1. BLOCK 10 A TINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA

2. HISTORY

3. PROFILE M.P. 52/F San Dionisio, Paranaque Single, works as a vollunteer at the cemetery Admitted 01/08/12

4. HISTORY OF PRESENT ILLNESS 7 years PTA: palpable mass, R breast: ~<1cm in greatest diameter, firm, movable, nontender, with no note of skin changes/ nipple discharge. No consult done. Interim: Progressive enlargement of mass; (+) occasional pain described as “tumutusok- tusok” VAS 2/10 (1 year PTA) and erythema and pruritus on the skin overlying the mass.

5. HISTORY OF PRESENT ILLNESS 2 months PTA: consulted at PGH-OPD  biopsy of the mass was done A> PHYLLODES TUMOR R Breast  scheduled for elective surgery

6. REVIEW OF SYSTEMS (-) wt. loss, easy fatigability, fever BOV, tinnitus, dysphagia Dyspnea, chest pain, palpitations, orthopnea, PND Bowel and bladder changes Polyuria, polydipsia, polyphagia Heat and cold intolerance

7. PAST MEDICAL HISTORY (-) previous hospitalizations/ surgical procedures (-)comorbidities

8. FAMILY MEDICAL HISTORY (-)Benign/Malignant breast neoplasia (-) other CA (+) HPN, sibling (-)DM (+) BA, both parents

9. PERSONAL AND SOCIAL HISTORY (+) Smoker, 22 pack years (+) Alcoholic beverage drinker, 1x a week, 2-3 bottles of beer

10. OB-GYN HISTORY Menarche: 16y/o Regular monthly period, lasting 5 days, consuming 4-5 ppd (+) dysmenorrhea LNMP: 1 st week Dec 2011 OB Score: G5P4 (4012) (-)OCP/IUD use

11. PHYSICAL EXAMINATION

12. BP 140/80 HR 70 RR 20 Temp 36.7 Systemic PE: E/NHEENT: (-) CLAD, NVE Chest: ECE, CBS, NRRR, Distinct S1 and S2 Abdomen: soft and flabby, NABS Extremity: FEP, PNB, (-) cyanosis, edema

13. The R breast is converted into a 8cm x 24cm x 10cm, firm, nodular, well-circumscribed, movable, non-tender mass. Overlying skin is shiny with a patch of erythema. (-) nipple discharge L breast: (-)masses/tenderness/skin changes/nipple discharge

14. Considerations Differential Diagnosis R/InR/Out Phyllodes TumorLarge mass, patient age, gender Cannot be ruled out, needs biopsy Giant Fibroadenoma Large mass, gender Common Usually in young females (small) (75% ), < 5% of grow rapidly. Cannot be ruled out, needs biopsy Breast Malignancy Breast massCharacteristic of the mass: movable, lacks skin changes and manifestations Cannot be ruled out, need other diagnostics

15. DIAGNOSTICS

16. Imaging of giant breast masses with pathological correlation M Muttarak, B Chaiwun Department M Muttarak, B Chaiwun.Imaging of giant breast masses with pathological correlation. Singapore Med J 2004 Vol 45(3) : 132 Mammography is always the imaging modality of choice for breast masses specially in ages 35 years and above.

17. FNA Biopsy: Smears disclose cohesive clusters of uniformly sized ductal cells many of which are arranged in knobby short branching patterns. Portions of fibromyxoid stroma can be observed in fields. Histopathologic Diagnosis: Negative for malignant cells, right breast mass Cytomorphologic features consistent with phyllodes tumor Recommend tissue biopsy for a more definitive diagnosis

18. DIAGNOSIS PHYLLODES TUMOUR

19. Phyllodes Tumour a.k.a. Phylloides tumours, cystosarcoma phyllodes – Cystosarcoma phyllodes– used to indicate only the tumour’s leaf-like fleshy appearance and propensity to contain macroscopic cyst and a misnomer since most PTs are benign – Cause: unknown, p53 defect MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

20. Clinical Presentation: – Unilateral, painless, palpable, firm and well circumscribed, variable size – Rapid growth and skin ulceration can occur (ischemia from pressure and stretching) MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

21. Rare, < 1 % of all breast neoplasm and 2-3 % of all fibro- epithelial breast tumors 35-54 y/o 3 Histopathologic types: benign, borderline and malignant (20%) L-R Benign, Borderline, Malignant Satyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer Research and Therapeutics 2010. Vol. 6, Issue 4. 511-515

22. Histologic Classification: Based on: infiltrative margin, stromal overgrowth, stromal atypia and cellularity, and mitotic activity FeaturesBenignBorderlineMalignant Stromal Cellular Atypia MildMarked Mitotic Activity< 4/ 10 hpf4-9/ 10 hpf≥ 10/ 1o hpf Stromal Overgrowth Absent Present Tumour marginsCircumscribedCircumscribed to Infiltrative Infiltrative Harris JR et al. Diseasesof the breast. 4 th Ed. Vol 2. 781-791

23. Phyllodes Tumour Core biopsy is better than FNAC yielding about 65% of correct diagnosis No distinct imaging characteristics distinguish it from fibroadenoma

24. Phyllodes Tumor Ian K. Komenaka; Mahmoud El-Tamer; Eliza Pile-Spellman; Hanina Hibshoosh. Core Needle Biopsy as a Diagnostic Tool to Differentiate Phyllodes Tumor From Fibroadenoma. ARCH SURG/VOL 138, SEP 2003. 987-990

25. Phyllodes Tumour Fibroadenoma

26. MANAGEMENT

27. Treatment is surgical, regardless of classification ◦ Wide excision and simple mastectomy (radical not done), surgical margin of at least 1 cm (1-2 cm) to prevent local recurrence ◦ Mastectomy: > 10 cm, malignant, recurrent ◦ Axillary lymphadenectomy is considered for clinically suspicious cases and sometimes not warranted since spread is hematogenous (metastatic) Harris JR et al. Diseasesof the breast. 4 th Ed. Vol 2. 781-791

28. Final assessment will depend on pathology report after complete surgical removal of the mass

29. Specific management (histologic consideration): – Benign and borderline: wide local excision – Malignant: simple mastectomy with or without reconstruction Satyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer

30. Controversial – Radiotherapy: adjuvant for high risk patients, >5 cm, with stromal overgrowth, with 10 mitotic elements/hpf, or with infiltrating margins – Chemotherapy: Doxurubicin and ifosfamide for metastatic spread – Hormonal management (ER/PR) still on research Harris JR et al. Diseasesof the breast. 4 th Ed. Vol 2. 781-791

31. PROGNOSIS

32. Recurrence and Survival Rate – Local recurrence for high-grade malignant lesions is 26% (12-65%): (+) stromal overgrowth, large size tumor, and involved margin – 5 yr survival rate (malignant): 54-82% – 10 yr survival rate : 23-42% Harris JR et al. Diseasesof the breast. 4 th Ed. Vol 2. 781-791