Evaluate fibroadenoma and phyllodes tumor sizes


Purposes and background. Fibroadenoma ( FA ) and phyllodes tumour ( PT ) are a group of fibroepithelial lesion of the chest consisting a heterogeneous tumor of the terminal ductal unit. The chief purpose of the survey was to measure the look position of ERI± , ERI? , Bcl2, p53, and MIB-1 protein in fibroepithelial lesion and correlative with clinicopathological factors.

Methods and survey design. A sum of 114 fibroadenomas and 67 PTs ( 43 benign, 12 boundary line and 12 malignant ) were examined utilizing immunohistochemistry ( IHC ) on tissue microarray ( Alphelys 0.6mm clout ) to find the look of ERI± , ERI? , Bcl2, p53 and MIB-1 in epithelial tissue and stroma.

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Consequences: The mean of tumour size was 3.4A±1.97 centimeter, 6.6A±4.48, 14.1A±8.4 and 9.9A±8.3 centimeter for fibroadenoma, benign PTs, boundary line PTs and malignant PTs, severally. The look of ERI? ( P & lt ; 0.001 ) , p53 ( p=0.012 ) and MIB-1 ( p=0.238 ) in the stroma constituent were greater in a larger tumour size. The p53 was important in stroma constituent of malignant PTs ( P & lt ; 0.001 ) . In add-on, p53 and MIB-1 look showed a important association in both epithelial tissues and stroma ( p=0.015, P & lt ; 0.001 ) every bit good as in ER and Bcl2 ( P & lt ; 0.001 ) .

Decisions: The association between MIB-1 and p53 with histological class, may bespeak their immunopositivity in benign chest tumour addition hazard for malignances and show to be a valuable marker in PTs, while a positive association between ER and Bcl2 defines that ER may be the regulator of Bcl2 protein.

Cardinal words: phyllodes tumour, fibroadenoma, MIB-1 protein, p53 antigen, estrogen, receptor, immunohistochemistry


Fibroepithelial tumours of the chest illustrated as a proliferation of epithelial tissue and stroma constituent. This tumour group ranges from benign to malignant ; includes fibroadenomas and phyllodes tumours ( PTs ) 1. Fibroadenomas ( FAs ) are the most common fibroepithelial tumour among immature adult females, but it can be besides diagnosed in post-menopausal adult females. It is composed of both glandular and connective tissue, characterized by hyperplasia and unnatural lobular chest units2,3,4. The phyllodes tumours are rare tumors and accounting for less than 1 % of all primary chest tumours 5,6,7. Phyllodes tumours show preponderantly of fibroadenoma standards, with a leaflike projection cells and more cellular connective tissue stroma constituent.

Phyllodes tumours may be classified as benign, boundary line and malignant subtypes harmonizing to gross and microscopic characteristics including border visual aspect, cellular polymorphism, stromal cellularity, mitotic activity and stromal distribution1,6,7,8. Apoptosis is one of the factors that play a cardinal function in the development and growing ordinance of normal and neoplastic mammary tissues and its dysregulation is suggested to excite the mutant that causes breast tumour 9,10. Bcl2 is an oncoprotein that plays a function in programmed cell death ; by barricading programmed cell decease, discourages the publicity of cellular proliferation and induces tumor development 10,11.

The look of Bcl2 is associated with cells that are protected from programmed cell death such as root cells or epithelia that undergo hyperplasia ; including chest and prostate ( Moore & A ; Lee 2001 ) and its look is related to steroid endocrine receptor 10,12.

The estrogen receptor ( ER ) , is ligand activated written text factors that usually present in normal and benign lesions of the chest 10,13. By and large, ER has been implicated in both normal and neoplastic mammary tissue as a Deoxyribonucleic acid adhering written text factor and induces cell proliferation 4,14. It was foremost cloned as ER located on the long arm of chromosome 6q25 and is now known as ERI± . The 2nd type of ER is ERI? , located on chromosome 14q22-24 13. ERI± was reported to show chiefly by epithelial cells in fibroepithelial tumours, while was normally hard to specify the presence of ERI± in the stroma constituent 15.

Ki-67 antigen is a cell proliferation-related protein that can be detected with monoclonal antibody MIB-1 and to measure proliferative activity in different types of tumour 16,17. Ki-67 is linked to cell rhythm ( Jacklin et al 2006 ) , specially expresses during late G1, S, M and G2 stage of the cell rhythm, is undetected in cells of the G0 stage 6,18. It is observed as a marker of cell proliferation and the best index in finding the growing fraction of cells 6.

