Case: 15 year old girl presented with, Unilateral breast swelling since 6months On examination Soft,non tender,bosselated surface Displayed dilated veins . was diagnosed as Phyllodes tumour
Excision done Recovered well Performed in Rajah Muthaiah Medical College Annamalai university Chidambaram,TamilNadu
Dr.A.Anwar Ali and Team Dr.P.RaviShankar, Dr.R.Dhilipan Pradap, Dr.P.Madhulika
Note: Pictures of the procedure are in treatment portion
Phyllodes tumors of the breast are rare, accounting for less than 1% of all breast tumors. The name “phyllodes,” which is taken from the Greek language and means “leaflike,” refers to that fact that the tumor cells grow in a leaflike pattern. Other names for these tumors are phylloides tumor and cystosarcoma phyllodes. Phyllodes tumors tend to grow quickly, but they rarely spread outside the breast.
Although most phyllodes tumors are benign (not cancerous), some are malignant (cancerous) and some are borderline (in between noncancerous and cancerous). All three kinds of phyllodes tumors tend to grow quickly, and they require surgery to reduce the risk of a phyllodes tumor coming back in the breast (local recurrence).
Phyllodes tumors can occur at any age, but they tend to develop when a woman is in her 40s. Benign phyllodes tumors are usually diagnosed at a younger age than malignant phyllodes tumors. Phyllodes tumors are extremely rare in men.
How Phyllodes Tumors Develop in the Breast
Unlike breast cancers called carcinomas, which develop inside the ducts (milk-carrying tubes) or lobules (milk-producing glands) of the breast, phyllodes tumors start outside of the ducts and lobules. Phyllodes tumors develop in the breast’s connective tissue, called the stroma. The stroma includes the fatty tissue and ligaments that surround the ducts, lobules, and blood and lymph vessels in the breast. It may be helpful to think of the stroma as the tissue that “holds everything together” inside the breast. In addition to stromal cells, phyllodes tumors can also contain cells from the ducts and lobules.
Symptoms and Diagnosis of Phyllodes Tumors of the Breast
Signs and symptoms of phyllodes tumors
The most common symptom of a phyllodes tumor is a breast lump that you or your doctor can feel while examining the breasts. Phyllodes tumors tend to grow quickly, within a period of weeks or months, to a size of 2-3 cm or sometimes larger. This rapid growth does not automatically mean the phyllodes tumor is malignant; benign tumors can grow quickly, too. The lump is usually not painful. If left unchecked, the lump can create a visible bulge as it pushes against the skin. In more advanced cases — whether benign, borderline, or malignant — a phyllodes tumor can cause an ulcer or open wound to form on the breast skin.
Diagnosis of phyllodes tumors
Like other less common types of breast tumors, phyllodes tumors can be difficult to diagnose because doctors don’t encounter them all that often. A phyllodes tumor also can look like a more common type of benign breast growth called a fibroadenoma. A fibroadenoma is a solid, growing lump of normal breast cells that is the most common kind of breast mass, especially in younger women.
Two key differences between fibroadenomas and phyllodes tumors are that phyllodes tumors tend to grow more quickly and develop about 10 years later in life — in the 40s as opposed to the 30s. These differences can help doctors distinguish phyllodes tumors from fibroadenomas.
Diagnosing phyllodes tumors usually involves a combination of steps:
- A physical examination of the breasts.Your doctor may be able to feel the lump in the breast, or you may feel it yourself during a breast self-exam.
- Amammogram to obtain X-ray images of the breast and locate the tumor. On a mammogram, a phyllodes tumor appears as a large round or oval mass with well-defined edges. Sometimes the tumor might look like it has rounded lobes inside it. Calcifications can show up as well. Calcifications are tiny flecks of calcium — like grains of salt — in the soft tissue of the breast. Your doctor likely will need to do additional testing to confirm that the lump is a phyllodes tumor.
- Ultrasound to obtain sound-wave images of the breast. The images form as the sound waves are “echoed back” by the tissue. On ultrasound, phyllodes tumors look like well-defined masses with some cysts inside of them.
- MRI to obtain additional images of the tumor and help in planning surgery.
- Biopsy to take samples of the tumor for examination under a microscope. Although imaging tests are useful, biopsy is the only way to tell if the growth is a phyllodes tumor. Your doctor can perform one of two procedures:
- core needle biopsy, which uses a special hollow needle to take samples of the tumor through the skin
- excisional biopsy, which removes the entire tumor
A pathologist then examines the tumor tissue under a microscope to make the diagnosis. He or she also classifies the phyllodes tumor as benign, borderline, or malignant. In a benign tumor:
- the edges are well-defined
- the cells are not dividing rapidly
- the stromal cells (connective tissue cells) still look somewhat like normal cells
- there is not an “overgrowth” of stromal cells — there are epithelial cells (the types of cells that line the ducts and lobules) as well
In a malignant tumor:
- the edges are not well-defined
- the cells are dividing rapidly
- the stromal cells have an abnormal appearance
- there is an overgrowth of stromal cells, sometimes with no epithelial cells present at all
Phyllodes tumors are called “borderline” if their features fall somewhere in between these two descriptions.
Treatment of Phyllodes Tumors of the Breast
Whether phyllodes tumors are benign, borderline, or malignant, the treatment is the same: surgery to remove the tumor, along with at least 1 centimeter of surrounding healthy breast tissue. Some doctors feel that an even wider margin of healthy tissue should be removed. This approach is sometimes called “wide excision.”
Wide excision is important because studies have shown that when wide excision is not done, phyllodes tumors are more likely to recur (come back) in the same area of the breast. This is true whether the tumor is benign or malignant.
If you had a phyllodes tumor removed with excisional biopsy, you may need to have surgery again to achieve these wide margins around the tumor. This can mean having a lumpectomy, or in some cases, mastectomy. If your phyllodes tumor was benign, you and your doctor may feel comfortable watching the area closely instead of operating again. In most cases, though, more surgery is recommended.
Possible surgical procedures to achieve wide excision for phyllodes tumors are: (Warning: Don’t watch if blood make you upset)
- Lumpectomy:The surgeon removes the tumor (the “lump”) and at least 1 cm of normal tissue surrounding it.
If the phyllodes tumor is very large and/or the breast is small, it may be too difficult to do a wide excision and preserve enough healthy breast tissue to achieve a natural look. In this case, your doctor may recommend mastectomy:
- Partial or segmental mastectomy:The surgeon removes the portion of the breast that contains the phyllodes tumor.
- Total or simple mastectomy:The surgeon removes the entire breast, but nothing else (such as lymph nodes or muscle).
If you feel strongly about having a lumpectomy rather than mastectomy, your doctor may agree to remove a smaller margin of healthy tissue. However, a margin of less than 1 cm does increase the risk of recurrence later. You and your doctor can work together to decide what’s best for your situation.
Phyllodes tumors rarely spread to the underarm lymph nodes, so in most cases it is not necessary to remove any of them.
Malignant phyllodes tumors are rare. In cases of malignant phyllodes tumors that have not spread outside the breast, radiation may be used. If a malignant phyllodes tumor has metastasized to other parts of the body, treatment would include chemotherapy.
source of the case discussion portion of the article