epithelial component (p< 0.001). In the stromal component, the number of positive cancer stem cell markers was related to higher histologic grade (p< 0.001), and increased stromal cellularity (p< 0.001), stromal atypia (p= 0.003), and stromal mitosis (p= 0.002). In benign PT, CD44 negativity (p= 0.013) and a decreased number of positive cancer stem cell markers (p= 0.012) in the epithelial component were related to poor prognosis.

CONCLUSIONS

The cancer stem cell markers, CD44 and CD166, are expressed in both the epithelial and stromal components of phyllodes tumor. Besides, ALDH1 is only expressed in stromal component. In the stromal component, expression of cancer stem cell markers increases with higher PT histologic grade. In the epithelial component, the absence of cancer stem cell marker expression is related to poor clinical prognosis.

Core needle biopsy in fibroepithelial tumors: predicting factors for phyllodes tumors

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.

A Giant Borderline Phyllodes Tumor of Breast With Skin Ulceration Leading to Non-Insular Tumorigenic Hypoglycemia: A Case Report and Literature Review

Phyllodes tumor (PT) is a special type of breast tumors, including three types: malignant, borderline, and benign. Most of these tumors form unilateral disease and can rapidly increase in size. The occurrence of axillary lymph node metastasis is rare. Tumor-associated hypoglycemia can be divided into non-islet cell tumor and insulinoma. In non-islet cell tumor hypoglycemia (NICTH), a considerable high molecular weight form of insulin like growth factor 2 (IGF-2) is formed, which abnormally binds to insulin receptors in the tissues and causes hypoglycemia. Breast phyllodes tumors with NICTH are rare and first reported in 1983. Surgical resection is the main treatment and hypoglycemia symptoms usually resolve after surgery. Nevertheless, prior to surgery, intravenous glucose infusion is used to maintain blood glucose levels. A female patient presented with a rapidly growing breast mass and was diagnosed with a phyllodes tumor with NICTH at our hospital in August 2020; she was successfully treated through surgical resection. We reviewed the relevant literature to investigate and analyze the relationship between NICTH and phyllodes tumors, as well as optimize its diagnosis and treatment.

Fibroadenoma versus phyllodes tumor: a vexing problem revisited!

BACKGROUND

Fibroepithelial lesions of the breast include fibroadenoma (FA) and phyllodes tumor (PT). Fibroadenomas are benign while phyllodes tumor range from benign, indolent neoplasms to malignant tumors capable of distant metastasis. Our study was to determine the select cytologic features that can accurately distinguish FA from PT.

METHODS

A retrospective review was performed of patients who had histopathology follow up of FA or PT and on whom a pre-operative fine needle aspiration was performed. Cytologic criteria i.e. epithelial component, stromal component and background cellularity were assessed.

RESULTS

46 FA and 24 PT were specimens were reviewed. Median age and tumor size for FA and PT were 23.0 and 39.0 years, and 2.0 and 5.0 cm, respectively. Univariate analysis and regression models based on generalized estimating equations revealed that large opened out, folded epithelial sheets, frayed and irregular stromal fragment contours, spindle stromal cell nuclei, spindle cell nuclei in the background and background cell atypia are significant cytological predictors of PT. The GEE regression model achieved 78.9% diagnostic accuracy (p <  0.001) in identifying PT based on cytological features. Median epithelial: stromal ratio was 3.4 and 2.6 for FA and PT, respectively.

CONCLUSION

Presence of large, opened out, folded epithelial sheets, frayed and irregular stromal contours with spindle nuclei, background spindle cells and atypia can help distinguish PT from FA.

The Impact of Radiotherapy and Histological Risk Factors on Outcomes in Malignant Phyllodes Tumors

PURPOSE

Breast phyllodes tumors (PT) are classified into benign, borderline, and malignant grades based on histopathologic characteristics. Specific to malignant PT (MPT), surgery is the mainstay yet relapse rates are high and knowledge gaps in the literature exist regarding adjuvant radiotherapy (RT). We aimed to investigate the outcomes of patients with MPT treated in a tertiary Asian institution.

METHODS AND MATERIALS

Patients with nonmetastatic MPT treated from February 1992 to June 2019 were analyzed retrospectively. RT details and relapse fields were studied. Outcomes of patients with and without RT were compared and hazard ratios were calculated using Cox proportional hazard test. Multivariable analysis was performed.

