GIANT INTRACA4NALICULAR FIBRO-ADENOMYXOhfA OF THE BREAST. THE 80-CiILLED CYSTOSARCOMA PHYLLODES MAMMAE OF JOHANNES MULLER BURTON J. LEE, M.D., AND GEORGE T. PACK, M.D. (From the Memorial Hospilnl for Concrr and A llicd Diseases, New Yorlc Cily) In the January 1931 issue of the Annals of Surgery, we pre- sented four case reports of giant intracanalicular myxomn of the breast and summarized the salient characteristics of this tumor. In the present article we will include a complete bibliography of the literature to date on this subject, a concise summary of one hundred and five case reports culled from this literature, and n report of two additional cases which we have observed. These two personal cases illustrate clearly the early and the late stages in the evolution of this curious neophsm. In 1835 Johnnnes Muller described this tumor as rz neoplastic entity, and gave it8 the name of cystosarcoma phyllodes. His classical description is worthy of quotation in detail: Three forms of cystosnrcomn have come under the author’s notice; the simple cyst os:trcoma, cyst osarcoma proliferum, and cyst 0s:ircoma with foliated warty excrescences from its cysts. In cystosnrcorna simplex, the cysts contained in the fibrous sarcomatous texture have each their distinct membmne, the inner wall of which is simple, smooth or at most beset with :L few vnscular nodules. “In the second form, the sarcomtttous mass is the same, but the cysts within it contain youiigcr cysts in their interior, which are attached to their walls by pedicles. This form of morbid growth is a repetition of the proliferating cysts, but inibeddetl in a sarcomatous mass, which constitutes the chief part of the tumor; and it may, therefore, be termed with propriety cystosnrcorna proliferum. The pedunculnted offsets from the cysts are hollow. “The third form, cystos:trcorn:~ phyllodes, differs greatly from the other two. The tumor forms a hrge firm mass, with :t more or less uneven surface. The fibrous substance which constitutes the greater part of it is of a greyish white color, extremely hard, and as firm as fibro-c:trtilage. Large portions of the tumor are made up entirely of this mass, but in some parts :ire cavities or clefts not lined with a distinct membrane. These cavities contnin but little fluid; for either their parictes, which are hard like fibro-cart il:ige, and finely polished, lie in ose apposition with each other, or :t number of firm, irregular 1amin:te 2583
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GIANT INTRACA4NALICULAR FIBRO-ADENOMYXOhfA OF T H E BREAST. THE 80-CiILLED CYSTOSARCOMA
PHYLLODES MAMMAE OF JOHANNES MULLER
BURTON J. LEE, M.D., AND GEORGE T. PACK, M.D.
(From the Memorial Hospilnl f o r Concrr and A llicd Diseases, New Yorlc Cily)
In the January 1931 issue of the Annals of Surgery, we pre- sented four case reports of giant intracanalicular myxomn of the breast and summarized the salient characteristics of this tumor. In the present article we will include a complete bibliography of the literature to date on this subject, a concise summary of one hundred and five case reports culled from this literature, and n report of two additional cases which we have observed. These two personal cases illustrate clearly the early and the late stages in the evolution of this curious neophsm.
In 1835 Johnnnes Muller described this tumor as rz neoplastic entity, and gave it8 the name of cystosarcoma phyllodes. His classical description is worthy of quotation in detail:
Three forms of cystosnrcomn have come under the author’s notice; the simple cyst os:trcoma, cyst osarcoma proliferum, and cyst 0s:ircoma with foliated warty excrescences from its cysts. In cystosnrcorna simplex, the cysts contained in the fibrous sarcomatous texture have each their distinct membmne, the inner wall of which is simple, smooth or at most beset with :L few vnscular nodules.
“ I n the second form, the sarcomtttous mass is the same, but the cysts within it contain youiigcr cysts in their interior, which are attached to their walls by pedicles. This form of morbid growth is a repetition of the proliferating cysts, but inibeddetl in a sarcomatous mass, which constitutes the chief part of the tumor; and it may, therefore, be termed with propriety cystosnrcorna proliferum. The pedunculnted offsets from the cysts are hollow.
