Core needle biopsy diagnosis of fibroepithelial lesions of the breast: a diagnostic challenge

Hierarchical diagnosis of breast phyllodes tumors enabled by deep learning of ultrasound images: a retrospective multi-center study

OBJECTIVE

Phyllodes tumors (PTs) are rare breast tumors with high recurrence rates, current methods relying on post-resection pathology often delay detection and require further surgery. We propose a deep-learning-based Phyllodes Tumors Hierarchical Diagnosis Model (PTs-HDM) for preoperative identification and grading.

METHODS

Ultrasound images from five hospitals were retrospectively collected, with all patients having undergone surgical pathological confirmation of either PTs or fibroadenomas (FAs). PTs-HDM follows a two-stage classification: first distinguishing PTs from FAs, then grading PTs into benign or borderline/malignant. Model performance metrics including AUC and accuracy were quantitatively evaluated. A comparative analysis was conducted between the algorithm's diagnostic capabilities and those of radiologists with varying clinical experience within an external validation cohort. Through the provision of PTs-HDM's automated classification outputs and associated thermal activation mapping guidance, we systematically assessed the enhancement in radiologists' diagnostic concordance and classification accuracy.

RESULTS

A total of 712 patients were included. On the external test set, PTs-HDM achieved an AUC of 0.883, accuracy of 87.3% for PT vs. FA classification. Subgroup analysis showed high accuracy for tumors < 2 cm (90.9%). In hierarchical classification, the model obtained an AUC of 0.856 and accuracy of 80.9%. Radiologists' performance improved with PTs-HDM assistance, with binary classification accuracy increasing from 82.7%, 67.7%, and 64.2-87.6%, 76.6%, and 82.1% for senior, attending, and resident radiologists, respectively. Their hierarchical classification AUCs improved from 0.566 to 0.827 to 0.725-0.837. PTs-HDM also enhanced inter-radiologist consistency, increasing Kappa values from - 0.05 to 0.41 to 0.12 to 0.65, and the intraclass correlation coefficient from 0.19 to 0.45.

CONCLUSION

PTs-HDM shows strong diagnostic performance, especially for small lesions, and improves radiologists' accuracy across all experience levels, bridging diagnostic gaps and providing reliable support for PTs' hierarchical diagnosis.

Phyllodes tumors of the breast: Real world data from a multi-institution cohort

INTRODUCTION

Phyllodes tumors (PT) are rare breast lesions arising from fibroepithelial stroma and may be hard to clinically distinguish from fibroadenomas. They are defined as benign, borderline or malignant. The purpose of this study was to describe diagnostic workup and surgical management, and to investigate incidence of local recurrence (LR) and overall survival (OS) in relation to tumor subtype, size, age, surgical margins, surgical method, and year of diagnosis.

METHODS

Retrospective cohort study of all patients surgically treated for a PT in Stockholm, Sweden from 1999 to 2018. Descriptive analyses were performed, and regression models were used to analyze associations between selected covariates and LR and OS.

RESULTS

Among 191 patients, 132 were treated for a benign PT, 40 for a borderline PT and 19 for a malignant PT. Preoperatively, results from diagnostic workup were often ambiguous, and only 45.6 % of cases had a preoperative diagnosis of PT. Initial surgery was breast-conserving in 93.2 % of patients. Recurrences occurred in 10.5 % of the total cohort. 5-year and 10-year OS was 96.1 % and 93.5 %, respectively, for the entire cohort. In a multivariable analysis, neither covariate was associated with risk of LR. Distant recurrences were only detected among patients with malignant PT.

CONCLUSIONS

In the workup of PT, common diagnostic methods such as FNAC, CNB, and mammography may be unreliable, and clinical suspicion plays a critical role in guiding pre-operative decision-making. We found no association between surgical margins and rate of LR or OS. We found no evidence of metastatic potential in benign or borderline PT.

Clinical values of nuclear morphometric analysis in fibroepithelial lesions

BACKGROUND

Fibroepithelial lesions (FELs) of the breast encompass a broad spectrum of lesions, ranging from commonly encountered fibroadenomas (FAs) to rare phyllodes tumors (PTs). Accurately diagnosing and grading these lesions is crucial for making management decisions, but it can be challenging due to their overlapping features and the subjective nature of histological assessment. Here, we evaluated the role of digital nuclear morphometric analysis in FEL diagnosis and prognosis.

