GIANT INTRACA4NALICULAR FIBRO …...the simple cyst os:trcoma, cyst osarcoma proliferum, and cyst...

GIANT INTRACA4NALICULAR FIBRO-ADENOMYXOhfA OF T H E BREAST. THE 80-CiILLED CYSTOSARCOMA

PHYLLODES MAMMAE OF JOHANNES MULLER

BURTON J. LEE, M.D., AND GEORGE T. PACK, M.D.

(From the Memorial Hospilnl f o r Concrr and A llicd Diseases, New Yorlc Cily)

In the January 1931 issue of the Annals of Surgery, we pre- sented four case reports of giant intracanalicular myxomn of the breast and summarized the salient characteristics of this tumor. In the present article we will include a complete bibliography of the literature to date on this subject, a concise summary of one hundred and five case reports culled from this literature, and n report of two additional cases which we have observed. These two personal cases illustrate clearly the early and the late stages in the evolution of this curious neophsm.

In 1835 Johnnnes Muller described this tumor as rz neoplastic entity, and gave it8 the name of cystosarcoma phyllodes. His classical description is worthy of quotation in detail:

Three forms of cystosnrcomn have come under the author’s notice; the simple cyst os:trcoma, cyst osarcoma proliferum, and cyst 0s:ircoma with foliated warty excrescences from its cysts. In cystosnrcorna simplex, the cysts contained in the fibrous sarcomatous texture have each their distinct membmne, the inner wall of which is simple, smooth or at most beset with :L few vnscular nodules.

“ I n the second form, the sarcomtttous mass is the same, but the cysts within it contain youiigcr cysts in their interior, which are attached to their walls by pedicles. This form of morbid growth is a repetition of the proliferating cysts, but inibeddetl in a sarcomatous mass, which constitutes the chief part of the tumor; and it may, therefore, be termed with propriety cystosnrcorna proliferum. The pedunculnted offsets from the cysts are hollow.

“The third form, cystos:trcorn:~ phyllodes, differs greatly from the other two. The tumor forms a hrge firm mass, with :t more or less uneven surface. The fibrous substance which constitutes the greater part of i t is of a greyish white color, extremely hard, and as firm as fibro-c:trtilage. Large portions of the tumor are made up entirely of this mass, but in some parts :ire cavities or clefts not lined with a distinct membrane. These cavities contnin but little fluid; for either their parictes, which are hard like fibro-cart il:ige, and finely polished, lie in ose apposition with each other, or :t number of firm, irregular 1amin:te

2583

2584 BURTON J. LEE AND GEORGE T. PACK

sprout from the mass, and form the walls of the fissures; or excrescences of a foliated or wartlike form sprout from the bottom of the cavities and fill up their interior. These excrescences are perfectly smooth on their surface, and never contain cysts or cells. The laminae lie very irregularly, and project into the cavities and fissures like the folds of the psalterium in the interior of the third stornnch of ruminant animals. In one instance the author saw these lamina here and there regularly notched or crenated like a cock’s comb. Sometimes the 1amin:te are but small, snd the warty excrescences from the cysts very largr, while in other instances both are greatly developed. Occasionally t hrse warty excrescences arc broad, sessile, and much indented; others have a more slender base, and somewhat resemble cauliflower condylomat,a.

“Tumors of this kind attain an enormous size; hitherto the nuthor has seen them only in the female breast, nor are they even there of frequent occurrence. They are decidedly innocent, occur earlier than i t is usual for cancer in the mamma to develop itsrlf, and sometimes they appear even in youth; they have but little tendency to grow to the skin or to the subjacent muscles, nnd are not attrnded with retraction of the nipple. They are not disposed to soften internally, but continue to grow slowly until they have attained an enormous size whrn they at length burst, and a very ill-looking suppurating fungus forms upon their surface. Even in this state, however, the operation has been performed with a successful result.

“Swelling of the axillnry glands is not a common occurrence, :in(!, when it is met with, is the consequence of simple irritation, :md suhsides after the operation. The extr:mrdinnry forms which cystosarconia phyllodes assumes, a t once suggest the notion of its cancerous nature; and yet, the disease is perfectly innocent, and as far removed from carcinoma as are those non-suppurating cauliflower condylomata of thc penis, and of the female genitals, which have so often been mist:tken for cancerous structures.”

This tumor of the breast had been reported in literature several times prior to Muller’s classification. Chelius had previously given an accurate gross description, which may be translated as follows :

“The sarcomatous or steatomatous degeneration of the mammary gland is one of the most benignant diseases to which that organ is subject, and it is with great impropriety that many have spoken of it as carcinoma mammae hydatides. It is characterized by the large size and great prominence of the tumor, which is not globular, but four-cornered, and projecting more a t one part then another; it does not cause retraction of the nipple, but that part projects and retains its natural appc:trance. The greatest diameter of the tumor is not a t its base, but a t a point some distance from the walls of the chest. This disease may be distinguished from scirrhus and fungus medullaris of the mammary gland, partly by the above mentioned signs; but other circumstances which servc still

FIBRO-ADENOMYXOMA OF THE BREAST 2585

further to distinguish it, are its different consistence a t different parts, i t being hard a t one spot, elastic and tense a t another, and even distinctly fluctuating a t a third; its mobility in d l directions, notwithstanding the great size it attains; the slight influence it exerts on thc general health, even after it has continued for a considerable time; and, lastly, the absence of swelling of the :ixillary glands. Although this tumor is inconvenient to the patient from its size, and painful from its dragging at surrounding parts, yet it does not affect the health.”

The characteristic features of this tumor have been summarized

1. Greatness in size, averaging 7.6 pounds. Frequently the

2. The lobulation and delimitation of the tumor with variable

3. Encapsulation of the tumor and non-invasion of the breast. 4. Mobility and usual non-adherence t o skin and fascia. 5 . No retraction of the nipple and no involvement of axillary

6. Possible occurrence in males (3 per cent). 7. Development from pre-existent fibro-adenomas, probably

intracanalicular fibro-adenomas. The transition occurs at the time when a gelatinous metamorphosis of the stroma takes place.