Expression of the proliferation marker Ki-67 has been reported to change among histological classs of phyllodes tumour every bit good as between phyllodes tumours and fibroadenomas and was besides reported in several surveies to demo a correlativity between MIB-1 positiveness and the histological class 7,19,20.

Besides, p53 immunohistochemical look, normally used as an designation for tumor-suppressor cistron mutant has been besides correlated with tumour grade 7,21. It is located on the short arm of chromosome 17p13, is a well-known tumour suppresser cistron, plays a function in the ordinance of normal cell growing and division, DNA fix and programmed cell death 22.

The purpose of this survey was to carry on immunohistochemical analysis to find the look position of ERI± , ERI? , Bcl2, p53, and MIB-1 protein in fibroepithelial lesion by tissue microarray. We determined the relationship between the immunostaining look with clinical standards such as age, tumour size and tumour types and to measure the utility of these markers in separating benign from malignant tumours.

Methods and survey design


Prior ethical blessing was taken to carry on the survey. The survey population consisted of 181 patients recruited during 1990 to 2008. All samples and patient ‘s informations were collected from Department of Pathology, Universiti Kebangsaan Malaysia Medical Centre ( UKMMC ) . A sum of 114 fibroadenomas and 67 phyllodes tumours ( benign PT, boundary line PT and malignant PT ) histology slides were examined through microscope and rating by diagnosticians to find the topographic point country ; consisting of both epithelial tissues and stroma constituents of fibroepithelial lesions. The phyllodes tumours were graded into benign, boundary line and malignant tumour, harmonizing to WHO classification23.

Tissue Microarray

Tissue microarray ( TMA ) was conducted to all selected instances utilizing 0.6mm diameter punch kit MTA Booster ( Alphelys, France ) . Approximately 50-70 instances were punched into a individual TMA block and quadruplicate, giving a sum of 16 TMA blocks24.

Immunohistochemistry ( IHC )

Immunohistochemical staining was performed manually to find the look of selected biomarkers in epithelial tissue and stroma utilizing DAB horseradish chromogen. 3Aµm subdivisions were cut onto poly-L-lysine coated slides and baked at 60°C for 30 proceedingss. Deparaffinisation in xylene and rehydration through graded intoxicant followed by handling with antigen retrieval for 40 proceedingss at 98°C. The subdivisions so were cooled down in room temperature and incubated with obstruction agent, H peroxide for 10 proceedingss followed by primary antibody incubation for 30-60 proceedingss in room temperature. The primary antibody and their dilution were shown in Table 1.

Incubation with Dako EnVision was followed by DAB chromogen sensing and so counterstained in haematoxylin solution. Sections of tonsil, colon glandular cancer, chest carcinoma and endometrium shown strong staining ( 3+ ) were used as a positive control for MIB-1 and Bcl2, p53, ERI± and ERI? , repectively. Negative controls were performed by excluding the primary antibody. IHC staining of p53 was interpreted as positive when more than 10 % staining of the tumour karyon were detected and Ki67 positive karyon divided by the entire figure of stroma or epithelial cells expressed as a per centum, modified from old surveies 7,17,25. The ER and Bcl2 were required as positive responsiveness when a‰?10 % of atomic or cytoplasm staining of at least 2+ strength of look detected 26.

Statistical analysis

Kruskal-Wallis trial was used to analyze differences of biomarkers expression between the four groups, and were correlated between different variables utilizing chi-square trial. Differences were considered to be statistically important at P & lt ; 0.05. All analyses were carried out utilizing the package Statistical Packages for the Social Sciences, SPSS v12.0 ( SPSS Inc. , Chicago, IL, USA ) . All human samples were collected with ethic blessing from ethic commissions of Faculty of Medicine, Universiti Kebangsaan Malaysia.


A sum of 114 fibroadenoma and 67 phyllodes tumour patients showed an addition in age and tumour size between benign to malignant tumours, except for malignant phyllodes tumour which was somewhat lower than in boundary line patients ( Table 2 ) . The average age of patients with fibroadenoma was 28.5 old ages ( scope, 10-59 ) . The average age for benign, boundary line and malignant phyllodes tumours were 39.8 ( scope, 16-74 ) , 49.8 ( 38-78 ) , and 44.8 ( 29-67 ) old ages, severally ( shown in Table 2 ) . The mean of tumour sizes were 3.4A±1.97 centimeter, 6.6A±4.48, 14.1A±8.4 and 9.9A±8.3 centimeter for fibroadenoma, benign PTs, boundary line PTs and malignant PTs, severally.