METHODS

A digital nuclear morphometric analysis was conducted on 241 PTs and 59 FAs. Immunohistochemical staining for cytokeratin and Leukocyte common antigen (LCA) was used to exclude non-stromal components, and nuclear area, perimeters, calipers, circularity, and eccentricity in the stromal cells were quantified with QuPath software. The correlations of these features with FEL diagnosis and prognosis was assessed.

RESULTS

All nuclear features, including area, perimeter, circularity, maximum caliper, minimum caliper and eccentricity, showed significant differences between FAs and benign PTs (p ≤ 0.002). Only nuclear area, perimeter, minimum caliper and eccentricity correlated significantly with PT grading (p ≤ 0.022). For differentiation of FAs from benign PTs, the model integrating all differential nuclear features demonstrated a specificity of 90% and sensitivity of 70%. For PT grading, the nuclear morphometric score showed a specificity of 78% and sensitivity of 96% for distinguishing benign/borderline from malignant PTs. In addition, a relationship of nuclear circularity was found with PT recurrence. The Kaplan-meier analysis, using the best cutoff determined by ROC curve, showed shorter event free survival in benign PTs with high circularity (chi-square = 4.650, p = 0.031).

CONCLUSIONS

Our data suggested the digital nuclear morphometric analysis could have potentials to objectively differentiate different FELs and predict PT outcome. These findings could provide the evidence-based data to support the development of deep-learning based algorithm on nuclear morphometrics in FEL diagnosis.

Deep learning-assisted distinguishing breast phyllodes tumours from fibroadenomas based on ultrasound images: a diagnostic study

OBJECTIVES

To evaluate the performance of ultrasound-based deep learning (DL) models in distinguishing breast phyllodes tumours (PTs) from fibroadenomas (FAs) and their clinical utility in assisting radiologists with varying diagnostic experiences.

METHODS

We retrospectively collected 1180 ultrasound images from 539 patients (247 PTs and 292 FAs). Five DL network models with different structures were trained and validated using nodule regions annotated by radiologists on breast ultrasound images. DL models were trained using the methods of transfer learning and 3-fold cross-validation. The model demonstrated the best evaluation index in the 3-fold cross-validation was selected for comparison with radiologists' diagnostic decisions. Two-round reader studies were conducted to investigate the value of DL model in assisting 6 radiologists with different levels of experience.

RESULTS

Upon testing, Xception model demonstrated the best diagnostic performance (area under the receiver-operating characteristic curve: 0.87; 95% CI, 0.81-0.92), outperforming all radiologists (all P < .05). Additionally, the DL model enhanced the diagnostic performance of radiologists. Accuracy demonstrated improvements of 4%, 4%, and 3% for senior, intermediate, and junior radiologists, respectively.

CONCLUSIONS

The DL models showed superior predictive abilities compared to experienced radiologists in distinguishing breast PTs from FAs. Utilizing the model led to improved efficiency and diagnostic performance for radiologists with different levels of experience (6-25 years of work).

ADVANCES IN KNOWLEDGE

We developed and validated a DL model based on the largest available dataset to assist in diagnosing PTs. This model has the potential to allow radiologists to discriminate 2 types of breast tumours which are challenging to identify with precision and accuracy, and subsequently to make more informed decisions about surgical plans.