RESULTS

Twenty-two of 89 patients received adjuvant RT and the median dose was 60 Gy. In the no-RT group, 4 patients received RT on relapse and had no further recurrences; a further 2 received RT for fungating relapses with good symptomatic relief. RT was only increasingly prescribed after 2004. Median follow-up in the RT group was 3.31 years, compared with 6.17 years in the no-RT group. In the RT group, 15 patients (68.2%) underwent mastectomy, versus 39 (58.2%) in the no-RT group. One patient in the RT group developed an infield local relapse, compared with 21 of 67 patients in the no-RT group. Multivariate model showed that RT decreased risk of locoregional failure (hazard ratio 0.12, 95% confidence interval [CI] 0.02-0.92, P = .04). Three-year locoregional recurrence-free survival was higher in the RT group, 92.3% (95% CI, 78.9-100) versus 73.3% (95% CI, 63.1-85.1) in the no-RT group (P = .03). There were no differences in 3-year survival.

CONCLUSIONS

We recommend that adjuvant radiotherapy be discussed for malignant PT for local control, even after mastectomy.

[A Case of Metachronal Phyllodes Tumors That Presented Bilaterally in the Breast]

A 33-year-old woman underwent resection of a right breast mass, which was diagnosed as a fibroadenoma 15 years ago. Ten years later, a right breast mass appeared again, and it was diagnosed as a fibroadenoma based on core needle biopsy. After observation for a while, the mass increased in size, and she underwent resection of the tumor, which was diagnosed as a borderline-malignant phyllodes tumor. A mass appeared again in the right breast and rapidly expanded. A malignant phyllodes tumor was suspected, and right mastectomy was performed. The pathological diagnosis revealed a benign phyllodes tumor. Four years ago, a left breast mass was also detected. Because the mass was suspected to be a fibroadenoma, it has been observed for a few years. The mass has increased in size since 1 year ago, and another mass emerged 2 months ago. Core needle biopsy of the 2 masses revealed that both were phyllodes tumors. She underwent left mastectomy, and the pathological examination revealed that both masses were benign phyllodes tumors. We report this rare case of metachronal phyllodes tumors that presented bilaterally.

[A Case of a Malignant Phyllodes Tumor That Was Difficult to Distinguish from Stromal Sarcoma]

A 72-year-old woman visited our hospital with the chief complaint of a mass in the right breast. Breast ultrasonography revealed a hypoechoic area with a distinct border in the right breast. A core needle biopsy showed the proliferation of spindle cells in the stroma, and she was diagnosed with stromal sarcoma or malignant phyllodes tumor. Right lumpectomy was performed. Pathological examination revealed a malignant phyllodes tumor with a sarcomatous lesion. Although she did not receive adjuvant chemotherapy, she is alive without any recurrence 2 years after the surgery. It is difficult to distinguish phyllodes tumors from stromal sarcoma, based on core needle biopsy, and the prognosis of malignant phyllodes tumors with distant metastases is poor. Rapid surgery to determine an accurate diagnosis and careful follow-up after surgery are impor- tant.

Radiopathological characteristics and outcomes of phyllodes tumor of the breast in Malaysian women

Phyllodes tumor or cystosarcoma phyllodes is a rare fibroepithelial neoplasm which arises from the periductal stroma of the breast. They are classified as benign, borderline, and malignant based on the histologic features. However, all phyllodes tumor (PT) subtypes are regarded as having malignant potential and correct diagnosis is important for surgical management and optimal care. This study is a retrospective review of 76 women diagnosed as PT with highlights on the imaging characteristics, pathology, and surgical treatment over a 7-year period in a tertiary medical center of urban population in Malaysia. There were 45 benign, 16 borderline, and 15 malignant PT. The median age for benign PT was 43, borderline 48.5, and malignant 42 years. The Malay ethnic group constitute 52.6% of cases, with 27.6% and 18.4% in Chinese and Indian ethnic groups, respectively. On mammograms, most benign (64.3%) and 33.3% of malignant PT showed high-density lesions. Calcifications were only seen in 2 benign PT. On ultrasound, 86% of benign PT was well-circumscribed whilst 50.0% of malignant PT had irregular outline. Cystic spaces were seen in 40.0% of malignant and 9.5% of benign PT. 80% of malignant PT lesions were heterogenous. Malignant PT demonstrates tumor heterogeneity, cystic spaces, and posterior acoustic enhancement on ultrasound. Half of malignant PT showed regular borders on ultrasound and appear well circumscribed on mammogram. A total of 46 patients had wide local excision or excision biopsy whilst 30 underwent mastectomy as primary treatment. The majority of the borderline and malignant PTs in our study (75.0% and 85.7% respectively) and only 5 out of the 43 (11.6%) benign PT underwent mastectomy. There were 2 tumor recurrence in the benign PT group and 1 case in the borderline and malignant group respectively.

