Causes, symptoms, diagnosis and treatment of leaf-shaped (phylloidal) fibroadenoma of the breast. Symptoms of leaf-shaped fibroadenoma of the breast, diagnosis and treatment

Leaf tumor (foliate fibroadenoma) It is formed from intraductal fibroadenoma and occupies an intermediate position between fibroadenoma and sarcoma (cancer) of the breast. Tumor malignancy occurs in 3-5% of cases.

Leaf-shaped tumors occur in all age groups, and the peak incidence occurs during active hormonal periods of life: 11–20 years and 40–50 years. The vast majority of leaf-shaped tumors are found in women, but isolated cases of tumor development in men have been described.

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Leaf fibroadenoma breast has many synonyms: phyllodes cystosarcoma, phylloid fibroadenoma, fibrosarcoma. This neoplasm accounts for about 2-5% of cases of all types of fibroadenomas.

Causes of leaf-shaped fibroadenoma

A huge number of factors can influence the occurrence of this tumor. The main culprits of the neoplasm:

1. Heredity - tumor processes in can be transmitted from generation to generation, which is associated with a mutation in some genes;
2. Metabolic disorders - obesity and atherosclerosis presumably affect the formation of tumor processes, although there are no exact data yet;
3. Failure in hormonal status - the likelihood of illness is higher in people with problems thyroid gland, ovaries. This is especially true for tumors that can produce additional hormones. This phenomenon is easily explained - the glands are hormone-dependent, so they immediately fall under the hormonal shock;
4. Early menstruation, a huge number of abortions, early menopause - also increase the risk of leaf-shaped fibroadenoma;
5. Features of nutrition - a large amount of meat and fat is dangerous in terms of the occurrence of a benign process in the gland;
6. Radiation background - irradiation contributes to the regeneration of healthy cells;
7. Taking hormonal medicines and COC.

Tissue structure

There are three stages in the development of leaf-shaped fibroadenoma:

Benign tumor - there is a well-defined capsule, few or no abnormal cells, cells lack mitotic activity (they do not divide). Fibrous and glandular tissue are evenly distributed;

Malignant leaf-shaped fibroadenoma - the capsule is no longer there, fibrous tissue in large quantities and significantly predominates over the glandular component. Cells are actively dividing, which leads to an increase in the number of atypical cells. There is a germination of the tumor in the breast tissue.

Border process - there is a division of atypical cells, although the process is still inactive. There may be a slow germination of cancer in the tissues of the organ.

Symptoms

At small sizes, the tumor does not appear, but it can be detected through a thorough examination of the gland and diagnostic measures. As the node increases, a pulling pain appears in the organ, there may be discomfort. If the size of the formation exceeds 3 cm, then the skin above them becomes thin, almost transparent, shiny, dilated veins are clearly visible. When close to the skin, a bulging of the node appears, which spoils the appearance of the organ, causing moral suffering to the woman. The tumor itself is large, densely elastic, the edges are clearly palpable.

As the tumor grows and grows into neighboring tissues, there is a constant pain in the gland, sometimes there is a discharge from the nipple of a transparent color.

Malignant leaf-shaped tumor gives hematogenous metastases. In most cases, the lungs and bones are affected. Metastasis through the lymphatic tract is not typical for this neoplasm, so nearby lymph nodes rarely increase in size.

Leaf fibroadenoma develops into cancer in about 5% of cases.

Diagnostics

• According to the results of mammography, a dense round or oval nodule with a sharply defined even edge is detected. In the tumor, in rare cases, there are foci of calcification (calcifications).
• Ultrasound examination can detect a neoplasm with a clear contour and small cysts.
• Magnetic resonance imaging is a highly effective method for diagnosing leaf-shaped fibroadenoma. The images clearly show a tumor with a lobular structure. This study is carried out with and without contrast, this is necessary for a more detailed diagnosis. MRI helps to clarify the size, nature and type of tumor, the extent of surgical intervention.
• Radionculoid study - carried out in cases where other studies failed to accurately determine the type of tumor.
• A biopsy in the case of leaf-shaped fibroadenoma is performed, but its effectiveness is very low - about 30%.
• If suspected, a bone and lung examination is performed. Plain x-rays are taken to rule out lung damage. For pain in the bones and pathological fractures, a scintigraphic examination is performed.

Treatment

If the tumor is small and there are no signs of malignancy, they resort to sectoral resection of the organ. In this case, the affected sector of the mammary gland is excised with the capture of healthy tissue, which helps to reduce the number of relapses of the disease. If the doctor decided to save the patient and performed enucleation - removing only the tumor with the capsule - this will result in the woman repeating leaf-shaped fibroadenoma.