Diagnostic Approach to Mesenchymal and Spindle Cell Tumors of the Breast

Mesenchymal and spindle cell tumors of the breast represent a broad and heterogeneous group of lesions that may be sampled on core needle biopsy or surgical excision. Mesenchymal lesions unique to the breast are those that derive from the specialized breast myofibroblast, such as mammary myofibroblastoma and pseudoangiomatous stromal hyperplasia. However, any mesenchymal lesion arising in extramammary soft tissue may also arise in the breast, including fibroblastic, peripheral nerve sheath, adipocytic, and vascular lesions. The spindle cell lesions pose the greatest diagnostic challenge, due to the significant radiographic, morphologic, and immunophenotypic overlap within the category of mesenchymal lesions and more broadly with other nonmesenchymal breast lesions. The distinction is particularly challenging on the limited material of breast core needle biopsies, and caution should be taken before definitively classifying a breast spindle cell lesion on core needle biopsy to avoid unnecessary treatment if misdiagnosed. Consideration of a wide differential diagnosis, adequate sampling of a resection specimen, use of a targeted immunopanel, and selective use of molecular assays are essential steps for accurate classification of mesenchymal lesions in the breast. This review covers the clinical, histologic, and immunophenotypic features of mesenchymal tumors of the breast, with a special emphasis on the differential diagnoses unique to the breast and challenges encountered on breast core needle biopsy.

Accuracy and Comparison of Core Needle Biopsy Diagnoses With Excision Specimen for Diagnosing Fibroepithelial Lesions of the Breast

Background Core needle biopsy (CNB) for fibroepithelial lesions (FELs) of the breast is commonly encountered by histopathologists. The distinction between fibroadenoma (FA) and phyllodes tumor (PT) can be challenging due to overlapping histological features and the limited nature of CNB material.  Objective This study aimed to assess the accuracy of CNB diagnosis of FA and PT by comparing it with a diagnosis on subsequent surgical excision specimen. Materials and methods A total of 166 cases of FELs of the breast who underwent CNB and subsequent surgical excision between January 2001 and December 2020 were included in our study. All microscopy glass slides were reviewed, and diagnosis confirmed. Results While 125 (75%) cases based on CNB received a definitive diagnosis of either fibroadenoma or PT, the remaining 41 (25%) cases were better classified on excision specimens and were descriptively diagnosed as fibroepithelial lesions on CNB. Diagnoses on CNB and on subsequent excision specimens were concordant in 113 (90.4%) cases. Among 12 cases that were discordant, three cases diagnosed as FA on CNB were upgraded to PT on excision specimens. Nine cases diagnosed as PT on CNB were diagnosed as FA on excision specimens. These included conventional, cellular, juvenile, and complex FA types. Three PTs, which were reported as FA on CNB, measured 6, 12.5, and 17.5 cm in the greatest dimension. Among 23 cases of PT which were further categorized on CNB, tumor categories changed on excision specimens in three cases. The diagnostic accuracy of CNB diagnosis was 90.4%. Conclusion CNB diagnosis showed good accuracy. PT diagnosis should be strongly considered in all tumors measuring >5 cm, especially those exceeding 10 cm. Cellular, juvenile, and complex FAs can be misdiagnosed as PT on CNB. Correlation with clinical and radiological findings can be helpful in establishing correct diagnosis.

Malignant phyllodes tumor with EGFR variant III mutation: A rare case report with immunohistochemical and genomic studies

A female in her 60's presented with a left-sided breast mass. A core needle biopsy specimen showed diffuse proliferation of a round cell tumor, which was positive for vimentin, NKX2.2, BCOR, and focal CD99 on immunohistochemistry (IHC). No fusion genes of the Ewing family sarcomas were detected. With a tentative diagnosis of primary breast sarcoma (PBS), total mastectomy was performed after chemotherapy. The resected tissues showed proliferation of round or spindle-shaped tumor cells with a high nuclear-to-cytoplasmic ratio, exhibiting solid and fascicular arrangements but no epithelial component or organoid pattern. While IHC indicated no particular histological diagnosis, genomic examination revealed gene alterations in MED12 p.G44D, MLL2 (KMT2D) p.T1496fs*27, and EGFR variant III (vIII). Moreover, a retrospective IHC study showed overexpression of EGFRvIII. A malignant phyllodes tumor (PT) with extensive sarcomatous overgrowth was indicated as an integrative diagnosis. This is a rare case of a malignant PT harboring EGFRvIII. The present case provides an importance of accurate diagnosis and genomic analysis of rare breast tumors, as malignant PT and PBS are different in its treatment strategy and prognosis.

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.

