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phyllodes_tumor

Phyllodes tumor

Key Terms: Areola, Fibroadenoma, Mitosis, Pathologist, breast cancer, lymphedema, arm lymphedema, cystosarcoma phyllodes, cystosarcoma phylloides, giant fibroadenomas, Cystosarcoma phyllodes

These are rare breast tumors that are found no where else in the body. They are formed within the connective tissue (stroma) and contain glandular as well as stromal tissue. Phyllodes tumors can grow noticeably within a matter of weeks, causing the overlying skin to become semi-transparent or reddish and warm to the touch. They do not, however, usually involve the nipple or areola.

A phyllodes tumor can be moved freely within the breast when the doctor performs a manual examination. The tumor has a firm, smooth texture, can be easily distinguished from the surrounding tissue, and may grow to be quite large and bulky. The average size of phyllodes tumors is about 2 in (5 cm), although tumors as large as 11.8 in (30 cm) have been reported. These tumors do not cause pain when touched. For reasons that are not yet understood, phyllodes tumors are more likely to develop in the left breast than the right. (1)

These tumors account for only about one percent of all malignant breast tumors. However, as with other types of cancer it can metastssize, so early detection and treatment is critical. It affects females predominantly with it being exceptional rare in males. It overwhelmingly affects female and can occur at any age, though the fifth decades is usually when they might appear.

Causes of Phyllodes tumors

Unknown at the present time.

Stages

Unlike other breast cancers, phyllodes tumors are not classified according to stages 1 to 4. The pathologist will be looking for two characteristics. First, the speed at which the cells are dividing and the number of irregularly shaped calls. (2)

Symptoms

Symptoms include a firm, palable mass in the breast (usually not painful) and the breast may itself become red or warm to the touch. These tumors are very fast growing and must be removed as soon as possible to prevent the spread of the disease. As the symptoms also mimic other types of breast cancer, it is critical for them to be evaluated quickly.

In advances cases a phyllodes tumor can cause an ulcer or open wound to form on the skin of the breast.

Complications of a Phyllodes tumor

The list of possible complications includes lymphedema, bleeding, hematoma formation, brachial plexus injuries (generally caused by radiotherapy), seroma formation and a cosmetic disfiguration. Infection is a potential complication of any intrusive procedure.

Diagnosis

While both, a mammogram and/or breast ultrasounds can detect the tumor, for accurate diagnosis, most doctors still prefer an open surgical biopsy. One difficulty with a phyllodes tumor is that radiologically, the tumor may look like a fibroadenoma.

In the removal surgery, one study from Italy indicated that a breast MRI provided the most accurate image of the tumor and subsequently help the surgeon to plan the surgery.

The treating physcian may perform an axillary lymph node dissection only for clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells. As removal of lymph nodes is a key factor in the development of lymphedema, be sure to discuss this completely with your doctor.

There are no known tumors markers or blood tests that are useful in the diagnosing of a phyllodes tumor.

Treatment

Treatment generally is through removal of the tumor itself. The surgeon will remove not only the tumor but a wide margin of tissue surrounding it. Other treatment modalities can include: lumpectomy, a mastectomy, radiation and/or chemotherapy. The specific plan of treatment will be determined by your oncologist subsequent to the diagnostic findings.

The tumor has been generally unresponsive to both chemotherapy and/or radiation in treatment, while hormonal manipulation has had no success documented.

Alernative and Complementary Therapies

I was not able to locate any alternative or complementary therapy that would treat or cure a [hyllodes tumor, neither benign or malignant. However, according to the American Cancer Society, breast cancer survivors and likely to use some form of alternative or complementary therapy during cancer treatment and sometimes years after treatment was completed.

The reasons given are: To maintain an active role in recovery from cancer; to reduce their stress level; to reduce the risk of recurrence, to maintain hope.

The specific CAM therapies included, exercise, humor, self-help books (bibliotherapy), prayer or spiritual practice, vitamin treatments, relaxation therapies, hypnosis, visualization, naturopathy and journaling. Acupuncture is also mentioned as a useful method to control pain.