“The third form, cystos:trcorn:~ phyllodes, differs greatly from the other two. The tumor forms a hrge firm mass, with :t more or less uneven surface. The fibrous substance which constitutes the greater part of i t is of a greyish white color, extremely hard, and as firm as fibro-c:trtilage. Large portions of the tumor are made up entirely of this mass, but in some parts :ire cavities or clefts not lined with a distinct membrane. These cavities contnin but little fluid; for either their parictes, which are hard like fibro-cart il:ige, and finely polished, lie in ose apposition with each other, or :t number of firm, irregular 1amin:te
2583
2584 BURTON J. LEE AND GEORGE T. PACK
sprout from the mass, and form the walls of the fissures; or excrescences of a foliated or wartlike form sprout from the bottom of the cavities and fill up their interior. These excrescences are perfectly smooth on their surface, and never contain cysts or cells. The laminae lie very irregularly, and project into the cavities and fissures like the folds of the psalterium in the interior of the third stornnch of ruminant animals. In one instance the author saw these lamina here and there regularly notched or crenated like a cock’s comb. Sometimes the 1amin:te are but small, snd the warty excrescences from the cysts very largr, while in other instances both are greatly developed. Occasionally t hrse warty excrescences arc broad, sessile, and much indented; others have a more slender base, and somewhat resemble cauliflower condylomat,a.
“Tumors of this kind attain an enormous size; hitherto the nuthor has seen them only in the female breast, nor are they even there of frequent occurrence. They are decidedly innocent, occur earlier than i t is usual for cancer in the mamma to develop itsrlf, and sometimes they appear even in youth; they have but little tendency to grow to the skin or to the subjacent muscles, nnd are not attrnded with retraction of the nipple. They are not disposed to soften internally, but continue to grow slowly until they have attained an enormous size whrn they at length burst, and a very ill-looking suppurating fungus forms upon their surface. Even in this state, however, the operation has been performed with a successful result.
“Swelling of the axillnry glands is not a common occurrence, :in(!, when it is met with, is the consequence of simple irritation, :md suhsides after the operation. The extr:mrdinnry forms which cystosarconia phyllodes assumes, a t once suggest the notion of its cancerous nature; and yet, the disease is perfectly innocent, and as far removed from carcinoma as are those non-suppurating cauliflower condylomata of thc penis, and of the female genitals, which have so often been mist:tken for cancerous structures.”
This tumor of the breast had been reported in literature several times prior to Muller’s classification. Chelius had previously given an accurate gross description, which may be translated as follows :
“The sarcomatous or steatomatous degeneration of the mammary gland is one of the most benignant diseases to which that organ is subject, and it is with great impropriety that many have spoken of it as carcinoma mammae hydatides. It is characterized by the large size and great prominence of the tumor, which is not globular, but four-cornered, and projecting more a t one part then another; it does not cause retraction of the nipple, but that part projects and retains its natural appc:trance. The greatest diameter of the tumor is not a t its base, but a t a point some distance from the walls of the chest. This disease may be distinguished from scirrhus and fungus medullaris of the mammary gland, partly by the above mentioned signs; but other circumstances which servc still
FIBRO-ADENOMYXOMA OF THE BREAST 2585
further to distinguish it, are its different consistence a t different parts, i t being hard a t one spot, elastic and tense a t another, and even distinctly fluctuating a t a third; its mobility in d l directions, notwithstanding the great size it attains; the slight influence it exerts on thc general health, even after it has continued for a considerable time; and, lastly, the absence of swelling of the :ixillary glands. Although this tumor is inconvenient to the patient from its size, and painful from its dragging at surrounding parts, yet it does not affect the health.”
The characteristic features of this tumor have been summarized
1. Greatness in size, averaging 7.6 pounds. Frequently the
2. The lobulation and delimitation of the tumor with variable
3. Encapsulation of the tumor and non-invasion of the breast. 4. Mobility and usual non-adherence t o skin and fascia. 5 . No retraction of the nipple and no involvement of axillary
6. Possible occurrence in males (3 per cent). 7. Development from pre-existent fibro-adenomas, probably
intracanalicular fibro-adenomas. The transition occurs at the time when a gelatinous metamorphosis of the stroma takes place.
