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Breast-nonmalignant
Benign tumors / changes
Phyllodes Tumor - malignant
Reviewer: Hind Nassar, M.D. in January 2009 (see Authors page)
Revised: 9 October 2012, last major update April 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.
Definition
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● Phyllodes tumors with increased mitotic activity, stromal overgrowth, atypia and infiltrative borders
Terminology
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● Also called high grade
Epidemiology
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● 10% of phyllodes tumors; very rare under age 20 years
Sites
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●
Etiology
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● Some cases apparently develop from fibroadenoma (Breast Cancer 2009 Dec 26 [Epub ahead of print], Appl Immunohistochem Mol Morphol 2009;17:345)
Clinical features
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● Aggressive with local recurrence, 3-22% metastasize to lung, bone, CNS
● Metastases are stromal but may entrap normal epithelium
● Death from disease is associated with recurrences and distant metastases (Am J Clin Path 2005;123:529)
● Better prognosis than invasive ductal carcinoma (Am Surg 2007;73:967)
Prognostic factors
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● Poor prognostic factors: tumor necrosis, stromal elements other than fibromyxoid
Case reports
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● Liposarcomatous stroma in primary and lung metastases (Am J Surg Path 1998;22:1284)
● Osteosarcomatous stroma (Arch Pathol Lab Med 2003;127:e227)
● Osteosarcomatous differentiation in lung metastases only (J Clin Path 2004;57:432)
● Rhabdomyosarcomatous stroma (Am J Surg Pathol 1978;2:423)
● Epithelium resembles tubular adenoma (Int J Med Sci 2006;3:130)
● Metastasis to thyroid Hurthle cell tumor (Arch Pathol Lab Med 2002;126:1233)
● Preceded by extensive vascular proliferation (Mod Pathol 2003;16:823)
● With osteoclast-like giant cells (Ann Pathol 2007;27:31)
● Pregnancy related, occurring in first trimester (Am Surg 2010;76:302), week 34 (Int J Gynecol Cancer 2008;18:856)
● Coexisting carcinomas may derive from phyllodes tumor (Breast Cancer 2007;14:327) or be collision tumors (Hum Pathol 2010;41:293)
Treatment
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● Excision with 1-2 cm margins
● No axillary dissection (J Surg Oncol 2005;91:185)
● Possibly radiation therapy for local control (Int J Radiat Oncol Biol Phys 2008;70:492)
● Chemotherapy has no apparent value (Breast J 2007;13:551)
Clinical images
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●
Gross description (Macroscopy)
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Gross images
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Tumors with hemorrhage and necrosis
Other images: circumscribed tumor
Micro description (Histopathology)
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● >10 mitotic figures per 10 high per fields AND stromal > ductal overgrowth (no ducts at 4x), densely packed anaplastic stromal cells and infiltrative border
● Also tumor necrosis, heterologous stromal elements, may have cellular stroma only around blood vessels
● Note: stroma is the malignant component, and may be present in only part of the tumor, so sample thoroughly
● Stroma may resemble MFH, fibrosarcoma, liposarcoma (Am J Surg Pathol 1994;18:720), osteosarcoma (Am J Surg Pathol 1999;23:815), cartilage, skeletal muscle
● Higher Ki-67 immunostaining than benign phyllodes tumors (Mod Pathol 2001;14:185)
Micro images
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Hypercellular tumor with stromal Multinucleated giant cells
overgrowth, atypia and mitotic figures
Squamous metaplasia and keratin cysts Osteochondroid metaplasia
Sarcomatous stroma Pleomorphic nuclei Infiltration into adipose tissue
Mitotic figures and abnormal mitotic figure
Multinucleated giant cells
Chondrosarcoma component
Fibrosarcomatous stroma
Liposarcoma component
MFH component
Osteosarcoma component
Rhabdomyosarcoma component
Sarcoma NOS component
Metastasis to thyroid Hurthle cell tumor
Ki-67
Fig A: benign tumor with minimal nuclear staining
Fig B: low grade malignant tumor with increased Ki-67
Fig C: high grade malignant tumor with frequent staining
p53+ p53 c-kit+ stromal cells and stromal giant cells
Virtual Slides
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Malignant phyllodes tumor
Videos
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Cytology description
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● Epithelial cells, isolated spindled or round cells, phyllodes fragments, spindle cells within stroma, bipolar naked nuclei
● Epithelial cells may overwhelm sarcomatous component (Diagn Cytopathol 2004;31:71)
Cytology images
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Positive stains
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● c-kit (46%, Mod Pathol 2004;17:827)
Negative stains
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Electron microscopy descriptions
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Electron microscopy images
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Molecular / cytogenetics description
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● Numerous recurrent chromosomal changes including 1q+ and 13q- (Mod Pathol 2007;20:435)
Molecular / cytogenetics images
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Differential Diagnosis
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● Sarcoma
Additional references
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End of Breast-nonmalignant > Benign tumors / changes > Phyllodes tumor - malignant
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