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

Current clinical practice in the management of phyllodes tumors of the breast: an international cross-sectional study among surgeons and oncologists

PURPOSE

Phyllodes tumors of the breast are rare fibroepithelial lesions that are classified as benign, borderline or malignant. There is little consensus on best practice for the work-up, management, and follow-up of patients with phyllodes tumors of the breast, and evidence-based guidelines are lacking.

METHODS

We conducted a cross-sectional survey of surgeons and oncologists with the aim to describe current clinical practice in the management of phyllodes tumors. The survey was constructed in REDCap and distributed between July 2021 and February 2022 through international collaborators in sixteen countries across four continents.

RESULTS

A total of 419 responses were collected and analyzed. The majority of respondents were experienced and worked in a university hospital. Most agreed to recommend a tumor-free excision margin for benign tumors, increasing margins for borderline and malignant tumors. The multidisciplinary team meeting plays a major role in the treatment plan and follow-up. The vast majority did not consider axillary surgery. There were mixed opinions on adjuvant treatment, with a trend towards more liberal regiments in patients with locally advanced tumors. Most respondents preferred a five-year follow-up period for all phyllodes tumor types.

CONCLUSIONS

This study shows considerable variation in clinical practice managing phyllodes tumors. This suggests the potential for overtreatment of many patients and the need for education and further research targeting appropriate surgical margins, follow-up time and a multidisciplinary approach. There is a need to develop guidelines that recognize the heterogeneity of phyllodes tumors.

Spindle Cell Lesions of the Breast: A Diagnostic Algorithm

CONTEXT.—

Spindle cell lesions of the breast represent a broad spectrum of entities, ranging from nonneoplastic reactive conditions to high-grade malignant tumors. The wide range makes breast spindle cell lesions a diagnostic pitfall.

OBJECTIVE.—

To review the classification of spindle cell lesions of the breast, including clinical features, morphologic characteristics, and the role of immunohistochemistry as well as molecular tools in assisting the differential diagnosis. A diagnostic algorithm will be proposed.

DATA SOURCES.—

Literature and personal experience are the sources for this study.

CONCLUSIONS.—

Spindle cell lesions of the breast can be classified as biphasic or monophasic, with the former including both spindle cell and epithelial components, and the latter including only spindle cell elements. Each category is further subclassified as low or high grade. In the biphasic low-grade group, fibroadenoma and benign phyllodes tumor are the most common lesions. Other uncommon lesions include hamartoma, adenomyoepithelioma, and pseudoangiomatous stromal hyperplasia. In the biphasic high-grade group, borderline/malignant phyllodes tumor and biphasic metaplastic carcinoma are the main lesions to consider. In the monophasic low-grade group, reactive spindle cell nodule, nodular fasciitis, myofibroblastoma, fibromatosis, and fibromatosis-like metaplastic carcinoma have to be considered. In the monophasic high-grade group, the possible lesions are monophasic spindle cell metaplastic carcinoma, primary breast sarcoma, and metastases. Awareness of the clinical history and careful evaluation of any epithelial differentiation (with a large immunohistochemical panel) are crucial in the distinction.

Fibroepithelial Lesions of the Breast: Update on Molecular Profile With Focus on Pediatric Population

CONTEXT.—

This review article derives from the breast pathology lecture at the Eighth Princeton Integrated Pathology Symposium (PIPS VIII).

OBJECTIVE.—

To provide a literature review and update on fibroepithelial lesions of the breast with molecular findings and findings regarding the pediatric population.

DATA SOURCES.—

The sources include extensive literature review, personal research, and experience.

CONCLUSIONS.—

Given significant differences in prognosis and management of fibroepithelial lesions, we aim to provide readers with pertinent definitions, pathomorphology, molecular findings, and management for each diagnosis, with insights on the pediatric population.

An integrative ultrasound-pathology approach to improve preoperative phyllodes tumor classification: A pilot study

OBJECTIVE

Preoperative diagnosis of phyllodes tumor (PT) is challenging, core-needle biopsy (CNB) has a significant rate of understaging, resulting in suboptimal surgical planification. We hypothesized that the association of imaging data to CNB would improve preoperative diagnostic accuracy compared to biopsy alone.

METHODS

In this retrospective pilot study, we included 59 phyllodes tumor with available preoperative imaging, CNB and surgical specimen pathology.

