2am thoughts

I really should stop giving in to temptation. Especially when it comes to things that I've sworn out of. Last weekend, I told Tibs that was the last gourmet coffee I will ever drink in this lifetime. I ate those words tonight. And now, I'm still awake at 2am.

I remember Mommy's first advice when we got home from the hospital last January 17th. That I should from that day on, get use to sleeping as early at 7/8pm. I should make sure I get my body's 8-hour sleep requirement. I thought that was pretty easy. Who doesn't like sleeping after all?

But then again, I always am ahead of myself. I tend to 'overestimate' my capabilities. Haha. The first thing I forgot then was I had a baby to take care of. So that 7/8 pm bedtime never came.

Today is a wake up call though. I realized that 11 months after Mommy gave that advice, my bedtime is pushing a bit later and later and later....

Starting tomorrow, I will be more cautious of my sleep schedule. That's now #1 on my new year's resolution.

Good night, errrr good morning everyone. Hope you all have a great weekend.

Phyllodes Studies

Found this site from a facebook Phyllodes Support Group.

Found it very informative, albeit bringing sudden sense of panic in me.

But I'm okay now. Nothing that a couple of breath in breat outs couldn't cure:


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Background

The phyllodes tumor, like the fibroadenoma, arises from the intralobular stroma of the breast. Overall, they are rare and all have the potential for metastasis. Thus, these tumors are divided into low-grade and high-grade tumors. The high grade tumors are sometimes referred to as cystosarcoma phyllodes. The vast majority of the tumors, however, are of low-grade behavior. They are variable in size but may grow to be many times larger than most fibroadenomas, sometimes encompassing the entire breast. Grossly, there is lobulation of the tumor as the stroma proliferates resembling a leaf (phyllodes means leaf-like in Greek).

The low grade tumors do have a potential for local recurrence while high grade tumors behave aggressively with increased local recurrence and potential for distant metastasis.

Tumors that do metastasize often do so after a local chest wall recurrence and usually spread to the lungs. Unlike carcinomas of the breast, these tumors spread by blood vessel invasion bypassing the lymph nodes.

OUTLINE

Pathogenesis
Histopathological Features and Variants
Special Stains/
Immunohistochemistry/
Electron Microscopy
Differential Diagnosis
Prognosis
Treatment
Commonly Used Terms
Internet Links

PATHOGENESIS CHARACTERIZATION
CELL CYCLE
Progressive Deregulation of the Cell Cycle With Higher Tumor Grade in the Stroma of Breast Phyllodes Tumors


Arno Kuijper, MD, etal. Am J Clin Pathol 2005;123:690-698 Abstract quote

We studied cell cycle–regulating proteins in phyllodes tumor pathogenesis by immunohistochemical analysis for Ki-67, cyclin A, cyclin D1, retinoblastoma protein (pRb), p53, p16INK4A, bcl-2, and p21waf1 in the epithelium and stroma of 40 primary (benign, 21; borderline, 8; malignant, 11) and 7 recurrent tumors of different grades.
In most cases, the epithelium showed no altered expression of cell cycle regulators.

Stromal overexpression of p16INK4A, p53, cyclin A, pRb, and p21waf1 correlated significantly with tumor grade. The number of altered proteins in stroma increased with higher grade and was accompanied by increased proliferation. Stromal cyclin A expression was the best separating marker between tumor grades. Correlations existed between stromal overexpression of p16INK4A and p21waf1, p16INK4A and p53, and p53 and pRb. No immunostaining differences were detected between primary tumors and recurrences. Four or more altered proteins and p53 expression in the stromal component were independent negative prognosticators for disease-free survival.


The stromal component of mammary phyllodes tumors displays an increasing level of cell cycle deregulation with higher tumor grade; the epithelial compartment mostly remains inconspicuous. Several combinations of aberrantly expressed cell cycle proteins seem important in the stromal progression of phyllodes tumors. The number of stromal cell cycle aberrations and stromal p53 expression might predict clinical behavior.


Tumour angiogenesis and p53 protein expression in mammary phyllodes tumors.

Tse GM, Lui PC, Scolyer RA, Putti TC, Kung FY, Law BK, Lau TS, Lee CS.

Departments of Anatomical and Cellular Pathology, Prince of Wales Hospital, Hong Kong, China. Mod Pathol. 2003 Oct;16(10):1007-13. Abstract quote


We examined 186 phyllodes tumors (106 benign, 51 borderline, 29 malignant) for angiogenesis by assessing stromal microvessel density by the hot spot method and assessing p53 protein expression; we correlated these factors with stromal cellularity, margin status, nuclear pleomorphism, mitosis, and stromal overgrowth.

Increased degree of malignancy in phyllodes tumors is associated with increased patient age and tumor size. Microvessel density and p53 protein expression also showed a similar increase with malignancy. Using a logistic regression model, microvessel density was shown to be useful in predicting malignancy in phyllodes tumors, independent of key criteria of stromal overgrowth, nuclear pleomorphism, and mitosis. Microvessel density showed correlation with stromal cellularity and margin status, suggesting an interrelationship between these parameters. P53 protein expression showed a positive correlation with microvessel density, suggesting possible overlap in the underlying mechanism of these two factors in the pathogenesis of phyllodes tumors. The numbers of recurrences and metastases are small in our series, and no significant difference was demonstrated in microvessel density and p53 protein expression compared with the primary.

We conclude that microvessel density and p53 are useful as independent criteria in evaluating malignancy in phyllodes tumors.


Increased p53 Protein Expression in Malignant Mammary Phyllodes Tumors.

Tse GM, Putti TC, Kung FY, Scolyer RA, Law BK, Lau TS, Lee CS.

Departments of Anatomical and Cellular Pathology (GMKT, FYLK), Surgery (BKBL), Prince of Wales Hospital, and Statistics (T-SL), Chinese University of Hong Kong, Hong Kong.
Mod Pathol 2002 Jul;15(7):734-40 Abstract quote
The authors reviewed 143 cases (87 benign, 37 borderline, and 19 malignant) of mammary phyllodes tumors (PTs) and used immunohistochemistry to detect p53 protein product semi-quantitatively as negative, weak, moderate and strong (scored 0 to 3).

For all PTs, an increasing trend of tumor size and malignancy was detected with increasing age. For p53 staining, 60 cases (42%) were negative, 55 (38%) stained weakly, 28 (13%) stained moderately, and 10 (7%) stained strongly. Of the 87 benign PTs, 41 (47%) were negative, 37 (43%) stained weakly, and 9 (10%) stained moderately. For the 37 borderline PTs, 16 (43%) were negative, 14 (38%) stained weakly, 6 (16%) stained moderately, and 1 (3%) stained strongly. Of the 19 malignant PTs, 3 (16%) were negative, 4 (21%) stained weakly, 3 (16%) stained moderately, and 9 (47%) stained strongly. The mean intensity score for p53 staining increased progressively from benign to borderline to malignant PT, with established statistical significance (P <.0001). This is significantly correlated with mitotic count but not stromal cellularity, pleomorphism, margin, and stromal overgrowth. When considering strong staining alone (score, 3), 47% of malignant, 3% of borderline, and none of the benign PTs were positive.

The use of strong positive staining for diagnosing malignant PT gave positive and negative predictive values, specificity, and sensitivity of 90%, 92.5%, 99%, and 47%, respectively. Thus diffuse strong p53 protein staining can be used as a soft sign in assisting the diagnosis of malignant PT. Conversely, negative or weak staining of p53 protein in PT is of little discriminatory value. The role of p53 gene mutation in the malignant transformation of PT is unclear; but this may not be the sole mechanism as many malignant PT were p53 protein negative.

ESTROGEN RECEPTOR-BETA
Estrogen receptor-beta is expressed in stromal cells of fibroadenoma and phyllodes tumors of the breast.

Sapino A, Bosco M, Cassoni P, Castellano I, Arisio R, Cserni G, Tos AP, Fortunati N, Catalano MG, Bussolati G.

1Department of Biomedical Science and Human Oncology, University of Torino, Torino, Italy.

Mod Pathol. 2006 Apr;19(4):599-606. Abstract quote

An estrogen dependency has been suggested for the growth of fibroadenomas: however, thus far, none of the steroid hormone receptors acting on breast tissues has been demonstrated in the stroma of breast fibroepithelial lesions.

