BLOCK 10 ATINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA

HISTORY

PROFILEM.P.52/F San Dionisio, ParanaqueSingle, works as a vollunteer at the cemeteryAdmitted 01/08/12

HISTORY OF PRESENT ILLNESS7 years PTA: palpable mass, R breast: ~

HISTORY OF PRESENT ILLNESS2 months PTA: consulted at PGH-OPD biopsy of the mass was done A> PHYLLODES TUMOR R Breast scheduled for elective surgery

REVIEW OF SYSTEMS(-) wt. loss, easy fatigability, feverBOV, tinnitus, dysphagiaDyspnea, chest pain, palpitations, orthopnea, PNDBowel and bladder changesPolyuria, polydipsia, polyphagiaHeat and cold intolerance

PAST MEDICAL HISTORY(-) previous hospitalizations/ surgical procedures(-)comorbidities

FAMILY MEDICAL HISTORY(-)Benign/Malignant breast neoplasia(-) other CA(+) HPN, sibling(-)DM(+) BA, both parents

PERSONAL AND SOCIAL HISTORY(+) Smoker, 22 pack years(+) Alcoholic beverage drinker, 1x a week, 2-3 bottles of beer

OB-GYN HISTORYMenarche: 16y/oRegular monthly period, lasting 5 days, consuming 4-5 ppd(+) dysmenorrheaLNMP: 1st week Dec 2011OB Score: G5P4 (4012)(-)OCP/IUD use

PHYSICAL EXAMINATION

BP 140/80 HR 70 RR 20 Temp 36.7Systemic PE: E/NHEENT: (-) CLAD, NVEChest: ECE, CBS, NRRR, Distinct S1 and S2 Abdomen: soft and flabby, NABSExtremity: FEP, PNB, (-) cyanosis, edema

The R breast is converted into a 8cm x 24cm x 10cm , firm, nodular, well-circumscribed, movable, non-tender mass. Overlying skin is shiny with a patch of erythema. (-) nipple dischargeL breast: (-)masses/tenderness/skin changes/nipple discharge

Considerations

Differential DiagnosisR/InR/OutPhyllodes TumorLarge mass, patient age, genderCannot be ruled out, needs biopsyGiant FibroadenomaLarge mass, genderCommonUsually in young females (small) (75% ),< 5% of grow rapidly.Cannot be ruled out, needs biopsyBreast MalignancyBreast massCharacteristic of the mass: movable, lacks skin changes and manifestationsCannot be ruled out, need other diagnostics

DIAGNOSTICS

Imaging of giant breast masseswith pathological correlationM Muttarak, B ChaiwunDepartmentM Muttarak, B Chaiwun.Imaging of giant breast masses with pathological correlation. Singapore Med J 2004 Vol 45(3) : 132

Mammography is always the imaging modality of choice for breast masses specially in ages 35 years and above.

FNA Biopsy:Smears disclose cohesive clusters of uniformly sized ductal cells many of which are arranged in knobby short branching patterns. Portions of fibromyxoid stroma can be observed in fields. Histopathologic Diagnosis:Negative for malignant cells, right breast massCytomorphologic features consistent with phyllodes tumor Recommend tissue biopsy for a more definitive diagnosis

DIAGNOSISPHYLLODES TUMOUR

Phyllodes Tumoura.k.a. Phylloides tumours, cystosarcoma phyllodes Cystosarcoma phyllodes used to indicate only the tumours leaf-like fleshy appearance and propensity to contain macroscopic cyst and a misnomer since most PTs are benignCause: unknown, p53 defect

MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

Clinical Presentation:Unilateral, painless, palpable, firm and well circumscribed, variable sizeRapid growth and skin ulceration can occur (ischemia from pressure and stretching)MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

Rare, < 1 % of all breast neoplasm and 2-3 % of all fibro-epithelial breast tumors35-54 y/o3 Histopathologic types: benign, borderline and malignant (20%)L-RBenign, Borderline, MalignantSatyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer Research and Therapeutics 2010. Vol. 6, Issue 4. 511-515

