Malignant transformation of phyllodes tumor: a case report and review of literature

Incidence and Outcome of Breast Sarcomas in England (2013-2018): An analysis from the National Cancer Registration and Analysis Service

BACKGROUND

Breast sarcomas (BS) are rare cancers originating from mesenchymal breast tissue with a paucity of national population level data detailing their incidence and outcomes.

METHODS

We performed an analysis of data collected by National Cancer Registration and Analysis Service (NCRAS) for patients diagnosed with BS between 2013 and 2018. Chi-square test was used to compare groups. Overall survival (OS) was calculated by Kaplan-Meier. Specialist sarcoma centres (SSC) were defined as centres with a sarcoma multidisciplinary team (MDT).

RESULTS

There were 684 patients with BS (357 malignant phyllodes tumours [PTs], 238 vascular tumours, 93 other morphology) with a median age of 64 (range 14-96); 187 (27%) had received breast radiotherapy for a prior malignancy; 633 (92%) had resection of the tumour within 12 months of diagnosis. Five-year OS was 82%, 54% and 48% in patients with PT, vascular tumours and other sarcomas, respectively, and 55% for those with radiation-induced BS. Patients managed within SSC more frequently had a biopsy prior to surgery 83% versus 72%, p < 0.05) and were less likely to require multiple operations (26% versus 41%, p < 0.05). Tumour stage and grade data were not available.

CONCLUSION

This is the first population series evaluating incidence and outcomes for BS. Patients treated at non-specialist sarcoma centres (NSSCs) are less likely to have a biopsy prior to surgery and more likely to require multiple operations. Based on these observational data, we would recommend all BS are discussed at a sarcoma MDT meeting early in their pathway and surgery to be considered at SSC where possible.

Malignant phyllodes tumor of the breast: a systematic review

Phyllodes tumors (PT) are fibroepithelial neoplasms of the breast showing a peculiar leaf-like appearance. They account for 0.3 to 1% of all primary breast tumors and 2.5% of all fibroepithelial breast tumors. PT are classified into benign, borderline and malignant based upon their stromal morphology with a distribution of 60%, 20%, and 20%, respectively. Malignant PT of the breast constitute an uncommon challenging group of fibroepithelial neoplasms. They have a relatively high tendency to recur, although distant metastasis is uncommon, and nearly exclusive to malignant PT. Adequate surgical resection remains the standard approach to achieve maximal local control. Giant malignant PT are rare and a pose a diagnostic dilemma for pathologists, especially when comprised of sarcomatous elements. This review highlights the morphological features of PT detected in cytology and histology specimens and discusses diagnostic pitfalls and differential diagnosis.

Malignant Phyllodes Tumor: Report of Two Cases and Review of Literature

Phyllodes tumuor (PT) is a rare biphasic breast neoplasm. It constitutes <1% of the entire tumours of the breast. Based on the World Health Organization's (WHO) proposal, premised on multiple histological features, phyllodes tumour is categorized into benign, borderline, and malignant breast neoplasms. Malignant phyllodes tumor (MPT) is even a rarer neoplasm. It occurs more commonly in older patients. However, it can uncommonly occur in younger individuals. The transformation of benign phyllodes into malignant forms is extremely rare. Here, we present two cases of young females (aged 20 and 27 years, respectively) who individually presented with rapidly progressive breast lumps. The two breast lumps were huge while one was recurrent and underwent a malignant transformation in approximately 7 weeks interval following an initial complete excision and histological diagnosis of benign PT. Indeed, even in young females below the modal/peak age of phyllodes, the suspicion should be high. Additionally, breast ultrasonography findings, although not common, can be highly suggestive of PT. Furthermore, every breast lump should be further evaluated, and even more so, histologically, irrespective of the patient's age as our first patient had an excision without histology.

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.

