Retrospective study of malignant phyllodes tumors of the breast: Younger age,prior fibroadenoma surgery,malignant heterologous elements and surgical margins may predict recurrence

PurposeThe potential recurrence rate of malignant phyllodes tumors (MPTs) of the breast is high, and the prognostic factors are still unclear. We therefore aim to study the factors affecting the outcome of MPTs.MethodsA retrospective review of MPT patients treated from 2006 to 2020 at our institution was conducted. Univariate and multivariate Cox proportional hazard models were used to examine the influence of different variables on RFS. Moreover, significant prognostic factors were combined to construct the nomogram to predict the probability of relapse occurring in MPT patients. The 5-year and 10-year RFS rates were estimated using the Kaplan–Meier method.ResultsDuring the study period, 188 MPT patients were identified. The presence of malignant heterologous elements was observed in 23 (12.2%) patients with MPT, and the patients with malignant heterologous elements who received chemotherapy had longer RFS, which could reduce the risk of recurrence (p = 0.022). Recurrence occurred in 56/188 (29.8%) patients, of whom 47 experienced local recurrence and 11 experienced distant metastases. The 5-year and 10-year cumulative RFS rates were 77.5% and 70.1%, respectively. Age (p = 0.041), fibroadenoma surgery history (p = 0.004), surgical margins (p = 0.001) and malignant heterologous elements (p < 0.001) were independent risk factors for postoperative RFS. Subsequently, a nomogram was built, with a C-index of 0.64 (95% CI: 0.629–0.661), to predict the risk of recurrence.ConclusionThe results of this study showed that younger age, fibroadenoma surgery history, malignant heterologous elements and surgical margins <1 cm predict a higher incidence of recurrence in MPT patients. Patients with malignant heterologous elements treated with chemotherapy could have a reduced risk of recurrence.     

超声在乳腺叶状肿瘤和纤维腺瘤鉴别诊断中的价值

目的探讨超声多参数综合分析对乳腺叶状肿瘤与纤维腺瘤鉴别诊断的价值。方法分析经病理证实的17例乳腺叶状肿瘤和92例乳腺纤维腺瘤的超声表现。结果17例乳腺叶状肿瘤中3例周围皮肤变薄（占17.65％），11例囊性变（占64．71％），12例内部静脉曲张（占70．59％）。结论皮肤变薄、肿瘤囊性变及肿瘤内部静脉曲张是乳腺叶状肿瘤与乳腺纤维腺瘤鉴别诊断的重要指标，能提高乳腺叶状肿瘤的诊断准确性。     

CD34与SMA在乳腺叶状肿瘤诊断中的作用及病理形态分析

目的观察乳腺叶状肿瘤(PT)及纤维腺瘤(FA)CD34、SMA的表达情况并探讨其意义。方法选取FA患者20例,良性PT患者10例,交界性PT患者5例,恶性PT患者5例进行免疫组化检测CD34、SMA的表达情况。结果 CD34在FA与良性PT中的表达部位存在差异,其表达强度与PT的恶性程度呈正比,SMA在FA中的表达与良性PT存在强度差异,其表达强度与PT的恶性程度呈正比。结论免疫组化检测CD34与SMA的表达可做为鉴别PT和FA的有效方法并对PT的分级有一定帮助。     

Small Breast Lesion Classification Performance Using the Normalized Axial-Shear Strain Area Feature

