Leaf-shaped tumor of the breast. The insidious enemy of the breast is leaf-shaped fibroadenoma

Over the past 30 years of operation of the oncological center, only 168 patients with this tumor pathology have been observed, which is 1.2% of all tumor diseases of the mammary glands. We have not identified men with this tumor pathology. The presence of a palpable node in the mammary gland in 166 patients (98.8%) was the main reason for visiting a doctor.

At the same time, only two women (1.2%) complained of pain in the affected mammary gland. Discharge from the nipple of the breast was observed in 2 patients (1.2%). In 2 women, the tumor was detected during a preventive examination. The age of patients with leaf-shaped tumor ranged from 11 to 74 years. The mean age of the patients was 39.9 years. Women between the ages of 30 and 50 are most susceptible to this disease.

The average age of patients with a benign leaf-shaped tumor was significantly lower (p Leaf-shaped tumors of the mammary glands were localized in the right gland in 83 cases (49.4%), in the left mammary gland - in 80 (47.6%), in both mammary glands - in 5 (2.97%) In 16 patients (9.5%) with a leaf-shaped tumor, more than one node was detected, while in 5 cases (2.97%) the tumors were localized in both mammary glands and in 11 cases (6.5% ) - in one of the glands (5 - in the right, 6 - in the left).

Synchronous occurrence of a leaf-shaped tumor and fibroadenoma in the other mammary gland was detected in 5 patients (2.97%). The presence of more than one node in the mammary gland reliably indicates a benign variant of the leaf-shaped tumor (p
The study of the anamnesis of the disease made it possible to identify the following options for the growth rate of leaf-shaped tumors: tumors characterized by slow, rapid or two-phase growth (a period of long-term stable existence is replaced by a stage of rapid growth).

In 63 cases (37.5%), rapid growth was detected, in 52 cases (30.9%), a slow increase in the tumor from the moment of its increase was noted, and in 53 cases (31.5%), a two-phase course of the process, when a long-term formation suddenly began to rise sharply.
However, this criterion does not allow differentiating different variants of leaf-shaped tumor.

When examining women with leaf-shaped tumors, in most cases, the skin over the neoplasm was not changed - 118 cases (70.2%). Such skin symptoms as its fixation over the tumor, the "platform" symptom, are extremely rare and are not typical for leaf-shaped tumors - 5 patients (2.97%). More often in patients with a leaf-shaped tumor, skin symptoms such as cyanosis, thinning of the skin over the formation, and a pronounced venous pattern occur. They reflect the rapid, expansive growth of the tumor and the violation of the trophism of the skin of the mammary gland, but by no means invasion of it by the tumor. The result of increasing trophic changes in the skin is its ulceration.

A leaf-shaped tumor on palpation was a well-defined neoplasm delimited from the surrounding breast tissue.
Clear contours were detected in 140 cases (83.3%), indistinct contours - in 28 cases (16.6%). Tuberosity and smoothness of the contours of the neoplasm were noted in almost equal proportions (75 (44.6%) and 93 (55.4%) cases, respectively).

Symptoms such as the heterogeneous consistency of the tumor and the tuberosity of its contours, detected by palpation, are a reflection of the characteristic macroscopic picture. When examining the removed tumors in such cases, cavities were found filled with a mucoid mass and polypoid growths in them.

Changes in the nipple, so typical of breast cancer, are not characteristic of a leaf-shaped tumor. We encountered nipple retraction in 3 patients (1.8%), nipple edema was found in 14 cases (8.3%) of leaf-shaped tumor. Palpable lymph nodes of elastic consistency on the side of the lesion were found in 26 patients (15.5%), enlargement of the lymph nodes was always reactive and was more common in women with trophic skin changes.

The size of leaf-shaped breast tumors varied from 1 to 35 cm. The average size in the total group of leaf-shaped tumors was 7.46 cm. However, interesting data were obtained when determining the average size of leaf-shaped tumors of various histological variants. It turned out that the minimum size of the tumor was detected in the benign variant of leaf-shaped tumors - 6.87 cm, while in the malignant variant - 14.09 cm (with the intermediate - 11.56 cm).

On this basis, benign leaf-shaped tumors with a size of up to 5 cm significantly differ from the intermediate and malignant variants of tumors (p
In the analysis of clinical diagnoses established in the clinic of the Russian Cancer Research Center. N.N. Blokhin of the Russian Academy of Medical Sciences, out of 168 patients with leaf-shaped tumors, 13 cases (7.7%) were diagnosed with a leaf-shaped tumor without specifying the degree of malignancy, and in 28 cases (16.7%) - a diagnosis of sarcoma. Breast cancer was diagnosed in 59 cases (35.1%), fibroadenoma in 58 cases (34.5%), and cyst and nodular mastopathy in 6 (3.6%) and 4 (2.4%) cases, respectively.

At the same time, in all cases with tumors less than 5 cm, an incorrect diagnosis was made ("fibroadenoma", "cancer", "cyst", "nodular mastopathy"). With tumors of large and giant sizes, clinicians in most cases diagnosed breast sarcoma - 28 cases (16.7%).

Thus, when the tumor size is less than 5 cm, the clinical diagnosis of a leaf-shaped tumor is extremely difficult. In the vast majority of such observations, the leaf-shaped tumor was represented by a well-demarcated, solid formation of a dense consistency without any skin symptoms and changes in the nipple-areolar complex, which led to the establishment of a clinical diagnosis of fibroadenoma in 58 cases (34.5%). The presence of a small seal of elastic consistency against the background of diffuse mastopathy without clear contours was the reason for the diagnosis of nodular mastopathy in 4 cases (2.4%).

Identification of skin symptoms (fixation of the skin over the tumor, "platform", etc.) in combination with a palpable tumor of a dense consistency with tuberous contours served as the basis for the diagnosis of breast cancer in 59 patients (35.1%). Cyst - in 6 cases (3.6%), diagnosed in those cases where clinically the formation had an elastic consistency, smooth, even contours (macroscopically it was represented by a single-chamber cavity with mucus-like contents and polypoid growths that did not fill its entire lumen). In 28 cases (16.7%), the basis for the diagnosis of breast sarcoma was a number of clinical and anamnestic data (rapid tumor growth with reaching large sizes; characteristic changes in the skin over the tumor in the form of thinning, hyperemia, cyanosis, increased venous pattern; heterogeneous consistency neoplasms, tuberosity of contours).

Thus, for the most part, the diagnosis of "leaf-like tumor" turns out to be a diagnosis established at the histological level. Thus, only 41% of preoperative diagnoses corresponded to the histological diagnosis.

Analyzing therapeutic approaches for benign and intermediate variants of leaf-shaped tumors, it can be stated that all variants of surgical interventions used in diseases of the mammary glands were used. The main option for surgical treatment is sectoral resection of the mammary gland (81.2% of cases). The use of various types of mastectomies and radical resections is due either to the large size of the tumor or to diagnostic errors.

The data in the table show that an increase in the volume of surgical intervention leads to a decrease in the likelihood of developing a local recurrence of the disease. So, in all cases of tumor enucleation, local recurrences occurred, with sectoral resections in 19.7% of cases, and after mastectomy - only in 1 case (4.8%). Relapses develop on average after 17 months (from 3 to 4 years). However, the time for the development of tumor recurrence after surgery is longer with a benign variant of a leaf-shaped tumor than with an intermediate one (45.5 and 26.3 months; p>0.05). Comparison of various options for performing mastectomy with the course of the disease did not reveal the presence of correlations between them.

The situation is similar with sectoral and radical resections of the mammary glands. There were no significant differences in the tendency to recurrence depending on age, neoplasm growth rate, morphological criteria. When comparing the histological variant of the tumor and the development of recurrence, it was revealed that intermediate leaf-shaped tumors recur more often than benign ones (23.8% and 17.4%, respectively, p > 0.05). Patients with relapses were re-operated: mastectomy was performed in 4 cases, sectoral resection was performed in the rest. It should be noted that the tendency to recurrence is a characteristic feature of leaf-shaped tumors, and sometimes it becomes persistent (15 relapses were noted in one patient)

Unjustified tightening of therapeutic measures (carrying out chemotherapy, radiation therapy) is due to errors in the diagnosis of the disease.

There were no distant metastases and deaths associated with these histological forms. A completely different picture is observed when analyzing the course of malignant leaf-shaped tumors (23 patients), where, along with local recurrence, there is also distant metastasis (malignancy is due to the development of sarcoma against the background of a leaf-shaped tumor). As mentioned earlier, the average size of malignant leaf-shaped tumors (11.6 cm) significantly predominates over that in other histological variants of this disease. A characteristic clinical picture is represented by an increase in the volume of the affected mammary gland. The skin of the gland is thinned, of a purple-bluish hue, with an expanded subcutaneous venous network. The tumor is mobile relative to the chest wall.

A malignant leaf-shaped tumor occurs significantly at a later age than a benign one (43.8 and 37.5 years, respectively; p
The data in the table indicate that recurrence is a characteristic feature of this tumor process and develops both after sectoral resections and after radical mastectomy. At the same time, after sectoral resections, local recurrences occurred almost twice as often as after mastectomy (40% and 22.2%, respectively; p>0.05). Relapses in a malignant variant of a leaf-shaped tumor develop significantly earlier than in a benign variant (14.25 and 45.5 months; p 0.05). No other correlations (including the fact of adjuvant treatment) affecting the likelihood of relapse were found.