In this study, the expression of estrogen receptor (ER)-alpha and -beta was investigated by immunohistochemistry in 33 fibroadenomas and in 30 benign, three borderline and seven malignant phyllodes tumors, all with spindle cell growth and in one distant metastasis. In addition, the presence of ER-beta mRNA and its variants was evaluated by RT-PCR in microdissected stroma. The possible correlation between hormone receptor expression and differentiation processes of stromal cells was investigated by smooth muscle actin and calponin immunostaining. ER-beta was the only hormone receptor expressed by stroma of fibroadenomas and phyllodes tumors, both at protein and mRNA level.

The highest percentage of ER-beta was observed in fibroadenomas with cellular stroma and in phyllodes tumors. In both lesions, ER-beta-positive stromal cells showed expression of smooth muscle actin and/or calponin, as demonstrated by double immunostaining. In addition, the mean age at diagnosis was significantly lower in patients with ER-beta-positive vs ER-beta-negative fibroadenomas. In contrast, in phyllodes tumors, ER-beta expression was higher in older patients. In conclusion, (i) only ER-beta is detected in the stroma of fibroadenomas and phyllodes tumors; (ii) its expression correlates with the expression of smooth muscle markers and suggests a role of ER-beta in myofibroblastic differentiation of stromal cells.

These two results, together with the young age of patients carrying fibroadenomas with highly ER-beta-positive stroma cells, may further indicate a hormone-receptor mechanism involved in regulating the growth of fibroadenomas. Conversely, the older age of patients with ER-beta-rich phyllodes tumors suggests that mechanisms, probably independent from estrogen stimulation, act on the growth of these tumors.



HISTOLOGICAL TYPES CHARACTERIZATION
GENERAL The histologic hallmark of all phyllodes tumors is stromal hypercellularity and overgrowth.

Low grade tumors are sometimes difficult to distinguish from fibroadenomas, especially if only a small core or limited biopsy is performed.

High grade tumors have considerable cellularity, stromal overgrowth, and atypia of the stromal cells with an increased mitotic rate. These mitotic counts should be performed within the stroma away from the epithelial component. There is no absolute number and mitotic counts alone do not make a diagnosis of malignancy.

In general, however, counts of 10 mitoses per 10 high power fields favor a diagnosis of malignancy. The margins of the tumor are infiltrating rather than pushing and there is often necrosis and hemorrhage. In some cases, the stroma may undergo metaplasia with bone, fat, cartilage, and skeletal muscle identified. If these metaplastic elements are cytologically malignant, a poorer prognosis is portended.

METASTATIC TUMOR

Phyllodes Tumor Metastatic to Thyroid HurthleCell Adenoma.

Giorgadze T, Ward RM, Baloch ZW, LiVolsi VA.

Departments of Pathology, East Tennessee State University, Johnson City (Dr Giorgadze), the Craven Regional Medical Center, New Bern, NC (Dr Ward), and the University of Pennsylvania Medical Center, Philadelphia (Drs Baloch and LiVolsi).
Arch Pathol Lab Med 2002 Oct;126(10):1233-6 Abstract quote
We present a case of a malignant phyllodes tumor metastasizing to a Hurthle cell adenoma of the thyroid. A 55-year-old woman underwent mastectomy for a malignant phyllodes tumor. Two years later, she presented with a left thyroid mass, which was a single, circumscribed, soft, deep red-brown nodular lesion with an eccentric area of firmer consistency.

Histologically, the thyroid tumor was composed of 2 distinct types of cellular proliferation. Atypical spindle cells were infiltrating between the Hurthle cell cords and follicles in a fibrosarcomatous pattern. A battery of immunohistochemical stains was applied to both the thyroid and breast tumors for comparison.

Based on the histologic and immunophenotypic features of the fibrosarcomatous components of both the breast and thyroid tumors, we rendered a diagnosis of cystosarcoma phyllodes metastatic to Hurthle cell adenoma. To the best of our knowledge, this unusual case is a first report of tumor-to-tumor metastasis of a sarcoma to a primary thyroid neoplasm.


PERIDUCTAL STROMAL TUMOR

Periductal stromal tumor: a rare lesion with low-grade sarcomatous behavior.

Burga AM, Tavassoli FA.
Am J Surg Pathol 2003 Mar;27(3):343-8 Abstract quote
Biphasic breast tumors with benign ductal elements and a sarcomatous stroma lacking a phyllodes architecture are a source of diagnostic problems, particularly because of the lack of an appropriate designation. At the Armed Forces Institute of Pathology, we have used the term "periductal stromal sarcoma" to distinguish these from phyllodes tumors. All cases coded as periductal stromal sarcoma or PDSH were retrieved from the files of the Armed Forces Institute of Pathology. Cases that fulfilled the following criteria were included in this study.

The histologic features of periductal stromal sarcoma were defined as 1) a predominantly spindle cell stromal proliferation of variable cellularity and atypia around open tubules and ducts devoid of a phyllodes pattern, 2) one or more often multiple nodules separated by adipose tissue, 3) stromal mitotic activity of >/=3/10 high power fields, and 4) stromal infiltration into surrounding breast tissue.

Criteria for periductal stromal hyperplasia included 1) nodular, bland stroma growing as cuffs around normal or altered ducts, 2) no to minimal atypia, and 3) at most 0-2 stromal mitotic figures per 10 high power fields. Immunohistochemistry was used to further characterize these neoplasms. Of the cases retrieved, 20 qualified as periductal stromal sarcoma and seven as periductal stromal hyperplasia. Patients with periductal stromal sarcoma ranged in age from 37 to 89 years (mean 55.3 years). The tumors measured 0.2-6.0 cm (mean 2.97 cm). Eighteen patients had excisional biopsies and two had partial mastectomies. Overall follow-up time ranged from 1 to 72 months (mean 25.3 months) with two patients (10%) showing recurrence or probable metastasis. The neoplastic cells of periductal stromal sarcoma were at least focally immunoreactive for CD34 (13 of 15), CD117 (6 of 15), less reactive for actin (HHF35, 2 of 15), and negative for estrogen and progesterone receptors. Periductal stromal sarcoma is a useful descriptive designation for generally low-grade biphasic tumors with sarcomatous stroma that do not have features of a phyllodes tumor.

The development of focal phyllodes pattern in the recurrent tumor as well as development of a specific soft tissue sarcoma in one of the above cases suggest that some and possibly all periductal stromal sarcoma may evolve into a phyllodes tumor with time. Given the presence of infiltrative margins, excision with a rim of uninvolved tissue is required.




IMMUNOPEROXIDASE AND SPECIAL STAINS CHARACTERIZATION
CD117
p53 and c-kit (CD117) protein expression as prognostic indicators in breast phyllodes tumors: a tissue microarray study.

Tan PH, Jayabaskar T, Yip G, Tan Y, Hilmy M, Selvarajan S, Bay BH.

1Department of Pathology, Singapore General Hospital, Singapore.
Mod Pathol. 2005 Dec;18(12):1527-34. Abstract quote

Breast phyllodes tumors are fibroepithelial neoplasms whose clinical behavior is difficult to predict on histology. There is relatively scant data on the role of biological markers.

In this study, we determined if p53 and CD117 (c-kit) protein expression was predictive of behavior in a series of 335 phyllodes tumors diagnosed at the Singapore General Hospital, using immunohistochemistry on tissue microarrays. Representative areas from 250 (75%) benign, 54 (16%) borderline and 31 (9%) malignant phyllodes tumors were selected for construction of tissue microarrays using the 2 mm punch.

Immunohistochemistry for p53 and CD117 was carried out using the streptavidin-biotin method. Staining proportion and intensity of both epithelial and stromal elements were analyzed. p53 immunostaining was observed in the epithelium of 28 (10%) of 278 microarrays; myoepithelium of 53 (21%) of 251 microarrays; and stromal cells in 105 (36%) of 289 microarrays. CD117 immunohistochemical reactivity was noted in epithelial and stromal components of 175 (of 267, 66%) and 17 (of 273, 6%) microarrays, respectively. Stromal p53 and CD117 protein expression was associated with tumor grade (P<0.05). Of 43 (13%) women who suffered recurrences during the follow-up period, CD117 stromal staining predicted recurrent disease (P<0.05), but p53 was not correlative.

We conclude that tissue microarrays are a convenient method for evaluating immunostaining results of large numbers of phyllodes tumors. Although positive p53 stromal immunohistochemical detection may corroborate histologic malignancy, it is CD117 protein expression in phyllodes tumor stromal cells that may be of potential utility in predicting recurrent disease.
Increased c-kit (CD117) expression in malignant mammary phyllodes tumors.

Tse GM, Putti TC, Lui PC, Lo AW, Scolyer RA, Law BK, Karim R, Lee CS.

Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong. Mod Pathol. 2004 Jul;17(7):827-31. Abstract quote

Mammary phyllodes tumors are uncommon stromal neoplasms, and are divided into benign, borderline and malignant groups basing on histologic criteria. While benign phyllodes tumors may recur, borderline phyllodes tumors show higher propensity to recur locally and rarely metastasize, and malignant phyllodes tumors show even higher chances of local recurrences or distant metastases. c-kit is a proto-oncogene that encodes a tyrosine kinase receptor (CD117) and is a marker for gastrointestinal stromal tumors (GIST).

With the advent of therapeutic agent targeted at this receptor for GIST, we investigated 179 phyllodes tumors (101 benign, 50 borderline, 28 malignant) for c-kit expression using immunohistochemistry. The staining was compared to the degree of malignancy, and to the degree of stromal cellularity, mitotic activity, nuclear pleomorphism and stromal overgrowth. The overall positive rate for c-kit was 29% (52/179) and 17% (17/101), 24% (12/50) and 46% (13/28), respectively, for benign, borderline malignant and frank malignant phyllodes and the differences between all categories were significant (chi2=13.844, P=0.001).

In mammary phyllodes tumors, there was increasing c-kit expression with increasing degree of malignancy, up to 46% in malignant cases. This provides strong evidence that c-kit receptor mediated tyrosine kinase involvement in the pathogenesis of phyllodes tumors, and the therapeutic agent, STI571, Glivec, may be a potentially useful drug for its management.



DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES
FIBROADENOMA
Fibroepithelial Lesions With Cellular Stroma on Breast Core Needle Biopsy
Are There Predictors of Outcome on Surgical Excision?


Timothy W. Jacobs, MD, etal. Am J Clin Pathol 2005;124:342-354 Abstract quote


Fibroepithelial lesions with cellular stroma (FELCS) in breast core needle biopsy (CNB) specimens may result in either fibroadenoma or phyllodes tumor at excision.

We evaluated histologic features, proliferation indices (by Ki-67 and topoisomerase II a immunostaining) and p53 expression in 29 cases of FELCS in CNB specimens and correlated these with excision findings in a blinded manner. On excision, 16 patients had fibroadenomas and 12 had phyllodes tumors. All CNB specimens with mildly increased stromal cellularity were fibroadenomas on excision (n = 4), and all with markedly cellular stroma were phyllodes tumors (n = 4). Among CNB specimens with moderate cellularity (12 fibroadenomas and 8 phyllodes tumors), only stromal mitoses were discriminatory histologically. Stromal proliferation indices were significantly higher in CNB that were phyllodes tumors vs fibroadenomas.

Assessment of stromal cellularity, mitoses, and proliferation indices might help determine the probability of phyllodes tumor occurring and guide management of these cases.

Aggressive giant fibroepithelial lesion with unusual vascular stroma--a case report.

Hanna W, AL-Maghrabi J, Malik A.

Department of Anatomical Pathology, Sunnybrook and Women's College Health Science Center, University of Toronto, Ontario, Canada.
Mod Pathol. 2003 Aug;16(8):823-7. Abstract quote
The stroma of fibroadenoma and phyllodes tumor usually consists of fibroblastic proliferation. Rarely the stroma contains bundles of smooth muscle. Pseudoangiomatous hyperplasia of the mammary stroma has been described in fibroadenomas. However, true benign vascular stroma has not been reported.

We report a case of a 34-year-old Chinese woman who presented with a large mass occupying the entire left breast. Left mastectomy was performed and showed a large, well-circumscribed, lobulated, rubbery-firm tumor measuring 13 x 10 x 6 cm. Microscopic examination revealed a fibroepithelial tumor formed by an organoid pattern of ductal structures with a very striking stromal appearance composed of extensive vascular proliferation and that demonstrated strong immunoreactivity for CD31, CD34, and Factor VIII. Ultrastructural examination revealed intercellular junctions, basal lamina, pinocytotic vesicles, and Weibel-Palade bodies in the cells lining the vascular spaces, confirming their endothelial nature.

These findings rule out the diagnosis of pseudoangiomatous hyperplasia. The patient developed local recurrence a year later, and the resection showed malignant phyllodes tumor with ductal carcinoma in situ.The extensive vascular stroma noted in the primary tumor may have played a role in the malignant transformation of the epithelial and stromal components in this tumor.

Distinction of phyllodes tumor from fibroadenoma: a reappraisal of an old problem.

Krishnamurthy S, Ashfaq R, Shin HJ, Sneige N.

Department of Pathology, University of Texas, MD Anderson Cancer Center, Houston 77030, USA.
Cancer 2000 Dec 25;90(6):342-9 Abstract quote

BACKGROUND: Using fine-needle aspiration (FNA) smears, it is difficult to distinguish low grade phyllodes tumor (PT) from fibroadenoma (FA) due to overlapping cytologic features between the two lesions. The authors retrospectively studied 45 histologically proven fibroepithelial breast tumors of which 33 were FA and 12 were PT (1 malignant, 8 borderline, and 3 benign) to define cytologic features that can help in the accurate categorization of these lesions by using FNA samples.

METHODS: The cytologic features analyzed included: 1) epithelial component for number (<5 or >5), architecture, apocrine metaplasia, squamous metaplasia, nuclear pleomorphism, and mitosis; 2) stromal fragments for number (<5 or >5), cellularity (on a scale of 1+ to 3+), borders, cell characteristics, nuclear pleomorphism, and mitosis; 3) individual dispersed stromal cells in the background for cellularity (on a scale of 1+ to 3+), and cellular shape (short/round/oval or long spindle) based on whether they were smaller or larger than 2 times the size of a small round lymphocyte.

RESULTS: The mean age of patients with FA was 34 years and of those with PT 44 years. The average size of FA was 2.0 cm, and the average size of PT was 4.0 cm. The characteristics of the epithelial fragments of PT and FA were not significantly different. Stromal fragments were noted in 60% of FA and 83% of PT samples examined. Fifty-six percent of PT and 30% of FA exhibited hypercellular stromal fragments (3+ cellularity), and the difference was not statistically significant. Large club-shaped hypercellular stromal fragments were present only in FA (in 21% of the samples). There was no difference in the overall cellularity of the background stromal nuclei in the two types of lesions. Long spindle nuclei averaging greater than 30% of the dispersed stromal cell population in the background were found only in cases of PT (in 57% of the samples; P < 0.001). Short/round/oval nuclei characterized most FAs. Long spindle nuclei constituting 10-30% of the dispersed stromal cells, however, occurred in both PT and FA to the extent of 43% and 21%, respectively.

CONCLUSIONS: Hypercellular stromal fragments occur not only in PT, but also in FA, and hence they cannot be used as the sole criterion for making a diagnosis of PT on FNA. The proportion of individual long spindle nuclei (>30%) amid the dispersed stromal cells in the background is the most reliable discriminator between the two lesions. Lesions in which long spindle nuclei constitute between 10% and 30% may represent either PT or FA, and therefore such lesions should be categorized as indeterminate on FNA.




PROGNOSIS AND TREATMENT CHARACTERIZATION
PROGNOSTIC FACTORS
GENERAL
Phyllodes Tumors of the Breast
The Role of Pathologic Parameters


Puay-Hoon Tan, MD, etal. Am J Clin Pathol 2005;123:529-540 Abstract quote


We aimed to establish whether morphologic parameters were prognostically important in a large series of breast phyllodes tumors in Asian women. Of 335 phyllodes tumors diagnosed at the Department of Pathology, Singapore General Hospital, Singapore, between January 1992 and December 2002, 250 (74.6%) were benign, 54 (16.1%) borderline, and 31 (9.3%) malignant, based on histologic review of archival slides.

Of the women, 43 (12.8%) experienced recurrences during the follow-up period. Recurrent disease was correlated with grade or classification (P = .028), stromal atypia (P = .016), stromal hypercellularity (P = .046), and permeative microscopic borders (P = .021). Multivariate analysis revealed that independent predictors of recurrence were pseudoangiomatous stromal hyperplasia (PASH) and margin status, whereby the presence of PASH and complete or negative margins reduced recurrence hazards by 51.3% and 51.7%, respectively.

The 7 women who died of disease during follow-up had malignant phyllodes tumor at the outset and experienced recurrences, and death was preceded by distant metastases.
Pathologic, Immunohistochemical, and Molecular Features of Benign and Malignant Phyllodes Tumors of the Breast

Celina G. Kleer, etal.
Mod Pathol 2001;14:185-190 Abstract quote

The histologic distinction between benign and malignant Phyllodes tumors (PT) is often difficult and arbitrary.

