Surgical Pathology Conference 一般外科 : CR 吳柏鋼 / VS. 張耀仁

Case Presentation Name: 鄭王 x 桂 ID: Q Gender: female Age: 58 y/o Date of admission: Date of operation: Date of discharge:

Chief Complaint Right breast mass was noted for 4 months

Present Illness This 58 y/o woman was healthy until 4 months ago. One nodule over right breast was noted and she visited CGMH initially. Rapid growth of the mass was noted and she came to our OPD for help. Microcalcification of left breast was found in mammography There was no fever, no nipple discharge, no tenderness

Personal History No DM, no HTN No surgical history Smoking (-) Alcohol consumption (-)

Physical Examination Consciousness: clear Vital signs: stable HEENT: grossly normal Neck: supple, no palpable lymph node Chest & lung: symmetric, clear breathing sound Heart: regular rhythm, no murmur Breast: huge firm mass over right breast, 8cm in diameter Abdomen: soft & flat, no tenderness, no palpable mass Back & spine: no deformity, no limited motion, no knocking tenderness Extremities: no deformity, no limited motion, no pitting edema Neurologic exam: negative

Lab. Data CBC: WBC: 6400 /uL, Hb: 12.9 g/dL, PLT: /uL GOT: 10 IU/L, GPT: 16 IU/L BUN: 8.4 mg/dL, CRE: 0.5 mg/dL Na: 139 mmol/L, K: 3.45 mmol/L GLU: 138 mg/dL CA125: 9.4 IU/mL, CEA: 1.77 ng/mL

CXR

Mammography (Right)

Mammography (Left)

Needle Localization

OP Findings 8x6x6 cm solid tumor under right areola, with abundant blood supply S/p needle localization, left breast Procedure: Wide excision of right breast tumor Wide excision of right breast tumor Needle-guide biopsy of microcalcification, left Needle-guide biopsy of microcalcification, left

Pathology Right: Phyllodes tumor, low grade Phyllodes tumor, low gradeLeft: Focal calcification, no malignancy Focal calcification, no malignancy

Discussion

Phyllodes Tumors (PT) Cystosarcoma phyllodes % of all breast tumors Occur in women of all age (mainly y/o) Malignant: 3-54% Local recurrence: 15-20% of both benign and malignant cases Metastatic spread: hematogeneous to lung

Histopathology Present of both stromal & epithelial component Criteia of classification Cellular atypia Cellular atypia Stromal cellularity Stromal cellularity Sarcomatous differentiation Sarcomatous differentiation Mitotic index Mitotic index

Differential Diagnosis Sonography Substantial overlap between PT & fibroadenoma Substantial overlap between PT & fibroadenoma Features of PT: Features of PT:Lobulation Heterogeneous hypoechoic pattern Absence of microcalcification Posterior acoustic enhancement Intramural cystic area Mammography High density (75% in PT & 37% in fibroadenoma) High density (75% in PT & 37% in fibroadenoma)

Treatment of PT Wide local excision with 1-2cm margin is the treatment of choice Adjuvant radiotherapy: Uncertain Uncertain For patients with poor prognostic features For patients with poor prognostic featuresChemotherapy No proven benefit No proven benefit

Risk Factors for Recurrence Local recurrence Stromal overgrowth (P<0.0001) Stromal overgrowth (P<0.0001) Large tumor size (P=0.0177) Large tumor size (P=0.0177) Surgical margin <1cm (P=0.0120) Surgical margin <1cm (P=0.0120) Systemic metastasis Stromal overgrowth (P<0.0001) Stromal overgrowth (P<0.0001) Patient survival Stromal overgrowth (P<0.0001) Stromal overgrowth (P<0.0001)

References Joshi SC et al. Cystosarcoma phyllodes: our institutional experience. Australasian Radiol 2003; 47: Shabbir J et al. Phyllodes tumor of breast. J Coll Physicians Surg Pak 2003; 13(3): Guerrero MA et al. Malignant phyllodes tumor of the breast: review of the literature and case report of stromal overgrowth. Surg Oncol 2003; 12(1): Asoglu O et al. Risk factors for recurrence and death afterprimary surgical treatment of malignant phyllodes tumors. Ann Surg Oncol 2004; 11(11): Yilmaz E et al. Differentiation of phyllodes tumors versus fibroadenoma. Acta Radiol 2002; 43(1): Chao TC et al. Sonographic features of phyllodes tumors of the breast. Ultrasound Obstet Gynecol 2002; 20(1):