In the presence of a large tumor that changes the appearance of the mammary gland, they resort to. The peculiarity of the operation for this form of cancer is the preservation lymph nodes. Subsequently, cosmetic restoration operations with implants are carried out.

If a malignant leaf-shaped fibroadenoma is detected, the affected gland is removed and then the woman undergoes chemotherapy.

Forecast

Disease proceeds well in most cases. Early detection of the tumor allows you to quickly remove the node and the woman returns to normal life. With sectoral resection, the recurrence rate of fibroadenoma is only 20%.

During the enucleation operation, the probability of recurrence of the disease is 100%!

With malignant degeneration, everything will depend on the woman herself and the response to the treatment.

Prevention

There is no specific prophylaxis. But there is a chance to reduce the risk of leaf-shaped fibroadenoma if a number of measures are followed.

For this you need:

• lead a healthy lifestyle, preferably with high physical activity;
• change your diet - increase the amount of seafood and sea fish;
• do not drink alcohol;
• avoid stress;
• follow recommendations for the treatment of chronic diseases.

For early process diagnostics you need to independently examine the mammary glands for seals and bumps, as well as annually visit the examination room. Since the small size of the tumor node sometimes does not allow it to be detected during examination, it is extremely important to undergo ultrasound and mammography of the mammary glands if necessary.

The patient is 13 years old. I independently discovered a seal in the mammary gland and amber bloody issues from the nipple.

Clinical examination: the mammary glands are developed correctly, on the skin of the left mammary gland in the upper quadrants - striae (skin stretch marks), near the areola - slight redness and irritation of the skin (according to the patient due to compresses).

Palpation: the right mammary gland is soft, without features; the left mammary gland is dense throughout. Discharge from left nipple on pressure amber.
Swab taken.

Cytology: erythrocytes, macrophages.

Ultrasound procedure:

The mammary glands are represented by glandular tissue. To the left, behind the areola, there is a polycyclic formation with a heterogeneous echostructure, clear, even contours, and anechoic inclusions up to 3 cm. Increased blood flow. Dimensions are out of visualization bounds. Structural lymph nodes

To resolve the issue of the volume of subsequent surgical treatment and the activity of the process, an MRI study of the mammary glands was performed in the axial and coronal plane, in 3D mode, as well as with intravenous administration 7.5 ml of Gadovist in dynamic contrast enhancement mode. In the left mammary gland, a volumetric formation is determined, occupying almost the entire zone of the glandular tissue, 6.6×4.6×5.2 cm in size. The structure of the tumor is lobular with multiple vessels along the interlobular septa. In the lower parts of the tumor, an irregularly rounded cyst with hemorrhagic contents up to 3.3 cm in diameter is visualized (Fig. 1)

Rice. 1. Ultrasound picture: a hypoechoic mass that goes beyond the size of the probe, with increased blood flow and polycyclic contours.
In the diffusion mode, this zone is pathologically changed. With dynamic contrast enhancement, there is a pronounced accumulation of the contrast agent by the tumor and cyst capsule, as well as by intracapsular growths (Fig. 2-3).

Fig 2. MRI.

Rice. 3. Graph of accumulation of the contrast agent.
The right mammary gland without features. Lymph nodes in the axillary zones are visualized, enlarged, structural.

After instrumental diagnostic methods, a diagnostic puncture of the formation from several places was performed.

Cytology: abundant accumulation of cuboidal epithelial cells (3-dimensional structures), oxyphilic masses.

Considering clinical picture, volume of the tumor, blood flow activity in it, ultrasound, MRI study and contrast accumulation graph, as well as the results of a cytological study, the diagnosis was made: "Foliate fibroadenoma with a cystic component of the left breast."

Enucleation of the breast tumor was performed.

Histology: phyllodes tumor (photo 1).

Photo 1. Macropreparation (phylloidal fibroadenoma)
When the patient was re-examined 3 months after surgery, no breast asymmetry was observed. Palpation of the left mammary gland without features. Ultrasound revealed cicatricial deformity of breast tissue at the surgical site (photo 2).

Photo 2. Postoperative scar.

Leaf-like fibroadenoma of the breast belongs to the group of fibroepithelial neoplasms, initially benign, but with a high tendency to degenerate into malignant forms. It is noted as a transitional stage from the usual fibroadenoma to the sarcoma of this gland, which is why it is so important to differentiate this tumor from similar pathologies and to undergo adequate therapy in a timely manner.

This pathology is often meant by other names: leaf-shaped tumor of the mammary gland, phyllodes or giant myxomatous fibroadenoma.

