Topic review

CASE PRESENTATION2010-06-25R3 CASE42/FC.C: Abnormal finding in screening mammography100998502

3

Asymmetry, Rt. upperBIRADS category 0( )rec) USG and Rt magnification view.4

DiagnosticAsymmetry, right breast.

At USRight breast 10 , nipple 7 cm palpable mass . mass 1.9 x 1.1 x 1.3 cm ovoid, partially well circumscribed, and partially microlobulated, and iso echoic mass. Mass vascularity . Suspicious abnormality US guided core biopsy 5 . immediate complication .Right breast 10 , nipple 6 cm 0.4 x 0.3 x 0.4 cm ovoid, well circumscribed, and hypoechoic nodule . Negative in left breast and both axilla.

At right magnification viewRight breast upper outer quadrant BB marker 2.0 x 1.5 x 1.3 cm irregular, partially well circumscribed, and partially obscured or indistinct, and iso dense mass .

1. US guided core biopsy was done for a suspicious abnormality in right breast, 10 o'clock direction.2. A small benign looking nodule in right breast, 10 o'clock direction.

BI-RADS category 4a.

5

7PathologyBreast, right, needle biopsy 1. Several ducts with atypical ductal hyperplasia 2. Fibrocystic change with adenosis Note) Ductal carcinoma in situ . Ductal carcinoma in situ . Excision .Pathology after excision

9

Treating carcinoma within phyllodes tumors according to carcinomatous component : Mastectomy + LN dissection

11DCIS arising in Phyllodes TumorClassified as fibroepithelial tumorsEpithelial elements & connective tissue of terminal duct-lobular unitLeaf-like appearance that extends into ducts

Malignant epithelial change in phyllodes tumor: rare event (occur in 1%2%)Infiltrative ductal carcinoma and lobular carcinoma in situDCIS: rare

epithelial component can transform into malignancyMalignant transformationof a phyllodes tumor usually occurs inthe stromal component, and it is very rare in theepithelial component 2). Thus there are only a fewreported cases of carcinoma intermingled with aphyllodes tumor ~6~, such as in our patient.Phyllodes tumor of the breast is a fi broepithelialneoplasm that has the potential to recur,11 and is predominantlycomposed of periductal stroma and ductepithelium12DCIS arising in Phyllodes TumorEtiological relationship between phyllodes tumors and carcinomas

- Theory 1) Sudden transformation of hyperplastic epithelium of phyllodes tumor- Theory 2) Carcinoma caused by chance in the mammary gland adjunct to the phyllodes tumorPTs is generally favourable,(12,13) however in a malignantPT the prognosis may be more guarded. Axillary lymphnode dissection is not part of the standard treatment forPTs, but is required when there is coexistent invasivecarcinoma. Conversely, in a PT where lymph nodes areclinically enlarged, extensive sampling of the tumour isimportant, to rule out foci of intraductal and/or invasivecarcinoma. As these cases are extremely rare, treatmentand follow-up of these cases are not standardised. It isrecommended that treatment be customised in each casebased on the presence of an invasive component, lymphnode and distant metastases, and the carcinomatouscomponent be treated independently of the PT.13

Surg Today (2008) 38:4245When a preoperatively diagnosed phyllodestumor is later identified as being combinedwith a carcinoma after histological examinationand a local excision, it is considered reasonable toselect a treatment such as additional axillary nodedissection or a postoperative adjuvant therapy,depending on the stage and/or the hormone receptorstatus of the coexisting carcinoma.14DCIS arising in Phyllodes TumorImaging studies : cannot distinguishShould be done for detection of any calcification May indicate phyllodes tumor with possible epithelial malignant change

Treating carcinoma within phyllodes tumors according to carcinomatous component : Mastectomy + LN dissection Lumpectomy + Rtx + tamoxifen(if ER+)

In the present case, the DCIS areas were not detectableon ultrasonography and magnetic resonanceimaging scans, even retrospectively, and mammographywas impossible because the tumor was too large.13~. The problem is now whether the presenceof carcinoma in situ in phyllodes tumor shouldinfluence the choice of treatment. Probablydue to its infrequency, the role of chemotherapy,radiation, and hormonal manipulation in both theadjuvant and palliative settings remain to bedefined. When a preoperatively diagnosed phyllodestumor is later identified as being combinedwith a carcinoma after histological examinationand a local excision, it is considered reasonable toselect a treatment such as additional axillary nodedissection or a postoperative adjuvant therapy,depending on the stage and/or the hormone receptorstatus of the coexisting carcinoma.15A Case of Noninvasive Ductal Carcinoma Arising in Malignant Phyllodes Tumor Breast Cancer 13:89-94, 2006.Ductal Carcinoma In Situ Arising in a Benign Phyllodes Tumor: Report of a Case Surg Today (2008) 38:4245