8. Long initial period of quiescence or slow growth, followed by sudden rapid acceleration.

9. Long duration-averaging seven years in 111 cases. 10. Important r81e of lactation and nursing difficulties in the

metamorphosis of simple fibro-adenoma to giant intracanalicular myxoma.

11. Intracystic polypoid excrescences moulded by apposition with each other.

12. Narrow sinuous distorted clefts between polyps. These epithelial-lined spaces contain variable quantities of clear yellow fluid.

13. Myxomatous stroma with cellular pseudosarcomatous regions.

14. Benignity; good prognosis with freedom from recurrence. 15. Successful treatment by wide local excision or simple

mastectomy. In addition to the metaplasia of the stroma into myxomatous

tissue, which is the distinguishing and essential feature of this variety of tumor, the cuboidal or columnar epithelium of the clefts

by us as follows:

tumor is as large as an adult head.

regions of fluctuation and resistance.

lymph nodes.


may undergo metaplasin, to form pavement epithelium, even true epithelial pearls, indicating functiond instability. Such pearls were found by Groh6, Gorham, Kursteiner, G. €3. Schmidt, Stumpf and Beneke. In the layers of cyliridricnl epithelium of the adenomatous clefts these groups of pavement epithelial cells show all the characteristics of cutaneous epithelium, such as corni- fication. These pearls never occur unless the stroma rextion or proliferation has been really enormous, which is the reason that these tumors have been designated :is mixed tumors.

The tendency found in intracnnalicu1:tr fibro-adenomas to form true glmds by the cxtension of ductal epithelium down into the connective tissue is likewise present in cystos:trcoma phyllodes. These glandulnr productions in the tlumor are probably tinalogous t o the g1:inds in the mammary tissue. The acini in the adjoining breast are frequently cystic.

The ordinary intr:tcnnaliculitr fibro-adenoma of the breast is formed as follows. The inner or subepithelial layers of the peri- canaliculnr connective tissue participate more actively in the growth of the tumor than do the outermost connective-tissue layers, in consequence of which buckling or folding of these inner layers occurs, and rounded or p:ipillnry projections of the peri- ductal tissue are invagimtted into the lumina of the tubules. The same txp1:m:ttion may be valid for cystosarcoma phyllodes.

Rcinhnrdt w:~s the first t o demonstrate thzt cystosarcomn could develop from fibro-ndenomrt of the breast. In describing this transition, Billroth said that, if the stroma enlarges intracnnalic- uhrly, then either obliteration of the lumen occurs or these 1umin:t enlarge to cover the stromous proliferation. Another factor to which enlargement of the ductal lumina was attributed was secre- tion, which c:tused the iritraductular projectioris to resemble polypoid tufts. Frangenheim and Ribbert independently as- serted that a particular type of intr:tcanalicular fibroma was pre- cursory, because in this variety the periduct:il and periacinar connective tissue seem quite embryonic. Beneke also attributed the origin of cystosarcoma phyllodes to pre-existing fetal adenomas ; on this account, they were said to retain their embryonal capacity to proliferate. Frangenheim explains that cyst:tdenomas are transitional stages between fibro-adenomas and cystosarcomas. Schimmelbusch said that cystos:trcoma phyllodes was merely an advanced developmental phase of fibro-adenoma and, therefore, should not be called sarcoma, since it was a benign tumor. True


malignant tumors may originate, however, in benign mammary fibro-adenomas. In such fibro-epithelial tumors the epithelium may become carcinomatous, or both fibrous and epithelial tissue may become malignant (sarco-carcinoma), as described by Dorsch, Coenen, Wehner, and Schlagenhaufer. Virchow knew that sarcoma could originate in the stroma of an epithelial tumor. Ehrlich showed, when transplanting carcinoma of a mouse into different animals, that the stroma may change so as eventually to replace the carcinoma and finally become sarcomatous. The mechanism of stimulation in these instances, as in cystosarcoma phyllodes, may be similar in kind if not in quantity.

FIG. 1. CASE 1: CLINICAL PHOTOGRAPH OF PATIENT. Kote the size of the affected breast, the livid intact skin, and the protuberant

elastic eminence in the inner segment.

Lukowsky, Krompecher, and Sasse believed that cystosarcoma phyllodes may originate in the fibro-adenomas developing in breasts which are involved by diffuse fibromatosis, but the majority of pathologists accept the congenital origin (theory of Cohnheim). These authors, notiibly Wilms, insist that the anlagen of these tumors are embryonal tissue anomalies included in the region of the breast. The delimitation of the tumor by capsulation and the lack of infiltration indicate the separate entity of the tumor and contradict the theory of its origin from adult breast tissue.


CASE REPORTS CASE I: E. R., a white, married wornan, aged forty-four years,

applied to the Rllemorinl Hospital, Oct,. 21, 1930, complaining of a painless lump in her right breast.

Ptrst History: Nine years previously a cyst of Bartholin’s gland was excised. The patient h:id been niarried only two years and had never been pregnant.

FIG. 2. CASE I: GROSS SPECIMEN ILLUSTRATING THE LARGE, INTRACYSTIC hIuxoh1- ATOUB 1’oLws SEPARATED BY N A I ~ I ~ O W . TORTUOUS CLEVTS.

Present Illness: One month prior to applicat,ion the patient chanced to feel a lump in her right breast. There was no mastalgia, and no discharge from the nipple. The tumor grew rapidly and soon produced a red mound-like eminence on t,he contour of the breast.

Physictrl Exatiiiriution: In the lower inner quadrant of the right breast was a firm, globular, freely movable tumor. The superficial part of the turnor seemed to be fluctuant. Both breasts were large. The nipples were erect. There were no palpable axillary 1ymphadenop:ithies. The immediate provisional diagnosis was cyst of the breast; but since aspiration by needle puncture did not yield fluid, the tentative diagnosis was changed to fetal adenoma.