RESULTS

Two ultrasound features: tumor heterogeneity and tumor shape were associated with tumor grade, independently of CNB results. Using a machine learning classifier, the association of ultrasound features with CNB results improved accuracy of preoperative tumor classification up to 84%.

CONCLUSION

An integrative approach of preoperative diagnosis, associating ultrasound features and CNB, improves preoperative diagnosis and could thus optimize surgical planification.

Diagnosis on Excision Biopsy of Breast Tissues Labeled As Fibroepithelial Tumors on Trucut Samples in a Developing Country

Introduction: Fibroadenomas (FAs) and phyllodes tumors (PTs) are less prevalent but allied to have malignant transformation in many instances. It is a challenge to diagnose the phyllodes by conventional trucut biopsy technique.

Objective: To evaluate the histological characteristics of tumors labeled as fibroepithelial lesions of breast tissues on trucut biopsy and compare with a diagnosis on excision biopsy.

Methods and materials: It was a descriptive cross-sectional study that was carried out in Shaukat Khanum Memorial Hospital and Research Centre within six years from January 2015 to January 2021. In trucut samples, stromal cellularity, stromal cell nuclear atypia, mitotic count, stromal overgrowth, the enhancement of stromal cellularity adjacent to epithelium were scrutinized. In each category, the activity was seen as absent, mild, moderate, or severe. Mitotic activity was graded as 0-1, 0-5, 5-10, >10.

Results: A total of 125 patients were registered for the study. The mean age of patients in our study was 33.86 ± 9.95 years. The mean size was 41.02 ± 27.38 mm with a mean lump duration of 7.52 ± 5.34 months. In the FA group, the trucut sampling report showed the stromal cellularity as mild in 62 (69.7%) and stromal cell nuclear atypia as absent in 68 (76.4%) cases. But in the phyllodes tumor group, the stromal cellularity was severe in 10 (27.8%) patients and stromal cell nuclear atypia was severe in five (13.9%). The ultimate outcome showed that 89 (71.2%) patients had FA and 36 (28.8%) had PT at excision.

Conclusion: Assessment of tumor size, stromal cellularity, mitoses, and enhancement of stromal cellularity adjacent to epithelium are useful markers for diagnosing the PT in trucut needle biopsy.

Upstaging of Fibroepithelial Lesions: A Single-Institution Experience

INTRODUCTION

Fibroepithelial lesions of the breast (FEL) are heterogeneous lesions ranging from fibroadenomas (FA) to phyllodes tumors (PT). FEL with cellular stroma are diagnostic challenges on core needle biopsy (CNB) as it is difficult to distinguish cellular FA from PT. The purpose of this study was to determine the features of FEL on CNB that may be predictive of PT, the upstage rate to PT after excision, and the outcomes of those who did not undergo excision.

METHODS

Overall, 305 patients with FEL on CNB between 2009 and 2019 were identified from a prospectively maintained institutional database. Presentation, imaging, and pathology were evaluated.

RESULTS

Mean age at diagnosis was 43.8 years. Pathology on CNB included 97 cases of FEL favoring FA, 19 cases of FEL favoring PT, 3 cases of FEL versus pseudoangiomatous stromal hyperplasia, and 186 cases of FEL not otherwise specified. Following CNB, 96 (31.5%) patients were observed, 158 (51.8%) patients had an excisional biopsy, 48 (15.7%) patients underwent segmental mastectomy, and 3 (1.0%) patients underwent a mastectomy. The upgrade rate from FEL on CNB to PT upon excision was 25.8%. PT on final pathology was more commonly seen when the CNB identified stromal overgrowth, necrosis, and diagnosis of FEL favoring PT. On multivariable analysis, a final diagnosis of PT was associated with age >50 years, larger tumor size >2 cm, stromal overgrowth, and ≥1 mitoses/10 high power fields (HPF) on CNB. Patients who were observed had smaller tumors compared with those who underwent excision.

CONCLUSION

In this 10-year single-institution experience of FEL, the upstage rate to PT was 25.8%. Excision of FEL is recommended. Furthermore, the observation of lesions appeared to be safe in select cases, specifically in patients with smaller tumor size.