Relapses that occurred in 5 patients were promptly removed. Two of them relapsed (in one case - after radiation therapy), which, in turn, required additional surgical intervention (in one patient, the pectoralis major muscle was removed with resection of the anterior rib segments - she is alive in the subsequent 8 years).

The presence of malignancy of the stromal component predetermined the features of the course of the disease. We did not reveal metastases of leaf-shaped tumors in regional lymph nodes. Hematogenous metastases were noted in 4 patients (lungs, liver, bones), which led to death.

In one case (liver metastases) occurred simultaneously with a recurrence in the area of ​​operation (after mastectomies) after 4 years, in the other - for 2 years, also after mastectomies. Attempts to conduct chemotherapy in all cases were unsuccessful. A significant relationship was found between the development of metastases and the size of the primary tumor node: for example, in the presence of metastases, the average size of the latter was 20 cm, while in the case of a favorable course of the disease, it was 6.37 cm (p

Breast sarcomas:

During the same period of time, from 1965 to 1999, 54 patients with a histologically confirmed diagnosis of breast sarcoma were treated in the clinics of the Russian Cancer Research Center of the Russian Academy of Medical Sciences, which is 0.34% of all tumor diseases of the mammary glands. In this group of tumor pathology, 1 man was noted.

The average age of patients is 44.1 years (16-69 years) and practically does not differ from that in malignant leaf-shaped tumors of the mammary glands. The advantage of the side of the lesion was not revealed: the process in the left mammary gland was detected in 26 cases, in the right - 28. Multicentricity, synchrony of the lesion in this group of patients was not noted. The size of the tumor node varied from 7 to 35 cm, averaging 14.09 cm.

Describing their disease, most patients note the rapid, sometimes rapid growth of the tumor, which is the main reason for visiting a doctor.

The clinical picture of mammary sarcomas does not fundamentally differ from that of a malignant leaf-shaped tumor: the affected mammary gland, as a rule, is significantly enlarged in volume, with purple-cyanotic skin and a pronounced subcutaneous venous network. Diagnostic criteria are more informative than for leaf-shaped tumors. More than half of patients (74%) have a short history of the disease (less than a year), which is due to the rapid, sometimes rapid growth of the tumor.

When assessing the growth rate of breast neoplasms, a history of rapid and two-phase growth rates was noted both in leaf-shaped tumors and in sarcomas. A slow growth rate was noted mainly by patients with leaf-shaped tumors. A slow growth rate is not characteristic of breast sarcomas (only 1.8%). Thus, the presence of a slow growth rate is more indicative of the presence of a leaf-shaped breast tumor than a sarcoma (p
With an increase in the size of the tumor node, the percentage of mammary sarcomas increases. Thus, when the size of the tumor node is more than 15 cm, sarcoma was detected in 71% of cases. At the same time, with a neoplasm size of up to 3 cm, not a single case of a malignant leaf-shaped tumor and sarcoma was detected.

According to the microscopic picture, the following types of soft tissue sarcomas were identified: osteogenic sarcoma - 1, angiosarcomas - 15, liposarcoma - 4, neurogenic - 5, leiomyosarcoma - 5, rhabdomyosarcoma - 0, malignant fibrous histiocytoma - 11. Review of histological preparations due to their absence in the pathoanatomical archive in 13 cases was not performed (it was treated as a polymorphic cell sarcoma without regard to histogenetic affiliation).

The large size of the tumor node, the rapid growth of the neoplasm and the threat of its ulceration predetermined the surgical stage of treatment in the vast majority of cases. Surgical intervention was an integral component of treatment in 92.6% of patients (50 patients). As an independent type of primary treatment in 33 patients (61.1%). In other cases, the operation was supplemented with radiation therapy - in 8 cases, chemotherapy - in 6 cases, and their combination - in 3 patients. 4 patients attempted chemotherapy due to the initial generalization of the process. In addition to surgery, radiation therapy (standard radiation therapy ROD 2 Gy, SOD 40-46 Gy, radiation therapy with large fractions ROD5Gy, SOD20Gy) and chemotherapy were used mainly for the malignant variant of leaf-shaped tumors and sarcomas.

As a postoperative effect, radiation therapy was used in 12 cases, in the treatment of relapses and (or) metastases - in 11. The use of various therapy regimens reflects the stages in the development of chemotherapeutic approaches in oncology: from Thio-Tef monotherapy to regimens using drugs from the group of anthracycline antibiotics and platinum preparations. As an adjuvant treatment, chemotherapy was performed in 9 cases, in 18 - as a therapy for the metastatic process. The most frequently used regimens included vincristine, adriamycin and cyclophosphamide (14 cases). Hormone therapy in the complex treatment of leaf-shaped tumors and breast sarcomas was carried out in two cases of steady progression of the metastatic process. The volume of surgical intervention varied from sectoral resection to radical Halsted mastectomy (radical resection was not performed).

There was no correlation between different types of mastectomies and the course of the disease, so all types of mastectomies are combined into one group. The table data eloquently show that the volume of surgical intervention in the form of sectoral resection is clearly insufficient - in 71% local recurrence of the disease, while with mastectomy - 22% (p
At the same time, additional therapeutic measures (radiotherapy, chemotherapy, or their combination) do not significantly affect the nature of the course of the disease. At the same time, if we do not detail adjuvant treatment by type, but divide patients with developed relapses according to the presence or absence of adjuvant therapy, then adjuvant treatment was accompanied by the development of relapse in 5 patients, and in the absence of treatment, relapse occurred in 12 patients (in 3 out of 8 after radiotherapy; in 1 out of 6 after chemotherapy and 1 out of 3 after chemoradiotherapy). And, although there is no significant difference in these groups (probably due to the small number of observations), these data should be taken into account.

Interesting results were obtained by comparing the course of the disease with the histological form of sarcoma. It turned out that in 12 (66.7%) of 18 patients with local recurrence of the disease, angiosarcoma of the breast was detected, which is characterized by persistent recurrence and an extremely unfavorable prognosis. No recurrence was found in lipo- and neurogenic breast sarcoma. Thus, the course of the disease, apparently, depends more on the histological form of the disease than on the volume of therapeutic measures.

Concerning the choice of the volume of surgical intervention, in our opinion, one should dwell on mastectomy. Lymphadenectomy has no grounds for its performance: lymphogenous metastasis is not typical for sarcomas. According to our data, histological examination of sarcoma metastases in regional lymph nodes were not detected. Metastasis was noted mainly in the lungs. The fact of local recurrence is an unfavorable prognostic factor for the development of distant metastases (in 11 out of 18 patients with local recurrence, distant metastases were detected; p
Patient survival is low. During the 1st year, 9 patients (16.6%) died, 5-year survival was 37.8%, 10 years survived 28.0%.

Treatment of distant metastases (lungs, bones, liver) is ineffective. Regardless of the type of chemotherapy, the effect was either absent or short-lived. Only 2 cases of success were noted: excision of a solitary metastasis in the lung (liposarcoma), the patient is alive for 22 years later, and 1 case of effective chemotherapy in lung metastases (malignant fibrous histiocytoma, 9 courses of chemotherapy with vincristine, carminomycin and interferon), death of this The patient came 5 years after the end of chemotherapy from the generalization of another malignant disease - gallbladder cancer.

Many women perceive any neoplasm in the breast as malignant. However, when diagnosing in 80% of cases, benign changes are detected - fibroadenomas. They may have a different shape. Phylloid fibroadenoma (leaf-shaped) is often detected. In most cases, it is treatable and does not turn into cancer.

Types of benign neoplasms

Fibrous adenoma of the breast is a collection of glandular and fibrous tissues. When probing the chest, it is possible to detect tissue compaction in the form of a round or oval nodule. It can cause discomfort to a woman when pain occurs. However, such a neoplasm does not pose a serious danger, since it belongs to the class of non-cancerous ones.

There are several types of fibroadenomas. They differ in localization, shape and structure:

Increased attention should be paid to the last type of fibrous adenomas. To determine the nature of changes in the mammary gland, it is necessary to know what properties a leaf-shaped fibroadenoma has.

Characteristics of the phyllodes neoplasm

Despite the fact that the tumor is benign, there is an increased risk of its transition to sarcoma. Therefore, it is important to know what properties distinguish it from other forms of formations.

Leaf-shaped tumor is most often diagnosed in women experiencing a period of hormonal surge. This is usually the time of puberty (11-20 years) or the onset of menopause (45-55 years).

The occurrence of this type of fibroadenoma is influenced by many factors, among which are noted:

• excess body weight;
• fibroadenoma in the uterus;
• diabetes; Taking hormonal drugs Pregnancy
• a large number of abortions in history;
• neoplasms in the ovaries;
• liver disease and disorders in the endocrine system;
• pregnancy and lactation;
• taking hormonal drugs, including contraceptives.

When a leaf-shaped fibroadenoma occurs, a seal is observed in the mammary gland, which has a limited localization. It is characterized by a lobed structure. When probing, you can detect the connection of several nodes into a single whole.

During the growth of the neoplasm, the appearance of the breast changes. The skin above it is stretched, has a cyanotic, sometimes purple color. A vascular and venous network is visible through it.

If there is a rapid growth of the neoplasm within 3-4 months, then doctors are inclined to make a diagnosis of "phylloid type fibroma". However, it can be confirmed only with the help of various instrumental studies.

