A case presentation and discussion on phyllodes tumor. Includes a brief discussion on the anatomy, physiology of the breast.

1. HANG IN THERE…
Alcaraz, Adrian
Medical Clerk

2. To be able to give an initial impression of the case
To discuss the anatomy and physiology of the breast
To differentiate benign from malignant breast mass
To present on Phyllodes Tumor
To identify appropriate management
OBJECTIVES:

3. Name: BA
Age: 41year old
Sex: Female
Address: Siay, ZSP
Civil Status: Married
Occupation: None
Religion: Born Again
Nationality: Filipino
PERSONAL DATA

4. Right Breast Mass
CHIEF COMPLAINT

5. 3 month PTC
2cm x 2cm , right breast, tender
No associated fever, , easy fatigability,
,
Consulted at ZCMC
Core Needle Biopsy was done
HISTORY OF PRESENT ILLNESS

6. Medical Illness: No known morbidities; no asthma
Hospitalization: No prior hospitalization
Surgical: No prior surgical operation
Medications: No medical maintenance
Allergies: No known allergies to food or drugs
PAST MEDICAL HISTORY

7. (+) hypertension
(-) diabetes mellitus
(-) bronchial asthma
FAMILY HISTORY

8.  Housewife with 3 living children
 Non-alcoholic beverage drinker
PERSONAL AND SOCIAL HISTORY

9.  G4P4 (4 0 1 3)
 Menarche at 14years old
 LMP: January 29, 2015, regular menstrual cycle
OB-GYNE HISTORY

10. No other pertinent symptoms
REVIEW OF SYSTEM

11. GENERAL APPEARANCE:
ambulatory, response to
questions and command; oriented
to time, place, and name; not in
cardio-respiratory distress
PHYSICAL EXAMINATION

12. VITAL SIGNS:
 Blood Pressure: 120/110 mmHg
 Pulse rate: 87 bpm
 Respiratory Rate: 18 cpm
 Temperature: 35ºC
PHYSICAL EXAMINATION

13. SKIN/HAIR/NAILS:
Warm to touch; no jaundice; no
pallor; no lesions
PHYSICAL EXAMINATION

14. Head: No scars; no lesions; normal hair
distribution and texture;
normocephalic;
Eyes: Anicteric sclera; pink palpebral
conjunctiva; pupils are round, regular,
equally reactive to light
PHYSICAL EXAMINATION

15. Ears: Both pinna symmetrical; no lesion on
auricle and both canals
Nose/Sinuses: Symmetrical; septum
midline
Mouth/Throat: Pink buccal mucosa;
tongue midline; no ulceration; no
lesions
PHYSICAL EXAMINATION

16. NECK
No mass, lesion; no visible pulsation
of jugular vein; no CLAD, mass; no
tracheal deviation; no tenderness
PHYSICAL EXAMINATION

17. THORAX & LUNGS
Inspection: No lesions; Symmetrical chest
expansion; No intercostal retractions.
Palpation: Non-tender on all lung fields
Percussion: Resonant on all lung fields
Auscultation: Equal clear breath sounds; no
crackles
PHYSICAL EXAMINATION

18. BREAST
Inspection: Symmetric, pendulous, (-)
peau d’orange, no ulceration, skin
lesions, or discharges.
Palpation:
PHYSICAL EXAMINATION

19. AXILLAE
Inspection: No lesions, no signs of
infection, no discoloration
Palpation:
PHYSICAL EXAMINATION

20. CARDIOVASCULAR
adynamic precordium; normal rate,
regular rhythm; no murmur
PHYSICAL EXAMINATION

21. ABDOMEN
flabby; normo-active bowel sounds;
soft and non-tender
PHYSICAL EXAMINATION

22. EXTREMITIES:
Warm skin, symmetrical, no
atrophy, no clubbing, no cyanosis,
no edema, CRT < 2secs
PHYSICAL EXAMINATION

23. Phyllodes Tumor, Benign Right Breast
s/p Core Needle Biopsy (December 16, 2014)
PRE-OP DIAGNOSIS

24. Partial Mastectomy
PROPOSED OPERATION

25. Unremarkable hospital stay
Discharged on the second post-op day
COURSE IN THE WARD

26. Phyllodes Tumor, Benign Right Breast s/p Core
Needle Biopsy (December 16, 2014)
FINAL DIAGNOSIS

27. Characteristic Benign Mass Malignant Mass
Signs and
Symptoms
 Mobile mass, usually
painful
 Nipple discharge
 Changes in size
 Fixed mass, often painless;
 Nipple discharge or
bleeding;
 Changes in the size or
contour of the breast;
 Changes in color or
appearance of areola;
 Peau d’orange;
 Weight loss;
Mass Margin Smooth and Round;
Well demarcated; with
Fibrous Capsule
Irregular Borders; with no
Capsule
BENIGN VS MALIGNANT

28. Characteristic Benign Mass Malignant Mass
Manner of
Growth
Grows by expanding
and pushing away and
against surrounding
tissue → mobile mass
Grows by invading and
sometimes destroying
surrounding tissue → fix mass
Metastasis Never metastasize Almost always metastasize
Examples Fibrocystic changes
Cysts
Fibroadenomas
Infection
Trauma
Phyllodes Tumor
Ductal Carcinoma
Lobular Carcinoma
Phyllodes Tumor
BENIGN VS MALIGNANT

