PATHOLOGY CASE DISCUSSION

1. INTERESTING CASE
DISCUSSION
Presenter: Dr. Khadija Irum
Moderator: Dr. Chandrakanth V R

2. • A 50 years old female patient presented to the surgery
OPD with the complaints of lump in her left breast
since 8 months.
• Progressive in size.
• On examination, lump palpated in the left breast
upper outer quadrant, mobile, firm in consistency,
non tender.
• Measuring 14x11cm.

3. USG:
• Large ill defined lobulated ,wider than taller, mixed
echoic ,predominantly hypoechoic lesion with cystic
areas in left breast with axillary lymphadenopathy.
• Possibly malignant etiology…BIRADS 4b/4c lesion

4. FNAC:
• Breast : Phylloids Tumor
• Left axilla: Reactive non specific lymphadenitis.
Negative for malignancy.

5. Surgery
• Wide local excision done

6. HISTOPATHOLOGICAL
EXAMINATION
GROSS:
• Received single
nodular grey white
mass measuring
16x11x10cm with
attached fibro fatty
tissue.

7. • On serial section, multiple nodules noted measuring
4.5cm to 1.5 cm across cleft like spaces.
• Area of hemorrhage 5cm in diameter noted

8. Microscopy:
• Section studied from the lesion showed spindle cell
lesions with area of necrosis, hyalinization and
hemorrhage.
• In some section spindle cells show moderate
pleomorphism and <5 MF/10x.

9. 10x
10x

10. 40x

11. 10x

12. 40x
4x

13. Diagnosis:
Borderline phylloids tumor.

14. • Again patient
turned up with the
complaint of 2-3
lumps in the same
breast within four
weeks of surgery.
• lump with
ulcerated skin

15. USG:
• Mixed echogenic, predominantly hypoechoic lesion
measuring 4x1.6x3.9 cm noted in midline lower inner
quadrant of left breast around the operated site in
subcutaneous plane
Possibly post operative collection.
• Well defined hypoechoic lesion in the left breast at
9’o clock position measuring 1.3x1.1 cm.
Small fibroadenoma

16. • Another 2 small hypoechoic lesions at 1-2’o clock
position noted in the left breast.
Possibly lymph node & fibroadenoma
• Right breast normal.

17. Surgery:
• Left modified radical mastectomy.

18. Histopathological Examination
Gross:
• Elliptical skin with
NAC complex.
• Recurrent phylloid
with ulcerated skin
• Axillary specimen
with lymph node.
2436/22

19. • Elliptical skin with NAC complex measures 17x4x0.3cm.
•External surface is unremarkable
•Cut section shows grey white firm area measures 4x4x2cm.

20. •Recurrent tumor with ulcerated skin measures 14x11x10cm.
Skin flap measures 11x6cm.
•External surface of skin is nodular and ulcerated.ulcer
measures7x6cm.

21. •Cut section shows irregular grey white to grey brown
tumor measures 8x6x5cm,consist of solid and few cystic
areas filled with hemorrhage.
•Tumor grossly involving SSM,1cm away from ISM,3.5cm
from MSM,6cm from LSM & 3cm from DSM.

22. •2 grey white fibro fatty tissue.
•Largest measuring 8x7x1.5cm,smallest measuring
7x2.51cm.
•On cut section largest shows grey white firm area measures
3.5x2x2cm, showing grey brown areas.
•Smallest on cut section shows grey white firm area
measuring 1cm across..

23. •Microscopy:

24. 4x
40x

25. 10x
20x

34. Differential Diagnosis:
Malignant spindle cell neoplasm
• Metaplastic carcinoma
• Malignant phylloids tumor with heterologus
differentiation.
• Primary Osteosarcoma of breast.

35. Post OP HRCT
Fluid collection in left axillary region-seroma
Round nodule m/e 2x1.5cm in right brest.

36. • DISCUSSSION

37. • Phyllodes tumor is the term for the biphasic
neoplasm originally named cystosarcoma phyllodes
by Johannes Müller in 1838.
• Tumor occurs in middle-aged and older women.1

38. Grossly:
• The typical phyllodes tumor is round, relatively well
circumscribed, and firm. Many phyllodes tumors are
large, and some reach huge dimensions.1
• The cut surface shows a characteristic whorled
pattern, resembling a compressed leaf bud, with
visible clefts.2
• Larger tumors frequently exhibit cystic spaces, and
foci of hemorrhage and necrosis.
• Rarely, the entire tumor undergoes hemorrhagic
infarction.