Diagnostic methods

If you suspect a phyllodes fibroadenoma, you must definitely visit a mammologist. She will prescribe the necessary examinations to confirm or refute the diagnosis. Before the appointment, the doctor will conduct a complete examination of the breast, palpation, and also collect anamnesis data. In the future, the patient will need to undergo research using laboratory and instrumental diagnostics.

1. At the first stage, it is necessary to donate blood for biochemical analysis. Based on its results, a conclusion will be made about the presence of hormonal disorders in the woman's body.
2. Next, the patient will be assigned a mammography - X-ray of the mammary glands.
3. The study can also be carried out using an ultrasound machine, which will allow you to assess the nature of changes in the breast. During this method, fibroadenoma is differentiated from a cyst.
4. During a biopsy, a piece of tissue is taken, which will be sent for cytological examination. According to the results of the analysis, the nature of the damage to the breast tissues, as well as the presence or absence of cancer cells, is noted. Biopsy Mammography

Only after the diagnosis, the doctor can prescribe treatment for the neoplasm.

Method of treatment of phyllodes fibroadenoma

If there is a formation in the breast less than 1 cm in size, doctors prescribe dynamic monitoring. In this case, a woman must visit a mammologist, repeat ultrasound and mammography after a while to identify the condition of phyllodes fibroadenoma.

If the neoplasm is large, then surgery is prescribed. It is shown when:

• rapid growth of neoplasm;
• the presence of a visible breast defect;
• an extensive neoplasm, the size of which exceeds 5 cm;
• planned pregnancy.

The operation is carried out in two
persons:

• enucleation method;
• sectoral resection.

During enucleation, the neoplasm is husked through a small incision made in the chest. In this case, there are practically no scars, they are insignificant.

Sectoral resection is distinguished by the removal of the neoplasm. The elimination of the tumor itself can be shown directly. In more severe cases, it is necessary to remove the tissue that surrounds it (3 cm from the edge of the nodes). The disadvantage of the method is the possible recurrence of fibroadenoma. In this case, amputation of the breast will be indicated.

Sometimes doctors resort to prescribing conservative treatment. It is indicated for small tumors, the size of which does not exceed 8 mm. Therapy is aimed at resorption of education. However, it does not always lead to a positive result.

After any medical manipulations, a woman needs to undergo a control ultrasound. Indeed, with complications and the absence of positive dynamics, the neoplasm can turn into a malignant one for no apparent reason. Therefore, with changes in the mammary gland, a woman should definitely consult a doctor.

Fibroadenoma of the breast - video

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Leaf tumor of the breast

Leaf-shaped tumor of the mammary gland is a fibro-epithelial formation of the mammary gland, belonging to a 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.

A leaf-shaped breast tumor in mammology is also found under the names of leaf-shaped fibroadenoma, intracanalicular fibroadenoma, giant myxomatous fibroadenoma, phyllodes fibroadenoma, etc. Like other two-component breast formations (fibroadenomas), leaf-shaped tumor is characterized by proliferation of epithelial and connective tissue components with a predominance of the latter. Among fibro-epithelial formations of the mammary gland, the incidence of leaf-shaped tumor is about 1.2-2%.

The 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.

A leaf-shaped tumor can be represented by a single 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.

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, adrenal and pituitary tumors, 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.

With the help of ultrasound of the mammary glands, a hypoechoic formation is revealed, on the cut it resembles a “head of cabbage”, which has a heterogeneous structure, multiple anechoic (liquid) cavities and crevices. With Doppler ultrasound, an abundant network of various veins and arteries is determined inside the nodular formation of the mammary gland. Carrying out mammography reveals a tumor conglomerate of an oval or irregular rounded shape, lobed structure with clear outlines; the tumor shadow is homogeneous and quite intense.

The importance of preoperative differentiation of benign leaf-shaped breast tumor and sarcoma dictates the need for a cytological assessment of the formation. For this purpose, a puncture biopsy of the tumor is performed from its various parts and subsequent cytological examination of the biopsy.

In view of the rapid progression, variability of the course and the potential for malignancy in relation to the leaf-shaped tumor of the breast, only surgical tactics are indicated. For benign and intermediate leaf-shaped tumors, a sectoral resection of the mammary gland or a quadrantectomy is performed.

Carrying out a radical resection of the mammary gland, subcutaneous or radical mastectomy is justified in the case of a large size of the 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 recurrence: 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.

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Leaf-shaped fibroadenoma - do not miss the threat!

Fibroadenoma foliaceus is a rare breast tumor that usually develops in women in their 40s. These tumors are also called phyllodes, from the Greek word phyllodes, which means leaf-like. We can say that the more correct name is “leaf-shaped tumors”, since this is a group of neoplasms, whose representatives can have very different behavior.

This name is due to the fact that tumor cells have a leaf-shaped growth pattern. Fibroadenoma foliaceus tends to grow rapidly but rarely spreads beyond the breast.

Types of leaf-shaped fibroadenoma

Phylloid fibroadenoma is observed in approximately 0.5% of all breast tumors, it is formed from a combination of stromal and epithelial cellular elements. A neoplasm can develop both in the right and in the left breast.

There are three main types of phyllodes tumors:

• Benign (non-cancerous) - make up approximately 50-60% of phyllodes tumors.
• Borderline tumors are not yet malignant, but they can turn into them.
• Malignant - make up approximately 20-25% of all leaf-shaped tumors.

In their least aggressive form, phyllodes tumors are similar to benign fibroadenomas, which is how they got their name, leaf-shaped fibroadenoma of the breast. On the other hand, malignant leaf-shaped neoplasms can metastasize with the bloodstream to distant organs, sometimes turning into sarcomatous lesions.

How do phyllodes tumors develop in the breast?

Unlike breast cancer called carcinoma, which develops inside the ducts or lobules of the breast (intracanalicular tumor), leaf-shaped tumors start growing outside of them (like pericanalicular fibroadenoma). Phylloidal tumors develop in the connective tissue (stroma) of the breast, which includes fatty tissue and ligaments surrounding the ducts, lobules, blood and lymph vessels in the breast. In addition to stromal cells, they may also contain cells from the ducts and lobules of the mammary gland.

Symptoms and signs of leaf-shaped fibroadenoma

The most common symptom of phyllodes tumors is a nodule in the breast, which the patient or physician may find on self-examination or breast examination. These neoplasms can grow rapidly over several weeks or months to a size of 2-3 cm, and sometimes more. Such rapid cell proliferation does not mean that a phyllodes tumor is malignant, because benign tumors can also grow rapidly.

The nodule is usually painless. If left without medical attention, the nodule can create a visible bulge. In more advanced cases, a leaf-shaped tumor can lead to the formation of an ulcer or an open sore on the skin of the breast.

Diagnostics

Like other, rare, types of breast tumors, leaf-shaped fibroadenoma is difficult to diagnose, since doctors almost never encounter it. Phylloid tumors may also look similar to the more common benign fibroadenomas.

The two key differences between fibroadenomas and leaf-shaped tumors are that the latter grow more rapidly and develop about 10 years later in age (after 40 as opposed to 30). These differences can help doctors distinguish between these growths.

Establishing a diagnosis is usually carried out in several steps:

• Physical examination of the mammary glands;
• Mammography;
• Ultrasound procedure;
• Magnetic resonance imaging.

Biopsy and histology is the only way to accurately establish the diagnosis of a leaf-shaped tumor. In addition, it is possible to determine the type of neoplasm (benign, borderline or malignant) and the degree of cell proliferation.

The term "benign tumor" often leads people to think that the disease is not dangerous and does not require treatment. But benign phyllodes tumors, like malignant tumors, can grow to large sizes, create visible nodules on the breast, and even break through the skin, causing pain and discomfort. Therefore, any type of these neoplasms requires treatment.

Treatment

Whether a leaf tumor is benign, malignant, or borderline, the treatment is the same - surgery to remove the tumor along with at least 1 cm of surrounding healthy breast tissue. Some doctors believe that even more healthy tissue needs to be removed.

Wide excision is important because, when it is not performed, phyllodes tend to recur in the same area of ​​the breast. This applies to both malignant and benign neoplasms.

Possible surgeries:

1. Lumpectomy - The surgeon removes the tumor and at least 1 cm of normal tissue around it.
2. If the mass is very large or the breast is small, it can be very difficult to perform a wide excision and retain enough healthy tissue to provide a natural looking breast. In this case, the doctor may recommend carrying out:
   • Partial or segmental mastectomy - the surgeon removes the part of the breast that contains the tumor.
   • Total or simple mastectomy - the surgeon removes the entire breast, but nothing else.

Phylloidal tumors rarely spread to the axillary lymph nodes, so in most cases they do not need to be removed.

Malignant leaf-shaped tumors are rare. If they have not spread beyond the breast, radiation therapy may be used to stop cell proliferation. If they have metastasized to other parts of the body, treatment should include chemotherapy.

Care after treatment

The doctor should observe the patient after treatment. Phylloidal tumors can sometimes recur. Relapse usually develops within a year or two after surgery. Malignant leaf-shaped tumors may reappear faster than benign ones.

Physician and patient should cooperate by scheduling visits and examinations, which may include:

• Physical examination of the breast by a doctor within 4-6 months;
• Mammography and ultrasound examination 6 months after treatment;
• Magnetic resonance or computed tomography - as prescribed by the doctor, if he suspects the risk of distant metastases.