29. ULTRASOUND – BENIGN MASS
Intense and Uniform Hyperechogenicity
Ellipsoid shape and thin Echogenic Capsule
Smooth margins
Starvos, et al. Radiology 1995; 96:23-34

30. Thin
Echogenic
Capsule
Ellipsoid Shape
(wider than tall)
Fibroadenoma
ULTRASOUND – BENIGN MASSStarvos, et al. Radiology 1995; 96:23-34

31. Anechoic
Ellipsoid Shape
(wider than tall)
Smooth Surrface
Cyst
ULTRASOUND – BENIGN MASSStarvos, et al. Radiology 1995; 96:23-34

32. Spiculation
Angular Margins
Hypoechogenicity
Shadowing
Calcification
Duct Extension
Branch pattern
Microlobulation
ULTRASOUND – MALIGNANT MASSStarvos, et al. Radiology 1995; 96:23-34

33. Angular
Margin
Microlobulation
Hypoechoic
ULTRASOUND – BENIGN MASSStarvos, et al. Radiology 1995; 96:23-34
Irregular Margin

34. THE BREAST

35. ANATOMY
2nd or 3rd Rib
6th or 7th Rib
Lateral Border
of the Sternum
Anterior
Axillary LIne

36. ANATOMY
Pectoralis Major
Serratus
Anterior

37. ANATOMY

38. ANATOMY
Subclavian
Artery
Internal
Thoracic a.
perforating
branches
Axillary Artery
Lateral
thoracic a.
Lateral mammary
Branches
Lateral mammary
Branches of lateral
cutaneous branches of
posterior intercostal aa.

39. ANATOMY
Axillary vein
(lateral) nodes
drainage from the upper
extremity
External Mammary
(anterior or pectoral)
Scapular (posterior or
subscapular)
drainage from the lateral aspect
of the breast
drainage principally from the
lower posterior neck, the
posterior trunk, and the
posterior shoulder
Central(anterior or
pectoral)
from the axillary vein, external
mammary, and scapular
groups of lymph nodes, and
directly from the breast
Subclavicular (apical)
Interpectoral (Rotter’s)
directly from the breast
drainage from all
of the other groups of axillary
lymph nodes

40. ANATOMY
External Mammary
(anterior or pectoral)
Scapular (posterior or
subscapular)
Axillary vein
(lateral) nodes
Central(anterior or
pectoral)
Subclavicular (apical)
Interpectoral (Rotter’s)

41. BREAST DEVELOPMENT
Birth 2 years
After
Puberty
Estrogen
↑Estrogen

42. BREAST DEVELOPMENT
Birth 2 years
After
Puberty
After Pregnancy
Estrogen
↑Estrogen
Progesterone
Prolactin
Oxytocin

43. PHYLLODES TUMOR
Aka. Cystosarcoma Phyllodes
Derived from the Greek words sarcoma (“fleshy
tumor”), and phyllon (“leafy”)
Rare (1% of breast tumor), predominantly benign
tumor
Composed mainly of connective tissue
Benign Phyllodes do not metastasize, but can grow
aggressively, can recur locally

44. PATHOPHYSIOLOGY

45. EPIDEMIOLOGIC
Exclusively occur in the female breast
Can develop at any age, median age = 50s

46. MALIGNANT PHYLLODES
10-15% of Phyllodes tumor
Matastasize hematogenously
Recurrent malignant tumors seem to be more
aggressive
Lung, skeleton, heart, and liver – most common
metastatic site
Roughly 30% of patient with malignant Phyllodes die
from this disease
May present with dyspnea, fatigue, and bone pain

47. PRESENTATION
Presents larger mass, and display rapid growth
Rarely involves the nipple-areola complex or ulcerate
the skin
Frim, mobile, well-circumscribed, nontender breast
mass
Overlying skin may display shiny appearance and be
translucent enough to reveal underlying breast veins
Very large Phyllodes may erode through overlying skin

48. MANAGEMENT
Complete excision of the tumor
2cm margin for small tumors
5cm margin for large tumor
> Tumor-to-breast ratio – total mastectomy
Axillary dissection – not recommended

49. ADJUVANT THERAPY
No proven role for adjuvant chemotherapy or
radiotherapy

50. POST-OP COMPLICATION
Infection
Seroma formation
Local or distant recurrence

51. Tissue Involvement Skin-sparing Total (simple)
Breast Tissue + +
Nipple-Areola
Complex
+ +
Scars + +
Skin +
Level I nodes
Level II nodes
Level III nodes
Pectoralis Major
and Minor
MASTECTOMY

52. Tissue Involvement Extended Simple Modified Radical Halsted Radical
Breast Tissue + + +
Nipple-Areola
Complex
+ + +
Scars + + +
Skin + + +
Level I nodes + + +
Level II nodes + +
Level III nodes +
Pectoralis Major
and Minor
+/- Pectoralis
Minor
+
MASTECTOMY

53. Borders Modified Radical
Laterally Anterior margin of the Latissimus dorsi
muscle
Medially Midline of the sternum
Superiorly Subclavius muscle
Inferiorly Caudal extension; 2-3cm inferior to
the inframammary fold
MODIFIED RADICAL
MASTECTOMY

54.  THANK YOU 