This survey showed a important association between p53 ( p=0.012 ) look in the stroma with tumour size, which 10.7 % ( 6/56 ) were less than 3cm, 4.2 % ( 3/72 ) ranges 3 to 5 centimeters and 21.2 % ( 11/52 ) were more than 5 cm size of tumour, as shown in the Figure 1. Our informations showed positive look of ERI? ( P & lt ; 0.001 ) and MIB-1 ( p=0.238 ) in the stroma constituent that were greater in the larger tumour size ( & gt ; 5cm ) .

The look of p53 in the epithelia constituent ( Figure 2 ) was chiefly seen in little tumour size, but was non statistically important compared to Bcl2 look in the epithelial tissue showed a important correlativity to the little size of tumour ( p=0.018 ) .

Figure 3 showed a tissue microarray slide. A positive look of survey markers for fibroadenoma and three types of phyllodes tumours ( benign, boundary line and malignant ) were shown in Figure 4 ; fibroadenoma ( Figure 4A ) , benign PT ( Figure 4B ) , marginal PT ( Figure 4C ) , and malignant PT ( Figure 4D ) . ERI± showed a strong staining in karyon of epithelia constituent, while ERI? immunoreactivity was detected in both epithelial tissues and stroma constituents. Bcl2 staining was detected in the karyon of epithelia cells and besides expressed in stroma constituent of malignant phyllodes tumour. Besides, p53 was strongly expressed in malignant phyllodes tumour and weak staining was detected in benign tumours.

The consequences of overexpression of biomarkers are listed in Figure 5. The p53 look was low in the stroma of benign tumour and increased in malignant tumour ( & gt ; 10 % look ) . Both types of ER look were greater in epithelial tissue of benign than malignant tumours. Surprisingly, both types of ER look were common in stroma of malignant phyllodes tumours compared to benign tumours. However, ERI? expressed higher per centum than ERI± particularly in the stroma constituent, while ERI± was undetected in fibroadenoma to borderline phyllodes tumours. Contrary to stroma constituent, look of p53, ER and Bcl2 were greater in most of epithelial of benign tumours than in boundary line PTs and malignant PTs, but were non statistically important for p53 and ER. Significant association between ER and Bcl2 look was seen in the stroma constituent ( P & lt ; 0.001 ) .

The present survey showed a different form of p53 look which had greater per centum of staining in benign tumours than malignant tumours in the epithelial tissue cells, contrary to MIB-1 which strongly expressed in malignant tumours in both epithelial tissues ( Table 3 ) and stroma constituent ( Table 4 ) . However, fibroadenoma and benign PTs showed weak staining of p53 in the bulk of instances. The monoclonal antibodies p53 showed a important value in the stromal constituent, of malignant PTs merely ( P & lt ; 0.001 ) . In add-on, p53 and MIB-1 look showed a important association in both epithelial tissues and stroma constituents ( p=0.015, P & lt ; 0.001 ) .


Tissue development is the consequence of a balance between cell proliferation, distinction and programmed cell death 10. Proliferation of fibroepithelial tumour is chiefly in the stroma constituent, followed by proliferation of epithelia cells 15. The stromal elements were considered as the neoplastic constituent and hence believed as the determiner of biological activity 27.

The Bcl2 protein are normally expressed in normal tissue and benign proliferative lesions, as they discourage the publicity of cell proliferation by inhibit programmed cell death 10. There was a important difference of the Bcl2 look between the benign ( 60.5 % ) , boundary line ( 75 % ) and malignant PT ( 25 % ) in epithelial tissue, and 12.5 % , 8.3 % and 25 % in benign, boundary line and malignant PT, severally of the stroma constituent, but was non statistical important in the stroma. Bcl2 look can be detected in many hormonally regulated cells, such as epithelia cells of normal chest and ER/PR-positive chest carcinomas10,28,29. Besides, Bcl2 has been shown to be of import downstream mediates of estrogen action endurance of malignant neoplastic disease cells and other survey ( Yang et al 2006 ) showed relation of Bcl2 protein look to the look of steroid endocrine receptors such as ER, similar to this survey ( p=0.001 ) 4,10.

Estrogen has a important function in advancing malignance in chest and potentially to be a go-between of the mammary secretory organ since it is necessary for development and metastasis13. The consequences of the present survey showed a important differences of ER look in stroma constituent, which increased with malignance ( p & lt ; 0.05 ) . In other surveies, ER on a regular basis present in normal and benign lesions of chest and metastasis tumours were normally negative for ER 10. As in this survey, ERI± look was common in benign tumour, 63.2 % and 60.5 % of fibroadenoma and benign PT, severally, but low look was detected in epithelia cells of malignant PT ( 50 % ) . However, the look of ER was somewhat increased in boundary line instances ( 66.7 % ) , proposing a different cellular activity between tumours. On the other manus, ERI? showed an first-class form in epithelia constituent with high look in benign instances and reduced with malignance ; 81.4 % of, 74.4 % in, 66.7 % and 33.3 % in fibroadenoma, benign PT, boundary line PT and malignant PT ; severally, but was non statistically important.