We analyzed a group of benign and malignant PT to determine whether specific histologic features and expression of Ki-67 and p53 could be useful in distinguishing benign PT from malignant tumors. We also determined whether deletions in Chromosome 3p at the FHIT and hMLH1 loci are common abnormalities in PT. Twenty PT were histologically classified as benign (7) or malignant (13). Seven of the malignant PT were low grade, and six were high grade. Ki-67 and p53 immunohistochemistry was performed on all tumors and analyzed for the stromal and for the epithelial component. PCR-based loss of heterozygosity analyses were performed with the following markers on Chromosome 3p: D3S1478 (3p21.2–21.3), D3S1289 (3p21.1–21.2), and D3S1295 (3p14.3–21.1). The distribution of immunoreactivity for Ki-67 was analyzed by quantifying the percentage of positive nuclei and expressed as the labeling index (LI).

Patients’ ages ranged from 13 to 71 years (median: 51 y). After a mean follow-up period of 8 years, none of the PT metastasized, whereas three recurred locally. Although malignant PT were larger than benign PT (means, 7.1 versus 4.3 cm), this difference was not statistically significant. Five tumors had infiltrating margins, and 14 were circumscribed.

The Ki-67 LI in low-grade malignant PT (16 ± 25.5) was significantly higher than that in benign PT (3.6 ± 4.8), whereas the LI in the high-grade malignant PT group (50 ± 21.9) was significantly higher than that in low-grade malignant tumors (P = .012). The Ki-67 LI in the three tumors that recurred was less than 10%. Two of seven (29%) benign PT were focally positive for p53, whereas four of seven (57%) low-grade malignant and three of six (50%) high-grade malignant PT were diffusely positive for p53. The three tumors that recurred initially were histologically benign, as were two of the recurrences. One recurrent tumor evolved to a high-grade malignant PT. Margins were greater than 1 cm in all tumors except four, three of which recurred locally. No allelic loss of 3p was found.

In summary, Ki-67 expression may assist in distinguishing benign from malignant PT in diagnostically difficult cases. 3p deletions do not play a significant role in the development of these tumors. Neither Ki-67 nor p53 can reliably predict recurrence. Histologically high-grade malignant PT have a favorable prognosis if widely excised. We emphasize the importance of adequate margins in the treatment of benign and malignant PT.


Hormonal receptors expression in epithelial cells of mammary phyllodes tumors correlates with pathologic grade of the tumor: a multicenter study of 143 cases.

Tse GM, Lee CS, Kung FY, Scolyer RA, Law BK, Lau TS, Putti TC.

Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, NT, Hong Kong, People's Republic of China.


Am J Clin Pathol 2002 Oct;118(4):522-6 Abstract quote
We used immunohistochemical analysis to detect the presence of estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (AR) protein expression in the epithelial and stromal cells of 143 phyllodes tumors (PTs).

Expression of epithelial ER and PR proteins was common, occurring in 43% to 84% of PTs. Expression of epithelial AR protein and stromal ER, PR, and AR proteins was low (5% or less) in all tumors. An inverse relationship of epithelial ER and PR protein expression with degree of malignancy in PT was found (P < .05), and ER expression also correlated with mitotic count (P < .05).

When considering PT with the expression of ER or PR proteins and the coexpression of both, the inverse relationship with tumor grade also was significant (P < .05). As the hormonal receptor protein expression shows a consistent decrease with increasing malignancy, we infer that the epithelium has a crucial role in the pathogenesis or progression of PT.

MIB-1

p53 and Ki-67 expression as prognostic factors in cystosarcoma phyllodes.

Erhan Y, Zekioglu O, Ersoy O, Tugan D, Aydede H, Sakarya A, Kapkac M, Ozdemir N, Ozbal O, Erhan Y.

General Surgery Department, Celal Bayar University, School of Medicine, Guzelyali-Izmir, Turkey.
Breast J 2002 Jan-Feb;8(1):38-44 Abstract quote
We have reviewed the histopathological, clinical outcome and immunohistochemical status in 21 women with cystosarcoma phyllodes (CSP) tumors of the breast.

We assessed 12 tumors as histopathologically benign and 9 tumors as malignant. The median patient ages in benign and malignant CSP tumors were 39.6 and 45.4 years of age, respectively. The stromal cellularity, stromal cellular atypism, high mitotic activity, atypic mitoses, stromal overgrowth, infiltrative tumor contour, and heterologous stromal elements were significant features of the malignant CSP tumors. Benign CSP tumors were predominantly of fibroadenomatous architecture with cellular stroma (mild or moderate) and some distortion and elongation of glandular elements. Five malignant CSP tumors were stained positively with p53, and 6 malignant CSP tumors were stained immunohistochemically with Ki-67. All benign CSP tumors were negatively stained for p53 and Ki-67. The patients with benign CSP tumors were treated with local excision ( n=11) and with subcutaneous mastectomy ( n=1). Malignant CSP tumors were treated with wide local excision ( n=1), partial mastectomy ( n=1), simple mastectomy ( n=2), and modified radical mastectomy ( n=5). Two patients with a high mitotic rate and high values of p53 and Ki-67 received additional radiotherapy and chemotherapy. One case had liver metastasis. This tumor had high mitotic figures, stromal overgrowth, severe stromal cellularity, and 20% Ki-67 and mild p53 positivity.

We suggest that p53 and Ki-67 can play an important role in predicting prognosis and yielding additional therapy besides conventional prognostic factors in the treatment of the CSP patients.


Immunohistochemical profile of cystosarcoma phyllodes of the breast: a study of 23 cases.

Dacic S, Kounelis S, Kouri E, Jones MW.

Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania
Breast J 2002 Nov-Dec;8(6):376-81 Abstract quote
Cystosarcoma phyllodes (CP) of the breast is a rare biphasic tumor composed of benign epithelium and a spindle cell stroma. Biologic behavior of CP cannot be predicted with certainty on the basis of morphologic criteria only.

We studied immunohistochemical expression of basic fibroblastic growth factor (bFGF), urokinase, Ki67, p53 protein, and microvessel density in stromal and epithelial components of 14 low-grade CP (LCP) and 9 high-grade CP (HCP). bFGF was more often positive in LCP than in HCP. The stroma was positive for bFGF in 86% of LCP and 67% of HCP, and the epithelium was positive in 64% of LCP and 14% of HCP. Urokinase was positive in stromal cells of 86% of LCP and 93% of HCP. The epithelial positivity for urokinase in both groups resembled closely that of the stroma. p53 protein was more often positive in stromal cells of HCP (67%) than in LCP (50%). Ki67 was positive in the stroma of 43% of LCP and 89% of HCP and in the epithelium of 14% of LCP and 33% of HCP. There was no significant difference in microvessel density (MVD) in low- and high-grade lesions.

Our study demonstrates that stromal Ki67 and p53 immunohistochemical positivity are more often associated with high-grade tumors. The positive immunostaining for bFGF, urokinase, Ki67, and p53 in stroma and epithelium of the majority of CP supports the existence of epithelial-stromal interactions and recognizes epithelium as an integral part of this tumor.

VASCULAR ENDOTHELIAL GROWTH FACTOR

Stromal expression of vascular endothelial growth factor correlates with tumor grade and microvessel density in mammary phyllodes tumors: a multicenter study of 185 cases.

Tse GM, Lui PC, Lee CS, Kung FY, Scolyer RA, Law BK, Lau TS, Karim R, Putti TC.

Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, Shatin, Hong Kong.

Hum Pathol. 2004 Sep;35(9):1053-7. Abstract quote

A retrospective review of 185 mammary phyllodes tumors (105 benign, 51 borderline, 29 malignant) from 4 centers was performed by immunohistochemistry to investigate the expression of vascular endothelial growth factor in the epithelial and stromal cells of mammary phyllodes tumors.

The correlation of vascular endothelial growth factor with tumor grade, stromal cell nuclear pleomorphism, cellularity, mitotic rate, margin histomorphology, and the stromal microvessel density was evaluated.

Vascular endothelial growth factor expression was found in the epithelium in 29% and in the stromal cells in 31% of cases. There was significant increase of vascular endothelial growth factor expression in the stromal cells with increasing degree of malignancy, but not the epithelium. Microvessel density in the stroma also showed significant correlation with tumor malignancy, and a correlation was shown with the stromal vascular endothelial growth factor expression. Statistical overlap of stromal vascular endothelial growth factor and microvessel density in predicting malignancy suggests that angiogenesis may be an effector mechanism for vascular endothelial growth factor.

Assessment of stromal VEGF may be useful as an adjunctive diagnostic criterion in the histologic assessment of malignancy in phyllodes tumors.