FIBRO-ADENOMYXOMA OF T H E BREAST 2589

Treatment: On Oct. 22, 1930, the tumor was simply excised, without the removal of mammary tissue. This was accomplished by an elliptical skin incision surrounding the protuberant part of the tumor. Conva- lescence was uneventful.

Gross Pathologic Anatomy: The encapsulated tumor measured 8 x 5 x 4 cm. On hemisection numerous intracanalicular polypoid projections were found closely packed within the capsule. The polyps were separated by intercommunicating clefts, which contained thin, clear, straw-

There has been no recurrence to date.

FIQ. 3. CASE I: CROSS-SECTION OF A TYPICAL INTRACANALICULAR FIBRO-ADENOMYXOMA

colored fluid. The stroma was smooth, loose, and gelatinous in certain regions, especially within the polyps.

Pnlhnlogic Histolog!j: Myxomntous t,issue was found in many of the polypi. The spindle cells of the stroma tend to run parallel to the e1ong:tted clefts. Some parts of the stromn were composed of fusiform cells with bizarre nuclei, which were n:irrow and rod-like, resembling smooth muscle nuclei. Some hyulin degeneration had occurred in the polypoid tissue. The clefts were lined by cylindrical and cuboidal epithelium, which projected into the stroma to form pseudo-glandular lacunae.

FIQ. 4. CASE I: COMPLETE HYALINE METAMORPHOSIS OF NIJMEROUR POI~YPFI, WHICH HAVE RETAINED T H E I I ~ EPITHELIAL INVE~TMENTS.

I?IQ. 5. C A S E 1: SINUOUS, DI~~TORTED, ANA6TOMOTIC CLEFTS, h N E D BY CUBOIDAL 14:I’ITHELIUM AND FORMINQ SECONDARY I’SEUDOACINAR C R Y P T S .

The spindle cells of the stroma run parallel to these ductal clefts.

2590

FIBRO-ADENOMYXOMA OF THE BREAST 259 1

CASE 11: M. E., a white, married woman, aged fifty-two years, applied to the Memorial Hospital, June 20, 1927, complaining of large tumor masses in each breast.

Past History: The patient’s only child, born in 1895, had nursed both breasts without difficulties in lactation. The menopause had been passed without complica tions.

Present Illness: Forty years earlier, when the patient entered puberty, a t the age of twelve years, she discovered a small lump in the lower segment of the right breast. This lump gradually increased in size until 1922, when it grew wit>h greater rapidity. Five years before the patient was seen (1922), another lump appeared in the upper half of the left breast; this tumor gradually grew to involve the skin and became

FIG. 6. CASE 11: CLINICAL PHOTOQRAPH OF PATIENT WITH GIANT INTRACANALICULAR FIBRO-ADENOMYXOMA OF RIQHT BREAST; BULKY ADENOCARCINOMA OF

LEFT BREAST.

the size of an orange, The only discomfort experienced was the weight of the right breast.

Physical Excmintition: The right breast was completely replaced by a bulky, lobulated, elastic, semi-fluctunnt tumor. The nipple was obliterated. The tumor was encapsulated and freely movable. The breast was pedunculated, due to the traction exerted by the weight of this tumor, which rested against the upper abdomen. The right breast measured 21 inches in circumference. In the upper segment of the left breast was an ovoid movable tumor S x 5 cm. in diameter. The super- jacent skin was purplish-red and firmly adherent. There were no palpable axillary lymph nodes. A radiograph of the chest was negative except for obliteration of the left costophrenic angle by adhesions. There were no discernible regions of *calcification in the tumor of the

There never was any cough or pain.

27

FIG 7. CASE 11: GROSS SPECINEN OF A GIANT INTI~ACANALICULAR MYXONA OF THI

There is marked overgrowth of the stroma in lobular arrangement; some of these BREAST.

lobulea appear myxosarcomatous when examined microscopically.

2692


right breast. The provisional clinical diagnosis was sarcoma of both breasts,

Treatment and Progress: In June 1924 a simple mastectomy of the right breast was performed. At the same time 62; millicuries of radon in 25 gold seeds were implanted in the tumor of the left breast,. By December 1927 this tumor had disappeared completely, but the patient complained of pain in the left shoulder girdle. A radiograph of the left shoulder revealed early metastasis to bone. In November 1928 a left radical mastectomy was performed, using a transverse Stewart incision;

FIQ. 8. CASE 11: SPINDLE AND STELLATE CELLS OF MYXOMATOUS STROMA OF ADENO-

The numerous mitoses, loss of polarity, and character of the nuclei indicate a low- FIRROMYXOMA.

grade malignancy, i . e . , myxosarcomn.

the wound could not be closed and was permitted to heal by secondary intention. Pulmonary metastases developed, and the patient died Dec. 5, 1929.

Gross Pathologic Anatomy: The right breast was completely replaced by a tumor measuring 18 x 15 cm. On section the tumor appeared lobulated, with smooth, glistening, gelatinous stroma. Several of the lobules exhibited central necrosis and cavitation, a phenomenon more frequently found in mammary sarcomas than in giant intracanalicular myxomas of the breast. The polypoid projections were sessile. The tumor was well encapsulated and did not invade the adjacent breast tissue.

TA

BL

E I

The

Age

and

Sex D

istr

ibut

ion

of C

ysto

sarc

onia

Phy

llode

s an

d F

ibro

-ade

nom

as o

f th

e M

amm

ary

Gla

nd

Typ

e Se

x an

d C

ivil

Sta

te

Fibr

o-ad

enom

a M

ale.

. ...

......

......

......

. hl

arri

edfe

mal

e.. ..

....

....

...

Sing

le f

emal

e.. ..

....

....

....

. TOTAL..