40. Microscopically:
• Stromal hypercellularity
• Benign glandular elements.
• Phylloids tumor can be classified by histopathological
features as benign, borderline or malignant,

41. Benign Borderline Malignat
Like fibroadenomas but
with a hypercellular
stroma and some
imbalance of the gland
to stroma ratio.
Intermediate between
benign and malignant
phyllodes tumors with
moderately cellular
stroma
high degree of stromal
cellularity, greater
imbalance in the
distribution of glands in
the stroma
Mild stromal cell atypia
and
Mild to moderate
stromal cell atypia,
Marked stromal cell
nuclear atypia,
Few mitoses ( < 5/ 10
high power field).
5–9 mitoses per 10 high-
power fields
Numerous mitoses (≥10
per 10 high-power
fields),
No (or very focal)
stromal overgrowth
Tumor show stroma
only, without epithelial
elements (“stromal
overgrowth”)
Well-defined border Well-defined border, but
it may be focally
permeative
An infiltrative or
permeative tumor border

42. • The neoplastic stromal component of malignat
phylloid tumor may be monomorphic or highly
pleomorphic, and its appearance is most often
reminiscent of fibrosarcoma.
• But liposarcomatous differentiation may also be
seen;
• Heterologous elements such as metaplastic
cartilage, bone, or, exceptionally, skeletal muscle
may be encountered.
• Phyllodes tumors with heterologous stromal elements
are more aggressive.

43. • S.Warrior et al has reported two cases of phyllodes
tumor with heterologus sarcomatous differentiation.
• A 50 year female with 2years of large palpable breast
mass.Diagnosed phylloids tumor on core biopsy.
• A 53 year female with palpable lump in upper outer
quadrant.3

46. Metaplastic carcinoma:
• The term metaplastic carcinoma was introduced by
Huvos et al, in 1973.
• Metaplastic carcinoma refers to a highly
heterogeneous group of neoplasm with an admixture
of carcinomatous epithelial and mesenchymal
elements with a reported incidence of 0.2-1%.4

47. • Wartagotz et al, in 1990, studied a largest series of
247 cases of metaplastic carcinoma and suggested
five variants- matrix producing metaplastic carcinoma
of breast, squamous cell carcinoma, spindle cell
carcinoma, carcinosarcoma and metaplastic
carcinoma of breast with osteoclastic giant cells.4

48. Primary osteosarcomas of the breast:
• Very rare, aggressive, and heterogeneous neoplasms
• Derived from non-epithelial elements of the gland an
• Represent less than 1% of breast cancers and less than
5% of all sarcomas.5

49. • Extra skeletal osteosarcoma is a malignant
mesenchymal neoplasm that produces osteoid, bone,
or chondroid material and is located in the soft tissue
without attachment to the skeleton.6
• Some studies have reported that a tumor is likely to
be caused by a history of trauma to the breast or
radiation therapy for a malignant neoplasm,
transformation from a preexisting fibroadenoma or
phyllodes tumors.

50. • Osteosarcoma of the breast should be differentiated
from other two similar entities, cystosarcoma
phyllodes and metaplastic carcinoma.7
• Which can be arises from the adjacent bone structure
(sternum, ribs)

51. • Due to the rarity of primary osteosarcoma of the
breast, there are no validated guidelines for treatment,
and the best therapeutic approach remains wide local
excision or mastectomy, depending on the size of the
tumor and the remaining breast tissue.
• A complete resection with negative resection margins
is needed, as margin involvement is a major predictor
for local disease recurrence.

52. • Prognostic factors for primary osteosarcomas of the
breast include tumor size, number of mitoses, and
presence of stromal atypia .
• In general, osteosarcomas are aggressive tumors with
blood-borne spread more common than lymphatic
spread.
• Hematogenous metastases most commonly occurred
in the lungs (80%), bone (20%), and liver (17%)

53. • In a study of 50 patients with primary breast
osteosarcoma, Silver and Tavassoli reported a 5-year
survival of 38%, with 28% percent of patients
developing local recurrence and 41% distant
metastases.11

54. Immunohistochemistry
• Most phyllodes tumors express CD34 and bcl2 in the
stromal component, whereas spindle cell carcinoma is
negative.1,2
• Metaplastic carcinoma may be distinguished by
positive immunostaining of the spindle cells with
epithelial markers such as 34βE12, MNF116, and
Cam5.
• Vimentin & ki 67(30-35%) shows positivity in a
cases of primary osteosarcoma of breast,study done
by Ramesh Omranipour et al.12

55. • Conclusion

56. REFERENCES
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Myers. Rosai and Ackerman’s Surgical Pathology.
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2. Christopher D.M. Fletcher. Diagnostic
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3. Sanjay W Y. Hwang, Keagan Gibbings a, Hugh C ,
Sandra O’T. Phyllodes tumour with heterologous
sarcomatous differentiation: Case series with
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58. 9. Julie C, Veronique J,Christine G,Jean-Claude P &
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Journal of Surgical Pathology;vol.23.815–821.
11.Mariusz S,Wiesław J K,Maciej C, Urszula S-K ,
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12. R Omranipour,F Ensani, M Hassanefahani.Primary
Breast Osteosarcoma:A case report and review of
literature.Clin Case Rep.2021;9:e05044.