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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 8  |  Page : 1169-1171

Coexistence of phylloides tumour and invasive ductal cancer in the breast


1 Department of Gastroenterological Surgery, Kartal Koşuyolu High Speciality and Training Hospital, Istanbul, Turkey
2 Department of General Surgery, Adana City Hospital Adana City Hospital Training and Research Hospital, Adana, Turkey
3 Department of Pathology, Adana City Hospital Adana City Hospital Training and Research Hospital, Adana, Turkey

Date of Acceptance21-Feb-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. H Bozkurt
Department of Gastroenterological Surgery, Kartal Koşuyolu High Speciality and Training Hospital, Istanbul - 34865
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_602_18

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   Abstract 


Phylloides tumor in the breast is a rare fibroepithelial tumor, which is often seen in young adult women. Phylloides tumor of the breast accounts for about 1% of all breast tumors and approximately 3% of all fibroepithelial tumors. Pre-operative diagnosis is difficult. Since there aren't any specific mammography and ultrasound findings, they cannot be distinguished from fibroadenomas through these imaging methods and are mostly followed up as if they are fibroadenomas. Patients often present with the complaint of a mass that has been present for a long time and had started to grow suddenly. The primary preferred approach for treatment is wide local excision with negative surgical margins. Coexistence of invasive ductal carcinoma with phylloides tumor in the same breast is a very rare occurrence. We present in this article, a 42-year-old female patient with an invasive ductal carcinoma inside a phylloides tumor in the same breast.

Keywords: Breast cancer, invasive ductal cancer, phylloides tumor


How to cite this article:
Bozkurt H, Karakaya I B, Aktas E, Irkorucu O. Coexistence of phylloides tumour and invasive ductal cancer in the breast. Niger J Clin Pract 2019;22:1169-71

How to cite this URL:
Bozkurt H, Karakaya I B, Aktas E, Irkorucu O. Coexistence of phylloides tumour and invasive ductal cancer in the breast. Niger J Clin Pract [serial online] 2019 [cited 2019 Oct 15];22:1169-71. Available from: http://www.njcponline.com/text.asp?2019/22/8/1169/264420




   Introduction Top


Phylloides tumor of the breast is a rarely seen fibroepithelial tumor, which accounts for less than 1% of all primary breast neoplasms and 2–3% of all fibroepithelial tumors.[1] Phylloides tumors are generally found in females between the age of 35 and 55.[2] Phylloides tumors are often clinically well-demarcated and mobile palpable masses. They might be found coincidentally as a result of biopsy or appear in the form of fast-growing masses in a short time. They look like fibroadenomas structurally and thus might be easily confused with fibroadenomas during physical examination.[3] However, they are typically organized in leaf-like structures because of more cellular stroma.[4] They are histologically divided in three grades: Benign, borderline, and malignant.[5],[6] For diagnosis, fine-needle aspiration biopsy (FNAB) is often not sufficient, and core biopsy is more valuable.[7] Treatment can be performed by limited excision, wide excision and mastectomy. But recurrence might be seen in the options other than mastectomy. Preferred treatment of all benign lesions is breast-conserving surgery; when the mass is very large, mastectomy can be preferred due to aesthetic problems caused by excision.[8],[9] Invasive ductal carcinoma (IDC) accounts for 47–75% of all breast carcinomas and is the most common type of such cancers.[10] Coexistence of Invasive Ductal Carcinoma and Phylloides Tumor in the same breast is a rare occurrence. According to the literature, presence of an invasive ductal carcinoma focus in the phylloides tumor is extremely rare.[9] We hereby report a case coexisting invasive ductal carcinoma in the phylloides tumor.