8. Long initial period of quiescence or slow growth, followed by sudden rapid acceleration.
9. Long duration-averaging seven years in 111 cases. 10. Important r81e of lactation and nursing difficulties in the
metamorphosis of simple fibro-adenoma to giant intracanalicular myxoma.
11. Intracystic polypoid excrescences moulded by apposition with each other.
12. Narrow sinuous distorted clefts between polyps. These epithelial-lined spaces contain variable quantities of clear yellow fluid.
13. Myxomatous stroma with cellular pseudosarcomatous regions.
14. Benignity; good prognosis with freedom from recurrence. 15. Successful treatment by wide local excision or simple
mastectomy. In addition to the metaplasia of the stroma into myxomatous
tissue, which is the distinguishing and essential feature of this variety of tumor, the cuboidal or columnar epithelium of the clefts
by us as follows:
tumor is as large as an adult head.
regions of fluctuation and resistance.
lymph nodes.
2586 BURTON J. LEE AND GEORGE T. PACK
may undergo metaplasin, to form pavement epithelium, even true epithelial pearls, indicating functiond instability. Such pearls were found by Groh6, Gorham, Kursteiner, G. €3. Schmidt, Stumpf and Beneke. In the layers of cyliridricnl epithelium of the adenomatous clefts these groups of pavement epithelial cells show all the characteristics of cutaneous epithelium, such as corni- fication. These pearls never occur unless the stroma rextion or proliferation has been really enormous, which is the reason that these tumors have been designated :is mixed tumors.
The tendency found in intracnnalicu1:tr fibro-adenomas to form true glmds by the cxtension of ductal epithelium down into the connective tissue is likewise present in cystos:trcoma phyllodes. These glandulnr productions in the tlumor are probably tinalogous t o the g1:inds in the mammary tissue. The acini in the adjoining breast are frequently cystic.
The ordinary intr:tcnnaliculitr fibro-adenoma of the breast is formed as follows. The inner or subepithelial layers of the peri- canaliculnr connective tissue participate more actively in the growth of the tumor than do the outermost connective-tissue layers, in consequence of which buckling or folding of these inner layers occurs, and rounded or p:ipillnry projections of the peri- ductal tissue are invagimtted into the lumina of the tubules. The same txp1:m:ttion may be valid for cystosarcoma phyllodes.
Rcinhnrdt w:~s the first t o demonstrate thzt cystosarcomn could develop from fibro-ndenomrt of the breast. In describing this transition, Billroth said that, if the stroma enlarges intracnnalic- uhrly, then either obliteration of the lumen occurs or these 1umin:t enlarge to cover the stromous proliferation. Another factor to which enlargement of the ductal lumina was attributed was secre- tion, which c:tused the iritraductular projectioris to resemble polypoid tufts. Frangenheim and Ribbert independently as- serted that a particular type of intr:tcanalicular fibroma was pre- cursory, because in this variety the periduct:il and periacinar connective tissue seem quite embryonic. Beneke also attributed the origin of cystosarcoma phyllodes to pre-existing fetal adenomas ; on this account, they were said to retain their embryonal capacity to proliferate. Frangenheim explains that cyst:tdenomas are transitional stages between fibro-adenomas and cystosarcomas. Schimmelbusch said that cystos:trcoma phyllodes was merely an advanced developmental phase of fibro-adenoma and, therefore, should not be called sarcoma, since it was a benign tumor. True
FIBRO-ADENOMYXOMA OF THE BREAST 2587
malignant tumors may originate, however, in benign mammary fibro-adenomas. In such fibro-epithelial tumors the epithelium may become carcinomatous, or both fibrous and epithelial tissue may become malignant (sarco-carcinoma), as described by Dorsch, Coenen, Wehner, and Schlagenhaufer. Virchow knew that sar- coma could originate in the stroma of an epithelial tumor. Ehrlich showed, when transplanting carcinoma of a mouse into different animals, that the stroma may change so as eventually to replace the carcinoma and finally become sarcomatous. The mechanism of stimulation in these instances, as in cystosarcoma phyllodes, may be similar in kind if not in quantity.