Alternative therapies can be useful in helping give the patient a sense of control or inclusion in their healing process. However, before taking any herbal or vitamin treatment it is critical you discuss it fully with your doctor. Some homeopathic medicines may contradict the regular medicine your doctor prescribes and/or even be dangerous simply by themselves.

If you are considering any alternative medical therapy, please read our page: How to be Safe with Complementary and Alternative Medicine and our page: How to Evaluate Complementary and Alternative Medicine

Prognosis

The outlook for phylodes tumors depend upon it size, if the cancer has spread. The outlook for benign tumors is excellent. Smaller ones are simply removed by a lumpectomy, while malignant ones will be removed as will a wide excision or surrounding tissue (WLE).

If it has metastisized, it is generally observes in the lung, mediastinum and/or skeleton. (3)

For survivors, there is a possibility of lymphedema developing in the arm of the affected breast.

(1) Answers.com (2) About.com (3) eMedicine-Medscape

Abstracts and Studies

Comparative study of histological features between core needle biopsy and surgical excision in phyllodes tumor. Feb 2012

Choi J, Koo JS.

Source

Department of Pathology, Yonsei University Wonju College of Medicine, Wonju Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea.

Keywords: breast;core needle biopsy; grade; phyllodes tumor

Abstract

We analyzed histopathological features of core needle biopsy (CNB) and surgical excision specimen comparatively in 129 patients with surgically proven phyllodes tumor (PT). Stromal characteristics including cellularity, atypia, mitosis, overgrowth, tissue fragmentation, and the tumor margin were assessed. Benign/borderline/malignant phyllodes tumor (PT) were diagnosed in 90 (69.8%)/30 (23.3%)/9 (7.0%) patients. Among the 90 cases of benign PTs, 67 cases (74.4%) were diagnosed concordantly in CNB. For borderline and malignant PTs, three out of eight (26.6%) and four out of nine (44.4%) cases were diagnosed concordantly in CNBs. All 50 cases of discordant diagnosis were underestimated in matched CNBs, especially in their stromal cellularity and mitosis. The size of tumor is larger in discordant cases of PT (P= 0.013). The concordant rate of diagnosis between CNB and surgical excision was about 60% and accordingly, grading of PT based on the histological findings in CNBs has limitation. The discordance comes from heterogeneous stromal properties of PTs.

WileyOnline Pathology International

Stromal keratin expression in phyllodes tumours of the breast: a comparison with other spindle cell breast lesions. Jan. 2012

Chia Y, Thike AA, Cheok PY, Yong-Zheng Chong L, Man-Kit Tse G, Tan PH.

Source

Department of Pathology, Singapore General Hospital, Singapore.

Abstract

AimTo determine the frequency, pattern and distribution of stromal keratin expression in phyllodes tumours if any, which may impact diagnostic approaches.MethodsThe clinicopathological features of 109 phyllodes tumours comprising 70 (64.2%) benign, 30 (27.5%) borderline and nine (8.3%) malignant grades were evaluated, and the immunohistochemical expression of a keratin panel (MNF116, 34βE12, CK7, CK14, AE1/3, Cam5.2), p63 and CD34 in their stromal component was assessed.ResultsThere was focal and patchy cytoplasmic keratin staining in 1-5% of stromal cells in 13 (11.9%), 24 (22%), 31 (28.4%), 2 (1.8%), 9 (8.3%) and 2 (1.8%) cases for MNF116, 34βE12, CK7, CK14, AE1/3, Cam5.2, respectively. CD34 was expressed in 79 (72.5%) cases. There was no stromal staining for p63. Stromal MNF116, 34βE12 and Cam5.2 reactivity was significantly associated with phyllodes tumour grade (p=0.027, p=0.034, p=0.009 respectively), while MNF116 stromal staining was observed in tumours with increasing cellularity (p=0.036), necrosis (p=0.015) and cystic change (p=0.048).