Features and characteristics of this pathology

The pathological process can be observed at any age, but the peak falls on the most hormonally active periods: from 12 to 20 years and from 40 to 50 years. The presence of a tumor is manifested by the appearance in the gland of seals of various sizes, often gigantic. According to this principle, they are divided into two groups:

• up to 5 cm in diameter;
• more than 5 cm.

In the first case, the macroscopic neoplasm is characterized by a coarse-grained or lobular structure, it is limited from adjacent tissues, has a grayish-white or slightly pinkish tint. In the second case, the structure of the tumor of the leaf-shaped fibroadenoma of the mammary gland is distinguished by cystic cavities that are filled with a gelatin-like liquid and covered with polyps. In addition, the phyllodes has a sudden and rapid growth. This activity is due to a good blood supply to the neoplasms.

Interesting! In medical practice, a case was noted when this tumor reached 45 cm in diameter and weighed 6 kg 800 g at the same time (on the Internet you can find a photo of a leaf-shaped fibroadenoma of the giant mammary gland).

Neoplasm has three forms: benign, transitional and malignant. This is reflected in the symptoms and the chosen treatment tactics.

Causes leading to the appearance of the disease

Based on the fact that the growth of neoplasms is more often observed at a hormonally active age, the main cause of leaf-shaped fibroadenoma in the mammary gland is an imbalance of estrogen and progesterone.

Provoke pathology can:

• disturbed metabolism;
• frequent abortions;
• lactation;
• tumor diseases of the ovaries;
• some chronic diseases (diabetes, liver disease, etc.);
• problems with the endocrine system;
• low immunity.

Among the causes, the influence of a genetic predisposition to cell mutations and the development of tumors is not excluded.

Symptoms of the onset of the pathological process

For this disease a two-phase course is characteristic: first, a slow and long-term development, which can stretch for decades, then a stage of rapid and dynamic growth.

On the initial stage development, leaf-shaped fibroadenoma of the breast most often does not show symptoms, and then it is found in the form of a painless movable seal when the woman herself palpates the breast or at the next visit to the gynecologist.

The growth of the neoplasm leads to thinning of the skin in the area of ​​​​the lesion and a change in its color (the skin becomes purple with cyanosis). Further, the symptoms of phyllodes fibroadenoma of the breast are:

1. pain in the gland;
2. enlarged saphenous veins;
3. discharge of fluid from the nipple.

The growth of the tumor is often accompanied by a general deterioration in the state of the body, fever, and weakness. The malignant process causes anemia, pain that is not relieved by conventional medicines, lack of appetite, and increased fatigue.

Methods of modern diagnosis of the disease

In addition to palpation examination and detection of a nodular neoplasm (one or more), in order to make a final diagnosis, it is necessary to undergo:

When conducting ultrasound of this pathology, a neoplasm is detected that has heterogeneous structure, with different cavities and numerous crevices (in appearance it looks like a head of cabbage). Photographs of a leaf-shaped fibroadenoma of the mammary gland obtained with ultrasound will help to study the structure and determine the exact size of the tumor formation. You may need to do dopplerography (another type of ultrasound, which is aimed at studying the network of blood vessels that feed the tumor).

Mammographic examination will show a clearer outline of the tumor, which may be round, irregular or oval in shape, give a full picture of the lobular structure, coarse-grained or cystic.

In order to prescribe an adequate course of treatment, it is very important to differentiate this neoplasm and determine whether there is a benign process or a transformation into a malignant leaf-shaped breast tumor has occurred. To do this, a puncture biopsy is performed (tissue is taken from different parts of the tumor) with further cytological examination of the material.

What is the necessary treatment for pathology

The course of therapy for leaf-shaped fibroadenoma of the breast is prescribed based on what form is detected, what are the dimensions of the lesion, taking into account the state of the woman's body.

The basis of treatment is surgery. If and has small size, then either enucleation or sectoral resection is possible. In the first case, the leaf-shaped fibroadenoma is “husked” under local anesthesia through a minimal incision in the gland. In the second case, the neoplasm and adjacent healthy tissues are removed.

With large lesions and the detection of a malignant form, in order to improve the survival prognosis for a leaf-shaped breast tumor, a radical mastectomy is indicated (complete removal of the gland along with the pectoral muscles).

- fibro-epithelial formation of the mammary gland, belonging to the group of potentially malignant tumors. The presence of a leaf-shaped tumor is manifested by a seal in the tissues of the mammary gland, sometimes of gigantic size; in some cases - pain and discharge from the nipple. Diagnostic tactics include ultrasound, mammography, puncture biopsy and cytological examination of the material. Treatment of a leaf-shaped tumor of the breast is only surgical and may include performing a sectoral resection, radical resection, or mastectomy.

