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Fibroepithelial and Spindle Cell Lesions of the Breast

Fibroepithelial and Spindle Cell Lesions of the Breast. Fouad Boulos, MD. Fibroepithelial Lesions. Very common Wide histologic spectrum Vast majority benign. Fibroadenoma. Hyperplasia of the lobular unit Most common palpable lesion in young women Peak incidence in third decade

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Fibroepithelial and Spindle Cell Lesions of the Breast

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  1. Fibroepithelial and Spindle Cell Lesions of the Breast Fouad Boulos, MD

  2. Fibroepithelial Lesions • Very common • Wide histologic spectrum • Vast majority benign

  3. Fibroadenoma • Hyperplasia of the lobular unit • Most common palpable lesion in young women • Peak incidence in third decade • May present as calcifications

  4. Fibroadenoma • Microscopically well-defined • Stroma with low cellularity • Intracanalicular and pericanalicular patterns

  5. FA and Epithelial Proliferations • Kuijper et al: 396 FAs • Hyperplasia 32% • DCIS 1.26% (5) • LCIS 0.76% (3) • 3 cases of CIS involved adjacent tissue • No invasive carcinoma

  6. FA with… • Carcinoma: re-excise especially if unclear about margins and FA shelled out • Atypical Hyperplasia: worry? Excise?

  7. FA with… • Carter et al: 1,834 women with FA 1950-68 • 0.81% had ADH or ALH • NO increased risk

  8. Special FAs • Juvenile FA • Large • Rapid growth (hormone sensitive) • Gynecomastoid hyperplasia • Increased stromal cellularity • Differential: Phyllodes vs virginal hypertrophy

  9. Special FAs • Complex FA • Apocrine change • Calcification • Cyst formation • Adenosis • Tubular adenoma • Lactational adenoma

  10. Fibroadenomatosis • Multiple • Ill-defined • Likely to “recur”

  11. Phyllodes Tumor • Biphasic with epithelial and stromal proliferation • Stroma more cellular than FA, and has propensity for malignant degeneration • Local recurrence common though majority benign

  12. Phyllodes Tumor • 0.6% of all “malignant” breast tumors • 40 and above • 5 cm average size • Well-circumscribed with leaf-like pattern

  13. Phyllodes Tumor • Epithelial cells polyclonal • Stromal cells clonal • FA: both polyclonal • Phyllodes can arise from FA

  14. Benign PT • Pushing margins • Minimal cellular atypia • Low mitotic rate (<4 per 10 hpf)

  15. Malignant PT • Stromal overgrowth (4X without epithelium) • Infiltrative border • Stromal cellular atypia • High mitotic rate (10 per 10 hpf)

  16. Borderline PT • As the name implies • Stromal cells cytologically similar to benign PT • Higher tendency for local recurrence because of infiltration and stromal overgrowth

  17. Malignant PT • Malignant heterologous elements are definitive clues to histologically malignant PT • Liposarcoma • Osteosarcoma • Fibrosarcoma

  18. Phyllodes Tumors • 45 cases from Memorial Sloan-Kettering aged 10-24 years • 34 benign • 11 malignant • 6/36 with f/u showed local recurrence • 1/36 metastasized (rhabdo)

  19. Phyllodes Tumors • 101 patients from MD Anderson • 58 benign, 12 borderline, and 30 malignant • 8 with distant mets • 13% 10-year rate • Stromal overgrowth is the only independent risk factor.

  20. Phyllodes Tumors Outcome Benign (Compiled from 7 studies)

  21. Phyllodes Tumors Outcome Borderline (Compiled from 7 studies)

  22. Phyllodes Tumors Outcome Malignant (Compiled from 7 studies)

  23. SEER Data (1983-2002) • 821 malignant PT cases • 91% survival at 5 years • 89% survival at 15 years • Wide excision equivalent to mastectomy

  24. Few Pointers • Fibroadenoma with phyllodal features • CD10 • Epithelium can be very proliferative • Metaplastic carcinoma within phyllodes • Always look hard for the epithelial component (PT much more common than primary sarcomas in the breast)

  25. Summary • Wide excision very important • The more it looks like a soft tissue sarcoma, the more likely it is to behave like one • Rarely an aggressive tumor with fatal outcome

  26. Spindle Cell Lesions • All spindle cell lesions occurring in the soft tissues can happen in the breast • Overlapping morphologies for drastically different lesions • Important to maintain a wide differential

  27. Spindle Cell Lesions • Myofibroblastoma • Fibromatosis • Nodular fasciitis AND Their differentials…

  28. Myofibroblastoma • Originally thought to be a neoplasm of the male breast • Wide age range • Average size of 2.5 cm • Usually well-circumscribed

  29. Myofibroblastoma • Wide range of morphologies • Bland spindled to epithelioid cells with amphophilic cytoplasm in fascicles, singly, or in small clusters • Well-defined or infiltrating • Collagen or myxoid stroma • Pleomorphism (pleomorphic lipoma-like)

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