Perioperative diagnosis of cystosarcoma phyllodes of the breast may be enhanced by MIB-1 index

World's Oldest Case of Synchronous Bilateral Benign Phyllodes Tumors of the Breast: A Rare Occurrence

Phyllodes tumors are rare fibroepithelial tumors of the breast. They account for less than 0.5% of breast cancers. Bilateral presentation is a rare event, and seems to be associated with the more benign subtype but, reports are scarce. It is more common to have multiple ipsilateral tumors or bilateral asynchronous presentations. However, bilateral synchronous phyllodes are seldom reported. A literature search has revealed only five cases of synchronous and one case of metachronous bilateral phyllodes tumor of the breast. The age ranges of these patients are between 16-42 years. We are reporting the world's first case of bilateral synchronous phyllodes tumor of the breast in a patient over the age of 50 years.

Case Report: presentation of pleomorphic liposarcoma arising in a borderline phyllodes tumor

INTRODUCTION

The stromal component of Phyllodes tumors represents the neoplastic portion of the lesion. A variety of associated malignancies can arise from PTs, with its dual population of cells.

PRESENTATION OF CASE

We share a very rare case of "borderline"breast phillodes tumour with a 75% liposarcoma component. A 48-year-old woman presented at the surgical clinic with a mass in the left breast. On mammograms, the lesion was dense with radiolucent areas inside which were thought to be compatible with fat. The mass was assumed to be breast imaging-reporting and data system (BIRADS) 3 on sonography as it was well contoured. The needle biopsy was reported to be consistent with a fibroadenomatous lesion. The lesion was completely excised. On microscopic examination, the lesion has benign mammary duct epithelium lining the slit-like spaces. The stroma composed of fibrous and adipous tissue. The fibrous part was cellular, and several cells appeared bizarre. Adipous tissue replaced most of the stroma and was diagnosed as pleomorphic liposarcoma.

DISCUSSION

According to the 3 tiered grading criteria of PTs, our case normally suits in borderline category, without liposarcoma component. Heterologous sarcomatous elements usually accompany high grade PTs. Rare cases of benign and borderline PTs with sarcoma component have been reported.

CONCLUSION

The presence of a malignant heterologous component places the tumour into the malignant category regardless of other histological features.

Benign phyllodes tumor with tubular adenoma-like epithelial component in FNAC: A diagnostic pitfall

Benign phyllodes tumor (BPT) is a biphasic neoplasm composed of bland stromal and epithelial elements. Cytologic diagnostic criteria of BPT, though documented in the literature, diagnostic pitfalls in fine-needle aspiration cytology (FNAC) may occur due to sampling error, high cellularity, ductal hyperplasia, paucity of stromal component, and occasional dissociation of epithelial cells. Here, we describe a case of BPT diagnosed by histology in a 19-year-old female, where FNAC features were inconclusive due to paucity of stromal component, predominance of tubular adenoma-like epithelial component, and due to the presence of other overlapping features with fibroadenoma.

Large Malignant Phyllodes Tumor of the Breast with Metastases to the Lungs

Phyllodes tumors of the breast account for less than 0.5% of breast cancers and present most commonly in women 45 to 49 years old. The importance in managing fibroepithelial lesions lies in distinguishing fibroadenomas, which are benign, from phyllodes tumors, which can be malignant and require complete surgical excision. We report the case of a 56-year-old female who presented with a rapidly enlarging mass in her right breast 18 cm in maximum dimension that completely effaced the breast and distorted the nipple. The patient underwent a successful total mastectomy after core biopsy revealed a diagnosis of phyllodes tumor. Surgical resection is the primary treatment modality; neoadjuvant and adjuvant therapies remain controversial. Here, we report the case of a large malignant phyllodes tumor metastatic to the lungs, review the literature, and discuss diagnostic modalities and adjunct nonsurgical therapies.

Phyllodes tumours of the breast diagnosed as B3 category on image-guided 14-gauge core biopsy: analysis of 51 cases from a single institution and review of the literature

AIMS

Image-guided 14-gauge (G) core biopsy (CB) has been shown to be an accurate method providing histological diagnosis of breast lesions. The purpose of this study was to evaluate the reliability of image-guided 14-G CB in the diagnosis of phyllodes tumours (PT) reported as B3 category and its accuracy in distinguishing this lesion from fibroadenomas (FA).

MATERIALS AND METHODS

The records of 10 000 image-guided 14-G CB of the breast performed from January 2001 to August 2011 at the Diagnostic Senology Unit of Careggi University Hospital were reviewed; 2554 (25.5%) were fibroepithelial lesions: 56 of them (2%) were diagnosed as PT and reported as B3 category. The database of the Pathological Anatomy Unit of Careggi University Hospital was then searched to verify the histological diagnosis after surgical excision. Fifty-one cases of PT diagnosed as B3 category in 51 women were included in the present study.

RESULTS

Of the 51 cases of PT diagnosed as B3 category on 14-G CB, 39 (76.5%) lesions were confirmed as PT on SE (30, 4 and 5 as benign, borderline and malignant PT respectively) with a PPV of 76.5%. Twelve lesions (23.5%) were diagnosed as FA after surgical excision.

CONCLUSIONS

Our study shows that 14-G CB is a valuable tool, in a preoperative setting, in diagnosing PT.