Besides, other surveies besides reported that ERI± was chiefly expressed by epithelial tissues cells while its look by stromal cell was controversial with merely 8.3 % look in malignant PT and absent in boundary line and benign PT, in the present survey 15. Previous surveies demonstrated that ERI? were found in stromal cells in the fibroadenoma and PT 13,15.We opine that ERI? showed better look than ERI± which was extremely noticeable in the stromal constituent. The greater look of ERI? suggests that it may be the chief ER in the chest. So that, Speirs and co-workers ( 2002 ) believed that cells ab initio considered ERI± negative may really be showing ERI? 13.

Recent survey demonstrated the look of ER was related to the proliferative index of the tumours measured by immunolabelling with antibodies against Ki-67 and bespeaking a good forecast with endocrinal therapy 10. Another survey suggested that cells that were immunopositive for ERI± really seldom undergo proliferation, as determined by the deficiency of look of the cell rhythm associated antigen Ki-67 and proliferative cell atomic antigen which was similar to the present survey but was non statistically important 13. Expression of the proliferation marker, Ki-67 has been reported to be different between histological classs 7,21.

Other writers and our survey have shown a correlativity between MIB-1 positiveness and the histological classs 7,19,30. Our consequences showed a important difference of MIB-1 positiveness in both epithelial tissues and stroma constituents. The look of MIB-1 in epithelial tissue was 14 % ( 6/42 ) , 42 % ( 5/12 ) and 33 % ( 1/3 ) , severally in benign, boundary line and malignant PTs and 12 % , 33 % and 17 % in the stromal constituent, similar to an earlier study by Tse et Al ( 2010 ) ; 5-25 % , 15-100 % in benign and malignant instances, severally 30. MIB-1 negativeness or low look indicated a really low proliferation rate, seemingly noticeable in fibroadenoma and benign PT. Benign phyllodes tumours with more than 10 % of cells were positive for MIB-1 were at hazard of malignant alteration, as described by Chan et Al ( 2004 ) 17,31.

Like Ki-67, p53 position may be correlated to histological class of tumours. Published surveies reported that Ki-67 and p53 looks correlated good with the structural scaling of phyllodes tumor 7,17,19. P53 is utile as independent standards for measuring the malignance of phyllodes tumour and its look tends to be greater in the phyllodes tumour with a higher malignant possible 32. In the present survey, high degree p53 look was confined to stromal cells, with merely low degrees of look found in the epithelial tissue, 26.8 % ( 30/112 ) , 9.8 % ( 4/41 ) , 8.3 % ( 1/12 ) of fibroadenoma, benign PT and borderline PTs severally, but was absence in the epithelial tissue of malignant PT. In the stroma constituent, there was important association of Ki-67 with histological class with 7 % ( 8/114 ) , 4.8 % ( 2/42 ) , 33.3 % ( 4/12 ) and 50 % ( 6/12 ) of fibroadenoma benign PT, boundary line PT and malignant PTs severally, back uping the averment that the stroma instead than the epithelia constituent is neoplastic 27. Even so, interactions between both stroma and epithelial tissues, may act upon the pathogenesis of PTs 27. Although p53 look correlated good with the histological classs, nevertheless immunopositive of p53 may non observe an increased hazard for developing breast malignant neoplastic disease among patient with benign tumour 33. In add-on, the negativeness of p53 in the stromal cells confirmed the benign of the phyllodes tumor 21,30,34. In this survey, merely 4.8 % of weak staining was detected in the stroma of benign PTs while others remained negative.

Neither Ki-67 nor p53 look may separate benign from malignant phyllodes tumour in diagnostically hard instances such as boundary line or low proliferative malignant instances. Ki67 antigen nowadayss as the true proliferation activity and overexpression of p53 is caused by sensing of mutant in a instance that progressed from benign to malignant tumour 17. The association between Ki67 and p53 with histological class, indicates that their immunoreactivity in benign chest lesion may increase hazard for malignances and show to be possible index in PTs while ER look position plays the function in finding the intervention in chest tumour 35. A positive association between ER and Bcl-2 suggests that ER may be the regulator of Bcl2 protein. Besides, high detection of ERI? subtype compared to ERI± particularly in the stroma constituent may propose that ERI? is a dominant ER in the chest tissues ( Speirs et al 2002 ) .


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