Recurrent giant fibroadenomas with transformation to cystosa
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Fibroadenoma is the most prevalent benign breast lesion that generally affects middle-aged women; it is rare in adolescents and younger children. The transformation into malignancy is not common. However, multiple recurrences of rapidly enlarging fibroadenomas suggest a high possibility of transforming into phyllodes tumors, which are uncommon fibroepithelial lesions that account for 0.3–0.5% of female breast tumors and typically present in premenopausal women.

A 17-year-old Syrian girl presented in hospital in November 2016 with multiple masses in her left breast. She had no history of anorexia, fever, weight loss, skin ulceration, or nipple discharge. Furthermore, the patient has no siblings, and her family history was insignificant except for diabetes mellitus. On clinical examination, five well-defined mobile masses measuring 9, 8, 5, 3, and 2 cm were present. She did not have axillary lymphadenopathy, and the results of her blood examinations were within normal limits. The breast masses were excised, and microscopically, sections revealed a diffuse proliferation of fibrous tissue, surrounding acinar and cystically dilated ductal structures with no evidence of malignancy within the limits of the specimens. Accordingly, our patient was diagnosed with multiple juvenile FAs.

One year later, the patient was readmitted to the hospital with multiple breast masses. She had a lobulated mass measuring 2.5 cm in diameter in her right breast, and her left breast had five masses measuring 8, 7, 6, 5, and 4 cm respectively. All six lesions were resected, and morphological examination revealed the diagnosis of multiple cellular FAs with no evidence of cellular atypia. Long-term follow-up of the patient was recommended.

A few months later, patient had a new large lobulated mass in her left breast. At this time, her blood examination results were normal, and she had no skin changes. The excisional tumor measured 15 cm in diameter (Fig. 1), and the diagnosis confirmed a giant cellular FA with no cellular atypia. The patient had only 6 months of dormancy before she was readmitted again due to rapid enlargement in the left breast. Clinical examination revealed several lobulated masses, and the patient underwent lumpectomies (Fig. 2). Gross examination revealed multiple masses measuring 20 × 15 × 16 cm (Fig. 3). Interestingly, the largest mass measured 8 cm in diameter, and microscopically it revealed nodular proliferation of multiplicated cellular fibrous tissue and distended ductal structures with prominent areas of stromal overgrowth, nuclear pleomorphism, and occasional mitotic figures (5–7/10 high-power fields) (Fig. 4). As a result, the diagnosis of the largest mass confirmed a high-grade malignant PT (cystosarcoma phyllodes) with microscopic positive foci in the margins, whereas the other lumps were diagnosed as multiple cellular FAs. Computed tomographic images showed no visceral or lymph node metastases.

No reexcision was performed, and the patient was referred directly for radiotherapy (50 Gy in 25 fractions) and monitored regularly with ultrasound scanning according to the oncologist’s recommendations. A timeline of the patient’s case is provided in Fig. 5. From her last visit until the initial date of submitting the manuscript of the present report for publication, our patient reported a good general status, and she is still undergoing long-term follow-up. No recurrence has been detected by ultrasound.

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