Inflamed Phylloides Tumour in a Girl: A Challenging Diagnosis in Paediatric Breast Lesions

Introduction: Phylloides tumours (PTs) are rare fibroepithelial neoplasms that account for 0.3⁻0.9% of all breast tumours. These tumours typically occur in women aged 30⁻70 years. The occurrence of these tumours in older children and adolescents poses particular diagnostic and therapeutic problems. However, early diagnosis is mandatory because although most of the cases of PTs in children are benign, the borderline and malignant cases with potential negative outcomes cannot be excluded. Case presentation: A 12-year-old girl presented at the Paediatric Emergency Department for hyperaemia and warmth of the left breast that occurred a few days prior without fever. The girl experienced menarche 8 months previously. She experienced no previous trauma and she had no family history of breast cancer. On physical examination, the left breast was painful, enlarged and tender. The overlying skin was erythematous and warm. A breast ultrasonography (US) revealed a large mass with features of an abscess, including a hyperechoic wall, scattered internal echoes and hypoechoic peripheral lacunae of apparent colliquative nature. After 4 days of unsuccessful antibiotic therapy, surgical drainage was performed due to the suspicion of a mammary abscess. At the surgical incision site, the lesion was not-well circumscribed and lacked a capsule. In addition, purulent material was not detected. Histological examination revealed that the tissue alterations were compatible with benign PT. With this diagnosis, the girl underwent definitive surgical removal of the lesion. The postoperative period passed without negative events. An US performed 6 months later revealed that no new mass was present at this time, suggesting no recurrence of the tumour. Conclusion: This case shows that in the presence of a clinical picture suggesting the inflammation of the breast in adolescent females, PT should be considered as a possible diagnosis and US-guided core biopsy should be considered to confirm this suspicion. Thereafter, when surgical excision is performed, particular attention must be paid to both the preservation of all the normal breast parenchyma and future aesthetic problems.

Prognostic factors in breast phyllodes tumors: a nomogram based on a retrospective cohort study of 404 patients

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.

Phyllodes tumors of the breast: clinicopathological analysis of 106 cases from a single institution

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.

Phyllodes tumors of the breast in 2 sisters: Case report and review of literature

RATIONALE

Phyllodes tumors (PT) of the breast are rare neoplasm originating from fibroepithelial component. To our knowledge, our report is the first reported case of PT in 2 sisters.

PATIENT CONCERNS

We presented 2 cases of PT of the breast involving in 2 sisters. On physical examination of the younger sister, a firm mass measuring approximately 3 cm in diameter was identified in upper inner quadrant of the right breast. Physical examination of the elder sister revealed a 3 cm lump in upper outer quadrant of the left breast.

DIAGNOSES

Histopathology of the younger sister revealed a malignant PT. The elder sister was diagnosed with borderline PT.

INTERVENTIONS

The younger sister with malignant PT underwent right mastectomy. The elder sister with borderline PT was scheduled for wide resection of the mass in the left breast.

OUTCOMES

After a follow-up of 23 months, no local or distant recurrence was observed.

LESSONS

Our cases indicate that genetic factor may contribute to the risk of PT of the breast. Markers such as p53 and Ki-67 may have some correlation with PT malignancy.

Giant breast tumour in a 13-year-old girl

This study describes a rare case of a giant phyllodes tumor in a 13-year-old girl. The authors have conducted an analysis of the diagnostic process and have shown the results of operative treatment of the tumor. Moreover, organisational aspects of the diagnostics concerning breast diseases in patients from smaller towns in Poland have been discussed. It has been indicated that the availability of suitable diagnostics and treatment of breast diseases in children and teenagers from rural areas and smaller towns is limited.

Cytological Criteria to Distinguish Phyllodes Tumour of the Breast from Fibroadenoma

OBJECTIVE

To determine whether there are significant differences between fibroadenomas and phyllodes tumours with regard to selected cytomorphological features.

