Abstracts
CONTEXT: The malignant variety of the phyllodes tumor is rare. The occurrence of invasive lobular carcinoma within fibroadenoma is rare as well. DESIGN: Case report. CASE REPORT: A 58-year-old black female patient was referred to the Mastology unit of the Department of Gynecology, Federal University of São Paulo / Escola Paulista de Medicina, in February 1990, presenting an ulcerated tumor in the right breast with fast growth over the preceding six months. She was a virgin, with meno-pause at the age of 45 years and had not undergone hormone replacement treatment. The physical examination showed, in her right breast, an ulcerated tumor of 20 x 30 cm which was not adher-ent to the muscle level, multilobular and with fibroelastic consistency. The axillary lymph nodes were not palpable. The left breast showed a 2 x 3 cm painless, movable nodule, with well-defined edges, and fibroelastic consistency. We performed left-breast mammography, which showed several nodules with well-defined edges, the largest being 2 x 3 cm and exhibiting rough calcification and grouped microcalcifications within it. The patient underwent a frozen biopsy that showed a malignant variant of the phyllodes tumor in the right breast and fibroadenoma in the left one. After that, we performed a total mastectomy in the right breast and an excision biopsy in the left one. Paraffin study confirmed the frozen biopsy result from the right breast, yet we observed that in the interior of the fibroadenoma that was removed on the left, there was a focal area of invasive lobular carcinoma measuring 0.4 cm. The patient then underwent a modi-fied radical mastectomy with total axillary lymphadenectomy. None of the 21 dissected lymph nodes showed evidence of metastasis. In the follow-up, the patient evolved asymptomatically and with normal physical and laboratory examination results up to July 1997.
Fibroadenoma; Phyllodes Tumor; Breast Cancer
CONTEXTO: O tumor Phyllodes variedade maligna é raro na literatura. A associação entre fibroadenoma e carcinoma lobular invasivo no seu interior também é rara. OBJETIVO: Descrever a concomitância das três neoplasias na mesma paciente, situação esta ainda não descrita. TIPO DE ESTUDO: Relato de caso. RELATO DE CASO: Paciente de 58 anos, mulher, foi atendida na Unidade de Mastologia do Departamento de Ginecologia da Universidade Federal de São Paulo em fevereiro de 1990, apresentando tumor ulcerado na mama direita com rápido crescimento nos últimos seis meses. Era virgem, com menopausa aos 45 anos e não recebeu reposição hormonal. Ao exame físico, tumor ulcerado na mama direita, de 20x30 cm que não estava aderida aos planos musculares, era multilobular e com a consciência fibroelástica. Linfonodos axilares não eram palpáveis. Na mama esquerda, um nódulo móvel de 2x3 cm, com limites bem definidos e consistência fibro-elástica. Foi realizada mamografia na mama esquerda que mostrou vários nódulos de limites bem definidos. O maior de 2x3 cm exibindo calcificação e um grupo de microcalcificações. A biópsia por congelação apresentou uma variação maligna do tumor de phyl-lodes na mama direita e fibroadenoma na esquerda. Foi realizada a mastectomia direita e biopsia excisional esquerda. O exame histopatológico confirmou o resultado da biópsia por congelação da mama direita e apresentou no interior da fibroadenoma da mama esquerda uma área apenas com carcinoma invasivo lobular medindo 0.4 cm. A paciente foi submetida a mastectomia radical com linfadenectomia axilar total. Nenhum dos 21 nódulos dissecados apresentou metástase. No seguimento, a paciente evoluiu assintomática até julho de 1997.
Fibroadenoma; Tumor Phyllodes; Câncer de Mama
Case Report
Luiz Henrique Gebrim
Júlio Roberto de Macedo Bernardes Júnior
Afonso Celso Pinto Nazário
Cláudio Kemp
Geraldo Rodrigues de Lima
Malignant phyllodes tumor in the right breast and invasive lobular carcinoma within fibroadenoma in the other: case report
Department of Gynecology, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil
ABSTRACT
CONTEXT: The malignant variety of the phyllodes tumor is rare. The occurrence of invasive lobular carcinoma within fibroadenoma is rare as well.
DESIGN: Case report.