....

....

....

....

...

Cys

tosa

rcom

a M

ale.

....

....

....

....

....

...

Sing

le f

emal

e.. ..

....

....

....

. Ph

yUod

es

Mar

ried

fem

ale.

....

....

....

..

Age

15

20

25

3

0

35

40

45

50

5

5

60

65

70

75

to

to

to

to

to

to

to

to

to

to

to

to

to

19

24

29

34

39

44

49

54

59

64

69

74

79

~

-----------~

2

1

1

1

8 13

18

14

20

19

7

1

1

2 5

16

9 5

5 3

8 24

22

23

20

23

19

7

1

1

2 1

11

2

6 7

91

21

31

56

6

2 1

2 1

11

23

21

1

__

__

__

-_

_ ------ ~

__

I I

Age

n

ot

give

n

Tot

ah

TOTAL ......

......

......

...

(1

I 151

I

4 7

7 10

13

16

19

8

7 2

1

~-

1

I 3

1

__

_-

{ 15

1 108 1

4 10

4 43

__

_-

16

111

1


The left breast contained a small, hard tumor measuring 2 x 13 x 1 cm., situated in the upper medial portion. The skin over the tumor was slightly ulcerated.

Pathologic Histology: The right mammary tumor consisted almost entirely of myxomatous tissue which had completely replaced the original stroma. The interlobular clefts were lined by cuboidal epithelium. The spider-like cells of the myxomatous stroma were very large but not closely packed. Microscopically one obtains the impression that the tumor is of low-grade malignancy, i e . , myxosarcoma.

The tumor in the left breast was obviously a necrotic carcinoma, probably of the sweat gland type. No metastases were found on micro- scopic examination of the lymph nodes in each axilla.

Comment: The tumor in the left breast was a bulky adenocarcinoma, which caused the patient’s death, but was histologically and histo- genetically not related to the giant intracanalicular fibro-adenomyxoma of the right breast.

[over]

TABLE 11: * Giant Intracanalicular Fibro-adenomysoma of the Breaat 4a CI

Author and 2 date

0

4

Relation tn lactation and

pregnancy

Dura- tion in yenra

__ 5

__ 10

_- Many ycars

Skin of breast

Chief physirnl findin and symptoms Location Size

:hild’s hra 57 01.

8: lb: 1 5 x 8 in.

-__

13 lb.

Rulkv breast tiimor. I cilialing pain during n struation

Left Stimulated

Right Chclius 30 1828

Normal

0 m.

0 m. __

Left I4 3” in. eircum.

Addt heal -__

Nodular tumor, Buctuo

-____ Fkcher 30

Orucft: 31)

I835 -____

1838

Never nursed Ulcer 1

__ 2

Funcation. Varicose vc Nodular, tluctuant.

0 m. After lalit prep. nancy

Left Ulcer 22 Ib. 8 02.

Circumference 58 in. 1 mor filled lap. Cyanti skin. I’ainafterfungat

Ulcer 16 Moderate

1x39 Itight Normal 4

__ I

Nodular, irregular turn(

(:lobul:rr fused tunioi No p i n

- - E66

12 Ib. Warren 1 1839

0 Nnrmal

0 1.

0 m. -

Lcft No p i n Entire brenst

2 Ib.

Two fista

__ 6 Lcbert 50

I814 1 Nornl:il Iliaht: lower left quadrant

Biue Movable tumor undt skjn. veins dilated. N pain

Coote 36 1816

0 m. Ridit: uppei left quadrant

Recurrener 2 sears aft( mastectomy. I’irin moiitlis

P m.

0 ~

Ulcer 7 I\). Fungntion throulrh ad herent skin. No pain

Oiily 4 nurscd bread

Ulcer Urodie 1816

Orawe

Large Urodie 1846 1 Left Ulcer Fluetuaat tumor. Di.i

charge from pressure ulcei -_____ Gorup- 41 Hcsnnes

1849

hlettcn- 35 hrimer

1850

-_____

Ulue 3 Small Lanrinating pain Nodule after still. birth

Left: upper right quadrant

Right Q m. Normal TWO fiats

1 Ih.

Nodular, movable tunior Fatty t w o w dischnrgr from nipple

Lobulateil. aoft. elastic tumor. Good health

__ 10 0 I). Left: upper

right quadrant

Ulrer Birkett 51 1850

--___ ~

Erichscn 35 1852

Right Ulcer

0 8 . Ulcer 5 Ib., ize of head

Left Nodular cystic tumor. In- convenience of weight

Pcrauson 1 40 1853

0 m. Ulcer Left

Left

Nodular. cystic tumor. Inconvenience of weight

Immense movable tumor. Incoiivenience of weiglit

1st Ib.

8 Ib. Corlrtt 38 1853

P m. Stimulated Vormal

Road this table direotly across the facing paues. t S = slow rate of growth. R = rapid. M = moderate. SR = nlow growth with later rnpid growth

2596

Cases Reported i n the Literatwe

Nomenclature Treatment Gross patholosic anatomy Histopathologic anatomy

___-_.

Firm, cystic with intracystic fungois growths

Extirpation

- Vascular intact capsule Extirpation I’endulou~ intn-cystic tumors ystic hydalids

ystic liydatid~ Extirpation

Constriction amputation b! ligature

Simple mastectomy Lobulated, also cystic Fibrous t i w e of lobules very cellular like warcoma

ystossrcoma

teatomntoua and sarcomatous dc- cnoration

Simple mastectomy Five distinct portions. Resembles eoty kdolls or arbor vitae cereklli