TREATMENT Excision

Inspiring video

This brought tears to my eyes. Partially I guess because I so very much envy these group of people. I wish I'd someday get to personally meet somebody like me too, here in the Philippines. What great comfort would that bring...I mean, having to talk to and swap stories with somebody who's going through the same experience as I am.

But I'm glad its been a good, pleasant 9 months for me. I do hope it always stays that way.

October is Breast Cancer Awareness Month

I was going to join my first Walk as One event this weekend but it seems like I will have to pass on this again. The weather just won't let me.

October was supposed to be something to look forward to. This month I celebrate my 2nd year as a wife and my 1st year as a mother. Both of which I consider as the most wonderful milestones of my lifetime.

I am still hopeful that Pinoys will rise tall and proud amidst the tragedy that hit the country in this past week. It just breaks my heart to see people suffer and I could not do anything to directly help ease the pain of their suffering. I feel useless in times like these.

I hope though in the coming weeks when Maia becomes a lot more independent, I'd still get to help. I mean directly help. Maybe help build a home and help clean up. Just something more hands on apart from sending money and relief goods to the victims.

As the breast cancer awareness month kicks off today, I am making a BIG note on my diary to keep on convincing people to have themselves checked whenever they feel something weird on their bodies. In the coming years, I'd like to be more active with this cause. Right now, I still have no concrete plans towards achieving this goal but I hope to have a clearer vision in the coming months.

PT Update

I am going back to my doctor today for my 6-month routine mammosonogram and 3-month routine check up. A lot has happened since my last visit and I have so many questions in mind, I had to write them so I won't forget.

I guess once cancer hits you, the sleepless nights are always going to be there. Going on my 7th month now, I still can't claim I'm cancer-free. Not till I hit my 2nd year mark. There are days when paranoia gets the best of me. I'd stare at Maia and wonder how she'd grow up. I hope she will be fine and will only have happy thoughts of Mommy.

There are days though that I can't help but be surprised of myself too.

Like this morning for instance, I posted an update in Facebook. And in no time, I had people asking how I was doing. I was chatting with a former officemate when I typed this line - "it's a blessing that God sent me the cancer after I had Maia. She gave me so much reason to fight for and keep fighting".

I used to think that Maia was so unlucky to have a Mommy like me. But now, the tone has changed with out me realizing it. Now, I feel so lucky having Maia around.

Breast Cancer Breakthrough

Something that I lifted from rare-cancer.org news. Good news?

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The Cure: Breast Cancer Vaccine On The Way?

by Cynthia Demos

Breast cancer caught early can mean the difference between life and death. Now, a breast cancer vaccine may be on the horizon. It's already showing promise in clinical trials.

Dr. Geoffrey Zann, a gynecologist, routinely suggests patients look for the traditional symptoms to detect breast cancer. "You look for things such as a palpable mass, or changes in the skin, dimpling, puckering, buckling, a lump that sticks out, sometimes tenderness," explained Dr. Zann.

But frequently, his patients ask him why a vaccine to prevent breast cancer hasn't been developed, like it was for polio or measles.

"Breast cancer is not one disease, when you hear people tell you, there are different kinds of breast cancer. I had intraductal, I had lobular, I had lobar, I had phyllodes tumor. It's not just one disease so it's hard to develop one vaccine," Dr. Zann explained.

But there is progress being made in the development of vaccines. Susan Kristoff was diagnosed in 2003 with Stage I HER2 positive breast cancer. "In 2003, HER2 was one of the worst diagnoses you could get. It's a very aggressive type of cancer," said Kristoff.

After her initial treatment Susan's cancer returned as Stage IV cancer, sometimes referred to as incurable cancer. She decided to participate in a clinical trial with a new breast cancer treatment Herceptin and her cancer went into complete remission.

"I guess the story is that Stage IV isn't a death sentence for a cancer patient, that many people can live a normal life and manage it like diabetes, and wait on the cure. I'm confident that for many types it will be here shortly," Kristoff said.

De Quervain??? De What?

Today, I was back at my surgeon's clinic because I could not sleep well for the past 2 days since I discovered a tiny bump on my right arm. It was just a little under my elbows. A tiny little lumpy growth that the hubby initially thought was an insect bite. Only that it's been 2 days and it never itched. So today, I decided to skip work and set an early appointment with my surgeon. I was due for my regular check up in 2 weeks anyways.

First thing she asked when she saw me was, "you're back early, may nakapa ka????" Hahaha. I pointed worriedly at the bump on my arm. To which she immediately replied, "oh that...is nothing. If you're thinking it's related to the PT (phyllodes tumor) it's not." (She actually mentioned the term for the tiny cyst...but the term now evades my memory...tsk tsk...old age?)

I asked if I need to have it removed. She told me I can, if that would help me sleep well. But it's still too small. It's not really a cause for worry. I asked her what could have caused it to grow, and she told me they don't know. She added, "sinuwerte ka lang". Then we started laughing, it seems I've been really lucky with the lottery on lumps lately. Too bad really...this is one lottery I never and will never ever dream of joining on.

So since I was there already, she decided to check on how my mastectomy recovery is going. Okay. All's well. I'll come back on September na lang. That's my next sonogram schedule. We're hoping the 4 tiny nodes on my other breast will disappear already. Hay...life. It just keeps throwing me stuff that aren't worth catching. Haha. But I keep on catching them anyway. Ano ba Faye!

So when I was about to leave, I also mentioned I was having this problem with my wrist. Told her my OB (Again???) thought it was probably still related to my mastectomy. I was prescribed some nerve vitamins to make the pain go away. But it's been two weeks and the pain still lingers. She told me, "oh that's not related to the mastectomy. I'm guessing it's decorvein..."

What's that doc??? De-cor?-vein???

No, De-qua-r-vein...

Oh...is that so? What do I need to do then?

Go see an orthopedic surgeon after this. Get it fixed while it's still early. Pag pinatagal mo pa yan, you might need another surgery for that. Hu-whatttt??? Sige, I'll find an ortho pronto! Hahaha.

So after I left my surgeon's clinic...I went looking for an ortho right away. Good thing, there's somebody available to see me. It turns out, I still got the spelling wrong. What I have is called

de Quervain's Tenosynovitis.

The ortho asked me how long have I been experiencing the pain. I told him it's been a month already. He said it's still early and it's still easy to treat. But it's been a month, he might as well inject some medicine into it. He asked me to buy the supplies at the nearly drugstore and when I came back he injected me with cortisone to treat the swelling. It was painful. Haha. But tolerable.

So now, while I type away...I'm trying hard to concentrate on not getting my left thumb worked up. I've been using them too much and now they're complaining.

Lesson learned today. Use the mouse more often. Hehe.

Weathering Storms

When one is forced to face storms? Is there an effective way of weathering it through?

In the past 30 years, I have had my share of stormy times already. But I guess, the worst storm that I've ever been through was my stormy battle with cancer. I used to dread saying it. But now, I learned to live with it. It doesn't scare me anymore. I know there's still so much hope out there for me.

What gave me the change of heart?

After my surgery I was scheduled for 6 consecutive weekly visits to my surgeon for follow up check. I went home with my Jackson Pratt drain after all and the surgeon has to monitor that. It was on the 2nd week that I was told my pathology results revealed that my breast tumor was malignant.

Anyways, it was on my last visit that I met this fellow patient named Helen. She had this wonderful aura around her and she was so cheery it felt contagious. Soon I was joining her chat with our surgeon's receptionist.

It wasn't long after when she sad down beside me and asked me what my story is. And I obliged. I just felt an instant connection I had no qualms sharing a personal story with her. She patiently listened. And when I was finished, she immediately share her own cancer story. That's when I learned that she was recenlty diagnosed with breast cancer and have just had bilateral radical mastectomies. When I chanced upon her on the clinic that day, she has gotten through 6 sessions of chemotherapy. She was back at the clinic that day to pick up her bone scan results. She happily shared the results were good. And that she won't be coming back to the clinic anymore for the next 6 months. Such a relief she says. But she adds, there are still days when she wakes up and remembers the hell that she's recently been through and can't help but cry for a bit. But she says she's just glad to put that all behind. Because life is still good after all. And we still have a role to play in the world of the living.

Isn't that so inspiring to hear? This was after all coming from a 39-year old single lady who still had so much coming for her. I may be only 30 but God was good enough to give me Maia before tragedy struck. I felt I have every reason to stay happy and positive. But her...well...she found her purpose by sharing inspiring stories to cancer patients like her. By giving them a boost of positive energy to weather their battle.

Thinking of people like Helen...makes me appreciate life everyday.