If malignant leaf-shaped tumors reappear in the breast, treatment includes wide excision or mastectomy. Some doctors also recommend radiation therapy.

Less than 5% of phyllodes tumors recur in other areas of the body (distant metastases). Possible treatments include surgical removal, radiation therapy, and chemotherapy.

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Phylloid tumor | Pharmacy in the House

A phyllodes tumor is a type of fibroadenoma, a benign tumor of the breast. With a small size, a phyllodes tumor is difficult to distinguish from a fibroadenoma.

Phylloid, or as it is also called a leaf tumor, can be of various sizes, ranging from the smallest to the giant. A phyllodes tumor can be detected by palpation of the breast. It is round or oval in shape with clear contours and a smooth surface. Such a tumor has a lobular structure. It consists of several nodes.

Considering the phylloidal tumor in more detail, we can say that it is a gray-white tissue with a layered structure and slit-like cystic cavities. You can also see traces of hemorrhage and necrosis. Phylloid layers resemble sheets of a closed book, hence the second name - sheet.

A phylloidal tumor that has a cellular stroma is a rare disease. It usually occurs in women in their 40s and 50s. Usually this tumor is benign affecting the connective epithelial part of the skin. Most often it is unilateral.

The morphological composition of the tumor is the same as that of fibroadenoma. Their difference lies in the fact that with a fibrous tumor, the connective tissue becomes fibrous, and with a leafy tumor, it becomes multicellular, and stroma cells are profiling. In the future, these cells become polymorphic and, if not treated, they can transform into sarcomatous.

Leaf sarcoma refers to "boundary" tumors. They border on malignant and benign tumors. If we consider a biopsy of a phyllodes tumor, atypical cells can be detected. They differ from healthy ones, but they cannot be called malignant either.

Symptoms

Phylloid tumor occurs quickly and suddenly. Its growth and increase in size is also fast. It can range in size from a few centimeters to 20 cm. When feeling the chest, you can find balls that have a smooth shape. Its consistency is heterogeneous and may include dense elastic areas and softened ones.

Causes of phyllodes tumor

The main cause of the tumor is dishormonal disorder. If the fibroadenoma stops growing after the elimination of the hormonal disorder, then the phyllodes tumor does not stop growing, even if all the disorders are eliminated. In addition, phyllodes fibroadenoma can degenerate into sarcoma.

Phylloid tumor treatment

Before prescribing treatment, the doctor conducts some research. Among them are mammography and examination of the patient. Histological studies are also prescribed, since the tumor may have a different structure depending on its location. A mammologist in order to make an accurate diagnosis conducts a series of studies. This is a puncture biopsy, and blood tests for hormones.

The most common treatment for a phyllodes tumor is surgery in the form of a sectoral resection, and a quadrantectomy of the mammary gland can also be performed. However, it is worth remembering that sectoral resection can cause relapses, and as a result, one has to resort to amputation of the mammary gland.

Depending on the size (up to 5-8 mm) of the phyllodes tumor, conservative treatment can also be used. Such treatment aims at resorption of the tumor, but this does not always happen, despite the most selected course of treatment. It is worth remembering that the correct treatment, as well as an accurate diagnosis, can only be made by a mammologist, based on the studies carried out.

It also happens that phyllodes tumors can also have inclusions of non-invasive or invasive ductal carcinoma, as well as cancer of the lobular, but this happens extremely rarely.

But in order for the treatment to be most effective and short-term, it is necessary to consult a doctor in time for help. Early treatment will greatly facilitate treatment, which can last from 4 to 6 months.

After the treatment, it is necessary to re-examine and do a control ultrasound. If, after conservative treatment, the control ultrasound shows no dynamics, then it is urgently necessary to proceed to preparing the patient for surgery, since there is a risk of sarcoma.

In addition, on the basis of scientific research, medicine has concluded that a phylloidal tumor can become malignant for no apparent reason, and almost no mammologist can give an accurate forecast at what time a benign tumor will develop into a malignant one.

Prevention of phyllodes tumor

I would like to say that, despite the fact that the tumor has been removed, it can occur again and again in different parts of the breast. It has nothing to do with surgery. But to prevent this from happening, it should be remembered that prevention is better than cure.

As a preventive measure, you need to know, and avoid, those moments that can damage the mammary gland. These moments are:

• injections and inflammation of the female genital organs. All this leads to a violation of the hormonal background and has a bad effect on the mammary gland;

• abortions, which, like inflammatory processes in the genital organs, lead to hormonal imbalance;

• late birth of the first child;

• long-term use of oral contraceptives (more than 4 years);

• radiation, a large amount of sunlight, a sharp weight loss uncontrolled by doctors and nutritionists;

And finally, I would like to say that the most dangerous in the treatment of this disease is self-medication. This is what can lead to the occurrence of breast cancer much faster than the wrong treatment or its absence at all.

Read more: breast fibroadenoma

How to treat phyllodes tumor video

Among the many pathologies of the mammary glands in women, a leaf-shaped or phylloidal tumor differs little in its danger to life from other altered states of the cells of this organ. It can be benign, no different in degree of pain or any other inconvenience from cysts or other forms of similar tumors. Or maybe in a very short time, even after decades of being passive in the chest, it suddenly begins to grow rapidly with metastases to the surrounding tissues: to the lungs, to the bones, to the liver.

External signs of such a tumor are not symptoms yet. First you need to distinguish it from other similar tumors. A greater number of cases in periods from puberty to 20 years and from 40 years to menopause inclusive may indicate the hormonal nature of this disease.

Many researchers have noted the relationship between the occurrence of a leaf-shaped tumor and a lack (in most cases) of progesterone. Or too much estrogen. But in any case, we are talking about hormonal imbalance. This hypothesis fits well with the fact that the age from 20 to 40 is the most acceptable in the reproductive sense, with a decrease in the possibility of a favorable outcome the more, the closer to forty or more years.

That is, there is a connection between female fertility and normal production of progesterone: up to 20 years, during the rampage of hormones and their instability, due to the maturation of the body, production, its content in the blood can be much higher than normal. It was then that the first foci of a leaf-shaped tumor in the tissues of the mammary gland may appear.

After the normalization of the hormonal balance after 20 years, often associated with the onset of sexual activity, pregnancy and childbirth, the resulting focus stops in development, encapsulates. But closer to forty years or later, with the onset of menopause or its first signs and repeated, already age-related imbalance of the endocrine system, the dormant tumor is activated again and the explosive growth of its modified cells can begin.

Diagnostics

Whether a leaf-shaped tumor carries signs of a sarcoma or is it benign and so far life-threatening, only a cytological analysis after a biopsy of the tumor can reveal, moreover, punctures to determine the benignity or malignancy of the neoplasm should be taken from several tumor sites at once. And the larger it is, the more simultaneous punctures should be done.

The difference between a leaf-shaped tumor and other similar pathologies is revealed even by palpation: only its lobed, merging from several nodes, structure, inherent only to its lobed, merging from several nodes, is felt in its seals, filled with a gel-like, viscous during the surgical incision, substrate.

Outwardly, at the beginning of the period of active growth, the tumor looks like a grayish-whitish or pinkish elevation above the skin of the breast. Later, as it grows, the tumor may change, become bluish-purple in the form of swelling on a flat surface of the skin, with a coarse-grained and lobular structure clearly visible through it. Dimensions and weight from 3-4 centimeters to 20 or more and from 5-10 grams to 6 kilograms in rare, advanced cases.

Microscopic examination of the structures of the tumor reveals the predominance of the connective tissue, or stromal, component. Stroma, by the way, differs from the altered connective tissue in fibroma of the mammary glands similar to a leaf-shaped tumor in that nuclear polymorphism and proliferation of stromal cells are more pronounced and are determined faster.

As in most tumor formations, the dislocation of the leaf-shaped tumor is rarely subject to the principle of symmetry, and is located mainly on one breast. Bilateral simultaneous growth requires the simultaneous impact of the same unfavorable external factors, the probability of which is low.

Difficulties in identification

Due to the duality of the nature of a phylloidal tumor, that is, its classification as a fibroepithelial neoplasm, consisting of two components - epithelial, directly adjacent to the skin, and mesenchymal, or stromal, connective tissue, the localization of a malignant neoplasm inside a benign tumor can be hidden for the time being by surrounding tissues.

Since the effectiveness of treatment largely depends on the timing of the detection of the disease, on its stage, a puncture biopsy must be done in many places. And the larger the tumor, the more samples are required to complete the picture. One tiny missed area, where exactly the origin of sarcoma is possible, can cause missed opportunities for saving the mammary gland, when there is no other way than amputation or even mastectomy - removal, along with the affected mammary gland, and adjacent tissues.

Relationship between tumor size and prognosis

Alas, most often such a connection is not revealed. A small, up to 5 centimeters, leaf-shaped tumor is capable of transforming into a malignant one under certain uncertain conditions. And vice versa, having grown to a size of tens of centimeters and having an unsightly and even sinister appearance, it is able to remain benign.