:ystosarcoma phyllodes Simplc mastectomy Diagnosed by J. Miillcr

Cauliflower excrescences in cysts -

Simple mastectomy ~~ ~

Simple mastectomy Globular nodules in dairy fluid jydntid tumor of hrmst

Hydatid tumor of breast Cystic with globular growths; fluid red dish

Simple mastectomy

Mastectomy, death, wouni irifcctioii

~~

Lobulated; cauliflower growth into cys

~

hlastectomy, rccurrcnce, exci sion

Simple mastectomy Firm, irregular tumor adhercnt to skin fluctuant, cystic

Plicated. fimbriatcd intracystic ex crcsccnce

___- Simple mastectomy Sero-cystic tumor

Sero-cystic tumor Simple mastcctorny Many intracystic excresccnees. pize a to oran@

Lamcllated structure of tumor (intra tumoral strurture)

__-- Radical mastcetoniy

~~ ~

Brownish-rcd paiiillary intracysti vegetations, looked like cock’s comb

Not all vegetations vested with epithelium

Calcarcoua deponita in tumor ________

Simple mastectomy

~

Extirpation I n addition to eystosarcoma phyllode: aiiotlier fibroaderioma was present

____ __- Ilistolonically, similar to Paget’s de- scri~!tion

Cystic mrcomn.. . . . . . . . . . . . . . . . Simple mastectomy. recurrenc~

Simple mastectomy ~

Cyatie cavities with fungous indusioiir Cystic sarcoma

Cystic earcoma Cystic cavities with funroue inclusions Puncture, Inter mastectomy

Simple mastectomy Cauliflower excrescence in c3vit.y Vsscular tissue; no invasion; gelatinous Cystic sarcoma

2597

TABLE 11: Giant Zntracannlicular Fibro-adenomy.roma of the Breast

Relation to lartation and

pregnanry

____-~

Dura- tion in years

-

__ I

__

Skin of breast

Chief physical findinl and symptoms

Author and datn Locntian Size

2 Ih.

Largcappli

11 Ill

-- Velpeau

1854

~ _ _ - Irregular. nodular. 0 tuant, movable turn painful at mcnstrual riods

I~luctuant. Painlrss _____

_______ Right: upper Normal right quadrant

Left: upper Normal, rei right quadrant

_ _ _ _ ~

______- Normal

24

__ young Stimulatcd

~~

Benjamin 1855

Cruveilhier 1858

Enormous soft, 110s latcd, Huciuant tumor

young

- 20

~

52

1 Enormous Nadulnr, fluctuant cn nenees. Sanguineous d c h q e from iiipple. 1 pain

Bryant 1861

a: i in. ilinm 22 in.

clrcum.

Movable. clastic. Burtila tumor. No Inin. Sa siiincoua discliarse fro rlipplc

RiKht: Sub- Red. dilate1 areolar locn- vcin8 tion

Castresana 1861

2 16X13X7 cm.

Skin adherence Coiiti ually painful

Normal,

Riglit Weinlcchnci 1866

50

2 i ~

5 14 Ib. Enormous Huctunnt ti mor. Heaviness. No pai

Clear yellow fluid fro1 nwlc . Slight pain

-__ I___

Weiiileehna 1875

3 wnlnllt Right

Left: uppcr right quadrant

Right: lower right quadrant

______

_ _ _ ~ Weinlcchnei

1875 22 Walnut

__- Two lists

Vcry largc

Normal Bvrstre 1SG8

Demnrquay 1808

Tumor hoth solid and c y tic. Slight pain

Bosselated tumor, partlj solid. part1 cystic. Pair for 4 moi i t t

Niiiple retracted. Mobilc tumor. Nn symptoms

~ _ _ _ _ _ _

Never nursed Right: lower Tcnse, cya rinht quad- notic rant

hshhurst 1871

2 in. diam. Right Di!ated

Right Ulcer

vc1119 ___-.

Ilclmuth 1811

20 From clavicle to thigl

Nodular. bluish, mnliile tuinor extending a Imc clavicle. Distress from weislit --__ ___

Sutiareolnr Normal lllcatiolr

I Amndo

1872 I +

15

Partly hard. partly Huc- tuant. Erysipchs followed prcliminnry puncture

Orange

4 1 I!., 6 in. ham.

Gross 1874

Di!atcd vellls

Movnble, elastic, hbu- lated tumor. Good health

niddle age

5 Adult h a d Non-adherent. movable tumor. Inconvcniencc of weight

Lcft Lllccr

___ Skin udher cncn

Ivcrscn 11177

52

49 ~

8 Lnrge Fluctuant with peripheral nodulcs. MastalJa

Well circumscribed lump. No win

- Watson

1878 I3ipht: uppc eft quad- .silt

ILrft

Normal Walnut

-~ Normal Watson

1878 48

36 ~

8 lox20 em.

Enlargcd a t time of menses

Irrcgulnr. tense. fluctunnt nodule. No pain

Movalde, nodular tumor. Traumntism, then pain, (hen tumor

Itidit Normal 3 IIcn's cgg Finrher 1x112

2598

Cases Reported in &he Literature (continued)

Extirpation. crysipelm. death

h'amenchtura

Edematoua polypid projections in to cystic clelta

Treatment

- Encarmulaled, Ruetuant. aolt ingrowths in cysts

~ _ _ _ _ _ _ - ~ __-- - ~ _ _ _

___ Extirpation

I G r m mtholopjc anatomy I

---i Hemorrhage; much elastic tisauc

-

.~

?stosarcvma

istosarcoma - ~ - - ~

Histopathologir anatomy '

__ .. . - - . . - . - - Inrision; then rxtirpation lntr~eystic polypoid crowths I

I I

- .. . - . . - --

! 1 - - - -

- . -- - Extirpation, no nnrmsi~

__ - - - .. . . - - . .. - - . . .. . . . . - - .-

Simple msstcctomy I I I

!ystasarcoma phyllodm

.~

Extirpalion - I I . . . - -. - - __ - - . - -. I - . .

Simple mastectomy I I

. _______-_---- . - - - I

_ - _ I yetosurcoma pbyllodea IGi rpn t ion

I

Simple mmtectomy 300 m. liquid; iiitracystic vegetation as 1 large as egg I --

:ystoplrcoma phyllodea Vewtntion. covered by flat and cyliii- drical cclle !