STUDY DESIGN

A 10-year retrospective review was performed of patients who underwent excision of a fibroadenoma or phyllodes tumour and in whom a preoperative fine-needle aspiration was performed. The following cytological criteria were assessed: number of stromal and epithelial fragments, stromal-to-epithelial ratio, stromal cellularity, stromal borders, stromal atypia, and proportion of background wavy spindled cells. Patient age, tumour laterality, and tumour size were recorded.

RESULTS

Fifty fibroadenomas and 17 phyllodes tumours were included. Compared to phyllodes tumours, fibroadenomas had a larger number of epithelial fragments, a smaller number of stromal fragments, and a lower stromal-to-epithelial ratio. The stroma tended to be less cellular and less atypical compared to phyllodes tumours and the background cellular population contained fewer spindled cells.

CONCLUSION

Fibroadenomas and phyllodes tumours differ with regard to various cytological features, aiding in their distinction on fine-needle aspiration biopsy.

[Fibroepithelial tumours of the breast: not always a simple fibroadenoma]

Fibroepithelial tumours are the most common type of solid breast tumours. They include the common fibroadenomas and the rare phyllodes tumours. Fibroadenomas usually present in younger patients and are smaller than phyllodes tumours. They are benign and do not require any treatment or follow-up. Further examination (usually ultrasound-guided thick-needle biopsy) is recommended if in doubt about the diagnosis. Phyllodes tumours can be divided into benign, borderline and malignant tumours and are primarily treated with surgery, breast-conserving surgery if possible. In this article, we present three cases and an overview of characteristics, diagnosis, and treatment of fibroepithelial breast tumours.

A Case of Giant Borderline Phyllodes Tumor of the Breast Associated with Hypoglycemia

We report a patient with a giant phyllodes tumor of the right breast associated with a hypoglycemic attack. A 48-year-old woman experienced a loss of consciousness and was transferred via ambulance to our hospital emergency department. Upon arrival, her blood glucose level was 26 mg/dl, and a giant tumor (>20 cm in diameter) with skin ulceration was observed on the right breast. Core needle biopsy led to a histological diagnosis of a phyllodes tumor of the breast. Ultrasonography and computed tomography detected neither distant metastasis nor a pancreatic endocrine tumor. Her preoperative serum insulin-like growth factor (IGF)-II and insulin levels were 1,330 ng/ml (normal range, 519-1067 ng/ml) and <1.0 µU/ml, respectively. Following a simple mastectomy, the 24-h postoperative serum IGF-II and insulin levels were 496 ng/ml and 10.0 µU/ml, respectively. The IGF-II levels detected in the phyllodes tumor and normal breast tissue were 10,600 ng/Wg (wet weight in grams) and 855 ng/Wg. We conclude from these findings that the hypoglycemic attack was related to the elevated IGF-II level in the giant phyllodes tumor of the breast.

Breast cancer in women in their thirties (2007-2013): a retrospective review

Due to an increasing number of breast cancer diagnoses in younger women anecdotally noted at our institution, we conceived of this study %was to retrospectively review the records of women diagnosed with breast cancer under the age of 40 for potentially alterable versus unalterable risk factors in their history. Between 2007 and 2013, there were 52 patients less than 40 years of age with breast cancer at our institution: 79% (41/52) presented with a clinical abnormality (palpable mass, nipple discharge or inversion) and 21% (11/52) were asymptomatic but diagnosed on early screening mammograms. Seventy-five percent (39/52) of the cancers had an invasive component and 87% (45/52) were intermediate to high grade. Sixty percent (31/52) of subjects had stage 0 or I disease, but 40% (21/52) had later stage disease (stage II or greater). The vast majority of the cancers were ER+ (82%) and PR+ (78%). Fifty-six percent (28/50; 2 unknown) of the subjects had a documented history of hormonal contraception. Fifty-three percent (27/51; 1 unknown) of had no family history of breast cancer whatsoever, and 80% (41/51) had no family history of breast cancer in a first degree relative. Six were positive for BRCA 1, 2, or a variant (6/52 = 12%).

Comparison of diagnostic accuracy of touch imprint cytology and frozen section techniques in detecting breast malignancies

OBJECTIVE

To compare the diagnostic accuracy of touch imprint cytology and frozen section in the diagnosis of malignant breast lumps keeping histopathological diagnosis as the gold standard.