Benign leaf tumor

Elongated thin cavities with clearly defined boundaries, with a distinct echolocation signal on ultrasound. The structure of the surrounding tissues without disturbances, the shape of the cavities is longitudinally oriented, with spindle-shaped lobules. With the introduction of a contrast agent, its accumulation is minimal and homogeneous, without changes in the network of vessels around.

malignant tumor

Cyst cavities with irregularly shaped edges, with heterogeneous echoes on ultrasound, the size of the cavities with a predominance of transverse orientation. With the introduction of a contrast agent, traces of hemorrhages and decay are visible, the MRI structure reveals heterogeneity, with asymmetry of the vascular network that is clearly manifested against the background of the skin and an increase in contrast in the images.

Visual interpretation and recording, used in a systematic approach using MRI, coinciding with the results of a histological examination (BI-RADS category), allows the identification of a tumor as malignant or benign with a probability of more than 95%.

The reasons

Among the causes of the appearance of a leaf-shaped tumor and other phylloidal fibroadenomas, to which it belongs, in the hormonally active transitional age period in the life of women, which falls on 11-20 years and 40-50, one can also distinguish:

• in fibrocystic form;
• Frequent abortions;
• Complicated pregnancies with incorrect or inappropriate drug treatment;
• lactation;
• Extragenital pathologies of the endocrine system.

Separate reasons can be identified metabolic disorders in the body associated with:

• Tumors of the pituitary and adrenal glands;
• obese;
• diabetes mellitus;
• Liver diseases;
• Failures of the menstrual cycle due to drug effects or oral contraceptives that are incompatible with this type of organism;
• Impact or penetrating trauma to the mammary glands.

Elevated levels of estrogens and glucocorticoid hormones can provoke the appearance of fibroadenomas. If the production of somatotropic hormones joins this process, the growth of connective tissue with the transformation of cells becomes almost inevitable.

The degeneration of leaf-shaped tumors into malignant ones can take three forms:

1. carcinomas;
2. Sarcomas;
3. Carcinosarcomas.

The third option is almost always fatal if a radical removal operation is not performed in time, since carcinosarcoma in the second stage is able to metastasize to the most distant tissues, since metastases can spread through the bloodstream.

Carcinomas arise in the epithelial volume of the breast. Sarcomas - in the connective tissue. Carcinosarcoma is a mixed, and therefore especially dangerous type of cancer.

Symptoms

The leaf-shaped tumor is characterized by its two-phase state. Usually, initiated by hormonal changes at a young, still very young age, upon reaching the age of childbearing, the tumor stops developing and remains poorly diagnosed even with the help of Doppler ultrasound.

A more reliable way to detect the disease was and remains palpation, moreover, carried out by the patient herself: with appropriate instructions given by the doctor, it is easier to identify the compaction of its nature by herself, when sensations in the chest are added to the sensitivity of the fingers during the examination. Visually, the presence of a tumor in the breast can be determined by the manifestation of large and small vessels under the skin, which were not previously observed.

And the only confirmation of the diagnosis will be mammography, with its precise determination of the location of the tumor conglomerate, which gives a uniform and intense shadow as a result of the image. For its part, the experienced eye of a mammologist, by the nature of the shadow, identifies a leaf-shaped tumor from a number of possible pathologies of the female breast. To three possible methods for diagnosing this pathology in the form:

1. Palpation;
2. ultrasound studies;
3. mammography.

Cytology is also used to clarify the diagnosis and exclude the degeneration of the tumor into a malignant one.

Additional Research

The ambiguity of the etiology and the "disguise" of a leaf-shaped tumor for other tumor pathologies also require, in addition to the three types of examinations noted, additional ones.

Scintimammography

This method, based on radiodiagnosis using gamma rays (which have a shorter wavelength, and therefore more detail on the sims made with their help), allows the use of labeled radioisotopes. Selectively accumulating in organs and tissues, they give a distinct 3-dimensional picture of the location of the tumor. According to the characteristic accumulation of the introduced isotopes in the tumor node, the probability of a correct diagnosis increases by an order of magnitude. But only large specialized medical centers or private clinics can afford such diagnostics, where doctors are not dominated by limited budget funding.

Sonoelastography

On ultrasound machines with a special mode of operation, it is possible to carry out SEG - sonoelastography. The method is based on color layer-by-layer mapping of the mammary gland with a neoplasm in it, carried out online. Since different parts of healthy and tumor tissue have different coefficients of stiffness and elasticity, the characteristics of the modified areas of the breast are determined using previously compiled maps based on the results of other examinations that allow revealing statistics. The accuracy of diagnosis with this method reaches 70% or more.

MRI

Non-invasive, safe, informative method for determining nodular neoplasms in the breast, as an additional clarifying factor in the diagnosis. Tomographic studies are carried out in a 3D projection, which allows you to get a three-dimensional picture of changes in the tissues of the mammary glands. The contrast agent is gadolinium.

Magnetic resonance mammography using gadolinium is indicated for:

1. Suspicion of oncology in young women with the structure of the mammary glands of increased density;
2. Difficulties in identifying the tumor in other ways;
3. Edema, fibrosis and postoperative conditions of the mammary glands;
4. Enlarged adjacent lymph nodes;
5. Local changes in the retrolocal space of the mammary gland.

The use of this method is advisable between 6 and 14 days of the monthly cycle, scanning should be carried out twice: BEFORE the contrast agent is injected and AFTER such an injection, for a comparative analysis of changes, if any. The MRI procedure allows with a high degree of probability to identify, with their exact localization, multinodular and diffuse neoplasms less than 1 cm in size due to their high contrast in the images, where both homogeneous structures and seals with varying degrees of density will be clearly visible.

DNA histogram

After biopsy punctures, a cytological analysis of the samples taken is carried out: using a laser analyzer, together with computer modeling, a DNA histogram is made. It allows you to analyze the distribution of altered cells, taking into account the details of their number and phases of the development cycle.

tumor markers

With the accumulation of knowledge about the underlying causes of oncological diseases in recent years, the experimental method of using oncomarkers, which is based on the study of changes in the genotype of cell nuclei, is becoming more widespread. According to studies, the leaf-shaped tumor in its malignant form is associated with a mutation of the BRCA1 / 2 gene, and the TP53 gene determines the rate of the disease.

For a leaf-shaped tumor, an increase in lymph nodes on the diseased side of the chest is uncharacteristic. But there are no rules without exceptions: in about 15% of cases, the axillary nodes of the lymphatic system also change, which is an additional factor that makes diagnosis difficult.

Using a combination of these methods, a doctor with a high, almost 100% probability, will be able to make an accurate diagnosis and start treatment on time.

Treatment of leaf tumor

Benign leaf-shaped tumors are less (up to 3 times) more likely to relapse after treatment than malignant ones. According to medical statistics of such diseases, it is clear that up to a quarter of borderline and frankly oncological cases recur within 2 to 5 years. Surgeons-oncologists, based on their experience, concluded that the reason for this was the cleaning of the surgical field that had not been completed to the end.

But today, a general approach to the treatment of such diseases has not yet been developed due to their small number as a percentage in relation to other forms of breast cancer. Some surgical oncologists generally consider mandatory amputation and even mastectomy indicated not only in malignant forms of a leaf-shaped tumor, but also in borderline conditions and even in a benign course of the disease. And they justify this by a too high probability of re-development of the tumor after 2, 3 or 4 years after surgery.

In the presence of metastases, a radical operation is performed not only to remove adjacent sections of the lymphatic network, but also nearby muscles. This is due to the fact that neither radiological methods of suppressing the leaf-shaped tumor, nor chemotherapy do not have any significant therapeutic effect - unlike other forms of malignant neoplasms.

Recently, the emphasis in therapy has been on individual studies of cellular tissue with the identification of target genes. There are reliably recorded cases of curing leaf-shaped tumor with Sunitinib active at the second stage of the disease with no recurrence for 7 years.

Predictions after treatment

It can be said that the prognosis is not entirely favorable due to the poor knowledge of the leaf-shaped tumor associated with its small spread. After all, it is clear that when it comes to saving human life, there is little time left for in-depth clinical research. Or rather, it doesn't stay at all. The instability of the development of such a dangerous disease as a leaf-shaped tumor dictates the decision on a radical operation and the intensity of postoperative manipulations.

Regular follow-up with a doctor in the postoperative period should be mandatory. To increase the chances of not recurring the disease, it is better for a woman to undergo mammography every six months after surgery and strictly follow all medical recommendations.

Conclusion

The search for morphological, genetic and other factors for the occurrence of a leaf-shaped tumor and the course of all its forms has been going on for a long time. So far, based on the accumulated statistics, it follows that the survival rate for 5 years after radical surgery is about 59%. Cases of recurrence were observed in 29% of those operated on.

Based on the fact that the main cause of the disease is hormonal imbalance at different ages, it is advisable to carry out preventive examinations by endocrinologists at the earliest possible age.

Leaf-shaped tumors and sarcomas of the mammary glands: clinic, diagnosis, treatment.

Nonepithelial and fibroepithelial tumors mammary glands are quite rare (1.54%) and therefore little studied. All these tumors are characterized as neoplasms having a two-component structure with a predominant development of the connective tissue component, which is absolute in sarcomas, and in the group of fibroepithelial tumors it is combined with the parallel development of epithelial tissue. The rarity of these neoplasms, the peculiarity of the clinical course, and the polymorphism of the morphological structure explain the limited awareness of doctors about them and the heterogeneity of their views both on the nature of these processes and on the principles of treatment approaches.