Contrary to common understanding, these findings confirm that stromal cells in phyllodes tumours can sometimes express keratins, albeit focal and in a patchy distribution. In comparison, fibromatosis and dermatofibrosarcoma were uniformly negative for the same keratin panel, while spindle cell components of eight metaplastic carcinomas expressed at least two or more keratins in a wider distribution of up to 90% of positively stained spindle cells. All eight spindle cell sarcomas were negative for keratins.ConclusionThe use of keratins as an adjunctive immunohistochemical diagnostic tool in the differential work-up of spindle cell tumours of the breast has to be interpreted with caution especially on limited core biopsy material.

PubMed

Giant malignant phyllodes tumor: a case report. 2011

MIKI TAKENAKA1)2), UHI TOH2), HIROKO OTSUKA2), HIROKI TAKAHASHI2), NOBUTAKA IWAKUMA2), SHINO NAKAGAWA2), TERUHIKO FUJII2), RIN YAMAGUCHI1), HIROHISA YANO1), KAZUO SHIROUZU2) and MASAYOSHI KAGE3)4)

1) Department of Pathology, Kurume University School of Medicine 2) Department of Surgery, Kurume University School of Medicine 3) Department of Diagnostic pathology, Kurume University Hospital 4) Research Center for Innovative CancerTherapy, Kurume University

Key words: giant phyllodes tumor, phyllodes tumor, phyllodes tumor malignant type

Summary: We present a case of a 57-year-old woman with a giant malignant phyllodes tumor (PT) in her right breast, with maximum diameter of 20 cm. The core-needle and excisional biopsy specimens were diagnosed as suspicious for low-grade myofibroblastic sarcoma (LGMS). The subsequent total mastectomy with partial resection of the pectoral muscles showed predominance of stromal hypercellularity without an epithelial component. However, we diagnosed this as a malignant PT because focal areas showed a leaf-like pattern. In the case of large malignant PTs that exhibit stromal predominance, it can be difficult to distinguish between a pure sarcoma and malignant PT. It is important to thoroughly examine multiple sections from the view point of residual epithelial structure in morphological diagnosis.

Kurume medical Journal

Comparison of stromal CD10 expression in benign, borderline, and malignant phyllodes tumors among Egyptian female patients. Oct 2011

Ibrahim WS.

Source

Department of Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt.

Abstract

Keywords: CD10, immunohistochemistry, phyllodes, stromal breast tumors

Background: Phyllodes tumors are group of biphasic fibroepithelial tumors of the breast of varying malignant potential, ranging from benign tumors to fully malignant sarcomas. According to the Egyptian National Cancer Institute, female malignant cases showed appreciable increase in the recent time period for breast cancer with the malignant phyllodes tumors representing 0.41% of cases in the year 2003-2004.

Aims: This is an immunohistochemical study to compare CD10 expression in benign, borderline, and malignant phyllodes tumors, in order to highlight its diagnostic and prognostic values.

Materials and Methods: This study conducted 34 Egyptian female cases of phyllodes tumors of different grades to be studied histologically and immunohistochemically using antibodies against CD10. Statistical

Analysis: The Chi-square test was used to determine differences in CD10 expression between benign, borderline, and malignant tumors. One-way ANOVA test was used to determine whether the difference was significant. Significance was established at P<0.05.

Results: In the 24 cases of benign phyllodes tumors, only four cases (16.7%) showed positive CD10 reactivity. Three cases (60%) out of five borderline phyllodes tumors showed positive CD10 reactivity, while four (80%) out of five cases of malignant phyllodes tumors showed positive CD10 staining.

Conclusion: From these highly significant results, we believe that there is a strong correlation between CD10 expression and tumor grade, which could be an important observation that may have both diagnostic and prognostic implications as well as promising potential target for development of novel therapies.

Pathology and Microbiology

The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases. March 1996

Reinfuss M, Mituś J, Duda K, Stelmach A, Ryś J, Smolak K.

Source

Department of Radiotherapy, Center of Oncology, Maria Sklodowska-Curie Memorial Institute, Krakow, Poland.

Abstract

BACKGROUND: The study addresses the controversial prognostic and therapeutic aspects of phyllodes tumor of the breast.

