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Kamis, 27 Oktober 2011

Phyllodes Tumor

Dewi Fransiska, Maelissa Pramaningasih Ririmasse, Wulan Ayudyasari, IGN Gunawan Wibisana

Department of Surgery FKUI/ RSCM, Jakarta, October 2011


Translated by Feyona Subrata & Caroline Supit


A 58 year-old woman was submitted to the Cipto Mangunkusumo hospital with a chief complaint of a lump on the left breast since 2 years before submission. The lump was growing slowly. At first it was about 2 cm in diameter and it grew until ± 11x11x8 cm within the last 2 years. There was pain before menstruation, no history of trauma on the breast and no history of discharge from the nipple. There was no changes in skin color, shape, ulcer or peau d’orange, no nipple retraction and lumps in other places.

There was no unexplainable weight loss, severe headache, bone pain, shortness of breath or chronic cough. Patient had her merache when she was 12 year-old, got married when she was 23 year-old with normal menstrual cycle of 30 days. There was a history of oral contraception for 3 years and injected contraception for 5 years. There was no history of radiation.

            From the inspection on physical examination, asymetric was found. There was a coconut sized mass on her left breast, accompanied with venectation. There was no erythema, peau d’orange, nipple retraction, ulcus, or satellite nodule. On the palpation of the left breast, there was a lump felt, approximately 11 x 11 x 8 cm on the supero-inferiomedial quadrant. The consistency was hard, partly cystic with a lobulus surface and distinct boundary of the lump. The mass was mobile to pectoralis muscle and there was no pain on the breast. Left and right axillary lymph nodes were not palpable, the left and right (superior and inferior) clavicula lymph nodes were also not palpable.


Picture 1. Pre operative clinical appearance of the breasts
Picture 2. Mammographic result
Picture 3.Ultrasound result

            The mammography examination showed multiple mass on the median quadrant of the left breast, suggestive benign. Patient was diagnosed with tumor on the left breast suggestive benign, and treated with incisional – biopsy procedure and frozen section procedure. On the intraoperative, the result was accordance with the phyllodes tumor, and the surgeon have decided to do the simple mastectomy technique.  Tumor mass was removed with the entire  breast tissue, pectoralis major fascia involving the skin up to 2cm above the tumor, the incisions were closed with sutures.

Picture  4. Surgery design
Picture 5. Phyllodes Tumor tissue
Picture 6. Surgical wound closed with drain procedure    


Afterwards, patient was treated in the regular treatment room. The initial drainage on the first day post-operative was 100 cc ; hemorrhage, second day was 90 ; hemorrhage, third day was 50 cc ; hemorrage, forth day was 30 cc : serous-hemorrage fifth day was 12 cc ; serous- hemorrhage, then the drain was removed.


Literature Review
Cystosarcoma phyllodes, also known as phyllodes tumor is one of the rare types of breast neoplasm, they account for less than 1% of all breast neoplasms, and only 2-3 % of all breast tumor that comes from Fibroepithelial tissue. Muller was the first one who discovered this tumor in 1838, when he cut through the tumor it looked like a leaf, so he called this tumor as “phyllodes” derived from Greek word that had a meaning of “leaf like appearance”. The naming of cystosarcoma phyllodes is not exactly right, because this tumor is usually benign, although some of them could become malignant. Occurrence is most common in women, including young adult and elderly, commonly between the ages of 35-54 years old.

WHO classified phyllodes tumor as benign, borderline, and malignant, based on histopathology features. The tissue originally comes from intralobular stroma, and rarely comes from existed fibroadenoma. The biggest mass of this tumor is composed of fibrous tissue which is the combination of solid, cystic and gelatinous. The cystic area is the area which undergoes necrotic and infarct.

The clinical characteristics of this tumor are firm, mobile, and well-circumscribed with average size of 4-5 cm. It is usually unilateral and non tender mass. In 20 % of the patients, the axillary lymph node are enlarged, but this is not caused by metastatic, but by the reactive changes. Mammography result that shows calcification and necrotic can’t differentiate between benign, borderline or malignant, these makes difficulties to differentiate between benign, malignant, and fibroadenoma phyllodes tumor.  Ultrasound examination shows lesion with distinct border, hypoechoic, firm structure could be surrounded with cystic. Histologic examinations show increased of of stroma celullarity with anaplasia, invasive focus on the border of the tumor, increased mitotic activity, and fast growing of the tumor size with stroma invasion of breast tissue.Phyllodes tumor are usually localized, and can be treated with excision. In malignant lesion the reccurence could happen, but it stays localized, while in more malignant case, around 15 % has distant metastatic. Most of the malignant Phyllodes Tumor consisted of liposarcoma or rhabdomyosarcoma element , rather than fibrosarcoma element.


·        Vocabulary
     -  Peau d’orange : skin that has the appearance  and dimpled texture of an orange peel.
·       -  Retraction: The state of being retracted/ pull backward.
·       -  Venectation : Varicosity of a vein.
·       -  Cystic : Related with cyst.
·    - Simple Mastectomy: removal of the breast tissue, nipple, areola and skin but not all the lymph nodes
·    - Rhabdomyosarcoma : a cancerous (malignant) tumor of the muscles, originally comes from primitive mesenchyme cell and shows differentiation along the line of rhabdomioblastik, including the one that doesn’t show clear muscle characteristic.
     
      Reference
  1. Crum PC, Lester SC, Cotran RS. The Female Genital System and Breast. Dalam : Kumar V, Cotran RS, Robbins SL, editor. Robbins Basic Pathology. 7th ed. Philadelphia: Saunders; 2003. Hal 710.
  2. Bland KI, Beenken SW, Copeland III EM. The Breast. Dalam: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE, editor. Schwartz’s Principles of Surgery. 8th ed.  New York: McGraw-Hill; 2005. Hal 494.
  3. Verma S, Singh RK, Rai A, Pandey CP, Singh M, Mohan N. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. J Can Res Ther [serial online] 2010 [cited 2011 Oct 2];6:511-5. Available from: http://www.cancerjournal.net/text.asp?2010/6/4/511/77085.
  4. Non-epithelial Noeplasm of the Breast. Dalam : Kruere’s Breast Surgical Oncology. New York : McGraw-Hill; 2010. Hal 251-4.
  5. Dorland, WA Newman. Kamus Kedokteran Dorland. Huriawati Hartanto dkk., editor. Edisi 29. Jakarta: EGC; 2002.


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