General information

A leaf-shaped tumor of the mammary gland is a difficult-to-diagnose formation with a tendency to intensive growth, recurrence, and malignant degeneration into sarcoma. Malignancy of the leaf-shaped tumor of the mammary gland is observed in 3-5% of cases.

Characteristics of leaf-shaped tumors of the breast

The international histological classification classifies a leaf-shaped tumor as a fibro-epithelial formation and distinguishes three possible forms - benign, borderline (intermediate) and malignant.

The macroscopic picture of a leaf-shaped breast tumor depends on the size of the formation. Tumors up to 5 cm in diameter are a solid formation of a grayish-white or pinkish color with a coarse-grained or lobed structure delimited from the surrounding tissues. The section shows slit-like cavities and small cysts containing a viscous mucus-like mass. The macrostructure of leaf-shaped tumors of the mammary gland larger than 5 cm is always represented by cystic cavities and crevices filled with a gelatin-like secret, polypoid growths in cystic cavities.

Microscopically, the stromal (connective tissue) component predominates in the structure of a leaf-shaped breast tumor. The difference from breast fibroma is a more pronounced stroma with significant phenomena of nuclear polymorphism and proliferation of stromal cells.

Leaf tumor may present as a solitary or multiple nodes located in one or both mammary glands. Phyloid tumors are characterized by sudden, rapid growth; the size of leaf-shaped fibroadenoma is variable - from small nodules to 20 or more cm in diameter.

Causes of the formation of a leaf-shaped tumor of the breast

The etiology of leaf-shaped breast tumor is unclear. Its development is associated with hormonal imbalance, primarily with hyperestrogenism and a lack of progesterone. In this regard, the peaks in the detection of phyllodes fibroadenomas fall on the hormonally active transitional periods of women's lives: 11-20 years and, most often, 40-50 years. In isolated cases, leaf-shaped tumors of the mammary glands occur in men.

Provoking factors in the formation of leaf-shaped breast tumors can be pregnancy, abortion, lactation, fibrocystic mastopathy, as well as extragenital endocrinopathies and metabolic disorders - diabetes mellitus, tumors of the adrenal and pituitary glands, thyroid nodules, obesity, liver disease, etc.

Symptoms of a leaf-shaped tumor of the breast

For a leaf-shaped tumor of the mammary gland, a two-phase course is typical. Usually, after a long period of slow development, which sometimes lasts for decades, there comes a phase of sudden rapid growth. The average size of phyllodes fibroadenomas is 5–9 cm, although cases have been described when the tumor reached a diameter of 45 cm and weighed 6.8 kg. At the same time, the size of the leaf-shaped breast tumor does not have prognostic value - a small formation can be malignant and, on the contrary, a giant fibroadenoma can be benign.

Usually, a leaf-shaped breast tumor is detected by the patient herself or by a mammologist during palpation in the form of a dense node. With a large size of a leaf-shaped tumor, the skin over the mammary gland becomes thinner, acquires a purple-cyanotic hue with translucent dilated saphenous veins. There may be pain in the mammary gland, discharge from the nipple of the affected gland, skin ulceration.

A leaf-shaped tumor is more often localized in the upper and central quadrants of the mammary gland, and in large sizes it occupies most or all of the breast. A malignant leaf-shaped tumor of the breast usually metastasizes to the lungs, liver, bones; lymph node metastases are uncommon.

Diagnosis of a leaf-shaped tumor of the breast

On palpation, a leaf-shaped tumor of the mammary gland is determined as a seal delimited from the surrounding tissues with a lobed structure, consisting of several nodes merging with each other.

Carrying out a radical resection of the mammary gland, subcutaneous or radical mastectomy is justified in the case of big size tumor or its malignant nature. Lymphadenectomy is usually not performed. After radical interventions, reconstructive mammoplasty is performed with own tissues or endoprostheses. Radiation and hormone therapy for leaf-shaped breast tumors are not indicated.

Prognosis for leaf-shaped tumor of the breast

A feature of leaf-shaped tumors of the breast is their frequent tendency to relapse: according to observations, benign phyllodes fibroadenomas recur in 8.1% of cases, borderline - in 25%, malignant - in 20%.

Relapses often occur within a period of several months to 2-4 years; at the same time, the transition of a benign form to an intermediate or sarcomatous one is possible. Expansion of the scope of intervention (mastectomy) leads to a decrease in the risk of developing local recurrences of a leaf-shaped breast tumor.