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 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
- 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.
- 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.
- 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.
- Non-epithelial
Noeplasm of the Breast. Dalam : Kruere’s Breast Surgical Oncology. New
York : McGraw-Hill; 2010. Hal 251-4.
- Dorland, WA
Newman. Kamus Kedokteran Dorland. Huriawati Hartanto dkk., editor. Edisi
29. Jakarta: EGC; 2002.
