Differential diagnosis between fibroadenoma and phyllodes tumor on core needle biopsy

Department of Pathology

Seoul National Univ. Hospital

Han Suk Ryu M.D., Ph.D.

[Education Session 7] April 26 (Fri), GBCC 2019

Quiz #1

Tiger?

Quiz #2

Lynx ?

Quiz #3

Lynx cub ?

Fibradenoma vs. Malignant PT

Cellular FAvs.

Benign PT(excision)

Cellular FA

vs.

Benign PT

(needle biopsy)

Cellular FA

vs.

Benign PT

(needle biopsy)

??Cellular FA

Benign PT Borderline PT

Malignant PT Benign PT

• The sensitivity of FNAC, CNB (core needle biopsy) and imaging for diagnosing phyllodes tumours was 40%, 63% and 65% respectively.

Ward et al. International Journal of Surgery 2012

• “Precise distinction may be extremely challenging in an individual case.”

• “An unanimously accepted criterion drawing does not exist.”

• “Even among experienced pathologists, it may be no easy task to achievediagnostic consensus on core biopsy material...”,

Benjamin et al. Surgical Pathology. 2018

15% - 17% 10% - 17%Recurrence rate

FibroadenomaBorderline PT: 35%Malignant PT : 8%

Recurrent tumor

Fibroadenoma Benign PT

Clinical differences between FA and benign PT

Benjamin et al. Surgical Pathology. 2018

Initial diagnosis is cirtical

Summary of pathologic findings on CNB

Text mining with recent studies (Cellular fibradenoma (CFA) vs. Benign PT)

IHC (2)Stromal component (10)

Cellular component (3) 6 1

# of Publication

A AA A

Increased stromal cellularity : Benign (or Borderline) PT > CFA

Gregor et al. Seminars in Diagnostic Pathology 2017

Increased stromal cellularity : Benign (or Borderline) PT > CFA

Gregor et al. Seminars in Diagnostic Pathology 2017

Cellular FABenign to borderline PT

Benign PTSaba et al. AJCP 2014

Stromal overgrowth : Benign (or Borderline) PT > CFA

Saba et al. AJCP 2014

Stromal overgrowth : Benign (or Borderline) PT > CFA

Benign PT

Stromal fragmentation : Benign (or Borderline) PT > CFA

Saba et al. AJCP 2014Benjamin et al. Surgical Pathology. 2018

Stromal fragmentation : Benign (or Borderline) PT > CFA

FA

Adipocyte infiltration: Benign (or Borderline) PT > CFA

Saba et al. AJCP 2014

Timothy et al. Anatomic Pathology 2005

Stromal heterogeneity : Benign (or Borderline) PT > CFA

Saba et al. AJCP 2014

same case, PT

Saba et al. AJCP 2014

Gregor et al. Seminars in Diagnostic Pathology 2017

Subepithelial condensation : Benign (or Borderline) PT > CFA

Stromal cell atypia: Benign (or Borderline) PT > CFA

FABenign PT

Immunohistochemistry

Cellular FA PT

Topoisomerase IIa Lower Higher

Ki67 Lower Higher

CD34 Higher Lower

Ana Richelia Jara-Lazaro et al. Histopathology 2010

Timothy et al. Anatomic Pathology 2005

Fibroepithelial lesions in young patients

Simple or cellular fibroadenoma Juvenile fibroadenoma Benign PT

Growth Slow

Stromal cellularity -/+ + +

Tumor size smaller Larger Larger

Pericanalicular pattern - + with lobular architecture +

Leaf-like fronds + - +

Epithelial hyperplasia - + +/-

Stromal mitosis 1.3/10HPF 1.8/10HPF 3.1/10HPF

Nuclear atypia No No Yes

Stromal uniformity + + -

Timothy et al. Journal of clinical pathology. 2015Benjamin et al. Surgical Pathology. 2018

Ross et al. Breast J. 2017

Fibroepithelial lesions in young patients

Simple or cellular fibroadenoma Juvenile fibroadenoma Benign PT

Growth Slow

Stromal cellularity -/+ + +

Tumor size smaller Larger Larger

Pericanalicular pattern - + with lobular architecture +

Leaf-like fronds + - +

Epithelial hyperplasia - + +/-

Stromal mitosis 1.3/10HPF 1.8/10HPF 3.1/10HPF

Nuclear atypia No No Yes

Stromal uniformity + + -

Timothy et al. Journal of clinical pathology. 2015Benjamin et al. Surgical Pathology. 2018

Ross et al. Breast J. 2017

Take home messages

• Cellular fibroadenoma and benign PT are clinical different.

• Cellular FibroEpithelial Lesions (CFELs) including Cellular fibrodenoma andindolent PT is challenging on needle biopsy sample.

• Seven morphologic variables including increased stromal cellularity helppathologists make a differential diagnosis.

• IHC might be valuable in some cases.

Take home messages - Lynx?

Oral presentation 4 (April 27. Sat. AM 9:18),

TNXBCD36COPZ1MYL12AHSPA5HSPA8XRCC6FLNACFL1SERPINH1PGDTUBA1BHDLBPMDC1

Title: PROTEOMIC LANDSCAPE OF FIBROEPITHELIAL TUMOR OF BREAST

Thank you for your attention