Coping and Surviving

I was back at my doctor's clinic yesterday for a routine check up and to submit my mammogram and sonogram results. Although 4 more nodules were detected on my left breast, my doctor agreed with the radiologist that they were not a cause for alarm and that I should not let them worry me.

Earlier while I was still waiting for Dra. Cruz to come back from a series of surgeries, I was lucky to meet another cancer survivor and unlike the last encounter I had Helen was the one who showed interest to hear my cancer experience. She showed real concern knowing I'm only 30 and just had a baby. But at the same time, I felt a sudden jolt of inspiration seeing how positive she is. She did not look like she just recently went through 6 sessions of chemotherapy. She just so full of life that I realized I am going to win this battle.

It's been two months since my surgery and I am starting to feel like things are back to normal. The hubby and I are now able to put all the worries behind and genuinely enjoy our moments with Maia.Sometimes, on really good days, I tend to forget the challenges that we went through at the beginning of the year. We're starting to laugh a lot more often - laughter that has more depth.

I can only hope that this situation at home remains like that forever. But of course I will have to be realistic. Thoughts of recurrence and mets will probably linger. One thing I've proven from all these is that with family support, it is easier to face a cancer diagnosis. With that I am very, very grateful.

Revisiting Forgotten Memories

I was re-reading my journal this morning and found this entry. I wrote this last year when we still did not have internet connection at home. I kept a journal then - I needed some place to store my thoughts in. And some place to practice my writing each time the inspiration hits me. Anyways, before I digress any further here's a snippet of that journal entry I made on July 17th last year. I was about 24 weeks pregnant then. And the Hubby and I had that weekend ritual of starting our day with a round of music from the past. That day, sort of blasted me off to my last few years in college. I immediately got my journal and started writing.

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While enjoying breakfast today, the Hubby played an old CD that brought torrential flashes of memories back. Memories of time spent in UP. Those were pretty good ones. I hope someday my daughter will have something as good as those to go back to from time to time.

I recall Friday nights spent at our apartment with the girls. We'd sit at our bare living room and giddily await Dawson's Creek on TV. Yes. You read it right. We were crazy over Pacey and Joey back then. But I guess looking back now, it was not the memory of the TV show that brings a smile to my face but the memories of quality time spent with great friends.

These girls were witnesses to a lot of things going on then. Going home past curfew time, they would stay up and help me get in. Coming home from 48-hour vigils over numerous case studies and feeling really depressed and really exhausted, somebody's always there to listen to my ranting or just keep me company.

Now, we all live all over the world but I guess that foundation that we had before kept us really bonded that even till now we always try to reach out and remain updated with each other's lives. But today, I just miss the company of the girls. I wish everybody's just a call away.

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Fast forward to year 2009, there's still the three of us who made Luzon as our homebase but since all of us are now living busy lives, a get together is extremely difficult to organize. But then one of our housemates came home from the US, we eventually ran of excuses and finally found time to meet up for lunch. I almost forgot how much fun I shared with these girls. Fact is, it was mostly them who kept me sane. Thanks girls for making me feel young and vibrant again! haha...I wish we can do this again. I can barely recall the last time I laughed this hard.

Celebrating the 4th on February

Maia turned four months on the 18th. And it was 4 weeks since my operation on valentine's day itself. There is so much to thank for in this past few weeks.

One of them are the Maia's little milestones that we get to witness when we're at home. It's sheer happiness for the hubby and me! :)To date, she so graceful at this already. i can't wait for the time when she calls 'Mommy' for the first time. I do hope I'm home to hear that!

A weekend family affair

We went up to Tagaytay this weekend. I tried to recall when was the last time that we were here and realized that it was during our wedding. That was over a year ago. We haven't been back since then. We promised ourselves we will be back there for our first wedding anniversary since the hubby and I used to love going here but my delicate pregnancy did not allow us to do that.

A lot has changed since then. I counted and there were almost about 10 hotels along the highway that sprouted since our last visit. That alone made me feel like we missed so much. But that was only for a while. I secretly said a prayer of thanks after that. I told myself I should be thinking of how lucky we were to finally get the opportunity to go up there again...this time with our little angel Maia.

The purpose of our trip was to actually to pay the Pink Sisters a visit. I've made several trips there in the past years to ask for prayers for my friends. All of my requests then were granted. Now, I am up there again...this time to ask for personal favors. Unlike my previous visits, we were lucky to see the sisters this time. That made me very hopeful. My prayer request will be heard.

After spending about an hour at the chapel...we headed to the Mahogany market to buy fresh fruits and vegetables. My sister and I enjoyed going through stalls and stalls of fresh goodies. When we were done with the marketing, we decided to grab some snacks before heading home. Since I officially scratched out red meat in our diet, my Tinang (short for Tita Ninang) suggested we eat at the Mushroomburger joint. Food was cheap but very filling.

I am glad we had this opportunity today. I do hope we'll have more trips with Maia in the coming years.

Hope and Prayers

Hope and Prayers. These and the love of family and friends kept me going everyday.

Yesterday, I was again filled with anxiety as I opened the folder that contained the results of my CT Scans. My hands were trembling but I'd rather see it then and there than wait for my doctor to announce the bad news if there is. I scanned the document for a few seconds and decided to sit down so I can clearly grasp every word that's written on this precious document. First few paragraphs had a lot of medical jargon written on them but I understood what they said.

My heart leaped after I saw the words clear and unremarkable. My lungs and liver are clear! Woooo-hoooo!!!! I wanted to ran back home and hug Maia. But then, I immediately gathered my composure since it's never going to be final unless my doctor says it. It has to come from her.

When I reached the clinic, I cannot hide the smile on my face. She asked me if I've seen the results. I said yes. "So how was it?" I said my understanding is that I'm clear. "Ok. Let's take a look" So one by one she took out the films. By the time she's done with the last film, she also had a grin on her face. I was soooo happy. Then she just said..."that's it. So far we're okay. You can relax now. Basta just to don't be lazy to see me regularly ha? Don't be like the others, they disappear after sometime." I just nodded my head. Of course I will be there. I will not miss any of my appointments. I will remain a very good and obedient patient (hehe).

Getting the scans done was not easy for me. It was one of the most painful procedures I've gone through besides the surgery (but then I was asleep so this is still the winner) in this lifetime. The scanning procedure itself was just easy breezy. What was painful was I had to be injected with 50cc of IV contrast (iodine solution one of the nurses said) so the technicians can get a clearer picture of my organs. My veins were however too tiny and too narrow to handle the instant injection that for a minute, I felt like my arm was going to explode. I was not allowed to move so I can only cry out in pain. After that my body felt like hot water was being poured over it. In a few seconds it was replaced but a cold sensation. All these I guess was so stressful for my body that I was not able to stop myself from throwing up. I'm a nightmare for nurses. Haha. But all that felt like nothing now...the sacrifice was worth it... the scans are clear that's all that matters.

Again, thank you to YOU who never forgets to include me in your everyday prayers. Thank you to YOU who never failed to cheer me up when I am on the verge of giving up. You are right. God is Good.

I know I'm still not safe from this monster. Cancer is still cancer. But I will continue to fight. I will continue to stay positive that eventually, somebody will come up with a cure for this disease that I have. For now, I have the optimistic attitude, the lifestyle change (go organic! gulay na lang!), the diligence for my monthly check ups and all your prayers as my weapons. I believe these should be enough get me through this storm.

Shaking off the anxiety

Dear Lord,

I am again scheduled to visit my doctor today. I pray that you give me enough strength to face and accept whatever news she has for me. I was telling my sister early today that we've had so many surprises already this month and I am hoping that it stops here. I know this is just to much to take already and my family is only trying so much to hold their individual selves together for me.

I would like to thank you for blessing me with so people who cares and loves me. Despite of the distance, friends are there to cry with me when I need to vent out all my worries. I thank you for giving me people to talk to when I need somebody to perk me up and take my mind off the anxieties that have been building up since we received the bad news. I thank you for friends and family who never get tired of asking me how I am doing. Having them around always make my day a lot brighter.

I thank you most especially for helping me find a support group. Linking up with people who are going through the same experience as I am is very comforting. Knowing that there are people who survived this disease for years gives me a lot of hope and optimism that I will win this fight.

Lastly, I thank you for giving me my daughter. She always gives me the enthusiasm to wake up and live the day as if I have nothing to worry about.

CT Scans and whatnots

I recently signed up on a support alliance for Phyllodes Tumor patients. It feels good to finally find people who share the same worries with me. Reading one of the community members comments of us being the lottery winners when it came to this tumor because we belong to the 1% of the population made me laugh.

