Diagnosis and management of liposarcomatous differentiation in a phyllodes tumor: a rare clinical conundrum
Keywords:Cystosarcoma phyllodes, Liposarcomatous differentiation, Malignant transformation, Sentinel lymph node biopsy
The solitary variant of rapidly growing large breast masses consisting of both epithelial and stromal components with no nodal involvement is called a phyllodes tumor and they are rare neoplasms of the breast. They constitute about 1% of all breast masses, with a slightly higher incidence in the Asian population. Although 10-30% of phyllodes tumors eventually undergo malignant transformation, which can either be in the epithelium or the stroma. However, heterologous transformation of phyllodes is an extremely rare entity. Here, we reported the case of a 60-year-old woman with an expeditiously growing breast mass for six months, which on biopsy raised a suspicion of malignant mesenchymal neoplasm. The patient underwent mastectomy with axillary sentinel lymph node biopsy (SLNB) and the final histopathological and immunohistochemistry examination revealed a phylloides tumor with a pleomorphic variety of liposarcomatous differentiation. Even with a typical mammographic appearance, liposarcomatous differentiation in phyllodes tumors can present a diagnostic dilemma on histopathology. Axillary sentinel lymph node biopsy (SLNB) forms a middle path in such cases of diagnostic challenge, which not only avoids the unnecessary morbidity of axillary lymph node dissection but also, at the same time, addresses the axilla in case the final histopathology shows evidence of invasive carcinoma.
Fiks A. Cystosarcoma phyllodes of the mammary gland-Müller's tumor. For the 180th birthday of Johannes Müller. Virchows Arch a Pathol Anat Histol. 1981;392(1):1-6.
Jara-Lazaro AR, Tan PH. Molecular pathogenesis of progression and recurrence in breast phyllodes tumours. Am J Transl Res. 2009;1(1):23-34.
Kuroda N, Sugimoto T, Ueda S, Takahashi T, Moriki T, Sonobe H, et al. Malignant phyllodes tumor of the breast with expression of osteonectin and vinculin. Pathol Int. 2001;51:277-82.
Parker SJ, Harries SA. Phyllodes tumours. Postgrad Med J. 2001;77(909):428-35.
Aziz AM, Sullivan F, Kerin MJ, Callagy G. Malignant phyllodes tumour with liposarcomatous differentiation, invasive tubular carcinoma, and ductal and lobular carcinoma in situ: case report and review of the literature. Patholog Res Int. 2010:501274.
Breast. In: Rosai J, editor. Rosai and Ackerman’s Surgical Pathology. 9th ed. Vol 2. Ch 20. India: Mosby; 2009:1829-31.
Guerrero MA, Ballard BR, Grau AM. Malignant phyllodes tumor of the breast: review of the literature and case report of stromal overgrowth. Surg Oncol. 2003;12:27-37.
Tan H, Zhang S, Liu H, Peng W, Li R, Gu Y, et al. Imaging findings in phyllodes tumors of the breast. Eur J Radiol. 2012;81(1):e62-9.
Liberman L, Bonaccio E, Hamele-Bena D, Abramson AF, Cohen MA, Dershaw DD. Benign and malignant phyllodes tumors: Mammographic and sonographic findings. Radiology. 1996;198(1):121-4.
Kalambo M, Adrada BE, Adeyefa MM, Krishnamurthy S, Hess K, Carkaci S, et al. Phyllodes tumor of the breast: Ultrasound-pathology correlation. AJR Am J Roentgenol. 2018;210(4):173-9.
Treves N, Sunderland DA. Cystosarcoma phyllodes of the breast: a malignant and a benign tumor; a clinicopathological study of seventy-seven cases. Cancer. 1951;4:1286-332.
Anand P, Sarin N. Phyllodes Tumor with Sarcomatous Differentiation - A Rare and Distinct Entity. Int J Recent Sci Res. 2017;8(9):19969-72.
Jones AM, Mitter R, Springall R. A comprehensive genetic profile of phyllodes tumours of the breast detects important mutations, intra-tumoral genetic heterogeneity and new genetic changes on recurrence. J Pathology. 2008;214(5):533-44.
Kuijper A, Snijders AM, Berns EM. Genomic profiling by array comparative genomic hybridization reveals novel DNA copy number changes in breast phyllodes tumours. Cellular Oncology. 2009;31(1):31-9.
La´e M, Vincent-Salomon A, Savignoni A. Phyllodes tumors of the breast segregate in two groups according to genetic criteria. Modern Pathology. 2007;20(4):435-44.
Sawyer EJ, Hanby AM, Ellis P. Molecular analysis of phyllodes tumors reveals distinct changes in the epithelial and stromal components. American J Pathology. 2000;156(3):1093-8.
Kefeli M, Yildiz L, Akpolat I, Balci P, Ozen N. The coexistence of invasive ductal carcinoma and malignant phyllodes tumor with liposarcomatous and chondrosarcomatous differentiation in the same breast in a post-osteosarcoma case. Pathology Research Practice. 2008;204(12):919-23.
Isotalo PA, George RL, Walker R, Sengupta SK. Malignant phyllodes tumour with liposarcomatous differentiation. Arch Pathol Lab Med. 2005;129:421-2.
Telli ML, Horst KC, Guardino AE, Dirbas FM, Carlson RW. Phyllodes tumors of the breast: natural history, diagnosis, and treatment. J Natl Compr Canc Netw. 2007;5(3):324-30.