FIG. 1. CASE 1: CLINICAL PHOTOGRAPH OF PATIENT. Kote the size of the affected breast, the livid intact skin, and the protuberant
elastic eminence in the inner segment.
Lukowsky, Krompecher, and Sasse believed that cystosarcoma phyllodes may originate in the fibro-adenomas developing in breasts which are involved by diffuse fibromatosis, but the majority of pathologists accept the congenital origin (theory of Cohnheim). These authors, notiibly Wilms, insist that the anlagen of these tumors are embryonal tissue anomalies included in the region of the breast. The delimitation of the tumor by capsulation and the lack of infiltration indicate the separate entity of the tumor and contradict the theory of its origin from adult breast tissue.
2588 BURTON J. LEE AND GEORGE T. PACK
CASE REPORTS CASE I: E. R., a white, married wornan, aged forty-four years,
applied to the Rllemorinl Hospital, Oct,. 21, 1930, complaining of a painless lump in her right breast.
Ptrst History: Nine years previously a cyst of Bartholin’s gland was excised. The patient h:id been niarried only two years and had never been pregnant.
FIG. 2. CASE I: GROSS SPECIMEN ILLUSTRATING THE LARGE, INTRACYSTIC hIuxoh1- ATOUB 1’oLws SEPARATED BY N A I ~ I ~ O W . TORTUOUS CLEVTS.
Present Illness: One month prior to applicat,ion the patient chanced to feel a lump in her right breast. There was no mastalgia, and no discharge from the nipple. The tumor grew rapidly and soon produced a red mound-like eminence on t,he contour of the breast.
Physictrl Exatiiiriution: In the lower inner quadrant of the right breast was a firm, globular, freely movable tumor. The superficial part of the turnor seemed to be fluctuant. Both breasts were large. The nipples were erect. There were no palpable axillary 1ymphadenop:ithies. The immediate provisional diagnosis was cyst of the breast; but since aspiration by needle puncture did not yield fluid, the tentative diagnosis was changed to fetal adenoma.
FIBRO-ADENOMYXOMA OF T H E BREAST 2589
Treatment: On Oct. 22, 1930, the tumor was simply excised, without the removal of mammary tissue. This was accomplished by an elliptical skin incision surrounding the protuberant part of the tumor. Conva- lescence was uneventful.
Gross Pathologic Anatomy: The encapsulated tumor measured 8 x 5 x 4 cm. On hemisection numerous intracanalicular polypoid projections were found closely packed within the capsule. The polyps were sepa- rated by intercommunicating clefts, which contained thin, clear, straw-
There has been no recurrence to date.
FIQ. 3. CASE I: CROSS-SECTION OF A TYPICAL INTRACANALICULAR FIBRO-ADENOMYXOMA
colored fluid. The stroma was smooth, loose, and gelatinous in certain regions, especially within the polyps.
Pnlhnlogic Histolog!j: Myxomntous t,issue was found in many of the polypi. The spindle cells of the stroma tend to run parallel to the e1ong:tted clefts. Some parts of the stromn were composed of fusiform cells with bizarre nuclei, which were n:irrow and rod-like, resembling smooth muscle nuclei. Some hyulin degeneration had occurred in the polypoid tissue. The clefts were lined by cylindrical and cuboidal epithelium, which projected into the stroma to form pseudo-glandular lacunae.
FIQ. 4. CASE I: COMPLETE HYALINE METAMORPHOSIS OF NIJMEROUR POI~YPFI, WHICH HAVE RETAINED T H E I I ~ EPITHELIAL INVE~TMENTS.
I?IQ. 5. C A S E 1: SINUOUS, DI~~TORTED, ANA6TOMOTIC CLEFTS, h N E D BY CUBOIDAL 14:I’ITHELIUM AND FORMINQ SECONDARY I’SEUDOACINAR C R Y P T S .
The spindle cells of the stroma run parallel to these ductal clefts.
2590
FIBRO-ADENOMYXOMA OF THE BREAST 259 1
CASE 11: M. E., a white, married woman, aged fifty-two years, applied to the Memorial Hospital, June 20, 1927, complaining of large tumor masses in each breast.
Past History: The patient’s only child, born in 1895, had nursed both breasts without difficulties in lactation. The menopause had been passed without complica tions.