Histologic Classification:Based on: infiltrative margin, stromal overgrowth, stromal atypia and cellularity, and mitotic activity

Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

FeaturesBenignBorderlineMalignantStromal Cellular AtypiaMildMarkedMarkedMitotic Activity< 4/ 10 hpf4-9/ 10 hpf 10/ 1o hpfStromal OvergrowthAbsentAbsentPresentTumour marginsCircumscribedCircumscribed to InfiltrativeInfiltrative

Phyllodes TumourCore biopsy is better than FNAC yielding about 65% of correct diagnosis

No distinct imaging characteristics distinguish it from fibroadenoma

Phyllodes TumorIan K. Komenaka; Mahmoud El-Tamer; Eliza Pile-Spellman; Hanina Hibshoosh. Core Needle Biopsy as a Diagnostic Tool to Differentiate Phyllodes Tumor From Fibroadenoma. ARCH SURG/VOL 138, SEP 2003. 987-990

Phyllodes TumourFibroadenoma

MANAGEMENT

Treatment is surgical, regardless of classificationWide excision and simple mastectomy (radical not done), surgical margin of at least 1 cm (1-2 cm) to prevent local recurrence

Mastectomy: > 10 cm, malignant, recurrent

Axillary lymphadenectomy is considered for clinically suspicious cases and sometimes not warranted since spread is hematogenous (metastatic)

Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

Final assessment will depend on pathology report after complete surgical removal of the mass

Specific management (histologic consideration):

Benign and borderline: wide local excisionMalignant: simple mastectomy with or without reconstruction

Satyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer

ControversialRadiotherapy: adjuvant for high risk patients, >5 cm, with stromal overgrowth, with 10 mitotic elements/hpf, or with infiltrating marginsChemotherapy: Doxurubicin and ifosfamide for metastatic spreadHormonal management (ER/PR) still on research

Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

PROGNOSIS

Recurrence and Survival RateLocal recurrence for high-grade malignant lesions is 26% (12-65%): (+) stromal overgrowth, large size tumor, and involved margin5 yr survival rate (malignant): 54-82% 10 yr survival rate : 23-42%Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

**7 years PTA, patient noted a palpable mass on the R breast, measuring ~ PHYLLODES TUMOR R Breast. Patient was then scheduled for elective admission.

**

Pertinent: size of mass, consistency (hard), movable, demarcation, movable/non-movable, tenderness, skin appearance (peau d orange, dimpling)

**< 5% of grow rapidly and display the clinical and histologic characteristics of giant fibroadenomas**Mammography is always the imaging modality of choice for breast masses specially in ages 35 years and above.***a.k.a. Phylloides tumors, cystosarcoma phyllodes Coined by WHO in 1931 due to lack of uniformity in nomenclatureCystosarcoma used to indicate only the tumors leaf-like fleshy appearance and propensity to contain macroscopic cyst and a misnomer since most are benign

MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

*MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

*Satyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer Research and Therapeutics 2010. Vol. 6, Issue 4. 511-515

(infiltrative margin, stromal overgrowth, stromal atypia, cellularity, and mitotic activity) not accurate predictors of tumour behavior, and no single parameter is reliable in all cases

Phyllodes tumours are histologically similar to fibroadenomas but have more cellularity and stromal proliferation. Approximately 20-50% are malignant.*Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791**On mammography, they are seen as well-defined masses while on US, they appear as well-defined masses with low-level uniform or scattered internal echoes. The diagnosis of phyllodes tumour may be suggested by the presence of fluid-filled, elongated spaces or clefts within a solid mass. These features are characteristic but not pathognomonic of the diagnosis. There are no known reliable imaging criteria to differentiate benign from malignant phyllodes tumours. **Surgical treatment is the generally accepted as the most important and primary therapy for PT regardless of type- wide excision (simple mastectomy, radical not done), borders of at least 1 cm (1-2 cm) to prevent local recurrence- mastectomy: > 10 cm, malignant, recurrent - axillary lymphadenectomy is considered for clinically suspicious cases and sometimes not warranted since spread is hematogenous for metastatic type

Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

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