|Year : 2015 | Volume
| Issue : 3 | Page : 651
Malignant phyllodes tumor with heterologous differentiation: A rare case report
Geeta V Patil Okaly1, Clement Wilfred Devadass2, Sudha Horakerappa Metikurke2
1 Department of Pathology, M S Ramaiah Medical College, Bangalore, KarnatakaDepartment of Pathology, M S Ramaiah Medical College, Bangalore, Karnataka, India
2 Department of Pathology, M S Ramaiah Medical College, Bangalore, Karnataka, India
|Date of Web Publication||9-Oct-2015|
Geeta V Patil Okaly
N016, Flat No-111 B, Wing Comfort Enclave, 2nd Main, Ganganagar, Bangalore - 560 032, Karnataka
Source of Support: None, Conflict of Interest: None
Sarcomas of the breast are rare neoplasms accounting for less than 1% of breast malignancy. A 40-year-old-female with left breast mass underwent wide-excision and on histopathological examination a diagnosis of malignant phyllodes tumor with heterologous differentiation of osteosarcoma and chondrosarcoma was rendered. The heterologous elements were tumor osteoid formation and tumor chondroid formation. The rarity of the lesion was considered for reporting and on follow-up the patient was free of metastasis.
Keywords: Heterologous differentiation, malignant phyllodes, sarcoma breast
|How to cite this article:|
Patil Okaly GV, Devadass CW, Metikurke SH. Malignant phyllodes tumor with heterologous differentiation: A rare case report. J Can Res Ther 2015;11:651
| > Introduction|| |
Phyllodes tumor of the breast is a biphasic fibroepithelial neoplasm and accounts for 0.3 - 1.5% of all female breast tumors. ,,, The majority of these are benign, with the remainder divided between borderline and malignant subtypes. Heterologous sarcomatous stromal elements, such as, chondrosarcoma, liposarcoma, osteosarcoma, rhabdomyosarcoma, angiosarcoma, and leiomyosarcoma are rarely encountered in a malignant Phyllodes tumor. , The rarity of malignant phyllodes showing stromal elements of osteosarcoma and chondrosarcoma was considered when reporting this case.
| > Case report|| |
A 40-year-old woman with a past history of previous surgery for left breast lump three years ago, presented to the Surgical Outpatient Department for recurrent left breast swelling. Physical examination revealed a large, hard, nontender, freely mobile mass in the upper inner quadrant of the left breast that was not attached to the overlying skin or to chest wall. Axillary lymphadenopathy was not seen.
On further interrogation, she reported that the mass was slowly growing over a period of three years, but last month the size had suddenly increased to the present size. There was no history of weight loss, nipple discharge or pain. The right breast and axilla were unremarkable, and a differential diagnosis of borderline phyllodes tumor with foci of osseous metaplasia and cellular fibroadenoma was rendered on the initial core biopsy specimen.
The patient was posted for surgery. On frozen section again a similar differential diagnosis was given and deferred for paraffin section to rule out malignancy. Hence, a wide-local excision/lumpectomy was done.
The lumpectomy specimen measured 9 × 7.5 × 3.5 cm. The cut surface revealed a relatively circumscribed, predominantly solid gritty tumor measuring 5 × 4 × 3.4 cm, with focal myxoid areas and minute cystic spaces, surrounded by a fibrofatty tissue thickness ranging from 1 cm to 2 cm [Figure 1].
|Figure 1: Gross: A well-circumscribed grayish-white tumor, with areas of myxoid tissue. Adjacent breast parenchyma is compressed|
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Microscopy revealed a biphasic focally infiltrative tumor with stromal overgrowth and focal leaf-like spaces lined by a bilayer bland epithelium [Figure 2]. The stroma was highly heterogeneous, composed of spindle cells with pleomorphic nuclei, high abnormal mitosis >10/10 HPF [Figure 3], areas of necrosis and hemorrhage, osteoid formation rimmed by tumor cells, along with osteoclastic giant cells [Figure 4] and [Figure 5], chondroid differentiation [Figure 4], and adipose metaplasia. Lymphovascular tumor emboli were not seen. The surgical margins were adequate and free of tumor. The adjacent breast parenchyma revealed changes of fibrocystic change with florid adenosis, papillomatosis, and columnar cell change. A diagnosis of malignant phyllodes tumor with a heterologous component of osteosarcoma and chondrosarcoma was rendered.
|Figure 2: 10x: Slit-like space lined by epithelium with active stromal overgrowth|
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|Figure 3: 40x: The stroma show tumor giant cells and many abnormal mitosis are noted|
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|Figure 4: 40x: The stroma show a junction of tumor having chondroid and osteoid differentiation, due to overgrowth compress, the slit-like space is lined by compressed epithelium|
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|Figure 5: 40x: The stroma show a tumor osteoid rimmed by tumor cells along with osteoclastic giant cells, osteosarcoma differentiation|
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The patient subsequently underwent simple mastectomy. The patient is alive and well at the one-year follow-up, with no clinical evidence of local recurrence or metastasis.
| > Discussion|| |
Sarcomas of the breast are rare neoplasms accounting for less than 1% of breast malignancy. ,, A malignant phyllodes account for 0.18% of all breast malignancies.  These tumors with heterologous differentiation of osteosarcoma and chondrosarcoma are rare, accounting for 1.3% of all phyllodes tumors. ,, In the population of Asian women, the incidence of phyllodes is 6.92%, as compared to the western population, where the quoted incidence is 0.3 to 1.5%.  Tumors of the breast showing bone and cartilage differentiation are: Intraductal papilloma with stromal metaplasia, cystosarcoma phyllodes, stromal sarcoma, and adenocarcinoma with metaplasia.  The process of the formation of bone and cartilage is different in each category. In adenocarcinoma, metaplasia of the epithelial cells to cartilage or bone occurs, while in cystosarcoma and intraductal papilloma there is metaplasia of the stromal cells. ,
Our case had a prior surgery for breast tumor; however, the slides and report were not available for review. The recurrent tumor was present for the last three years, but a sudden painless increase in the size of the tumor indicated a malignant change in a benign tumor. The finding of malignant heterologous stromal elements placed the tumor in a malignant category. 
Various investigators have found cellular pleomorphic, stromal overgrowth, tumor necrosis, and heterologous stromal elements or the combination of histological features to be prognostically useful. ,,, According to Hawkins et al. four features - high mitotic count, stromal overgrowth, severe nuclear pleomorphism, and infiltrating margins - were useful predictors for the development of metastases.  They also showed that the most reliable predictor for metastasis was the presence of stromal overgrowth, and a primary tumor with stromal overgrowth had a 72% risk of metastatic spread.  Hence, these patients need a close follow-up with a CT scan of the bones and lungs.
Our case did show minimal stromal overgrowth and a close follow-up for one year did not show any metastasis.
| > Conclusion|| |
Overall mammary sarcomas are biologically aggressive tumors characterized by early recurrence and hematogenous metastasis. Hence, they need a close follow-up with a CT scan for local recurrence and distant metastasis.
| > Acknowledgments|| |
The authors would like to thank Dr. KC Mahadev and Dr.Vijaya V Mysorekar.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]