CASE REPORT: A 58-year-old black female patient was referred to the Mastology unit of the Department of Gynecology, Federal University of São Paulo / Escola Paulista de Medicina, in February 1990, presenting an ulcerated tumor in the right breast with fast growth over the preceding six months. She was a virgin, with meno-pause at the age of 45 years and had not undergone hormone replacement treatment. The physical examination showed, in her right breast, an ulcerated tumor of 20 x 30 cm which was not adher-ent to the muscle level, multilobular and with fibroelastic consistency. The axillary lymph nodes were not palpable. The left breast showed a 2 x 3 cm painless, movable nodule, with well-defined edges, and fibroelastic consistency. We performed left-breast mammography, which showed several nodules with well-defined edges, the largest being 2 x 3 cm and exhibiting rough calcification and grouped microcalcifications within it. The patient underwent a frozen biopsy that showed a malignant variant of the phyllodes tumor in the right breast and fibroadenoma in the left one. After that, we performed a total mastectomy in the right breast and an excision biopsy in the left one. Paraffin study confirmed the frozen biopsy result from the right breast, yet we observed that in the interior of the fibroadenoma that was removed on the left, there was a focal area of invasive lobular carcinoma measuring 0.4 cm. The patient then underwent a modi-fied radical mastectomy with total axillary lymphadenectomy. None of the 21 dissected lymph nodes showed evidence of metastasis. In the follow-up, the patient evolved asymptomatically and with normal physical and laboratory examination results up to July 1997.
KEY WORDS: Fibroadenoma. Phyllodes Tumor. Breast Cancer.
INTRODUCTION
Fibroadenoma is the most frequent benign neo-plasia of the breast, but the malignant transformation of its epithelial component is rare. In fact, it occurs in only 0.02 to 0.1% of cases.1 The transformation of fi-broadenoma into a phyllodes tumor is still controver-sial. The latter is a rare fibroepithelial neoplasia which corresponds to 0.5% of the reported breast tumors. Its biological behavior is distinct from that of fibroad-enoma, since it shows between 20 and 40% of local recurrence, and if malignant may cause metastasis.2
Until now, the concomitance of an invasive car-cinoma within fibroadenoma and a malignant phyl-lodes tumor in the same patient had never been re-ported. This is why the present case is now being re-ported.
CASE REPORT
A 58-year-old black female patient was referred to the Mastology unit of the Department of Gynecology, Federal University of São Paulo / Escola Paulista de Medicina, in February 1990, presenting an ulcer-ated tumor in the right breast with fast growth over the preceding six months. She was virgin, with meno-pause at the age of 45 years and had not undergone hormone replacement treatment.
The physical examination showed, in her right breast, an ulcerated tumor of 20 x 30 cm which was not adherent to the muscle level, multilobular and with fibroelastic consistency (Figure 1). The axillary lymph nodes were not palpable. The left breast showed a 2 x 3 cm painless, movable nodule, with well-defined edges, and fibroelastic consistency.
We performed left-breast mammography, which showed several nodules with well-defined edges, the largest being 2 x 3 cm and exhibiting rough calcification and grouped microcalcifications within it (Figure 2).
Mammography of the left breast showing several lobular nodules with rough calcifications within most of them, the largest showing grouped and heterogeneous microcalcifications (arrow).
The patient underwent a frozen biopsy that showed a malignant variant of the phyllodes tumor in the right breast and fibroadenoma in the left one.
After that, we performed a total mastectomy in the right breast and an excision biopsy in the left one.
Paraffin study confirmed the frozen biopsy re-sult from the right breast, yet we observed that in the interior of the fibroadenoma that was removed on the left, there was a focal area of invasive lobular carcinoma measuring 0.4 cm (Figure 3). The patient then underwent a modified radical mastectomy with total axillary lymphadenectomy. None of the 21 dissected lymph nodes showed evidence of metastasis. In the follow-up, the patient evolved asymptomatically and with normal physical and laboratory examination re-sults up to July 1997.
Photomicrograph (hematoxilin & eosin 100X) showing an area of invasive lobular carcinoma within a fibroadenoma.
DISCUSSION
Fibroadenoma is a frequent cause of nodules in young women, with a peak incidence between 20 and 30 years of age. They are multiple in 15% of the patients. They originate from the breast lobules and are estrogen-dependent, as they grow during pregnancy and under hormone replacement therapy, participate in lactation and often decrease in the menopause.1,2
Fibroadenoma is not associated with an in-creased risk of breast cancer. However, DuPont et al.3 observed in a case-control study that complex fibroad-enomas (those with cysts greater than 3 mm in diam-eter, sclerosing adenosis, epithelial calcifications or papillary changes) increased the relative risk for breast cancer to 3.1.
It is known that more than 160 cases of carcino-mas originating from fibroadenomas have been re-ported. Most of the lesions have been characterized as lobular carcinomas in situ. Intraduct carcinoma was identified in 20% of the cases, invasive duct carcinoma in 20%, and invasive lobular carcinoma in 10%.1
The mean age of the patients was 43 years, rang-ing from 15 to 69 years, i.e., 20 years older than the mean age at which fibroadenoma usually occurs.1 The treatment for these lesions is similar to that recom-mended for carcinomas originating from other parts of the breast. The prognosis is generally good, since the lymph nodes are presented as mostly free from compromise.1
The concomitance of fibroadenoma and phyl-lodes tumor is common, leading some authors to be-lieve that phyllodes tumors originate from previous fibroadenomas.3
The malignant phyllodes tumor reported in this paper was a solitary mass of 25 cm with cellular aty-pia, stromatous overgrowth and high mitotic activity (14 mitoses in 10 HPF).