ICG/5-Fu coencapsulated temperature stimulus response nanogel drug delivery platform for chemo-photothermal/photodynamic synergetic therapy

The multiple diagnosis and treatment mechanisms of chemotherapy combined with photothermal/photodynamic therapy have very large application prospects in the field of cancer treatment. Therefore, in order to achieve effective and safe antitumour treatment, it is necessary to design an intelligent responsive polymer nanoplatform as a drug delivery system. Herein, the thermosensitive poly-N-isopropylacrylamide (PNIPAM) nanogel particles were prepared by soap-free emulsion polymerization and loaded with a large amount of photosensitizer indocyanine green (ICG) and anticarcinogen 5-fluorouracil (5-Fu), which effectively to realize the cooperative chemotherapy and photothermal/photodynamic therapy for tumours. The 5-Fu@ICG-PNIPAM nanogels significantly improved the bioavailability of the drug and achieved controlled release. In addition, under near-infrared laser (NIR) irradiation at 808 nm, 5-Fu@ICG-PNIPAM nanogels generated lots of heat and reactive oxygen, which significantly enhanced cellular uptake and in vitro antitumour treatment effects. The results showed that 5-Fu@ICG-PNIPAM nanogels were effectively endocytosed by HeLa cells, which also enhanced the drug's entrance into the nucleus. Moreover, compared with alone chemotherapy or photothermal/photodynamic therapy, 5-Fu@ICG-PNIPAM nanogels significantly increased cytotoxicity under NIR irradiation, suggesting that chemotherapy and photothermal/photodynamic synergistic therapy had excellent antitumour properties. Therefore, this temperature-responsive nanogel platform probably has great application prospects in clinical antitumour treatment.

Malignant phyllodes tumor with extensive lipomatous differentiation

Phyllodes tumors are uncommon neoplasms of the breast. Lipomatous differentiation of malignant phyllodes tumor is a rare stromal alteration of this fibroepithelial tumor, demonstrated as a fat-containing mass on imaging. We present the case of a 46-year-old woman who was diagnosed with a malignant phyllodes tumor of the breast that demonstrated extensive lipomatous differentiation.

Accuracy of p53 and ki-67 in the graduation of phyllodes tumor, a model for practical application

Background

The accurate graduation of a phyllodes tumor (PT) is critical for effective treatment as it allows correct surgical management, and avoids inadequate excision for malignant or borderline PT, or surgical overtreatment in benign PT. PTs of the breast are notoriously difficult to classify, and reliable differentiation of a benign PT from a borderline or malignant PT can be problematic, especially among relatively inexperienced pathologists. Although several authors acknowledge a strong relationship between the immunohistochemical expression of p53 and Ki-67 and the histopathological grade of PT—with potential impact on diagnostic accuracy—the literature lacks consensus about which cutoff defines a positive index test. The objective of this study is to establish a practical application score that increases the graduation accuracy of PT through the appropriate use of these auxiliary methods.

Methods

A retrospective study cohort of 146 pathology reviewed PTs surgically removed between January 2000 and December 2015. The Ki-67 test was considered positive if > 10% of neoplastic cells showed nuclear staining. The p53 test was considered positive if > 10% of neoplastic nuclear cells showed nuclear staining in a moderate or strong intensity.

Results

Of the 146 PT cases reviewed, 110 were classified as benign, 16 as borderline, and 20 as malignant. The correlation between age and size with benign, borderline, and malignant subgroups was statistically significant (p < 0.001). Significance was observed in the expression of both Ki-67 and p53 in the comparison of benign, borderline, and malignant PT with p < 0.001 and a 95% confidence interval (CI). When correlating the presence of positivity in either of the two index tests with the diagnosis of borderline or malignant PT, we reached a sensitivity of 100% and a specificity of 91.8 (p < 0.001; 95% CI).

Conclusion

We propose a practical methodology to achieve an accurate grade of PT, based on clearly defined and easy to apply cutoffs of a simple immunohistochemical panel of Ki-67 and p53. A PT positive for either of the index tests should be graded as borderline or malignant, so pathologists can use this test to improve accuracy. We hope this new approach might provide the basis for the development of standardization in using p53 and Ki-67 for grading PT.