I -____ ~. I'ultncrous, friahle polyp in cyst con-

Intratumoml injection alphcl Marked s ~ontnneaue degeneration: nol. death enscapulatea

--ltainiiiy honey-colored fluid 2 y h c earconla I Extirpation

Cystoearcomn phyllodea .__.___ -

-i

Intracanalieular earcoma

I I

Large nuclei in connective-tisauc cells

__ Cyst fillcd by urapelike tumors Icaving Sl)i!idlc c e l h parallel to delta lined by c i r r t y cyliridricnl cells

Simple mastectomy

I _ _ _ I

TelaiiKiwtatie cystosarcoma I Puncture. then cxtirpation large telaneicctatic papillary projce- ~cirrlious tissue with many spindle tioils iota cysts

_~___ -- 1 - ~ ____-.

Proliferow cystosnrcoma Extirpation

Cyetofi brosareoma I ~lastcetomy. rcciirrencc -I-_-

Smooth. clistciiing, striated. gelnlinous. ycllow. tissue

Verified microscopimlly .~

hlyxofibmmn. intracanaliculnr Simirle nustcctnmy I-%-cystie nodular projections: i thin nedielra -.I. lnlraeanaliclrlar papillary Libro- Sinililc mastectomy myxoma I

\\'all8 and clcfta lined by cylindrical cpit helium

hf yromntous slroma _..___-

I I

2599

TABLE 11: Giant Tnfrnctrnolicrrlnr Pibro-ndenoInlJ.~omri of the Brefrst

Dlira- tion i n years

__

Relation to lacfatinn and

prcgnancy Chief physicnl findir

and symptoms 4ut hor and

datu Skin of breast Locat ion Rizc

Enormous Itai n :.Pard 1x42

No cliiiiczl liistory S l V C l l

Jungst 1x84

Right Nornial I? Mail’s fi8t H a d nodular. non-:irl eiit turnnr. I’aii~fiil tncr~atrual pcricrd

Imalized ilur.tu:uit t i i l?iin i i i t iiinor

~. . . - Schmidt

18XI Adhcrcnt to tumor

7 Man‘s fist

Schmidt 1884

Aillicrcrit to tumor

Man’s fist Loealjzcd, fluctuallt tu I’tii i i i n trunnr

Srhmidt 1884

Stiniiilated by lac. taiiun

Glurtiuint tumor. 1’: 1111 hrrast

Schmidt 1880

Lcscr 1 888

Normal 3 10 X5 X 5 cnr.

Rielit. whol breast

Norm:il 1 li 7XliXB mi.

Nailulnr tumor, painle!

I m e r 1884

1,eeer 1888

.- -_ I4 1oxti

cm.

DXSXl rm.

Ciiild’n lirail

Marl’s t is t ..-

Fluctuiint tumor

Smrotli, i~odular tumi p:iiiili.ss

____ l’lccr bee r

1888

?I Solt, rooildcd. Ructrin tumor

IPscr 1888

Lescr 1888

Noetael 1892

.___

Nortzel 1x92

Ntietzel 18Y2

Noetzcl 1x92

Noetzcl

I’ i l l iet 1693

liursteincr 1804

HaPC kel 1804

Hawkel lXY4

Hacckel IS94

Pcurcc 1895

.-__

ino2 __

____

-___

_-_ ___

___

~

40 clinical history

Nouo Itidit: lowe lcf t quad rant

t 13XllX8 em.

11x11 nn.

-__ Noiw 9 Nodular. painful tumor i

I)ri.:ist Itiicht: lef half

I l ix l i t ~ _ _ Tense cyanotic

~

Mnsti,tis iit eacl lactation

Noildar tumor i n brmst

1)eliniitr.d nodule Non-adhcr- c n t

IOXIO cm.

No cliriiwl history

No rlinical history 15X 15x9 rm.

Orunae __-

Right: uppe riglit quad. rant

28 ~ ~~

lrreyular. firm, clnstic, tnd soft tumnr

Rirht: u p p half

Left: upper r i d i t quad. rant

N o r i d 12XOX7 ern.

Walnut

I I em. d im.

t

-_ 7

Small puiiiful lum” in )rcaqt

Vodule i n brcast ~ _ _ _ _ _

Left Cyanotic, rdherent

Inflamed, .cd, adherent

1 Child’s head

Large tumor in breast

Punfiition thrniich skin. -’?clieiia. 1,:inciintirig

-

I i l l l l Y

Hight Ulcer 15 Vursed 5 cliildren in left b ras t only

___~ Veins dilated Snow

l800 11, 4 t Ib. Mobile; irregular; ii ipplu

ib!itcrated. Slight dull inin

2600

Cases Reported in the Literature (continued)

Nomenclature Gross pathologic anatomy Histopathologic anatomy Treatment

coma with lacunar cysts Simp!e mastectomy Encysted; lobulatod Great lacunar slits. Stroma has long fusiform cells. Myxomatous aspect

Star-shaped stroma cells racannlicular mysoma Simjile mastectomy I'olypoid projcctions into cysts; narrou pedicles