Phyllodes tumor of breast: a review article

Introduction. Phyllodes tumours are rare fibroepithelial lesions. Accurate preoperative pathological diagnosis allows correct surgical planning and avoidance of reoperation. Treatment can be either wide local excision or mastectomy to achieve histologically clear margins. Discussion. The exact aetiology of phyllodes tumour and its relationship with fibroadenoma are unclear. Women aged between 35 and 55 years are commonly involved. The median tumour size is 4 cm but can grow even larger having dilated veins and a blue discoloration over skin. Palpable axillary lymphadenopathy can be identified in up to 10-15% of patients but <1% had pathological positive nodes. Mammography and ultrasonography are main imaging modalities. Cytologically the presence of both epithelial and stromal elements supports the diagnosis. The value of FNAC in diagnosis of phyllodes tumour remains controversial, but core needle biopsy has high sensitivity and negative predictive value. Surgical management is the mainstay and local recurrence in phyllodes tumours has been associated with inadequate local excision. The role of adjuvant radiotherapy and chemotherapy remains uncertain and use of hormonal therapy has not been fully investigated. Conclusion. The preoperative diagnosis and proper management are crucial in phyllodes tumours because of their tendency to recur and malignant potential in some of these tumours.

Distinction of phyllodes tumor from fibroadenoma: Cytologists' perspective

BACKGROUND

Fibroadenomas and phyllodes tumors may have similar cytological appearances. However, a detailed study of cytomorphology of stromal elements may be helpful in differentiation.

AIM

To evaluate the cytological features of phyllodes tumor in our study with special reference to features that can help distinguishing it from fibroadenoma.

MATERIALS AND METHODS

The archival materials of our hospital were searched from January 2006 to January 2009 for histopathologically-diagnosed cases of phyllodes tumor. The cases in which previous cytopathology smears were available were included in the study. The cytomorphology of 10 such cases were compared with 25 cytologically-diagnosed and histopathologically-confirmed cases of fibroadenoma.

RESULTS

The size, cellularity of stromal fragments, and the proportion of spindle cells in the background are important features in such differentiation.

Update on Fibroepithelial Lesions of the Breast

This article focuses on current issues relating to fibroepithelial lesions, predominantly those with cellular stroma, and covers key pathologic features, differential diagnosis, and pitfalls. Phyllodes tumors are emphasized, including the histologic categorization and prognostic features of these lesions. The management of fibroepithelial lesions on needle core biopsy is reviewed.

Needle core biopsy in the diagnosis of phyllodes neoplasm

BACKGROUND

Accurate identification of phyllodes neoplasms without surgical intervention is difficult, reducing the ability to manage "benign" lumps non-operatively and impacting on the open benign biopsy rate. Needle core biopsy is considered to be a highly accurate technique in the diagnosis of breast carcinoma. Its accuracy in the diagnosis of phyllodes neoplasm has not been established.

METHODS

A series of 3729 core biopsies performed between January 1999 and July 2005 were examined. All core biopsies followed by surgical excision were identified. Histologic concordance between core biopsy and excision specimen was analyzed.

RESULTS

Twenty-three patients had phyllodes neoplasm on excisional biopsy with prior core biopsy findings as follows: phyllodes neoplasm (n=2), "equivocal" for phyllodes neoplasm (n=12), fibroadenoma (n=3), benign (n=6). The false negative rate for phyllodes neoplasm was therefore 39% (n=9/23). Of the total biopsy series, 35 patients had a core biopsy suggesting the possibility of phyllodes neoplasm. Of these, 32% (n=11) were found to be phyllodes neoplasm on excision, 3% (n=1) phyllodes neoplasm with breast carcinoma, 6% (n=2) breast carcinoma, and 3% (n=1) sarcoma. When a preference for phyllodes neoplasm (n=4) was stated on the equivocal core biopsies, excision correlated with the stated preference; this correlation also occurred in 90% (n=9/10) of core biopsies where fibroadenoma was favored.

CONCLUSIONS

Needle core biopsy rarely produces a definite preoperative diagnosis of phyllodes neoplasm. A diagnosis of fibroadenoma or equivocal phyllodes neoplasm on core biopsy should not prevent excision if clinical suspicion remains.

Immunohistochemical expression of heparan sulfate correlates with stromal cell proliferation in breast phyllodes tumors

Phyllodes tumors are fibroepithelial neoplasms typified by stromal proliferation. We have previously shown the role of pathologic parameters and the prognostic significance of p53 and CD117 protein expression in these tumors. In this study, we evaluated the expression of heparan sulfate, which has been implicated in many biological processes such as cell adhesion, embryogenesis, and tumorigenesis (including malignant transformation of mammary cells) in 232 breast phyllodes tumors. We used a monoclonal antibody, 10E4, to examine the localization of heparan sulfate in phyllodes tumors by immunohistochemistry. The immunoreactivity of both epithelial and stromal components was examined and analyzed with pathological parameters and other immunohistochemical markers, including p53, MIB1, bcl2, and CD117. Stromal 10E4 expression was significantly associated with tumor grade, stromal p53, and MIB1 expression in proliferating cells, suggesting that heparan sulfate may participate in malignant tumor growth.

Optimising preoperative diagnosis in phyllodes tumour of the breast

The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. However, reliable differentiation of phyllodes tumour from cellular fibroadenoma remains difficult. Preoperative diagnostic accuracy allows correct surgical treatment, avoiding the pitfalls of reoperation because of inadequate excision, or surgical overtreatment. Specific clinical indices may arouse diagnostic suspicion but are unreliable for confirmation, as with current imaging modes. Fine needle aspiration cytology has a high false negative rate. Few studies have evaluated the role of core needle biopsy, but it may prove a useful adjunct. Both diagnostic and prognostic information may in future be gained from application of immunohistochemical and other techniques assessing the expression of proliferative markers including p53, Ki-67, and others.