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INTRODUCTION
Fibro adeno ma is the mo st frequent benign neo -plasia o f the breast, but the malignant transfo rmatio n o f its epithelial co mpo nent is rare. In fact, it o ccurs in o nly 0.02 to 0.1% o f cases.1 The transfo rmatio n o f
fi-bro adeno ma into a phyllo des tumo r is still co ntro ver-sial. The latter is a rare fibro epithelial neo plasia which co rrespo nds to 0.5% o f the repo rted breast tumo rs. Its bio lo gical behavio r is distinct fro m that o f fibro ad-eno ma, since it sho ws between 20 and 40% o f lo cal
recurrence, and if malignant may cause metastasis.2
Until no w, the co nco mitance o f an invasive car-cino ma within fibro adeno ma and a malignant phyl-lo des tumo r in the same patient had never been po rted. This is why the present case is no w being re-po rted.
CASE REPORT
A 58-year-o ld black female patient was referred to the Masto lo gy unit o f the Department o f Gyneco l-o gy, Federal University l-o f Sãl-o Paull-o / Escl-o la Paulista de Medicina, in February 1990, presenting an ulcer-ated tumo r in the right breast with fast gro wth o ver the preceding six mo nths. She was virgin, with meno -pause at the age o f 45 years and had no t undergo ne ho rmo ne replacement treatment.
The physical examinatio n sho wed, in her right breast, an ulcerated tumo r o f 20 x 30 cm which was no t adherent to the muscle level, multilo bular and with fibro elastic co nsistency (Figure 1). The axillary lymph no des were no t palpable. The left breast sho wed a 2 x
Case R eport
REVISTA PAULISTA DE MEDICIN AMalignant phyllode s tumor in the right bre ast
and invasive lobular carcinoma within
fibroade noma in the othe r: case re port
Department of Gynecology, Universidade Federal de São Paulo/
Escola Paulista de Medicina, São Paulo, Brazil
a b s t r a c t
CO N TEX T: The malig nant variety o f the phyllo des tumo r is rare. The o ccurrence o f invasive lo bular carcino ma within fibro adeno ma is rare as well.
DESIGN : Case repo rt.
CASE REPO RT: A 5 8 -year-o ld black female patient was referred to the Masto lo g y unit o f the Department o f G yneco lo g y, Federal Uni-versity o f São Paulo / Esco la Paulista de Medicina, in February 1 9 9 0 , presenting an ulcerated tumo r in the rig ht breast with fast g ro wth o ver the preceding six mo nths. She was a virg in, with meno -pause at the ag e o f 4 5 years and had no t underg o ne ho rmo ne replacement treatment. The physical examinatio n sho wed, in her rig ht breast, an ulcerated tumo r o f 2 0 x 3 0 cm which was no t adher-ent to the muscle level, multilo bular and with fibro elastic co nsistency. The axillary lymph no des were no t palpable. The left breast sho wed a 2 x 3 cm painless, mo vable no dule, with well-defined edg es, and fibro elastic co nsistency. W e perfo rmed left-breast mammo g raphy, which sho wed several no dules with well-defined edg es, the larg est being 2 x 3 cm and exhibiting ro ug h calcificatio n and g ro uped micro calcificatio ns within it. The patient underwent a fro z en bio psy that sho wed a malig nant variant o f the phyllo des tumo r in the rig ht breast and fibro adeno ma in the left o ne. After that, we perfo rmed a to tal mastecto my in the rig ht breast and an excisio n bio psy in the left o ne. Paraffin study co nfirmed the fro z en bio psy result fro m the rig ht breast, yet we o bserved that in the interio r o f the fibro adeno ma that was remo ved o n the left, there was a fo cal area o f invasive lo bular carcino ma measuring 0 .4 cm. The patient then underwent a mo di-fied radical mastecto my with to tal axillary lymphadenecto my. N o ne o f the 2 1 dissected lymph no des sho wed evidence o f metastasis. In the fo llo w-up, the patient evo lved asympto matically and with no rmal physical and labo rato ry examinatio n results up to July 1 9 9 7 .
KEY W O RDS: Fibro adeno ma. Phyllo des Tumo r. Breast Cancer.
• Luiz Henrique G ebrim • Júlio Ro berto de Macedo Bernardes Júnio r • Afo nso Celso Pinto N az ário • Cláudio Kemp • G eraldo Ro drig ues de Lima
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3 cm painless, mo vab le no dule, with well-defined edges, and fibro elastic co nsistency.