Metformin as a new option in the medical management of breast fibroadenoma; a randomized clinical trial

BACKGROUND

Fibroadenoma (FA) is the most common benign solid breast mass in women, with no definite method of management. Because fibroadenoma is dependent on female sex hormones and comprises hypertrophic changes at cellular levels, we investigated the effects of metformin (MF), a safe hypoglycemic agent with anti-estrogenic and anti-proliferative properties, in the management of fibroadenoma.

METHODS

In this randomized clinical trial study, eligible women with fibroadenomas were assigned randomly to the metformin (1000 mg daily for six months) or the placebo group. Breast physical and ultrasound exam was performed before and after the intervention, and the changes in the size of fibroadenomas were compared in the two groups.

RESULTS

Overall, 83 patients in the treatment, and 92 in the placebo group completed the study. A statistically significant difference in changing size between the two groups was observed only in the smallest mass. In the largest FAs, the rate of size reduction was higher in the treatment group (60.2 % vs. 43.5 %); while a higher rate of enlargement was observed in the placebo group (38 % vs. 20.5 %). In the smallest FAs, the rate of the masses that got smaller or remained stable was about 90 % in the treatment group and 50 % in the placebo group. We categorized size changes of FAs into < 20 % enlargement and ≥ 20 % enlargement. The odds ratio (OR) for an elargemnt less than 20% was 1.48 (95 % CI = 1.10-1.99) in the treatment group in comparison with the placebo group; the odds for an enlargement less than 20% was higher in women with multiples fibroadenomas (OR = 4.67, 95 % CI: 1.34-16.28). In our study, no serious adverse effect was recorded, and the medicine was well-tolerated by all users.

CONCLUSIONS

This is the first study that evaluates the effect of MF on the management of fibroadenoma, and the results suggest a favorable effect. Larger studies using higher doses of MF and including a separate design for patients with single or multiple FAs are suggested in order to confirm this effect.

TRIAL REGISTRATION

This trial (IRCT20100706004329N7) was retrospectively registered on 2018-10-07.

Extramammary Borderline Phyllodes Tumor Presenting as an Umbilical Mass

Phyllodes tumors (PTs) represent a spectrum of rare, fibroepithelial neoplasms of the breast, which can be subcategorized as benign, borderline, or malignant based on their histological appearance. Accessory breast tissue may present anywhere along the embryological mammary ridge, and at distant locations as aberrant breast tissue. We present the case of a 56-year-old lady with an umbilical mass, thought to represent a strangulated hernia. Sections showed a fibroepithelial tumor with leaf-like ducts, conspicuous mitotic activity (up to 8 per 10 high-power fields), and focal infiltration into fat. Immunohistochemical studies showed diffuse positivity of epithelial cells for estrogen receptor, mammaglobin, GCDFP-15, and CK7. These findings were consistent with a borderline PT. This is the first case report of PT presenting as an umbilical mass, and the first extramammary borderline PT described.

Current classification systems and standardized terminology in cytopathology

The history of classification systems and the search for a unified nomenclature in cytopathology spans several decades and expresses the preoccupation of all those involved to make cytopathology a reliable diagnostic tool and a trusted screening method. Early classification schemes, applicable to exfoliative and aspiration cytology, attempted to set some basic standards for how non-gynecological cytopathology findings should be reported. While useful in establishing some basic guidelines, these were not specific to the various fields of non-gynecologic cytopathology, often burdened with specific problems. Cytopathology has evolved tremendously in the last couple of decades, undoubtedly boosted by the emergence of various classification schemes that, more than ever, are based on evidence gathered by professionals across the globe. The benefit of classification systems and standardized nomenclature in cytopathology is to provide useful, clear, and clinically relevant information for clinicians and ultimately to provide the best patient care. Standardized reporting systems make cytopathology reports more meaningful and robust. It now became standard that these include by default elements, such as adequacy criteria, diagnostic groups, risk of malignancy (ROM), and recommendations for patient management. In this brief review, we attempted to summarize how these classification schemes emerged and how they are reshaping the landscape of diagnostic cytopathology.