   Case Presentation Top


A 42-year-old pre-menopausal female patient presented a mass in the right breast, which grew significantly during the last 3 months, no risk factors were found regarding breast cancer. According to the breast USG performed in our hospital, a mass of about 15 cm compatible with fibroadenoma was seen in the right breast. According to the bilateral mammography performed in the same center, left breast is normal whereas parenchyma in the right breast has a dense appearance, and a mass condensation with a diameter of about 16 cm is seen in lobular covers a large part of the breast. Mass contains calcification in the center. There is no axillary involvement. Excisional biopsy was performed on the patient in the same center and the pathology report was; the 4 μm sections of the paraffined blocks, which were fixated, sampled, and tracked at another center; was stained with hematoxylin and eosin. Biphasic breast tumor was seen in the sections of the mass that was specified in the dimensions of 18 × 18 × 15 cm. Moderate cellularity increase and mild to moderate atipia was observed in the stroma; the number of mitosis that was counted in 10 large magnification area was 5–9 and the tumor was classified as borderline phyllodes tumor according to WHO. In the biphasic tumor, grade 1 invasive ductal carcinoma, with intraductal carcinoma areas, in the dimensions of 2,5 × 2 × 1,5 cm drew attention. Immunohistochemically ER was %50 positive; PR was %60 positive; cerbB2 was score 3; Ki67 proliferative index was %8-10 and e-cadherin was positive in the invasive carcinoma.

For the purpose of staging, chest radiography, bone scintigraphy, and abdominal ultrasonography were performed, but no pathology was found. PET-CT was planned. In the right upper inner quadrant breast, irregular increased FDG (fluorodeoxyglucose) involvements (SUVmax: 4.21) were seen, which caused thickening of the breast skin. Besides, hypermetabolic focus was observed in the right lower outer quadrant breast, which pointed out increased FDG involvement (SUVmax: 3.33). Another mass of 3 cm was determined in the right lower quadrant, which didn't show any FDG involvement. Hypermetabolic multiple lymph nodes largest of which was 16 mm were seen in the right axilla, which showed increased FDG involvement (SUVmax: 4.09).

Tumor was discussed in the council since there was multifocal FDG involvement and axillary involvement in the PET-CT of patient. Modified radical mastectomy was decided. Pathology was reported as multifocal intraductal carcinoma [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. The patient with negative surgical margins was discharged on the 5th post-operative day after removal of drains.
Figure 1: (a) Dens stroma and interlacing clefts of phylloides tumor hematoxylin eosin 4×. (b) Stromal cellularity and epithelial line cleft in the phylloides tumor, hematoxylin eosin 10×. (c) Invasive carcinoma, ductal carcinoma in situ areas, hematoxylin eosin 4×. (d) Invasive carcinoma and ductal carcinoma in situ in phylloides tumor hematoxylin eosin 4×

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   Discussion Top


Phylloides tumor is one of the fast-growing tumors even though it is generally histologically benign. It might remain silent for many years and then start again to grow fast in some patients. Due to this fast growth, there might be axillary lymphadenopathies, enlargement in the skin and veins, nipple changes, and necrosis.[11] Mammography and ultrasonography used in diagnosis of breast masses are not very reliable in the differential diagnosis of PTs from fibroadenomas.[1],[2] In our case, diagnosis of either phylloides tumor or distinct invasive ductal carcinoma focus inside the tumor couldn't be established in the pre-operative USG and mammography, instead they were diagnosed at histology after excisional biopsy. Among the pre-operative histopathological diagnostic methods regarding phylloides tumors, while fine-needle aspiration biopsy isn't preferred due to its high false negative rate, results of core biopsy is found to be more reliable in diagnosis.[3],[11] In our case, since final diagnosis couldn't be established via pre-operative imaging method, excisional biopsy was planned and performed. Phylloides tumor and the invasive ductal carcinoma focus in it were determined in the sections. Surgery is essential in the treatment of phylloides tumors, and wide excision with negative surgical margins (at least 1 cm) is recommended for the surgical approach regardless of the histopathological type.[12] Local recurrence rates are 3–15% and 3–50%[9] for benign phylloides tumors and malignant cases, respectively. In this case, surgical margins were negative in the in the sections of phylloides tumor performed, but the surgical approach was changed due to the coexisting multifocal invasive ductal carcinoma.

Development of cancer inside a phylloides tumor is quite rare and about 30 such patients have been reported in the literature so far.[13] Reported sub-types are in situ and invasive lobular and ductal carcinoma, tubular carcinoma, and squamous carcinoma.[14] In this case, there was invasive ductal carcinoma focus inside the phylloides tumor. Additionally, other foci of multifocal invasive ductal carcinoma focuses were also found in the modified radical mastectomy material.

