Malignant Phyllodes Tumor of a Genotypic Male, Phenotypic Female with Liposarcomatous Differentiation

Abstract

A 53-year-old genotypic XY male, phenotypic female transgender, with a history of exogenous estrogen use since the age of 19 and status postbilateral saline implants since 1988 presented with a 2-month history of pain and induration in an enlarging left breast mass. Her history dates back 1 year ago when she noted that her left breast implant had deflated and shrunk in size but did not seek medical care at that time. Of note, her family history was positive for breast cancer in three sisters. Physical exam showed a morbidly obese, phenotypic female with a large, firm, indurated, erythematous, and focally fluctuant left breast. The patient was referred to our Breast Imaging Center.Imaging findings were as follows: On ultrasound, there was loss of the normal echogenicity and tissue fat planes with an ill-defined mass within the soft tissues of the left breast (Fig. 1). The lesion demonstrated internal vascularity on color Doppler ultrasound.A diagnostic mammogram was then obtained, which revealed a large, high density, and lobulated mass within the left breast. There were partially circumscribed, partially obscured margins as well as coarse, dystrophic calcifications, and adjacent skin thickening (Fig. 2). The mass measured 14 · 15 cm in the central region and occupied almost the entire breast.A fine-needle aspiration of the mass was performed. The hypercellular smears revealed abundant large sheets of bland ductal epithelium associated with hyperchromatic myoepithelial cells. Focally, hyperchromatic ovoid to spindled cells with crowding, architectural disarray, and prominent nucleoli were seen in a background of blood and necrotic debris. These findings were consistent with an atypical proliferative lesion suspicious for phyllodes tumor with the recommendation to completely excise the lesion for definitive diagnosis (Fig. 3). The patient underwent a simple mastectomy of the entire mass.Phyllodes tumors of the breast are rare neoplasms, comprising less than 1% of all breast tumors and only 2-3% of fibroepithelial neoplasms (1,2). First described by Johannes Muller in 1838, review of the literature has reported only 13 cases in males (3), of those, only 4 of the 13 were considered malignant. It has also been estimated that approximately 7% of phyllodes tumors contain adipose tissue in small amounts, with liposarcomas arising in the breast being extremely rare (Fig. 4) (4). Thus far, liposarcoma in malignant phyllodes had only been reported in females (5). Herein, we present a case of malignant phyllodes

A Case of Benign Phyllodes Tumor in a Transgender Woman Receiving Cross-Sex Hormones

“…There are few scattered reports of fibroadenomas occurring in hormonally-treated male-to-female transgender patients, 11,12 as well as one case report of a malignant phyllodes tumor in a transwoman. 13 However, to our knowledge, this is the first reported case of benign phyllodes tumor in this population.…”

Histologic Findings in Surgical Pathology Specimens From Individuals Taking Feminizing Hormone Therapy for the Purpose of Gender Transition

“…27,28 In addition, 1 benign phyllodes tumor has been reported, 10 as well as 1 malignant phyllodes tumor with liposarcomatous differentiation. 29 One case of angiolipoma in the breast of a 61-yearold transgender woman who had been on feminizing hormone therapy for 18 months has also been reported. 30…”

Breast Imaging in Transgender Patients: What the Radiologist Should Know

“…Invasive ductal carcinoma (ie, scirrhous and papillary subtypes), and poorly differentiated adenocarcinoma have been described (6,7). A few case reports have also documented evidence of malignant phyllodes tumors (8).…”

“…Therefore, it is crucial and timely to address this subset of patients in the context of health care and medical treatment. In particular, with a greater number of individuals undergoing gender-affirming hormone therapy and gender-affirming surgery as well as reports of breast cancer in the transgender population, it is increasingly important for radiologists to be aware of breast imaging considerations for this population and to review optimal breast imaging approaches for transgender individuals (5)(6)(7)(8).…”