So anyways, as I was going through the previous post, my initial fear that there's really no defined treatment for PT (Phyllodes Tumor) patients has been confirmed.

When we were informed that the tumor was malignant, we immediately asked my doctor what treatment options are available for us. She told us, for now, chemo/radiation therapy is the last resort. But that's only when there's metastasis already. For now, we just have to closely monitor my body through regular check ups. What we should be looking out for is the incidence of a recurrence. I was telling my family that this whole thing does not really scare me. But what I cannot handle right now is another surgery this year. I don't think my body can handle another surgical invasion after a mastectomy.

Later today, I am hoping to finally finish the CT Scan so we can get a clearer picture by the end of this week. We've been praying really hard that it stays clear so we can at least set aside our worries for the meantime.

My dear little Maia

Good morning baby. Mommy is currently going through so much as she writes this. She's trying hard to stay optimistic and sunny despite the nerve wracking news that she and Daddy received last Wednesday. For you sweetie. Mommy will fight this.

Before Mommy had you, she was a cry baby in every sense of the word. She would cry over small stuff and would cry harder when things get tougher. But that does not mean that she's weak, that's just how Mommy expresses her emotions when she's sad, frustrated or disappointed. Once the tears ebb down, the worries go with it. Then Mommy's all better. Nevertheless, people around Mommy especially Daddy, GrandMa and GrandPa does not like it when Mommy cries. So Mommy vowed to control the tears when Mommy was already carrying you. Guess what, you did help Mommy on this mission. From the moment you were born till about a month ago, she's finally mastered the art of crying.

But it seems all that was temporary. When Wednesday's news sunk in, the tears came back. You know why? Because Mommy kept thinking of you. Of how small and young you are yet. You do not deserve to be deprived of her love and attention just yet. Mommy did not cry when she received the news but she cries when her thoughts are flooded by you.

Mommy is now praying for strenght to fight this fight so she can spend a longer time with you. When Mommy's all better, she will take an advocacy to help others just like her. And she will do it with you. Because you are her inspiration for taking on this fight.

Mommy vows to be around to witness many of your firsts. I love you very very much baby. You are Mommy's world.

Just a little bit more faith and a tougher heart

My tissue biopsy results were released yesterday.

While the hubby was looking forward to hearing my doctor deliver a positive note, I had a nagging feeling at the back of my mind that it might not be as pretty as we would like it to be. To be on the safe side, I prepared myself for the worse.

Turns out, my instinct was correct.

The tumor is malignant. But unlike the time when my doctor told me my left breast had to be taken out, this one did not shock me anymore. I guess my preparation paid off after all.

So while we discuss the further actions that we need to take in order to prevent or maybe combat the worse that's yet to come, my mind floated to the confines of our bedroom where our little Maia spends most of her time playing, cooing and giggling. My heart felt like it's being crumpled to pieces. Surprisingly though, I never shed a tear. The lady who used to be a crybaby did not shed a single tear! I guess, this whole experience is indeed starting to toughen me up.

Now, in the next two weeks or so...I will undergo more testing just to ensure that the malignant 'cells' (i don't know if that's even the correct term for it) has metastasized to my lungs and liver. But now, I feel there's a light at the end of the tunnel. God seems to be telling me to hold on a little longer and keep the faith going. The should be an end to all of this.

As we leave my doctor's clinic, I took the hubby's hand and squeezed it reassuringly. We will get through this.

What is Phyllodes Tumor of the Breast?

After the surgery, I vowed to learn more about this condition that I have. This is the best article I found on the internet that could provide somebody whose totally clueless with the right information.

This is from www.answers.com:

What is Phyllodes Tumor?

Cystosarcoma phyllodes (CSP) is a rare type of breast tumor. It is categorized by the National Cancer Institute (NCI) as a tumor subtype that occurs within the breast but is not considered a typical cancer. Its name comes from two Greek words that mean "fleshy tumor" and "leaflike," because its internal structure resembles a leaf when the tumor is cross-sectioned. The term phyllodes tumor is considered preferable to CSP as of the early 2000s because most of these tumors are benign. Phyllodes tumors are also known as giant fibroadenomas of the breast.

Description

Phyllodes tumors develop only in the breast; they are never found in other parts of the body. They are formed within the stroma (connective tissue) of the breast and contain glandular as well as stromal tissue. Phyllodes tumors can grow noticeably within a matter of weeks, causing the overlying skin to become semi-transparent or reddish and warm to the touch. They do not, however, usually involve the nipple or areola.

A phyllodes tumor can be moved freely within the breast when the doctor performs a manual examination. The tumor has a firm, smooth texture, can be easily distinguished from the surrounding tissue, and may grow to be quite large and bulky. The average size of phyllodes tumors is about 2 in (5 cm), although tumors as large as 11.8 in (30 cm) have been reported. These tumors do not cause pain when touched. For reasons that are not yet understood, phyllodes tumors are more likely to develop in the left breast than the right.

There is some disagreement among specialists regarding the number of phyllodes tumors that prove to be malignant. Although figures of 16–30 percent are commonly given, some doctors think that the actual incidence may be higher, as more cases of malignant tumors have been reported in the early 2000s.

Demographics

Phyllodes tumors account for less than 1 percent of all breast tumors. Almost all occur in women, although a few cases have been reported in men. Phyllodes tumors have been identified in women in all age groups but are uncommon in adolescents. They are most likely to occur in women over 35.

As far as is known, phyllodes tumors occur with the same frequency in women of all races and in all parts of the world.

Causes & Symptoms

The cause of phyllodes tumors is not known as of the early 2000s.

The symptoms of a phyllodes tumor include the rapid but painless growth of a smooth, bulky mass within the affected breast. The patient may notice that her entire breast is enlarged and its shape distorted. The skin over-lying the tumor may feel warm to the touch and develop a shiny appearance; it may also become translucent.

Patients with metastases from a malignant phyllodes tumor may experience difficulty breathing (dyspnea), bone pain, and fatigue.

Diagnosis

The diagnosis of a phyllodes tumor may be made when the patient notices a rapidly growing mass in her breast and consults her doctor. After palpating (feeling) the mass and evaluating the appearance of the overlying skin, the doctor will order imaging studies and an open breast biopsy. Although a mammogram or ultrasound study may be useful in evaluating the size and location of the tumor, these tests are not reliable in distinguishing among benign phyllodes tumors, fibroadenomas, and malignant phyllodes tumors. In addition, fine-needle aspiration does not usually confirm the diagnosis; an open biopsy is considered the definitive diagnostic test as of the early 2000s.

There are no tumor marker or other blood tests that can be used to diagnose phyllodes tumors as of 2005.

Treatment Team

The treatment team for a patient with a phyllodes tumor will usually include a diagnostic radiologist, a gynecologist, a general surgeon, and a pathologist.

Clinical Staging, Treatments, and Prognosis

Staging

Phyllodes tumors are not staged in the usual sense; they are classified on the basis of their appearance under the microscope as benign, borderline (or indeterminate), or malignant. The pathologist makes the decision on the basis of the cells' rate of division (mitosis) and the number of irregularly shaped cells in the biopsy sample. In one series of 101 patients with phyllodes tumors, 58 percent were identified as benign, 12 percent as borderline, and 30 percent as malignant.

Treatments

Surgical excision (removal) is the usual treatment for phyllodes tumors, whether benign or malignant. In the case of benign tumors, the surgeon will usually try to spare as much breast tissue as possible, generally removing about 1 in (2 cm) of normal breast tissue from the area around the tumor as well as the tumor itself. If the tumor is very large, however, the doctor may remove the entire breast.

In the case of malignant tumors, the surgeon will remove a wider area of normal tissue along with the tumor—a technique known as wide local excision (WLE)—or perform a complete mastectomy.

Although radiation therapy has been tried as follow-up treatment after surgery, phyllodes tumors do not respond well to either radiotherapy or chemotherapy if they recur or metastasize. In addition, malignant phyllodes tumors do not respond to hormone therapy.

Prognosis

The prognosis for benign phyllodes tumors is good following surgical removal, although there is a 20–35 percent chance of recurrence, particularly in patients over the age of 45. Recurrence is usually treated with further surgery, either another local excision or a complete mastectomy.

The prognosis for patients diagnosed with borderline or malignant phyllodes tumors is more guarded. About 4 percent of borderline tumors will eventually metastasize. A Mayo Clinic study of 50 patients with malignant tumors found that 32 percent had a recurrence within two years after surgery; 26 percent developed metastases, and 32 percent of the group died from their malignancy. The most common sites for metastases from malignant phyllodes tumors are the lungs, bones, liver, and chest wall, although metastases to the lymph nodes have also been reported. Most patients with metastases from a malignant phyllodes tumor die within three years of their first treatment.