In order to assess the modern possibilities of diagnosing and optimizing therapeutic approaches for leaf-shaped tumors and sarcomas of the mammary glands, we summarized more than 25 years of experience of the Oncological Center in the treatment of these tumors; We also tried to analyze the receptor status of tumors and study the proliferative characteristics of tumors using laser flow cytofluorometry.

During this period, we identified 168 (1.2%) patients with leaf-shaped tumors and 54 (0.34%) with breast sarcomas (one of the largest observations in the world practice). During the year, no more than 10 patients with this tumor pathology receive complex treatment at the Oncological Center.

The clinical picture is not specific and varies from small tumors with clear contours to neoplasms occupying the entire mammary gland (Fig. 1). In the latter case, the skin is purple-bluish in color, thinner, with sharply dilated subcutaneous vessels. Often there is ulceration of the skin, which, however, does not always indicate the malignancy of the process.

Rice. 1. Breast sarcoma

Fig.2. Distribution of patients depending on the histological type of tumor

There are 3 histological variants of leaf shaped tumors that differ in the ratio of stromal and epithelial components, clarity of tumor contours, cellularity, nuclear polymorphism, the number of mitotic figures, and the presence of heterogeneous elements. As can be seen from fig. 2, the benign variant of the tumor predominates. The presence of various histological types of leaf-shaped tumors, which determine the characteristics of the clinical course, contributed to the emergence of numerous variants of clinical terminology for designating these neoplasms. The most common term is phyllodes cystosarcoma, indicating an aggressive course of the tumor. Of the histological variants of sarcomas, angiosarcomas and malignant fibrous histiocytomas predominate (49%). These neoplasms are detected at almost any age (from 11 to 74 years), but the peak incidence occurs at 40-50 years of age. We found benign leaf-shaped tumors significantly more often at a younger age - 38 years (Fig. 3).

Fig.3. Distribution of patients with different histological types of tumor by age (in %)

As the malignancy of the process increases, the average size of neoplasms increases: with a benign leaf-shaped tumor - 6.9 cm, with an intermediate variant - 11.6 cm, with a malignant variant and sarcomas - 14.1 cm. When analyzing the possibilities of various methods the study found no reliable diagnostic criteria. Thus, the primary conclusions of mammographic examination coincided with the histological diagnosis only in 29% of cases with leaf-shaped tumors (n=147) and in 24% with sarcomas (n=39). The so-called depletion zone was revealed by us only in 21% of cases. The greatest difficulties arise in neoplasms with a diameter of less than 5 cm. Radiological criteria have not been established to distinguish the malignant variant of leaf-like tumors from breast sarcoma (Fig. 4, 5).

Fig.4. Benign leaf-shaped tumor in patient B., 39 years old. In the right mammary gland in the lower outer quadrant, a lobular nodular formation of a homogeneous structure with clear contours, 6.5 * 5.0 cm in size, is determined. The skin, nipple and areola are not changed.

Fig.5. X-ray of the right mammary gland of the craniocaudal projection of patient A., 20 years old. Neurogenic sarcoma of the right breast. In the upper quadrant, a lobular nodular formation sized 7*6 cm is determined, the contours are clear, a strip of enlightenment along the perimeter of the tumor node.

We tried to find out the possibilities of ultrasound of the mammary glands (21 patients with leaf-shaped tumors and 3 with sarcoma). A small number of observations has not yet made it possible to identify clear diagnostic criteria for distinguishing histological variants of leaf-shaped tumors (Fig. 6, 7). The only sign that drew attention to itself was the low blood flow velocity (2.4-6.4 cm/sec), including the peak one.

Fig.6. Benign leaf-shaped tumor (patient K., 21 years old). Hypoecogenic formation with clear even contours, heterogeneous structure, slit-like cavities inside the formation.

Fig.7. Breast sarcoma (patient M., 49 years old). Hypoecogenic formation of a heterogeneous structure, with uneven fuzzy contours, infiltration rim.

An analysis of the possibilities of cytological examination of tumor punctures showed that the primary conclusions in 29% of cases with leaf-shaped tumors and in 29% with sarcomas corresponded to the actual diagnosis. Failures, in our opinion, are due to the peculiarities of the histological structure of tumors and polymorphism (a combination of epithelial and stromal components, the presence of cystic cavities). The analysis of preoperative diagnoses showed that the latter corresponded to the histological conclusion only in 42% of cases. Thus, in most cases, the diagnosis of a non-epithelial or fibroepithelial tumor of the breast was a histological diagnosis. When analyzing treatment approaches for benign and intermediate leaf-shaped tumors in 144 patients (Table 1), it can be seen that all variants of surgical interventions were used. More often performed sectoral resection of the mammary glands. The use of mastectomy or radical resection is due either to the large size of the tumors or to errors in diagnosis. An increase in the volume of surgical intervention significantly leads to a decrease in the likelihood of local recurrence. So, if after sectoral resection recurrence occurred in 19.7% of cases, after mastectomy - in 4.8%. In general, recurrence was noted in 19.4% of cases. Tumor enucleation in 100% leads to the development of local recurrence. Distant metastasis in the indicated histological forms was not noted. With these histological variants, we consider a sectoral resection to be a sufficient volume; in the case of a total lesion of the mammary gland - a mastectomy.

Table 1. Treatment of patients with benign and intermediate leaf tumors

The course of malignant leaf-shaped tumors (23 patients) was due to malignancy of the stromal component (development of sarcoma against the background of a leaf-shaped tumor). The analysis showed that the structure of surgical interventions differed significantly from that in benign tumors. Various types of mastectomy accounted for 76% (with a higher recurrence rate of 26%). Recurrence after sectoral resection was observed 2 times more often than after mastectomy (Table 2). Metastasis - hematogenous (lungs, bones, liver). Metastases to regional lymph nodes were not noted. Sufficient amount of surgical intervention - mastectomy. There is no need for a lymphadenectomy.

Table 2 Recurrence of malignant leaf tumors by treatment options

Treatment of metastases has been unsuccessful; The 5-year survival rate was 58.5%. Adjuvant treatment resulted in non-significant improvement in outcomes. The most unfavorable prognostically are breast sarcomas (53 women and 1 man). The large size of the tumor node, the rapid growth of the neoplasm, and the threat of ulceration in most cases predetermined the need for surgical treatment. Surgical intervention in the volume of sectoral resection is clearly insufficient - after it, the development of relapses was noted in 71% of cases, while after mastectomy - in 22%. At the same time, in 12 out of 18 patients with recurrence, the tumor turned out to be angiosarcoma. Necessary and sufficient volume of surgical intervention for breast sarcomas is mastectomy. There is no need to perform lymphadenectomy (metastases to regional lymph nodes have never been detected). Distant metastasis was noted in 41% of cases. Adjuvant therapy does not improve long-term outcomes; during its implementation, some deterioration in the results of treatment was noted, which, in our opinion, is due to a more pronounced initial prevalence of the process (Table 3).

Table 3. Features of the clinical course of breast sarcomas depending on the primary treatment options

Postoperative radiation therapy was performed in 12 cases, chemotherapy - in 9 (including a combination of these regimens - in 5), in which various schemes were used: from TIOTEF monochemotherapy to the use of platinum preparations and anthracycline antibiotics. Treatment of sample metastases is lematic. Radiation therapy was performed in 11 cases, chemotherapy - in 18, including 9 combined treatment. Treatment was successful in 2 cases: excision of solitary lung metastasis (liposarcoma) and full effect after 9 courses of chemotherapy for malignant fibrohistiocytoma (carminomycin, vincristine, interferon); The 5-year survival was 37.8%. Data on the survival of patients with various morphological variants of the tumor is presented in Fig. 1. eight.

Fig.8. Survival of patients (in %) with different morphological variants of tumors.

We do not have our own experience with hormone therapy. Tamoxifen was used as a step of desperation in 2 cases with steady progression of the process. The receptor status was analyzed in 48 patients (30 patients with leaf shaped tumor and 18 with sarcoma). It has been established that as the malignancy of the process increases, the content of steroid hormone receptors decreases, including estrogen (ER) - at the level of a trend, and progesterone (PR) - with significant differences.

Comparison of the level of receptors and the course of the disease in benign and intermediate leaf-shaped tumors showed an inversely proportional relationship between ER and PR (differences are not significant), while no local recurrences of receptor-positive tumors were observed in malignant primary neoplasms. In breast sarcomas, there were no differences in the content of receptors in primary tumors and in local relapses, while in the case of distant metastases in the primary tumor, a higher level of both ER and PR was noted.

Another equally important criterion characterizing the tumor process is the proliferative activity of the tumor, which is detected by flow cytofluorometry. As the process becomes more malignant, the frequency of aneuploid tumors (103 paraffin blocks) increases: with malignant leaf-shaped tumors, aneuploidy is 20%, with sarcomas - more than 92%. It should be noted that with a favorable course of leaf-shaped tumors, there were no aneuploid formations. An analysis of the distribution of cells by phases of the cell cycle showed that, in addition to significant differences in the content of cells in different phases of the cycle, there were significant differences between the primary and recurrent tumors in each of the histological variants of leaf-shaped tumors. The proliferation index in benign and intermediate leaf-shaped tumors in the case of recurrence was significantly higher than in tumors with a favorable course, and in malignant leaf-shaped tumors it corresponded to that in breast sarcomas. The development of the metastatic process in sarcomas was accompanied by a significantly higher proliferation index in primary tumors.