Present Illness: Forty years earlier, when the patient entered puberty, a t the age of twelve years, she discovered a small lump in the lower segment of the right breast. This lump gradually increased in size until 1922, when it grew wit>h greater rapidity. Five years before the patient was seen (1922), another lump appeared in the upper half of the left breast; this tumor gradually grew to involve the skin and became
FIG. 6. CASE 11: CLINICAL PHOTOQRAPH OF PATIENT WITH GIANT INTRACANALICULAR FIBRO-ADENOMYXOMA OF RIQHT BREAST; BULKY ADENOCARCINOMA OF
LEFT BREAST.
the size of an orange, The only discomfort experienced was the weight of the right breast.
Physical Excmintition: The right breast was completely replaced by a bulky, lobulated, elastic, semi-fluctunnt tumor. The nipple was obliterated. The tumor was encapsulated and freely movable. The breast was pedunculated, due to the traction exerted by the weight of this tumor, which rested against the upper abdomen. The right breast measured 21 inches in circumference. In the upper segment of the left breast was an ovoid movable tumor S x 5 cm. in diameter. The super- jacent skin was purplish-red and firmly adherent. There were no palpable axillary lymph nodes. A radiograph of the chest was negative except for obliteration of the left costophrenic angle by adhesions. There were no discernible regions of *calcification in the tumor of the
There never was any cough or pain.
27
FIG 7. CASE 11: GROSS SPECINEN OF A GIANT INTI~ACANALICULAR MYXONA OF THI
There is marked overgrowth of the stroma in lobular arrangement; some of these BREAST.
lobulea appear myxosarcomatous when examined microscopically.
2692
FIBRO-ADENOMYXOMA OF THE BREAST 2593
right breast. The provisional clinical diagnosis was sarcoma of both breasts,
Treatment and Progress: In June 1924 a simple mastectomy of the right breast was performed. At the same time 62; millicuries of radon in 25 gold seeds were implanted in the tumor of the left breast,. By December 1927 this tumor had disappeared completely, but the patient complained of pain in the left shoulder girdle. A radiograph of the left shoulder revealed early metastasis to bone. In November 1928 a left radical mastectomy was performed, using a transverse Stewart incision;
FIQ. 8. CASE 11: SPINDLE AND STELLATE CELLS OF MYXOMATOUS STROMA OF ADENO-
The numerous mitoses, loss of polarity, and character of the nuclei indicate a low- FIRROMYXOMA.
grade malignancy, i . e . , myxosarcomn.
the wound could not be closed and was permitted to heal by secondary intention. Pulmonary metastases developed, and the patient died Dec. 5, 1929.
Gross Pathologic Anatomy: The right breast was completely replaced by a tumor measuring 18 x 15 cm. On section the tumor appeared lobulated, with smooth, glistening, gelatinous stroma. Several of the lobules exhibited central necrosis and cavitation, a phenomenon more frequently found in mammary sarcomas than in giant intracanalicular myxomas of the breast. The polypoid projections were sessile. The tumor was well encapsulated and did not invade the adjacent breast tissue.
TA
BL
E I
The
Age
and
Sex D
istr
ibut
ion
of C
ysto
sarc
onia
Phy
llode
s an
d F
ibro
-ade
nom
as o
f th
e M
amm
ary
Gla
nd
Typ
e Se
x an
d C
ivil
Sta
te
Fibr
o-ad
enom
a M
ale.
. ...
......
......
......
. hl
arri
edfe
mal
e.. ..
....
....
...
Sing
le f
emal
e.. ..
....
....
....
. TOTAL..
....
....
....
....
...
Cys
tosa
rcom
a M
ale.
....
....
....
....
....
...
Sing
le f
emal
e.. ..
....
....
....
. Ph
yUod
es
Mar
ried
fem
ale.
....
....
....
..