METHODS: Records of 170 women with phyllodes tumor of the breast were reviewed. On the basis of the criteria proposed by Azzopardi and Salvadori et al., including estimation of tumor margin, growth of the connective tissue component, mitoses, and cellular atypia, the entire series was divided into three histotypes of phyllodes tumor, i.e., benign (92 cases, 54.1%), borderline (19 cases, 11.2%), and malignant (59 cases, 34.7%). Ninety-eight patients (57.6%) were treated by wide local excision (79 benign, 15 borderline, and 4 malignant), 43 (25.3%) by simple mastectomy (13 benign, 4 borderline, and 26 malignant), and 29 (17.1%) by radical mastectomy (all malignant).

RESULTS: Of the 170 treated patients, 141 (82.9%) survived 5 years without evidence of disease. In the Cox multivariate analysis the histotype of the tumor was the only independent prognostic factor: 5-year NED survival was observed in 95.7% of the patients with benign phyllodes tumor, 73.7% with borderline phyllodes tumor, and 66.1% with malignant phyllodes tumor. After a wide local excision 98.7% of the patients with benign tumor, and 80% with borderline tumor, were cured. Local recurrence was found in 14 patients (8.2%) (4 benign, 3 borderline, and 7 malignant); 10 of these underwent reoperation (7 wide local excision, 3 radical mastectomy) and survived 5 years NED.

CONCLUSIONS: The histotype of phyllodes tumor (benign, borderline, and malignant), assessed on the basis of the criteria proposed by Azzopardi and Salvadori et al., was the only prognostic factor in our group of patients. Based on the data from literature and our own observations, we observed that a wide local excision, with an adequate margin of normal breast tissue, is the preferred initial therapy for phyllodes tumor of the breast.

PubMed

External Links

Delayed cardiac metastasis from phyllodes breast tumor presenting as cardiogenic shock. 2011

Key words: Breast neoplasms/pathology, cardiac surgical procedures, electrocardiography, fatal outcome, heart neoplasm metastasis, heart ventricles, neoplasm invasiveness, neoplasms/secondary/surgery, phyllodes tumor/pathology/secondary/surgery, recurrence

THIJ Texas Heart Institute Journal

Predicting clinical behaviour of breast phyllodes tumours: a nomogram based on histological criteria and surgical margins. Nov 2011

BMJ

Molecules involved in epithelial-mesenchymal transition and epithelial-stromal interaction in phyllodes tumors: implications for histologic grade and prognosis. Dec 2011

Keywords: Breast – Phyllodes tumor – Grade – Twist

SpringerLink

Differentiation Between Phyllodes Tumor and Fibroadenoma Using Real-Time Elastography. Dec 2011

Key words fibroadenoma - phyllodes tumor - elastography - breast

ThiemeeJournal

Malignant transformation of breast fibroadenoma to malignant phyllodes tumor: long-term outcome of 36 malignant phyllodes tumors. Oct 2011

Keywords Malignant phyllodes tumor – Fibroadenoma – Malignant transformation – Breast tumor – Cohort study

SpringerLink

Malignant phyllodes tumor of the breast: case report. Oct 2011

ScieLo

Phyllodes Tumor of the Breast: Role of CD10 in Predicting Metastasis. Oct 2011

SpringerLink

Phyllodes tumors: race-related differences. Oct 2011

JACS

Diffuse expression of PAX2 and PAX8 in the cystic epithelium of mixed epithelial stromal tumor, angiomyolipoma with epithelial cysts, and primary renal synovial sarcoma: evidence supporting renal tubular differentiation. Sept 2011

Keywords PAX8, PAX2, AMLEC, MEST, synovial sarcoma

Surgical Pathology

Borderline phyllodes tumor with an incidental invasive tubular carcinoma and lobular carcinoma in situ component: a case report. Sept 2011

Keywords: Breast neoplasms, Breast screening, Fibroepithelial tumor, Mammography.

Journal of Breast Cancer

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phyllodes_tumor.txt · Last modified: 2012/10/16 14:40 (external edit)