Hndicnl mastectomy Many intracystic polyps Myxomatous stroma stosarcoms

'atmrcoma Simple mastcetomy Many intracystic polypn Myxomatous stroma

Extirpation

Simple mastectomy -___

istosarcoma myxomatoidea Mammary ciarid atrophied; tumor rcd- dish gray

Extirpation Multiple cysts, some with pnlypoid pro- jectioiis

Encnpsulated. Uyalinization of stroma .olileratinp cystic tumor

roliferating cystic tumor

roliferating cystic tumor

rolilerating cystic tumor

'rolilerating cystic tumor

'rooliferating cystic tumor

-

-~

Extirpation Cholcstentoma in onc cyst Polypoid excrescence in cyst

Many cysts: a few having cauliflowcr projections

Cdcilicd connective-tiesue stroma

Extirpation Many cysts. Papillary excrescences in cysts

Intracystic proliferations in many cysts

Myxomatous stroma

Myxomatous stroma; cpithelium, cylindrical -

Extirpation

Extirpation !My developing polypoid excrescences Ill cysts

Radical mqtectomy Smooth cauliflower growths in cysts. Clefts between polypi

Myxomatous and spindle-cell stromn

htomrcoma phyllodea Cauliflower excreecences in cysts eepa- rated by clefts

Myxomatous stroma and cylindrical cpit hclium

Extirpation

Extirpation Warty excrescences between ananasto- motic clefts

Cauliflower excrescences; aiiastomotic clefts

Stroma seems almost sarcomatous

Myxomatous stroma and cylindrical epithelium

Extirpation 'ystosarcoma pliyllodes

Cgstosarcoma mammae proliferun Extirpation Cauliflower polyps into cyst Myxomatous stroma

Fibrous tissue has sarcomatous aspect __

Cystosarcoma papillare Simplc mastectomy Arborescent vegetations

- Myxomatous stroma; qnamous metaplasia

Cleft-like lumina. Ifihulated. Encag sulated. Plump cubical polype

Simple mastectomy Papillama intracanalicular

Cystomrcomn phyllodes Extirpation Proliferations filled cyst; thin pedicles Myxomatous stroma; few nuclei

Cystosarcoma phyllodea Leaf-shaped vegetations in cyst, packed closely

Myxomatous stroma, cubical epithelium Simple mastectomy

S h ple masfLe tom y __ ~ ~~ ~

5 cysts. Iirtra-cystic proliferations with hroad base

Cystosarcoma phyllodes Myxom:itous stroma

Iiitracanaliculer fibroma with gelatinous metamorphosis

- _- latracannlicular fihroma with selat , inous mctamorphnsis

Simple mastectomy

Emhryoid spindle cells and adult fibrnua tissue

1 Intracystic maminary sarcoma White fibrous masscs in cyst containing fluid

2601

TABLE 11: Giant Intracanalicular Fibro-adenomyroma of the Breast

Author and dste

Relation to lactation and

pregnancy Skin nf hrcnst

Chief physical Endinl and symptom Location P c

E3

0 Left ~~

Siae

48x40 em.

Infant head

Dcsplnta 1900

Enormous tumor. Sma one in right breast. Shooting pnins

Noduliu movalile turn No pain

______

Veim dilate(

Qrohe 1000

27 v m.1 1 Wet nurse for : more children I Right Veins dilate(

-___ Right: lowei

rant left qud.

43

__

Fist Tumor, partly tluctun and partly solid

\Vilms 1001

Beneke 1902

Ulcer __- Ulcer Bcnekc

1902

Schmuckcrt IOU4

~~

50

34 -

__ 46

Mnn's head

Large tumor in brenst

Did r iot nurse Teosr. di- lnted veins

Lyge tuniirr i l l brexr nipple iioriiiiil Amciir rhea for 2 years; no ma talgin

Lnrgr 1i:ird tumor in rig1 brenst

______._

Child's head

Two fists 0 Right: sub. areolnr loen- tion

x Lcft -____

Finsterer 1907

28 Tense, cya- ootic

Man's l1eXI

Large thrice rccurrcr tumor

Latcr married, stimulated recur rencee

54

__ Enormous Fiiist,ercr

1907

Finsterer ID07

Also reported 16 oilier cliildreu: 4 had noije;

but 'agc and parit. 3: 1 had 4; 1 hac

~~

Ages 17. 2, '; 2 had 8; 81

!, 41, 45, 4t 17, 48, 50, 51. 01. No. c BRCB givinR no d e b liad 1; 2 had 2; 2 t

Stimulated by each pregnancy

- 42 Moriinrd nni

Maason 1900

6 20x25 em.

Veins form euput u i ~ d i i s 3 Fluctiration. Iiiroi~ven ienre of weidit

Risht: upper Ulcer, hem- left quad- orrhaacs rant

Right: upper Dilated vciii left quadrant

~ _ _ _ ~

~ ~ _ _ Ulcer

Prirnd 1YU0

54

__ 80

4 Adult's hund

Larrre tumor in breast Weight, no Inin

Girard 1910 Enormous

Hen's egg

Part of tumor ~ a n ~ r c n o u s Seroflanguineous dischargi

Small tumor (movable) No pain

Gorliam 1911

63 fight: sub- nrcular location

67 ~

60

Seeousse 1912

Prym 1912

Child's head

Hilohed tumor partly firm. partly tiuctuarit

Fist

Large

Virm round tumor in breast

l?lnstic, nodular. Ructunnt tumor

restermark 1918

63

59 -

- 36

4 Lactationnl diffi- :ulties

Right Normal

Right lower left quadrant

-___ Silvaa 1910 4 Ih.

1 2 x 8 om.

Orange -_

Hard tumor in breast. No pain

Wulfung 1Y23

Right

Lcft ~~

Wulfung 1923

44 -

Orange

Ch ild'fl head

Wulfung 1923 Nodular. movable tumor

-__ Wulfun:: 1923 1 Red 68 Movable tumor

Large confluent nodules. Wcakncss: emaciation

_______- A P P ~ ~

1885 Rrnms 13 X23 X 14

cm.