On studying the natural history of fibroadenoma, Carty et al.3 reported that the majority of these nod-ules remain stable or decrease in size. Thus, a passive but watchful conduct for women under 30 years of age is advisable, provided the cytologic or histologic di- agnosis of fibroadenoma is confirmed. This will result in mutual benefit for the patient and the health ser-vice.
This case report shows two rare situations in a single patient. These demonstrate that although fi-broadenomas show self-limited growth, they require periodic clinical control or biopsy, especially when they are detected in women aged over 40 years in whom the frequency of either carcinoma or phyllodes tumors is greater.
REFERENCES
1. Fukuda M, Nagao K, Nishimura R, et al. Carcinoma arising in fibroadenoma of the breast: a case report and review of the literature. Jpn J Surg 1989;19(5):593-6.
2. Rosen PP, Oberman HA. Fibroepithelial neoplasms. In: AUTOR??? Atlas of tumor pathology - tumors of the mammary gland. 3 rd ed. Washington: Armed Forces Institute of Pathology; 1993:101-14.
3. DuPont WD, Page DL, Parl FF. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med 1994;331:10-4.
4. Carty NJ, Carter C, Rubin C, Ravichandran D, Royle GT, Taylor I. Management of fibroadenoma of the breast. Ann R Coll Surg Engl 1995;77:127-30.
RESUMO
CONTEXTO: O tumor Phyllodes variedade maligna é raro na literatura. A associação entre fibroadenoma e carcinoma lobular invasivo no seu interior também é rara.
OBJETIVO: Descrever a concomitância das três neoplasias na mesma paciente, situação esta ainda não descrita.
TIPO DE ESTUDO: Relato de caso.
RELATO DE CASO: Paciente de 58 anos, mulher, foi atendida na Unidade de Mastologia do Departamento de Ginecologia da Universidade Federal de São Paulo em fevereiro de 1990, apresentando tumor ulcerado na mama direita com rápido crescimento nos últimos seis meses. Era virgem, com menopausa aos 45 anos e não recebeu reposição hormonal. Ao exame físico, tumor ulcerado na mama direita, de 20x30 cm que não estava aderida aos planos musculares, era multilobular e com a consciência fibroelástica. Linfonodos axilares não eram palpáveis. Na mama esquerda, um nódulo móvel de 2x3 cm, com limites bem definidos e consistência fibro-elástica. Foi realizada mamografia na mama esquerda que mostrou vários nódulos de limites bem definidos. O maior de 2x3 cm exibindo calcificação e um grupo de microcalcificações. A biópsia por congelação apresentou uma variação maligna do tumor de phyl-lodes na mama direita e fibroadenoma na esquerda. Foi realizada a mastectomia direita e biopsia excisional esquerda. O exame histopatológico confirmou o resultado da biópsia por congelação da mama direita e apresentou no interior da fibroadenoma da mama
esquerda uma área apenas com carcinoma invasivo lobular medindo 0.4 cm. A paciente foi submetida a mastectomia radical com linfadenectomia axilar total. Nenhum dos 21 nódulos dissecados apresentou metástase. No seguimento, a paciente evoluiu assintomática até julho de 1997.
PALAVRAS-CHAVE: Fibroadenoma. Tumor Phyllodes. Câncer de Mama
PUBLISHING INFORMATION
Luiz Henrique Gebrim - MD, PhD. Adjunct Professor of the Gynecology Department, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.
Júlio Roberto de Macedo Bernardes Júnior - Fellow of the Gynecology Department, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.
Afonso Celso Pinto Nazário - MD, PhD. Adjunct Professor of the Gynecology Department, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.
Claúdio Kemp - MD, PhD. Adjunct Professor of the Gynecology Department, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.
Geraldo Rodrigues de Lima - MD, PhD. Head of the Department of Gynecology, Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, Brazil.
Sources of funding: Not declared
Conflict of interest: Not declared
Last received: 28 October 1999
Accepted: 25 November 1999
Address for correspondence:
Luiz Henrique Gebrim
Rua Caçapava, 49 - conjunto 12
São Paulo/SP - Brazil - CEP 01408-010
E-mail: lgebrim@uol.com.br
publishing informatio
Publication Dates
-
Publication in this collection
11 May 2000 -
Date of issue
Mar 2000
History
-
Accepted
25 Nov 1999 -
Received
28 Oct 1999