Age
15
20
25
3
0
35
40
45
50
5
5
60
65
70
75
to
to
to
to
to
to
to
to
to
to
to
to
to
19
24
29
34
39
44
49
54
59
64
69
74
79
~
-----------~
2
1
1
1
8 13
18
14
20
19
7
1
1
2 5
16
9 5
5 3
8 24
22
23
20
23
19
7
1
1
2 1
11
2
6 7
91
21
31
56
6
2 1
2 1
11
23
21
1
__
__
__
-_
_ ------ ~
__
I I
Age
n
ot
give
n
Tot
ah
TOTAL ......
......
......
...
(1
I 151
I
4 7
7 10
13
16
19
8
7 2
1
~-
1
I 3
1
__
_-
{ 15
1 108 1
4 10
4 43
__
_-
16
111
1
FIBRO-ADENOMYXOMA OF THE BREAST 2595
The left breast contained a small, hard tumor measuring 2 x 13 x 1 cm., situated in the upper medial portion. The skin over the tumor was slightly ulcerated.
Pathologic Histology: The right mammary tumor consisted almost entirely of myxomatous tissue which had completely replaced the original stroma. The interlobular clefts were lined by cuboidal epi- thelium. The spider-like cells of the myxomatous stroma were very large but not closely packed. Microscopically one obtains the impression that the tumor is of low-grade malignancy, i e . , myxosarcoma.
The tumor in the left breast was obviously a necrotic carcinoma, probably of the sweat gland type. No metastases were found on micro- scopic examination of the lymph nodes in each axilla.
Comment: The tumor in the left breast was a bulky adenocarcinoma, which caused the patient’s death, but was histologically and histo- genetically not related to the giant intracanalicular fibro-adenomyxoma of the right breast.
[over]
TABLE 11: * Giant Intracanalicular Fibro-adenomysoma of the Breaat 4a CI
Author and 2 date
0
4
Relation tn lactation and
pregnancy
Dura- tion in yenra
__ 5
__ 10
_- Many ycars
Skin of breast
Chief physirnl findin and symptoms Location Size
:hild’s hra 57 01.
8: lb: 1 5 x 8 in.
-__
13 lb.
Rulkv breast tiimor. I cilialing pain during n struation
Left Stimulated
Right Chclius 30 1828
Normal
0 m.
0 m. __
Left I4 3” in. eircum.
Addt heal -__
Nodular tumor, Buctuo
-____ Fkcher 30
Orucft: 31)
I835 -____
1838
Never nursed Ulcer 1
__ 2
Funcation. Varicose vc Nodular, tluctuant.
0 m. After lalit prep. nancy
Left Ulcer 22 Ib. 8 02.
Circumference 58 in. 1 mor filled lap. Cyanti skin. I’ainafterfungat
Ulcer 16 Moderate
1x39 Itight Normal 4
__ I
Nodular, irregular turn(
(:lobul:rr fused tunioi No p i n
- - E66
12 Ib. Warren 1 1839
0 Nnrmal
0 1.
0 m. -
Lcft No p i n Entire brenst
2 Ib.
Two fista
__ 6 Lcbert 50
I814 1 Nornl:il Iliaht: lower left quad- rant
Biue Movable tumor undt skjn. veins dilated. N pain
TABLE I1 : Giant Intracanalicular Fibro-adenomgxoma of the Breast
Dura- tion in years
-- 8
-_ 37
Author and date
- _ _ ~ Hart 1937
Lee niid Pnrk 1930
Lecand Pack 1830
Leeand Pack 1930
I.ernnd Pack 1930
Lee and Pack 1931
Ler and Pack 1031
___
____-
_____
_____
_____
___-
-__
..7
'i %
26
4:
-- 5ti
40
34
28
44
53
SR
SR
SR
- "
- Sit
10
___ 8
_- 3:
-- One
month
40 years
__
Relotion to lactation and
pregnancy Chief physical findini
and symptoms Location Skin of breaat
Sinus
Ulcer
Size
Orange Large movable tun Rapid growth during pi nnocy
2
~
7
Never nursed this breast; st,imulated
Started after child- birth
Bulky cyntir !obulatcd mor. No pain
Richt
Both breasta Normal 13x11 em.
Bulky lohulated tumors both breasts. Oecasioi dull bilaternl pain
1 Right: uppe half
IfiX1OXQ cm.
9X7X5 em.
8x5 cm.