METHODS

The cross-sectional validation study was conducted at Foundation University Medical College, Islamabad, from February 2011 to February 2012, and comprised patients undergoing mastectomy/lumpectomy. The specimens were collected from the operation theatre of Fauji Foundation Hospital, Rawalpindi. After tissue fixation, three representative sections were processed and the slides were stained with haematoxylin and eosin stain. The person analysing touch imprint cytology slides was blinded to the frozen section and histopathological slide results and vice-versa. Data was analysed using SPSS 17.

RESULTS

Out of 76 patients with a mean age of 49±15.14 years, 61(80%) were diagnosed with malignant breast diseases. The sensitivity, specificity, positive predictive value, negative predictive value and true positives of touch imprint cytology were 96.72%, 100%, 100%, 88.24% and 96.72% respectively. The corresponding values of the frozen section were 100% each. The diagnostic accuracy calculated for touch imprints and frozen section was 97.37% and 100% respectively.

CONCLUSIONS

The diagnostic accuracy of frozen section was better than touch imprint cytology in rapid intra-operative diagnosis. However, touch imprints can safely be used as an alternative intra-operative procedure to ensure satisfactory results.

[Diagnosis and treatment of phylloides tumors of the breast]

Phylloides tumors (PT) are a rare and the least studied pathology of the breast. Data on physical examination and imaging methods of diagnostics in most cases do not allow accurate diagnosing at the preoperative stage as there are no clear characteristics that allow differentiating benign from malignant variants of PT or other benign breast diseases. Surgery is the main treatment of PT. Chemotherapy and radiation therapy of malignant variants of PT in the adjuvant setting do not significantly improve survival rates. In recurrent or metastatic forms of PT these methods can be effective in some cases. Currently there are identified molecular signaling pathways that play an important role in the pathogenesis of PT. Thus there are prerequisites for the study of the effectiveness of targeted therapies for this pathology.

Nipple sparing mastectomy with immediate silicone implant reconstruction for malignant phyllodes tumor in a 19-year-old girl

OBJECTIVE

Due to the rarity of MPT, the clinical records in the literature, collected along decades, lack to address a modern approach to breast reconstruction after mastectomy.

CASE PRESENTATION

We report a case of a teen-aged female diagnosed to have a malignant phyllodes in her right breast.

DISCUSSION

The surgical treatment of choice, taking in account the relation between the volume of the mass and the breast dimension, was considered to be a mastectomy. As the disease didn't involve the skin envelope a nipple-areolar-sparing gland removal allowed an immediate prosthetic reconstruction with a contralateral augmentation for symmetrization, so obtaining a satisfactory aesthetic outcome.

CONCLUSIONS

At our knowledge we present for the first time this surgical approach that, in selected patients, can reach the oncologic radicality and an adequate cosmetic result too.

Comparison of predictive factors for the diagnosis and clinical course of phyllodes tumours of the breast

BACKGROUND

To compare predicting factors for the diagnosis and clinical course of benign and malign/ borderline phyllodes tumours (PT) of the breast, and to discuss treatment modalities.

METHODS

Clinical and demographic characteristics of the patients with histopathological diagnosis of phyllodes tumour were examined. Patients were divided into group 1 (benign PT) and group 2 (borderline/malignant PT). Groups were compared in terms of demographic and clinical characteristics.

RESULTS

Of the patients studied, 37 (68.5%) had benign, 7 (12.9%) had borderline and 10 (18.5) had malignant histopathology. A statistically significant relationship was detected between the incidence of malignancy and mass diameter (p = 0.001) and age (p = 0.030) when the two groups were compared. Wide surgical excision was performed on 46 (82.5%) patients, simple mastectomy on 7 (13%) patients and modified radical mastectomy on one (1.9%) patient. Ten (18.5%) patients were re-operated for surgical margin positivity. Local recurrence was determined only in one (1.9%) patient. Distant metastasis due to malignant PT developed in two (3.7%) patients.

CONCLUSIONS

Among the patients who were considered to have PT, malignancy was likely to be present, especially if the patient's age was over 40 and the diameter of the mass was above 33.5 mm. Therefore, in patients with similar characteristics, surgical margins should be kept slightly wider or wider excisions should be preferred with or without simultaneous reconstructive surgery in appropriate cases.