Due to the similarity between phylloides tumors and fibroadenomas both clinically and radiologically, care must be taken in the pre-operative evaluation of PT cases.[14] In this case, even though pre-operative diagnosis was difficult, additional imaging methods were used after the excisional biopsy revealed coexistence of invasive ductal carcinoma. Due to PET-CT results showing the involvement of breast and axilla on the same side after excision, treatment was planned according to the invasive ductal carcinoma stage.

Phylloides tumors are rarely seen breast lesions and their diagnosis might often be confused with fibroadenomas. Even though rare, its coexistence with other malignancies must be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Buchanan EB. Cystosarcoma phylloides and its surgical management. Am Surg 1995;61:350-5.  Back to cited text no. 1
    
2.
Reinfuss M, Mitus J, Duda K, Stelmach A, Rys J, Smolak K. The treatment and prognosis of patients with phylloides tumour of the breast: An analysis of 170 cases. Cancer 1996;77:910-6.  Back to cited text no. 2
    
3.
Foxcroft LM, Evans EB, Porter AJ. Difficulties in the pre-operative diagnosis of phylloides tumours of the breast: A study of 84 cases. Breast 2007;16:27-37.  Back to cited text no. 3
    
4.
Chen WH, Cheng SP, Tzen CY, Yang TL, Jeng KS, Liu CL, et al. Surgical treatment of phylloides tumors of the breast: Retrospective review of 172 cases. J Surg Oncol 2005;91:185-94.  Back to cited text no. 4
    
5.
Pietruszka M, Barnes L. Cystosarcoma phylloides: A clinicopathologic analysis of 42 cases. Cancer 1978;41:1974-83.  Back to cited text no. 5
    
6.
Lim SM, Tan PH. Ductal carcinoma in-situ within phylloides tumour: A rare occurrence. Pathology 2005;37:393-6.  Back to cited text no. 6
    
7.
Komenaka IK, El-Tamer M, Pile-Spellman E, Hibshoosh H. Core needle biopsy as a diagnostic tool to differentiate phylloides tumour from fibroadenomas. Arch Surg 2003;138:987-90.  Back to cited text no. 7
    
8.
Chen WH, Cheng SP, Tzen CY, Yang TL, Jeng KS, Liu CL, et al. Surgical treatment of phylloides tumours of the breast: Retrospective review of 172 cases. J Surg Oncol 2005;91:185-94.  Back to cited text no. 8
    
9.
Asoglu O, Ugurlu MM, Blanchard K, Grant CS, Reynolds C, Cha SS, et al. Risk factors for recurrence and death after primary surgical treatment of malignant phylloides tumours. Ann Surg Oncol 2004;11:1011-7.  Back to cited text no. 9
    
10.
Glass AG, Lacey JV Jr, Carreon JD, Hoover RN. Breast cancer incidence, 1980-2006: Combined roles of menopausal hormone therapy, screening mammography, and estrogen receptor status. J Natl Cancer Inst 2007;99:1152-61.  Back to cited text no. 10
    
11.
Jacklin RK, Ridgway PF, Ziprin P, Healy V, Hadjiminas D, Darzi A. Review: Optimising preoperative diagnosis in phylloides tumour of the breast. J Clin Pathol 2006;59:454-9.  Back to cited text no. 11
    
12.
Kapiris I, Nasiri N, A'Hern R, Healy V, Gui GPH. Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phylloides tumours of the breast. Eur J Surg Oncol 2001;27:723-30.  Back to cited text no. 12
    
13.
Parfitt JR, Armstrong C, O'malley F, Ross J, Tuck AB. In-situ and invasive carcinoma within a phylloides tumour associated with lymph node metastases. World J Surg Oncol 2004;2:46.  Back to cited text no. 13
    
14.
Soyder A, Meteoğlu İ, Özbaş S. Phyllodes Tumour With Simultaneous Invazif Duktal Carcinoma in The Ipsilateral Breast. The Journal of Breast Health. 2008:4.  Back to cited text no. 14
    


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