___
__--
Tarae cystic lobulatcd t rnor muas. Occasional di pain
Movable non-adlierent t mor. Dragginr pain
Glolmlar, discrete. mo able, large tumor. No pa
Blue
Normal
-___- Adherent
Abscess in right breast
-
2
__ 0
Right: lower right quad- rant
Rirht: lower rirht quad- rnnt
-_F
1 -
Right Adherent 18x15 em. size of melon
Pedunculnted., baselate b r e d containing turn04 Nipple retrncted Bulk ndenocarcinorna in oppc site breast. No discomfor except weight
BIBLIOGRAPHY
ALEXANDER, G. : Cysto-fibrosarcoma phyllodes mammae, Objazat. pat.- anat. izslied. stud. med. imp. Charkov Univ., 1890, pp. 173-178.
AMADO, S. : Un caso de kisto-sarcoma telangiectasico a papillar da glandula mamaria do homcm, J. SOC. d. sci. m6d. de Lisboa 36: 56, 1872.
ARATA, P. : Cisto-sarcoma della mammella sinistra, Nuova Liguria med., Genova, 19: 401-403, 1874.
ASIIHURST, S.: Cystic sarcom;i of the breast, Am. J. M. Sc. 61: 154, 1871. BKNEKE: uber die Adenofibrome der Mamma, Verhandl. d. deutsche
path. Gesellsch. 4: 205, 1902. BENJAMIN, L. : Beitrng zur genaueren Kenntniss des Cystosarcoms der
weiblichen brust, Virchow's Arch. f . path. Anat. 9: 299-301, 1855. BERGERET AND BOTELHO : 13pith61-sarcome de la glande mammaire,
Gyn6c. et obst. 1: 139-147, 1920. BERKA, F. : Zur histologischen Charakteristik der fibroepithelialen
Mammatumoren, Beitr. z. path. Anat. u. z. allg. Path. 53: 284-323, 1912.
BERTOLET, R. M. : Cystosarcoma proliferum of the mammary gland, with metastasis in the liver and spleen (dog), Trans. Path. SOC. Phile. 4: 241, 1871.
BIEBL, M.: Das Mammasarkom und seine Beziehungen zur Fibrosis mammae wie zu den gutartigen Mammageschwulsten, Beitr. I . klin. Chir. 140: 52-74, 1927.
Nomenclature
wanalicular myxoma
ot intracanalicular myxoma stowmma phyllodes)
st intracanalicular myxoma Btosar~oma phyllodes)
mt intracannlicular myxoma atrmrmma phyllodes)
mt intramnalicular myxoma stcsarwma phyllodes)
ant intracanaliculsr myxoma of rvlt (cystmucoma phyllodes)
ant intracanalicular myxoma of wt (cystmarcoma phvllodes) th m osarcomatoua &an es. w bul$ adenocarcinoma of feft east
FIBRO-ADENOMYXOMA OF THE BREAST 2605
Cases Reported i n the Literature (continued)
Treatment
Simple mastectomy
S i p I e mastectomy
Extirpation
Radical mastectomy
Simple mnstectomy
Locnl excision of tumor
Simple mastectomy of righ breast: interstitial irradiatioi and simple mastectomy of lef breast
Grow pathologic anatomy
Large intracystic polyp
Intracystic polyp
Intracanalicular polypoid masses
Typical cystosarcoma phyllodes
Soft polypoid intracystic nodules
Intracanalieular papillary excrescences
Lobulated, smooth glistening tumo nodules. Some necrotic cavitation Slight preservation of intracanalicula arrangement
Histopathologic anatomy
Myxomatous stroma
Myxomatous stroms; calcification
Myxomatous stroma
~- Myxomatoue and xnntbomntou s t rom
Myxomatous stroma
Myxomntous stroma; hyalinization ir regions; secondary pseudoscinar crypt:
Myxosarcomatous metamarphoais oi stroma of this tumor: also adenocarci noma of opposite hresst
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2606 BURTON J. LEE AND GEORGE T. PACK
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FIBRO-ADENOMYXOMA OF THE BREAST 2607
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28
2608 BURTON J. L E E AND GEORGE T. PACK
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FIBRO-ADENOMYXOMA OF THE BREAST 2609
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