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Sakshi Andersen, Matilda Svenning Hunt, Tine M. Engberg Damsgaard. Case 9 (2023): Malignant Phyllodes Tumor of the Breast. Journal of Plastic, Breast & Reconstructive Surgery. 2023.
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Sakshi Andersen, Matilda Svenning Hunt, Tine M. Engberg Damsgaard
A 58-year-old female was referred to the Department of Breast Surgery with a red, swollen and tender right breast. The patient had a medical history of hypertension and benign cysts in the breasts and had undergone augmentation mammoplasty with breast implants 15 years ago. The symptoms debuted 14 days prior to admission, and she was initially treated with antibiotics on the suspicion of an infect
BeforeAfterA 58-year-old female was referred to the Department of Breast Surgery with a red, swollen and tender right breast. The patient had a medical history of hypertension and benign cysts in the breasts and had undergone augmentation mammoplasty with breast implants 15 years ago. The symptoms debuted 14 days prior to admission, and she was initially treated with antibiotics on the suspicion of an infection. The patient had not at any time presented with fever or any other symptoms of illness. According to the patient, no mass in the breast could be palpated initially.
Inspection and palpation of the right breast revealed a giant mass, which was estimated to be 12 cm in diameter, located behind the nipple-areola complex. The skin was stretched, and the shape of the breast was deformed. The contralateral breast was unaffected. No enlarged lymph nodes were found in the axillary region or the head and neck region. Nine days after the initial examination, the mass was clinically assessed to have enlarged to 30 cm in diameter.
An ultrasound was performed immediately and showed a large heterogenous mass in the right breast involving almost all of the breast with no clear arguments of invasion, classified as BIRADS 5. The breast implant was with extracapsular rupture on the right side, and the breast implant on the left side was with intracapsular rupture. The diagnosis of malignant phyllodes tumor was suspected. Hence, a mammography was substituted with an MRI-scan of the breasts, and subsequently a PET-CT scan. Furthermore, a core needle biopsy of the breast was performed which showed a borderline phyllodes tumor. Malignant phyllodes tumor of the breast is a rare type of cancer that arises from the connective tissue of the breast. It accounts for 0.3 to 1% of all breast cancers (1). Phyllodes tumors are classified into three categories: benign, borderline and malignant based upon the microscopic appearance of the stromal component with a distribution of 60%, 20%, and 20%, respectively (2). Treatment of malignant phyllodes tumor typically involves complete surgical resection of the tumor with a margin of normal breast tissue, with axillary lymph node dissection being reserved for selected cases. Adjuvant radiation therapy may be considered in certain situations such as positive margins or large tumors to reduce the risk of local recurrence. In a multidisciplinary team including the sarcoma team, breast surgeons and plastic surgeons, it was decided to perform resection of the tumor with a 2 cm resection margin without primary breast reconstruction. Depending on the defect after radical excision the following options for closure were considered: 1) split- or full-thickness skin graft 2) a thoraco-abdominal rotation flap or 3) a latissimus dorsi muscle flap.
1
A) MRI-scan and B) PET-CT-scan revealed a tumor measuring 12x12x13 cm in diameter with no deep invasion of the pectoralis muscle and several pathological looking lymph nodes in the left axilla and in the subpectoral area.
2
The surgery was initiated by the breast surgeon with a wide incision around the right mamma. Four lymph nodes from the right axillary region were resected and showed no evidence of malignancy with peroperative frozen section analysis.
The radical mastectomy was performed in the subcutaneos cleavage to the pectoralis muscle.
4
The sarcoma surgeon resected both the major an the minor pectoralis muscles and explanted the right breast implant.
The breast, including the pectoralis muscles were excised.
The defect measured 25 x 30 cm. Two drains were inserted. Primary closure was performed by undermining adjacent tissue. The defect was closed in three layers with vicryl and with nylon.
7
The final pathology diagnosis confirmed a malignant phylloides tumor and four lymph nodes with no malignancy. Follow-up is planned with MRI-scans and PET-CT scans every third month in at least five years in the sarcoma section. The patient is awaiting secondary breast reconstruction.