Thus, based on the study, the following conclusions can be drawn:

1. Existing research methods (X-ray, ultrasound of the mammary glands, routine cytological examination with Leishman staining), lacking reliable criteria for diagnosing non-epithelial and fibroepithelial tumors of the mammary glands, do not allow differentiating different histological variants of these neoplasms.
2. Necessary and sufficient amount of surgical intervention for benign and intermediate forms of leaf-shaped tumor - sectoral resection; with a total lesion of the mammary gland, with a malignant variant of leaf-shaped tumors and sarcomas of the mammary glands - mastectomy; there are no grounds for performing lymphadenectomy.
3. Adjuvant therapy for malignant leaf-shaped tumors and sarcomas of the mammary glands does not lead to a significant improvement in treatment outcomes: relapse-free 5-year survival rate for malignant leaf-shaped tumors in the case of adjuvant treatment - 81.8 ± 16.4%, without it - 53.4± 17.0% (p>0.05); with sarcomas - 33.73±12.5% ​​and 49.0±10.8%, respectively (p>0.05). The overall 5-year survival rate for malignant leaf-shaped tumors is 58.5 ± 15.0%, for sarcomas - 37.8 ± 8.5%.
4. Different morphological variants of leaf-shaped tumors significantly differ in proliferative characteristics: the proliferation index for benign leaf-shaped tumors is 20.08±1.35%, for intermediate ones - 25.33±2.02%, for malignant ones - 31.23±2.71 % (p<0,05). Индекс пролиферации при саркомах молочных желез соответствует таковому при злокачественных листовидных опухолях - 31,88±2,43%.
5. The high proliferative activity of the primary tumor in benign and intermediate leaf shaped tumors was significantly (p<0,05) ассоциируется с развитием местного рецидива. Так, индекс пролиферации при развитии местных рецидивов достоверно превышал та ковой при благоприятном течении заболевания (соответственно 26,78 ± 1,41 и 15,82±1,31%; 32,85±2,72 и 22,39±1,37%).
6. Metastatic process in breast sarcomas significantly more often (p<0,05) развивается в случае высоких значений индекса пролиферации первичной опухоли (34,46±2,77%), при отсутствии отдаленных метастазов - в 26,35±0,69%.
7. The morphological variant of the tumor is interrelated with the degree of aneuploidy of the neoplasm. In benign and intermediate leaf-shaped tumors, aneuploid neoplasms were not observed, while in its malignant variants and sarcomas of the mammary glands, aneuploidy was detected in 20 and 92.3% of cases, respectively (p<0,05).
8. As the malignancy of neoplasms increases (from benign leaf-like tumors to breast sarcomas), the level of PR decreases (44.46±8.75 and 9.05±2.57 fmol/mg protein, respectively; p<0,05). Различия в уровне ЭР недостоверны.
9. The development of recurrence in benign and intermediate variants of leaf-shaped tumors is associated with a higher level of ER compared with that in a favorable course of the disease (51.71±8.35 and 24.53±7.34 fmol/mg, respectively; p>0.05) ; changes in PR have the opposite direction, reaching maximum values ​​in the primary tumor with a favorable course of the disease (48.97±8.64 and 32.7±8.32 fmol/mg protein; p>0.05).
10. In breast sarcomas, the level of steroid hormone receptors in the primary tumor in the case of the development of a metastatic process is higher than in its absence (ER - 24±14.92 and 10.02±3.56 fmol/mg protein, respectively; PR - 15, 9±5.24 and 5.13±1.81 fmol/mg protein, p>0.05).

PHYLLODES TUMORS AND SARCOMAS OF THE BREAST: CLINICAL PICTURE, DIAGNOSIS, TREATMENT

I.K. Vorotnikov, V.N. Bogatyrev, G.P. Korzhenkova N.N. Blokhin Russian Cancer Research Center, Russian Academy of Medical Sciences

The material is taken from the journal "Mammology", No. 1, 2006

In the complex of diagnostic problems for the early detection of malignant lesions of the mammary glands, the timely detection of leaf-shaped tumors is of undoubted interest.

Leaf-shaped tumor of the breast is a rather rare disease (0.3-1% of all breast diseases).

In recent years, the number of publications devoted to this issue has been increasing, which can be explained by the great interest of morphologists and clinicians in this problem.

The leaf-shaped tumor is a mixed tumor, morphologically occupying an intermediate position between fibroadenoma and breast sarcoma. The literature has repeatedly pointed out the discrepancy between the clinical course and the histological picture of these tumors, which manifests itself in local recurrences and distant metastases or a long, relatively favorable course of malignant leaf-shaped tumors.

The leaf-shaped tumor differs from other neoplastic diseases of the mammary gland in the potential for transformation into sarcoma and carcinosarcoma.

Leaf-shaped tumor sarcomas are the most common pathology among malignant non-epithelial tumors of the mammary glands, which occurs in younger women. Most experts (Treves N., 1964; Von Rocek V., 1981; Bakhmutsky N.G., 1982; Gutman H., Pollock K.A., Janjan N.A., 1995) indicate that a relatively reliable diagnosis of a leaf-shaped tumor is possible in rare cases only with a large size of the neoplasm and its long existence.

Differential diagnosis of a leaf-shaped tumor with fibroadenoma, cyst during clinical examination is difficult, and in most cases impossible. According to Lengyel et al., malignant transformation of an existing benign tumor (fibroadenoma, leaf-shaped tumor) occurs much earlier than is detected in a routine clinical study.

Diagnosis of leaf-shaped tumors of small sizes - up to 5 cm is especially difficult. Differentiating such forms of leaf-shaped tumors from fibroadenoma and solitary cyst is very difficult, and often impossible, not only during clinical examination, but also during X-ray mammography. Evaluation of the information content of ultrasound examination of the breast is also ambiguous (Sickles EA et al., 1983).

In the international classification of oncological diseases of 1995 under the auspices of World Health Organization (WHO) leaf-shaped breast tumor refers to mixed connective tissue and epithelial tumors. 3 histological variants were identified: benign leaf-shaped tumor - 9020/0; leaf-shaped tumor (without other indications) - 9020/1; malignant leaf-shaped tumor - 9020/3.

at RONC im. N.N. Blokhin RAMS from 1976 to 1999, 155 patients with leaf-shaped tumors of the breast were examined and treated: with a benign leaf-shaped tumor - 63.2% of cases, with an intermediate variant of the leaf-shaped tumor - 26.45%, malignant leaf-shaped tumor - 10.35% cases. In addition to patients with leaf-shaped tumors, a separate group consisted of 25 patients with primary breast sarcomas.

The age of patients with leaf-shaped tumors ranged from 11 to 74 years, the average age of patients was 39.9 years. Women between the ages of 30 and 50 are most susceptible to this disease. In the age range up to 40 years, benign leaf-shaped tumors significantly predominate (p
In the interval from 41 to 50 years, the prevalence of malignant leaf-shaped tumors (p
As confirmation of the role of background processes in the mammary gland for the occurrence of leaf-shaped tumors, 45.2% of patients were diagnosed with previous changes in the mammary glands: diffuse fibrocystic mastopathy in 22.6% of cases and fibroadenoma constituted the main group of background diseases.

In addition to the background processes of the mammary gland, it is impossible not to point out conditions that directly or indirectly contribute to the occurrence of a leaf-shaped tumor. These include: impaired reproductive function in women, the presence of concomitant gynecological diseases, pregnancy, etc.

Leaf-shaped tumors of the mammary glands were localized equally often in the right and left mammary glands.

Among the clinical data, an important role is played by data on the duration of the existence of the tumor from the moment it was discovered to seeking medical help and the growth rate of the neoplasm of the mammary gland. The duration of the anamnesis varied from 2 months to 38 years.

When studying the duration of the existence of the tumor, the prevalence of malignant and intermediate variants of the leaf-shaped tumor over benign ones was noted in the duration of the anamnesis from 1.1 to 3 years (p
When studying the growth rate of leaf-shaped tumors, 3 groups were distinguished:

1 group. Tumors characterized by no or slow growth since discovery.
2 group. Tumors characterized by rapid growth.
3rd group. Tumors characterized by a two-phase clinical course (a long-term formation suddenly began to grow rapidly).

Assessing the growth rate of breast neoplasms, a history of rapid and two-phase growth rates was noted both in leaf-shaped tumors and in sarcomas. Only patients with leaf-shaped tumors noted a slow growth rate.

On examination, in most cases, the skin over the neoplasm was not changed (80.2% of cases). In primary sarcomas, no changes in the skin of the breast were detected in 32% of cases. Such skin symptoms as its fixation over the tumor, the symptom of "wrinkling", "platforms" are extremely rare (3.4%) and are not typical for leaf-shaped tumors.

More often in patients with a leaf-shaped tumor, cyanosis, thinning of the skin over the formation, a pronounced venous pattern, a change in the skin pattern (with a change in the direction and depth of the folds) occur. They reflect the rapid expansive growth of the tumor and the violation of the trophism of the skin of the mammary gland, but by no means invasion of it by the tumor. The result of increasing trophic changes in the skin is ulceration.

The size of the breast tumor plays an important role in the complex of clinical symptoms. The large size of the tumor is the main guideline for the correct diagnosis (Figure 5.40 a-e).