Breast cancers that are found and confirmed because they are causing symptoms tend to be larger and are more likely to have already spread to the lymph nodes and beyond. Thus, early detection and confirmation are of paramount importance. The normalized axial–shear strain area (NASSA) feature from the axial-shear strain elastogram (ASSE) has been shown to be a feature that can identify the boundary-bonding conditions that are indicative of the presence of cancer. Recently, we investigated and reported on the potential of the NASSA feature for breast lesion classification into fibroadenomas and cancers. In this article, we investigate the size distribution of the lesions that were part of the previous study and analyze classification performance specifically on small lesions (<10 mm diameter). A total of 33 biopsy-proven malignant tumors and 30 fibroadenomas were part of the study that involved three observers blinded to the Breast Imaging Reporting and Data System (BIRADS) ultrasound scores. The observers outlined the lesions on the sonograms and the lesion size (maximum circle-equivalent diameter in millimeters) was computed from this outline. The ASSE was automatically segmented and color-overlaid on the sonogram, and the NASSA feature from ASSE was computed semi-automatically. Receiver operating characteristic curves were then generated for the subset of cases involving small lesions. Box plots were produced for the two different lesion size groups, small and large, from a logistic regression classifier that was built previously. The results of our study show that approximately 38% and 22% of the fibroadenomas and cancers, respectively, were small. Furthermore, it was found that the NASSA feature resulted in a perfect classification of the small lesions, both in the training data and in the cross-validation. For lesions <10 mm the difference in fibroadenoma and cancer mean scores was 0.73 ± 0.13 (p < 0.001), whereas lesions >10 mm had a difference of 0.52 ± 0.24 (p < 0.001). The results also showed that the small lesions actually had better classification than the larger lesions (>10 mm). These results suggest that the ASSE feature can work equally well, even on small lesions, to improve the standard ultrasound BIRADS–based breast lesion classification of fibroadenoma and malignant tumors.     

A harmless evil: Giant fungating benign breast mass in an adolescent mimicking malignancy - Case report

IntroductionJuvenile giant fibroadenoma is a rare type of fibroadenoma characterized by rapid growth of a breast tumor in an adolescent. Benign in nature, they rarely present as fungating and ulcerating tumors. Benign tumors masquerading as malignancies are surgical conundrums. No co nsensus exists yet on the management of these cases. We aim to discuss the dilemma in managing a bleeding, fungating giant fibroadenoma in an adolescent female and highlight risks of alternative therapies.Presentation of caseA 19-year-old lady presented with a bleeding, fungating breast mass worsened with topical herbal concoction. Examination revealed a 10 × 15 cm fungating breast mass that obliterated her nipple- areolar complex (NAC). Computed Tomography (CT) scan reported a huge heterogeneously enhancing mass 10.6 × 14.5 × 15.1 cm with loss of normal fat plane with the overlying skin but a clear fat plane with the pectoralis muscle posteriorly.DiscussionGiant breast masses that fungate and ulcerate usually indicate a sinister pathology. Traditional remedies have been reported to exacerbate growth. In cases where most of the breast parenchyma and NAC has been destroyed, it is no longer possible to proceed with breast conserving techniques. Breast reconstruction is crucial in adolescents and should be tailored to the patient’s existing breast size as well as body habitus.ConclusionIn juvenile giant fibroadenomas where breast parenchyma and NAC has been destroyed, breast reconstruction is the goal. The lack of consensus in both diagnosis and management further compounds the difficulty in dealing with this sensitive population. Awareness needs to be raised regarding negative effects related to traditional medicine.     

When pathological and radiological correlation is achieved,excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted

BackgroundThe diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up.MethodsA retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded.Results2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41–70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.     

Fibroadenoma gigante de mama

Fibroadenomas are one of the most frequent tumors of the breast. These neoplasms are benign and are most frequently diagnosed in young women. The most common form of presentation is a solid, mobile, painless mass that can become very large if there is rapid growth. Diagnosis of these breast masses is normally made by physical examination supported by imaging techniques, mainly ultrasound in young women. Confirmation of the diagnosis is provided by histological analysis. Surgical treatment should be evaluated individually; large nodules with rapid growth should be excised for analysis and for differential diagnosis with other breast diseases and tumors, especially phyllodes tumors.We present the case of a 16-year-old girl who after delivery consulted for a giant breast mass. The mass was excised and the pathological diagnosis was giant fibroadenoma. We discuss the initial approach, treatment and management of these tumors in young patients as well as the importance of a correct differential diagnosis.     