We perfo rmed left-breast mammo graphy, which sho wed several no dules with well-defined edges, the
larg-Fig 3 - Photomicrograph (hematoxilin & eosin – 100X) showing an area of invasive lobular carcinoma within a fibroadenoma.
Fig 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). Fig 1 - Bulky ulcerated tumor in the right breast.
est being 2 x 3 cm and exhibiting ro ugh calcificatio n and gro uped micro calcificatio ns within it (Figure 2).
The patie nt unde rwe nt a fro ze n b io psy that sho wed a malignant variant o f the phyllo des tumo r in the right breast and fibro adeno ma in the left o ne.
After that, we perfo rmed a to tal mastecto my in the right breast and an excisio n bio psy in the left o ne. Paraffin study co nfirmed the fro zen bio psy re-sult fro m the right breast, yet we o bserved that in the interio r o f the fibro adeno ma that was remo ved o n the left, there was a fo cal area o f invasive lo bular carci-no ma measuring 0.4 cm (Figure 3). The patient then underwent a mo dified radical mastecto my with to tal axillary lymphadenecto my. No ne o f the 21 dissected lymph no des sho wed evidence o f metastasis. In the fo llo w-up, the patient evo lved asympto matically and with no rmal physical and labo rato ry examinatio n re-sults up to July 1997.
DISCUSSION
Fibro adeno ma is a frequent cause o f no dules in yo ung wo men, with a peak incidence between 20 and 30 years o f age. They are multiple in 15% o f the pa-tients. They o riginate fro m the breast lo bules and are estro gen-dependent, as they gro w during pregnancy and under ho rmo ne replacement therapy, participate in lactatio n and o ften decrease in the meno pause.1,2
Fib ro ade no ma is no t asso ciate d with an in-creased risk o f breast cancer. Ho wever, DuPo nt et al.3
o bserved in a case-co ntro l study that co mplex fibro ad-eno mas (tho se with cysts greater than 3 mm in diam-eter, sclero sing adeno sis, epithelial calcificatio ns o r papillary changes) increased the relative risk fo r breast cancer to 3.1.
It is kno wn that mo re than 160 cases o f carcino -mas o riginating fro m fibro adeno -mas have been re-po rted. Mo st o f the lesio ns have been characterized as lo bular carcino mas in situ. Intraduct carcino ma was identified in 20% o f the cases, invasive duct carcino ma
in 20%, and invasive lo bular carcino ma in 10%.1
The mean age o f the patients was 43 years, rang-ing fro m 15 to 69 years, i.e., 20 years o lder than the
mean age at which fibro adeno ma usually o ccurs.1
The treatment fo r these lesio ns is similar to that reco m-mended fo r carcino mas o riginating fro m o ther parts o f the breast. The pro gno sis is generally go o d, since the lymph no des are presented as mo stly free fro m co mpro mise.1
The co nco mitance o f fibro adeno ma and phyl-lo des tumo r is co mmo n, leading so me autho rs to be-lieve that phyllo des tumo rs o riginate fro m previo us
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fibro adeno mas.3
The malignant phyllo des tumo r repo rted in this paper was a so litary mass o f 25 cm with cellular aty-pia, stro mato us o vergro wth and high mito tic activity (14 mito ses in 10 HPF).
On studying the natural histo ry o f fibro adeno ma, Carty et al.3 repo rted that the majo rity o f these no
d-ules remain stable o r decrease in size. Thus, a passive but watchful co nduct fo r wo men under 30 years o f age is advisable, pro vided the cyto lo gic o r histo lo gic
di-agno sis o f fibro adeno ma is co nfirmed. This will result in mutual benefit fo r the patient and the health ser-vice.
This case repo rt sho ws two rare situatio ns in a single patient. These demo nstrate that altho ugh fi-bro adeno mas sho w self-limited gro wth, they require perio dic clinical co ntro l o r bio psy, especially when they are detected in wo men aged o ver 40 years in who m the frequency o f either carcino ma o r phyllo des tumo rs is greater.
1. Fukud a M, Nagao K, Nishim ura R, e t al. Carc ino m a arising in fibro adeno ma o f the breast: a case repo rt and review o f the literature. Jpn J Surg 1989;19(5):593-6.
2. Ro sen PP, Oberman HA. Fibro epithelial neo plasms. In: AUTOR??? Atlas o f tumo r patho lo gy - tumo rs o f the mammary gland. 3rd ed. Washingto n: Armed
Fo rces Institute o f Patho lo gy; 1993:101-14.