Fig.5.40 a, b, c, d, e, f. Variants of the echographic image of a benign leaf-shaped tumor. On ultrasound hemograms, a hypoechogenesis formation with clear contours is determined, the structure is heterogeneous. The initial amplification of the signal, lateral acoustic shadows are noted. With dopleography, vessels are visualized along the periphery and inside the formation. The maximum systolic speed is up to 7 cm/sec.

The size of leaf-shaped breast tumors varied from 1 cm to 35 cm. Interesting data were obtained when determining the average size of leaf-shaped tumors of various histological variants.

With an increase in the average size of the formation, the degree of malignancy increases:

Benign leaf-shaped tumors - 6.87 cm;
- intermediate leaf-shaped tumors - 7.16 cm;
- malignant leaf-shaped tumors - 11.56 cm;
- primary breast sarcomas - 14.09 cm.

With a size of up to 3 cm, not a single case of malignant leaf-shaped tumor and sarcoma was detected. On this basis, benign leaf-shaped tumors (Fig. 5.41 a-d) with a size of up to 5 cm significantly differ from intermediate and malignant tumors (p

Fig.5.41 a, b, c, d, e. Variants of the echographic image of a benign leaf-shaped tumor. On ultrasound tomograms, a hypoechoic formation with clear, even contours is determined, its structure is heterogeneous with multiple anechoic cavities and crevices. With doppleography, vessels are visualized along the periphery and inside the formation. The maximum systolic speed is up to 7 cm/sec.

With an increase in the size of the tumor node, the percentage of leaf-shaped tumors of intermediate and malignant variants, as well as sarcomas, increases.

In the analysis of clinical diagnoses established in the RCRC polyclinic, out of 155 patients with leaf-shaped tumors, in 7.8% of cases, a leaf-shaped tumor was diagnosed without specifying the degree of malignancy. At the same time, in all cases with tumors less than 5 cm, the diagnoses were different - fibroadenoma, cancer, cyst, nodular mastopathy.

With tumors of large and giant sizes, the clinician in most cases diagnosed breast sarcoma, which accounted for 16.8% of cases. At the same time, the following were observed: rapid growth of the tumor with the achievement of large sizes; characteristic changes in the skin over the tumor in the form of thinning, hyperemia, cyanosis, increased venous pattern; heterogeneous consistency of the neoplasm; tuberosity of contours; nipple changes characteristic of malignant tumors; swollen lymph nodes in the armpit. All these are signs of a malignant tumor of a non-epithelial nature.

In the late postoperative period, relapses in the surgical area occurred in 18.2% of patients with leaf-shaped tumors and in 23.8% of patients with breast sarcomas. At the same time, it turned out that the greatest number of recurrences occurred after performing safe operations without a sufficiently wide excision of healthy tissues.

At ultrasound examination (ultrasound) the following signs were analyzed: the nature of the contours of the formation of the mammary gland (clear, fuzzy); the presence of a surrounding hyperechoic rim; the structure of education (homogeneous, heterogeneous); the presence of liquid cavities, small cystic inclusions, slit-like structures; the presence of such acoustic effects as dorsal amplification, central acoustic shadow, lateral acoustic shadow (Fig. 5.42 a-d).

Fig.5.42 a, b, c, d. Variants of the echographic image of a benign leaf-shaped tumor. On ultrasound tomograms, a hypoechoic formation with clear contours, a heterogeneous structure due to multiple anechoic small liquid cavities and crevices, is determined. Dopplerography visualizes the vessels around the periphery and inside the formation. The maximum systolic speed is up to 6 cm / s.

Leaf-shaped tumors are characterized by the presence of a hypoechoic formation of an inhomogeneous structure with a clear contour, the presence of cracks and racemose cavities. In most cases, dorsal signal amplification was detected, and only in one case of a malignant leaf-shaped tumor, a central acoustic shadow was determined.

With small sizes, the cracks look narrow and delicate, a heterogeneous layered structure is characteristic, suggesting a leaf-shaped tumor. Visualization of rounded, oval, or irregularly shaped fluid structures, especially with fuzzy blurred contours, may indicate the malignant nature of the leaf-shaped tumor (Fig. 5.43a-d).

Fig.5.43 a, b, c, d. Variants of the echographic image of a malignant leaf-shaped tumor. On ultrasound tomograms, a hypechoic formation of an inhomogeneous structure with multiple anechoic cavities is determined. The contours of the cavities are blurred. Dopplerography visualizes the vessels around the periphery and inside the formation. The maximum systolic velocity was 5 cm/sec.

In the group of primary breast sarcomas, in all cases, the fuzziness of the contours of the formation was determined. The structure was heterogeneous, lubricated, and separate liquid cavities without clear contours. A rim of infiltration was determined around the formation.

A new direction in the diagnostic application of color Doppler mapping and pulsed Doppler ultrasound is the assessment of the degree and nature of tumor vascularization. In all cases, the tumor was well vascularized, there was an abundance of small arteries and veins of various sizes.

When analyzing the quantitative characteristics, low blood flow velocities were revealed - from 2.4 to 7.4 cm/sec (Fig. 5.44a-e).

Fig.5.44 a, b, c, d, e, f. Variants of the echoraphic image of a leaf-shaped tumor. On ultrasound tomograms, a hypoechoic formation with clear, even contours is determined, the structure is heterogeneous, multiple anechoic cavities and crevices. Dopplerography visualizes an abundance of vessels of various sizes along the periphery and in the central parts of the formation.

All 155 patients with leaf-shaped breast tumors underwent a cytological study. In total, this study established 10.3% of correct diagnoses of leaf-shaped tumor.

Causes of difficulties and errors in cytological diagnostics:

Proliferative processes in the stroma are accompanied by dramatic changes in the epithelium, which leads to misdiagnosis of breast cancer.
Punctates were taken from large cavities (clefts) and incorrectly regarded as the contents of a cystic cavity.
The predominance of epithelial cells in the cytogram in the absence or a small number of stromal elements did not make it possible to suspect a leaf-shaped tumor cytologically, and the diagnosis was interpreted as mastopathy or fibroadenoma.
Despite the heterogeneity of the leaf-shaped tumor, punctures were not taken from several of its sites.

Leaf-shaped tumors have a wide range of histological variants.

When evaluating the histological variants of the leaf-shaped tumor, the histological criteria proposed by Azzopardi were used:

1. The nature of the edge of the tumor (rated as clear, fuzzy and intermediate).
2. Cellularity of the stromal component (rated on a scale from + to +++).
3. Severity of the stromal component (on a scale from + to +++).
4. Nuclear polymorphism of stromal cells (rated on a scale from + to +++).
5. Mitotic activity - the average number of mitotic figures in 10 fields of view at high magnification (x40).
6. The presence of necrosis in the tumor.
7. Presence or absence of heterogeneous stromal components.

The diagnosis did not depend on a single histological criterion. The histological picture as a whole was assessed. Necrosis and heterogeneous elements were found only in malignant tumors. When evaluating the features of the histological structure of recurrent tumors, a more pronounced aggressiveness of relapses compared to the initial tumor (a tendency to greater stromal growth, an increase in cellularity, nuclear polymorphism, an increase in the number of mitotic figures), the appearance of heterogeneous stromal components were noted.

Multivariate analysis

To assess the entire amount of information, including both qualitative and quantitative parameters, we used the mathematical processing of the database using multivariate analysis. The task was to identify such a combination of signs that would be informative in determining the benignity and malignancy of leaf-shaped tumors.

As a result of multivariate analysis, out of 60 signs, 10 most informative factors were selected, allowing with a probability of up to 83.6% to indicate one of the variants of a leaf-shaped tumor. To increase the percentage of correct diagnoses after clinical and initial X-ray examination in patients with leaf-shaped tumors and breast sarcomas, a classical algorithm for assigning an object to one of two classes was applied.

Bayesian weighting coefficients are calculated. If the sum of the weight coefficients is more than 0, the patient belongs to class 1 (benign leaf-shaped tumor), if the sum is less than 0 - to class 2 (malignant leaf-shaped tumor).

Thus, the results of the practical application of the decision rule based on a multivariate analysis of informative features that characterize the most significant data about the patient (in the context of the breast pathology under study) make it possible, even without the use of a computer, to differentiate benign and malignant variants of a leaf-shaped tumor, based on numerical gradations of prognostic signs.

Diagnosis of leaf-shaped breast tumors in most cases requires a combination of clinical examination, X-ray mammography, ultrasound combined with Doppler sonography.

Attention should be paid to the inexpediency of X-ray mammography for young women under 30 years old with a pronounced glandular structure of the mammary glands (the information content of mammography decreases with a dense background of the mammary gland). With gigantic tumors, it is not advisable to perform a mammographic examination due to the impossibility of obtaining a high-quality image that would allow assessing the structure and contours of the neoplasm.

In these cases, a combination of clinical examination and Doppler ultrasound is sufficient to make a correct diagnosis. In addition, targeted puncture under ultrasound control will allow obtaining informative cellular material from various areas of the neoplasm.

With small sizes of leaf-shaped tumors, even after a complete clinical mammographic and ultrasound examination, the question of differential diagnosis with fibroadenomas remains. In such cases, we recommend additionally performing scintimammography with Tc-99m technetrile. The absence of accumulation of the radiopharmaceutical indicates in favor of fibroadenoma.

G.T. Sinyukova, G.P. Korzhenkova, T.Yu. Danzanova