Malignant Phyllodes Tumor of the Breast and Pregnancy: A Rare Case Report and Literature Review.

Phyllodes Tumor (PT) is a rare fibroepithelial breast tumor that can behave differently depending on its biologic features. Traditionally, PTs are classified by their histologic features into benign, borderline, and malignant. In most cases that were reported, all PTs may recur, but only the borderline and malignant PT can metastasize. PT usually occurs as a breast lump or accidental finding on ultrasound (US) examination. The clinical features include a well-defined breast mass, regular or lobulated. The diagnosis is based on the integration of morphology features, but remains challenging, particularly in the distinction from fibroadenomas. We report a case of a 36-year-old patient who presented for a voluminous breast mass, rapidly growing in the past 3-4 months. At presentation, the patient was 19 weeks pregnant. The breast tumor had the clinical and US aspect of PT. A core needle biopsy was obtained, confirming a benign PT, and local excision was performed with no postoperative complications. The final pathology report showed a borderline PT with close resection margins of 1 mm. Immunohistochemistry (IHC) established the diagnosis of malignant PT with heterologous sarcomatous differentiation. The case was discussed in the multidisciplinary tumor board (MDT) and mastectomy was recommended. The patient fully consented but refused surgery at 25 weeks' gestation, fearing premature delivery. The right breast was closely monitored by US, and at 9 weeks after the first surgery, signs of local recurrence were detected. At 35 weeks' gestation, right mastectomy was performed, with no perioperative complications. The pregnancy was closely followed up and no complication were found. The final pathology report describes multiples PT recurrences with heterologous sarcomatous differentiation. The pregnancy outcome was uneventful, and the patient delivered a healthy child vaginally at term with no peripartum complication. Postpartum, a computer tomography (CT) examination of the head, thorax, abdomen and pelvis was performed, with no evidence of metastases. Adjuvant chemotherapy and radiotherapy completed the treatment. The follow-up and CT scan showed no metastases or further recurrence 4 years after diagnosis. In conclusion, diagnosis of PT can be difficult, especially because of the easy confusion with fibroadenoma of the breast. There are rare cases when a pathology exam needs further assessment and IHC is recommended for accurate diagnosis. Although malignant PT is rare and accounts for <1% of all breast cancers, the diagnosis and treatment that are recommended are based on the reported cases. Moreover, when complete surgical excision is achieved, the rates of recurrence and distant metastases are low, and adjuvant therapy might not be necessary.

Complete Tubal Abortion: A Rare Form of Ectopic Pregnancy.

Tubal abortion is characterized by the extrusion of an ectopic product of conception implanted in the fallopian tube through the abdominal ostium into the peritoneal cavity. It can be either complete or incomplete and may lead to severe bleeding. Recognition of a complete tubal abortion may be challenging but is essential because it allows conservative management which make possible preservation of tubal function and fertility without the need for further cytostatic therapy. A case of a 30 years-old woman admitted for lower abdominal pain is reported.The level of hCG was 659.2 mU/mL and transvaginal ultrasound reveled a fluid collection in the pouch of Douglas. Laparoscopy was subsequently performed for the suspicion of ectopic pregnancy with hemoperitoneum. Corroborating the hCG dynamics with the laparoscopic findings, the diagnosis of complete tubal abortion was established. The histopathological examination confirmed the presence of intermediate trophoblastic cells in the tissue collected during laparoscopy. Ultrasound examination helps recognition of hemoperitoneum but adds little value to the diagnosis of tubal abortion. Laparoscopic findings alone are only suggestive for complete tubal abortion but in combination with hCG dynamics, the diagnosis can be established. Conservative management might be sufficient in complete tubal abortion and ensures preservation of tubal function and fertility.

Ovarian Germ Cell Tumors: Pictorial Essay.

Ovarian germ cell tumors of the ovary represent a histologically heterogenous group of tumors with a high incidence at reproductive age. Patients with this pathology are very often young women with amenorrhea. The aim of this article is to present a pictorial essay of this rare pathology and to promote a national tumor registry and protocol. The treatment is individualized according to age, and fertility-sparing surgery is the actual standard of surgical treatment for young patients in early stage of the disease.

Update on placenta accreta spectrum disorders by considering epidemiological factors, ultrasound diagnosis and pathological exam - literature review and authors' experience.

The aim of this paper was to correlate the circumstances that could lead to an abnormal invasion of placenta with the updated requirements to perform screening by ultrasound for all pregnant women prone to develop this pathology. To screen in the middle trimester of gestation for placenta accreta spectrum (PAS) disorders sets up an in-time referral opportunity for pregnant women prenatally detected with this pathology to a medical center with elevated level of expertise in the management of PAS disorders, able to act permanently by a multidisciplinary team (MDT) and to have access at medical resources including blood bank available. The literature review reveals especially useful data for clinical practice as regards novel explanations related to the etiology and physiopathology of PAS disorders, the composition of the MDT and the relevance of an indispensable pathologist physician at the time of Cesarean hysterectomy involved in the selection of best samples with the purpose of avoiding the possibility of losing undiagnosed cases with litigation implications. Conclusions show that the prenatal diagnosis of PAS disorders is possible so decreasing the risk of mortality and morbidity of pregnant women. Screening in the second trimester of pregnancy for PAS disorders becomes mandatory as the number of births by Cesarean section is expected to rise past three-fold until 2030. The professional expertise of the pathologist physician could be enriched by immunohistochemical staining in all suspected cases of placental invasion in myometrium wall.

Adnexal masses in pregnancy: perinatal impact.

The incidence of adnexal masses in pregnancy has increased significantly over the last decades and this is mostly because of the widespread use of ultrasound for pregnancy surveillance. Although a clear majority of adnexal masses found in the first trimester are functional cysts, which have a small diameter and disappear spontaneously, those that do persist into the second and third trimester require ultrasound surveillance for proper management. The presence of a large adnexal mass in the third trimester of pregnancy represents solid grounds for delivery via Caesarean section (C-section) both because of the risk of dystocia and the advantage of one-step approach of cystectomy/oophorectomy at the time of C-section. This is a retrospective study of all the third trimester pregnancy related adnexal masses that delivered in our Hospital in the last 10 years via C-section where cystectomy was also performed. Our aim was to look at the histological type of ovarian mass and to compare our results to those previously published by other authors. We also wanted to see whether the clinical suspicion based on prenatal ultrasound aspect, where this was available, was similar to the postnatal histology report. Secondary outcomes were gestational age at delivery, fetal weight and Apgar score. We found that dermoid cysts are the most common type of adnexal mass with an incidence of 46%, followed by mucous cysts 27%, serous cysts 18% and endometrioses 9%, which is consistent with the data published by other authors in larger series. In terms of prenatal clinical diagnosis, detailed ultrasound assessment of the ovarian mass was available only in less than half of these cases, but in these, the clinical suspicion was confirmed by histology report. In our series, we had no case that required premature delivery because of adnexal mass-related complications and fetal outcome was very good with normal birth weight and high Apgar score. Although this is a small series of cases, it confirms the incidence previously published of the different histological types of ovarian tumors. It also shows that fetal outcomes are very rarely affected by the presence of ovarian masses and premature iatrogenic delivery for maternal well-being is the only note wordy one of them.