Alternative and Complementary Therapies

Women who have had surgery for removal of a phyllodes tumor appear to use CAM therapies as often and for the same reasons as women treated for breast cancer. According to the Behavioral Research Center of the American Cancer Society, breast cancer survivors are highly likely to use some form of alternative or complementary therapy during cancer treatment or within a year or two of completing conventional treatment. A survey of 608 longer-term (8 years or longer) breast cancer survivors reported in early 2005 that the majority were still using CAM therapies. The survey respondents gave four reasons for using alternative treatments:

• To maintain an active role in recovery from cancer.
• To reduce their stress level.
• To reduce the risk of recurrence.
• To maintain hope.

Specific CAM therapies mentioned by the women in the ACS survey included exercise, humor, self-help books (bibliotherapy), prayer or spiritual practice, vitamin treatments, relaxation exercises, and support groups. Dr. Kenneth Pelletier, the former director of the program in complementary and alternative medicine at Stanford University School of Medicine, lists hypnosis, visualization, naturopathy, and journaling as other alternative approaches that breast cancer patients find helpful. Acupuncture is frequently mentioned as a useful method of pain control.

Coping With Treatment

Coping with the aftereffects of surgery for a phyllodes tumor is similar to coping with the effects of surgery for breast cancer. Patients who have had a complete mastectomy may experience pain, limited range of motion or weakness in the affected arm, scarring, or swelling. Exercises, outpatient physical therapy, and massage help to relieve these side effects of breast surgery. In terms of follow-up, most patients treated for phyllodes tumors are scheduled for a postoperative visit with the surgeon 1–2 weeks after surgery, with periodic checkups thereafter.

Clinical Trials

The National Cancer Institute (NCI) is not conducting any clinical trials involving phyllodes tumors as of 2005. There is, however, an ongoing study at the Dartmouth-Hitchcock Medical Center in New Hampshire of the effectiveness of radiation therapy in preventing recurrences of borderline or malignant phyllodes tumors in patients who have been treated with local excision of the tumor. Women who have had a borderline or malignant phyllodes tumor removed within the past three months may wish to consider participating in this study.

Prevention

There is no way to prevent phyllodes tumors as of the early 2000s because their cause is not yet known.

Questions to Ask Your Doctor

• What are the chances that my phyllodes tumor is either borderline or malignant?
• What are the chances of a recurrence?
• Would you recommend a total mastectomy rather than local excision to minimize the risk of recurrence?

Special Concerns

The special concerns of patients with phyllodes tumors are similar to those of patients diagnosed with breast cancer, particularly concern about disfigurement, physical weakness, or recurrence if the entire breast has been removed.

I survived surgery! =)

I am now back at home.

The past few days felt like the 4 longest days of my life and I am just very, very glad to be home again with Maia.

Wednesday went by like a blur. I was woken up by my nurse at 5am to inform me that I need to take a bath already so I'd be all cleaned up when the people from the OR fetch me.

I am emotionally ready. I have already thought of the worst possibilities I might encounter while on surgery and have already put my trust on my surgeon. I know she will do what she thinks is best for me.

But despite the mental preparation, I felt really clammy when I was wheeled in. I guess it's a pretty normal reaction considering that it is my first time to be in an operating room and definitely my first time to go under the knife. But I was telling myself to think happy thoughts. I thought of Maia's face when she giggles and it made it all better.

I was a bit shocked when my surgeon came in and told me she's doing the incision biopsy with me on local anesthesia for 30mins. Our discussion earlier during the week was that I will be put under general anesthesia from start to finish and hearing that I sort of felt panic. But I regained composure almost instantly. I recalled my earlier thoughts and decided that again my surgeon would know what's the best thing to do.

So for the first 30 mins of my scheduled 3-hour surgery, I was lying there both arms tied on the side waiting for the surgeons to finish taking samples of the tumor. Once they were done, I had to wait for 30 more minutes for the frozen section results. I kept the sunny disposition and decided to chat with the intern who was looking after the incision that was made earlier. We started laughing at my tumor since it was moving in all directions while the intern was applying pressure on the wound. It felt like I had a ball running wild inside my left breast.

Thirty minutes went by and my surgeon came back...sort of gloomy faced. She immediately announced that the labs proved the tumor was phylloides and patted me on the shoulder and told me they have to move on with the mastectomy. I just nodded my head and got myself ready for the show. It took just a few seconds for them to put me to sleep.

...after 2 hours, I woke up in the recovery room with a throbbing pain. It felt more intense than the pain I had when I gave birth. I immediately asked for pain relief and they signalled to the IV drip above my head. The nurses told me to just do breathing exercises so battle the pain. I guess I sort of felt asleep again because the next time I woke up, I was already being wheeled out of the recovery room. It was still very painful and the sight of Mommy and Tibs gave me an excuse to cry out the pain.

Thirty minutes after I was settled in my room, the pain finally went away. And my old bubbly self is back. To all who offered prayers, I could never thank you enough. I know God never left me all through out the surgery. I know because I would never have the strength I had without his help.

To everybody who made time to visit despite their busy schedules, I am very grateful because you made me feel really loved and you definitely lifted my spirits.

I may be left with only one breast at 30 but I have my friends and family to compensate for the loss. And despite knowing that it was my pregnancy that triggered the tumor to grow aggressively up to the size of a tennis ball, I have no regrets for choosing to get pregnant and have Maia. And if I had to, I will readily give up my other breast without skipping a beat, for her. Motherhood is something I will never trade for the world.

A Lumpy Discovery

Two days before Maia turned two months old, I went to see a surgeon at PGH to have the mysterious lump on the exterior part of my left breast checked. I had complained about this to my OB-Gyn during my routinary post-natal check up but I was instructed to just apply hot compress over it. My OB-Gyn was saying it was probably just due to lactation and it will go away once I stopped breastfeeding. But just to be sure she says, she'll schedule me for a mammosonogram once I ceased milk production.

But then my Mom and sister kept on prodding me to seek other doctor's opinion. To give them peace of mind, I gave in to their plea. It turns out however, the lump was indeed a tumor. One large tumor - measuring 4x5 cm - that had been sitting there for sometime and growing by the minute. Doctor's theory was, the lump had always been present but was left undetected.

Due to a family history of lumps and tumors (both of my maternal grandparents succumbed to cancer) plus undergoing hormonal treatment for my irregular menses earlier on and an intensive hormonal medication during my pregnancy, the lump's growth became aggressive. Thus, resulting to large mass like this one in just 5 months.

Due to the lump's size, I was not required to get a mammosonogram anymore. Instead, the doctor suggested a biopsy of the breast mass. But the guys at PGH were going to make small incision on my breast so my family and friends suggested that I seek another doctor's opinion before I had my breast sliced.

So I again went to see a different doctor, this time at the Makati Medical Center. But she only confirmed the previous findings. Only three days have passed since my PGH trip but the mass has now grown to 5x7cm. It's growing really fast! Good thing though, she did a fine needle aspiration biopsy so no incision was made. She told me we needed to rule out malignancy of the tumor before we go a step further on the treatment.

But since we were approaching the long holiday break, I had to wait on the results for 2 more weeks. Yesterday, I went back to discuss the biopsy results. I was hoping it would be nothing. And indeed, the biopsy findings were nothing to be alarmed about. What was alarming though was that the lump continued to grow. Now it's 5x8cm. The conversation became blurry to me after that. It was only after I met up with Tibs that it sunk in. Then I just cried.

Diagnosis was the lump is a phyloides tumor of the breast. It definitely has to be taken out. Due to its size, the doctor cannot do it under local anesthesia. I have to be put under general anesthetia and while I am 'sleeping' they will check the tissues from the breast mass to rule out phyloides. But if it turns out to be phyloides, they will take out ALL of my left breast. It was hard hit on me. It never crossed my mind that I will be left with just one breast at 30.

At this point though, I am more worried for Mommy than for me. She did not get any sleep last night. She's really scared I might end up like my grandmother. I was not able to get a decent sleep either but I vowed to stay tough. I kept looking at Maia and thinking how small and fragile she is. I need to stay healthy for her. Then I just prayed. Felt better after that. I thought, one breast is better than cancer. At least it's not cancer (--yet). But with all the support from family and friends, I know I will get through all this. God just wants our family to be a lot more stronger that's why he keeps sending us these challenges.

So this week, when I'm finally cleared for surgery, I will try my best to stay tough. I have prayers to guide me through. And my Maia to give me strength.