Phyllodes tumor

Case contributed by Dr Ammar Ashraf

Presentation

Painless left breast mass for 8 years. Increasing in size over the last 18 months.

Patient Data

Age: 50 years
Gender: Female
Mammography

Huge left breast lesion which could not be properly imaged with mammogram because of its size and density. No suspicious abnormality is seen in the right breast. 

Ultrasound

Large heterogeneous left breast mass lesion measuring more than 20 x 15cm, having both solid and cystic components and mild internal vascularity. 

CT

Very large left breast mass lesion having heterogeneously enhancing solid and non-enhancing cystic/necrotic components. Because of its huge size, it is not completely covered in the field of scan. No significant axillary lymphadenopathy is seen. No evidence of invasion in to the underlying chest wall muscles is noted. Small lymph node measuring 10 x 11 mm seen in the prevascular space anterior to the arch of aorta.  A few venous collaterals are seen in the upper anterior left chest wall. Unremarkable abdominal CT scan.

Nuclear medicine

Delayed whole body static images revealed abnormal soft tissue uptake in the area of left breast (known case of left breast mass). Focal areas of increased radiotracer uptake noted at both knees and ankle joints (likely osteoarthritic). Rest of the imaged skeleton shows homogeneous radiotracer distribution. 

Case Discussion

Procedure: Left breast mass biopsy followed by modified radical mastectomy (MRM).

Diagnosis: Phyllodes tumor, low grade. Tumor size: 27 x 26 x 15 cm. Tumor weight: 5600 grams. Surgical resection margins are all clear.  Skin ulcer, with fibrin deposition, granulation tissue and chronic inflammation. Nipple and areolar region: Unremarkable. Eleven (11) axillary lymph nodes are identified, none of which show metastatic tumor. The non-neoplastic breast tissue shows fibrocystic change/disease.

Comments: This phyllodes tumor most likely falls in the category of low grade based on the rather low mitotic count with a maximum of 2 mitosis per high power field in most mitotically active areas; however, the majority of the blocks show rare mitosis. The stromal nuclear pleomorphism is minimal and the margin is pushing rather than infiltrative.  Tumor size, however, is very large. The stromal component shows interestingly in places muscle and osseous metaplasia. It is, however, well known that no single feature alone or in combination is sufficient to predict the clinical behavior of this neoplasm with absolute certainty. Based on the negative surgical resection margins and the fact that this patient had a mastectomy and the phyllodes tumor is low grade, all of these features would favor a good prognosis, with low rate of local recurrence and rare incidence of distant metastasis.

Patient did well postoperatively and had no evidence of local recurrence or distant metastasis on follow up in eight years.  

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