REFERENCES
3. DuPo nt WD, Page DL, Parl FF. Lo ng-term risk o f breast cancer in wo men with fibro adeno ma. N Engl J Med 1994;331:10-4.
4. Carty NJ, Carte r C, Rub in C, Ravichandran D, Ro yle GT, Taylo r I. Management o f fibro adeno ma o f the breast. Ann R Co ll Surg Engl 1995;77:127-30.
r e s u m o
CO N TEX TO : O tumo r Phyllo de s va rie da de ma lig na é ra ro na literatura. A asso ciação entre fibro adeno ma e carcino ma lo bular invasivo no seu interio r também é rara.
O BJETIV O : Descrever a co nco mitância das três neo plasias na mesma paciente, situação esta ainda não descrita.
TIPO DE ESTUDO : Relato de caso .
RELATO DE CASO : Paciente de 5 8 ano s, mulher, fo i atendida na Unid a d e d e Ma sto lo g ia d o De p a rta me nto d e G ine c o lo g ia d a Unive rsid a d e Fe d e ra l d e Sã o Pa ulo e m fe ve re iro d e 1 9 9 0 , apresentando tumo r ulcerado na mama direita co m rápido crescimento no s último s seis meses. Era virg em, co m meno pausa ao s 4 5 ano s e não recebeu repo sição ho rmo nal. Ao exame físico , tumo r ulcerado na mama direita, de 2 0 x3 0 cm que não estava aderida ao s plano s musc ula res, era multilo b ula r e c o m a c o nsc iênc ia fib ro elá stic a . Linfo no do s axilares não eram palpáveis. N a mama esquerda, um nó dulo mó vel de 2 x3 cm, co m limites bem definido s e co nsistência fibro -elástica. Fo i realizada mamo g rafia na mama esquerda que mo stro u vário s nó dulo s de limites bem definido s. O maio r de 2 x3 cm exibindo calcificação e um g rupo de micro calcificaçõ es. A bió psia po r co ng elação apresento u uma variação malig na do tumo r de phyl-lo des na mama direita e fibro adeno ma na esquerda. Fo i realizada a ma ste c to mia d ire ita e b io p sia e xc isio na l e sq ue rd a . O e xa me histo pato ló g ico co nfirmo u o resultado da bió psia po r co ng elação da mama direita e apresento u no interio r da fibro adeno ma da mama esquerda uma área apenas co m carcino ma invasivo lo bular medindo 0 .4 c m. A pa c ie nte fo i sub me tida a ma ste c to mia ra dic a l c o m linfadenecto mia axilar to tal. N enhum do s 2 1 nó dulo s dissecado s a p re se nto u me tá sta se . N o se g uime nto , a p a c ie nte e vo luiu assinto mática até julho de 1 9 9 7 .
PALAV RAS-CH AV E: Fibro adeno ma. Tumo r Phyllo des. Câncer de Mama
Luiz He nrique Ge brim, MD, PhD. Adjunct Pro fesso r o f the Gyneco lo gy Department, Universidade Federal de São Paulo /Esco la Paulista de Medicina, São Paulo , Brazil.
Júlio Robe rto de Mace do Be rnarde s Júnior. Fello w o f the Gyneco lo gy Department, Universidade Federal de São Paulo /Esco la Paulista de Medicina, São Paulo , Brazil.
Afonso Ce lso Pinto Nazário, MD, PhD. Adjunct Pro fesso r o f the Gyneco lo gy Department, Universidade Federal de São Paulo /Esco la Paulista de Medicina, São Paulo , Brazil.
Claúdio Ke mp, MD, PhD. Adjunct Pro fesso r o f the Gyneco lo gy Department, Universidade Federal de São Paulo /Esco la Paulista de Medicina, São Paulo , Brazil.
Ge raldo Rodrigue s de Lima, MD, PhD. Head o f the Department o f Gyneco lo gy, Universidade Federal de São Paulo /Esco la Paulista de Medicina, São Paulo , Brazil.
Source s of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 28 Octo ber 1999
Acce pte d: 25 No vember 1999
Addre ss for corre sponde nce :
Luiz Henrique Gebrim Rua Caçapava, 49 - co njunto 12 São Paulo /SP - Brazil - CEP 01408-010 E-mail: lgebrim@ uo l.co m.br
p u b lis hin g in fo r m a t io n