Rinkert 1924

39 1

2602

Cases Reported i n the Literature (continued)

Simple mastectomy

Simple mastectomy

-~

Nomenclature

Encapsulated. Small clefta between proliferations

White pearls of aquamous meteplasia

Simpla mastectomy

Excision. then maatectomy for recurrence

_ _ ~ Edematous polypoid intracystic nodules

Hadienl masteetomy

Rad ia l mastectomy

Simple mnatectomy

Elongated clefts between polypoid nodules

Mastectomy; death from me- tastasea to lurras

Extirption

Typical cystosatcoma phyllodee

Extirpation

Extirpation

Intraeystic cauliflower maeaca

Bulbous cauliflower intracystic tumor

Extirpation

Iladical plr?stectomy. recurrence. excision

Necrotic nodule in cyst

Deudritic arborizations; polypoid

Histopathologic anatomy

Radical mastectomy I Simple mastectomy 1 Cysts Wed with proliferations istofibrosarcomo

vstoearcom

Myxomatous stroma; some snrcomatou~

Myxomatous stroma: some compact embryonal connective tissue

areas

Sarcomatous proliferation of cnnnwtivc tissue

Pseudo-sareomatous proliferation ~ - _ _ _ ~ _ I _

wly cystoearcoma phyllodes

denoma pseudosarcomatodes Extirpation 1 Ducts distorted to form clefte

ihroadenoma rntrmcanaliculnre apillare

Extirpation & ~ i n d ~ e - c e ~ ~ and myxomntous are39 in stroma

2 tumors. intracystic polypoid growth

Smaller tumor is typical

True Bbrosarcoma in stroma-verified by recurrences

:ystossrcoma phyllodea

I Maatcctomy by severance of pedicle

Myxomatous stroma; giant cells

- Radical mastectomy Cptic, with nodules and gelatinous

structure Stroma contains spindle cells and e m bryonal cells

Intracannlicular fibroma with sarcomatous change

Cyatoearcoma

Adenomyxofihroma intracanaliculare papillare

Star ceib in etroma; squamoue met* plasia

~~

Fibrosarcomatous myxomatous stroma

~ ~

Cyetofibroma intracanaliculare Recurrent tumor; myxomrcomatoun

Stroma earcornatnus -

CY6tOsarcoma

Fusiform cellular elements

Cystosarcoma phyllodea -

Polywid n d d w into clefb

Special tumor; intracanalicular polypoid

Extirpation

Extirpation

Very cellular stroma CyStO8arcoma phyllodes

Cystosarcoma phyllodes __

Diffuse Bbromatosis

Hyalinized stroma; bizarre nuclei; pig ment

CYstosarcoma phyllodes

Fihroadenoma intrncanaliculnre earcornatodes

~- Xanthomatous and sarcomatous rum


+

f f

SR 2 8

- SR

TABLE I1 : Giant Intracanalicular Fibro-adenomgxoma of the Breast

Dura- tion in years

-- 8

-_ 37

Author and date

- _ _ ~ Hart 1937

Lee niid Pnrk 1930

Lecand Pack 1830

Leeand Pack 1930

I.ernnd Pack 1930

Lee and Pack 1931

Ler and Pack 1031

___

____-

_____

_____

_____

___-

-__

..7

'i %

26

4:

-- 5ti

40

34

28

44

53

SR

SR

SR

- "

- Sit

10

___ 8

_- 3:

-- One

month

40 years

__

Relotion to lactation and

pregnancy Chief physical findini

and symptoms Location Skin of breaat

Sinus

Ulcer

Size

Orange Large movable tun Rapid growth during pi nnocy

2

~

7

Never nursed this breast; st,imulated

Started after child- birth

Bulky cyntir !obulatcd mor. No pain

Richt

Both breasta Normal 13x11 em.

Bulky lohulated tumors both breasts. Oecasioi dull bilaternl pain

1 Right: uppe half

IfiX1OXQ cm.

9X7X5 em.

8x5 cm.

___

__--

Tarae cystic lobulatcd t rnor muas. Occasional di pain

Movable non-adlierent t mor. Dragginr pain

Glolmlar, discrete. mo able, large tumor. No pa

Blue

Normal

-___- Adherent

Abscess in right breast

-

2

__ 0

Right: lower right quadrant

Rirht: lower rirht quad- rnnt

-_F

1 -

Right Adherent 18x15 em. size of melon

Pedunculnted., baselate b r e d containing turn04 Nipple retrncted Bulk ndenocarcinorna in oppc site breast. No discomfor except weight

BIBLIOGRAPHY

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ARATA, P. : Cisto-sarcoma della mammella sinistra, Nuova Liguria med., Genova, 19: 401-403, 1874.

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Nomenclature

wanalicular myxoma

ot intracanalicular myxoma stowmma phyllodes)

st intracanalicular myxoma Btosar~oma phyllodes)

mt intracannlicular myxoma atrmrmma phyllodes)

mt intramnalicular myxoma stcsarwma phyllodes)

ant intracanaliculsr myxoma of rvlt (cystmucoma phyllodes)

ant intracanalicular myxoma of wt (cystmarcoma phvllodes) th m osarcomatoua &an es. w bul$ adenocarcinoma of feft east


Cases Reported i n the Literature (continued)

Treatment

Simple mastectomy

S i p I e mastectomy

Extirpation

Radical mastectomy

Simple mnstectomy

Locnl excision of tumor

Simple mastectomy of righ breast: interstitial irradiatioi and simple mastectomy of lef breast

Grow pathologic anatomy

Large intracystic polyp

Intracystic polyp

Intracanalicular polypoid masses

Typical cystosarcoma phyllodes

Soft polypoid intracystic nodules

Intracanalieular papillary excrescences

Lobulated, smooth glistening tumo nodules. Some necrotic cavitation Slight preservation of intracanalicula arrangement

Histopathologic anatomy

Myxomatous stroma

Myxomatous stroms; calcification

Myxomatous stroma

~- Myxomatoue and xnntbomntou s t rom

Myxomatous stroma

Myxomntous stroma; hyalinization ir regions; secondary pseudoscinar crypt:

Myxosarcomatous metamarphoais oi stroma of this tumor: also adenocarci noma of opposite hresst

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1910, pp. 28-31.


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1919, p. 480.

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GIANT INTRACA4NALICULAR FIBRO …...the simple cyst os:trcoma, cyst osarcoma proliferum, and cyst...

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