超声造影在乳腺叶状肿瘤与纤维腺瘤鉴别诊断中的价值

目的探讨超声造影在乳腺叶状肿瘤与纤维腺瘤鉴别诊断中的应用价值。 方法选取我院病理诊断明确且术前进行过超声造影检查的患者（叶状肿瘤23例、纤维腺瘤57例）,回顾性分析其超声造影表现,采用χ²检验或t检验分析乳腺叶状肿瘤与纤维腺瘤在超声造影表现和病理中微血管密度间的关系。 结果乳腺叶状肿瘤与纤维腺瘤比较,边界是否清晰,差异无统计学意义（P>0.05）,而增强顺序、增强强度、均匀性三者比较,差异均有统计学意义（χ²=22.960、24.419、4.901,P均<0.05）。叶状肿瘤的超声造影表现为增强后边界清晰、散在的离心性不均匀低增强。纤维腺瘤超声造影表现为增强后边界清楚、向心性均匀高增强。 结论超声造影对乳腺叶状肿瘤与纤维腺瘤有一定的鉴别诊断价值,可为临床手术方法的选择提供参考。     

Fibroepithelial lesions; The WHO spectrum

Fibroepithelial lesions of the breast comprise a morphologically and biologically heterogeneous group of biphasic tumors with epithelial and stromal components that demonstrate widely variable clinical behavior. Fibroadenomas are common benign tumors with a number of histologic variants, most of which pose no diagnostic challenge. Cellular and juvenile fibroadenomas can have overlapping features with phyllodes tumors and should be recognized. Phyllodes tumors constitute a spectrum of lesions with varying clinical behavior and are graded as benign, borderline or malignant based on a set of histologic features according to recommendations by the World Health Organization (WHO). Recent developments have significantly expanded our understanding of the pathogenesis of fibroepithelial lesions, highlighting fibroadenomas as true neoplasms and underscoring a commonality with phyllodes tumors in the form of recurrent MED12 exon 2 mutations. In addition, sequencing studies have elucidated pathways associated with phyllodes tumor progression. Accurate diagnosis and grading of phyllodes tumors are important for patient management and prognosis, as grade broadly correlates with increasing local recurrence risk, and essentially only malignant tumors metastasize. However, classification of fibroepithelial lesions in many cases remains challenging on both core biopsy and excision specimens. A commonly encountered problem at the benign end of the spectrum is the distinction of benign phyllodes tumor from cellular fibroadenoma, which is largely due to the subjective nature of histologic features used in diagnosis and histologic overlap between lesions. Grading is further complicated by the requirement to integrate multiple subjective and ill-defined parameters. On the opposite end of the histologic spectrum, malignant phyllodes tumors must be distinguished from more common metaplastic carcinomas and from primary or metastatic sarcomas, which can be especially difficult in core biopsies. Immunohistochemistry can be useful in the differential diagnosis but should be interpreted with attention to caveats. This review provides an overview and update on the spectrum of fibroepithelial lesions, with special emphasis on common problems and practical issues in diagnosis.     

Spontaneous Infarction in a Fibroadenoma of the Breast

SUMMARY: BACKGROUND: Fibroadenomas are common neoplasms in young women but occur in a wide age range from adolescent females to octogenians. CASE REPORT: A 21-year-old female patient presented with a 10-week history of a mass in her breast. Ultrasound examination demonstrated a 3.5 × 3 cm, well-circumscribed, semisolid mass. An excisional biopsy but no fine needle aspiration was performed. The patient had no history of pregnancy or lactation, or trauma or infection to the area of the lesion. The histopathological examination showed a spontaneously infarcted fibroadenoma. CONCLUSIONS: Spontaneous infarction is an uncommon complication in fibroadenoma of the breast, and there are very few reported cases in the literature.