MATIAS H. AZNAR MEMORIAL COLLEGE OF MEDICINE, INC.

Redemptorist Plaza, Camputhaw, Cebu City

Phyllodes
GROUP 8B
presentsBEDAR, BLANCIA, BOKINGGO,

Tumor
COLOT, ORONGAN, PIEZAS,
PRESIADOS, RADIAMODA, TANZO
 GENERAL DATA

V. Y. Inabanga, Bohol

60yo / F / Married Admitted: 1st time on 1/2

Filipino,; Catholic Informant: Patient & Husband

Born on Oct 10, 1958 Reliability: 80%

 Past Medical History

(+) HPN
 Since 2017
 Taken maintenance last Oct,2018
 Amlodipine 10 mg OD
 Losartan 50 mg OD
 Carvedilol 25 mg OD
 Atorvastatin 40 mg OD
 Past Medical History

(+)DM type 2
 Metformin 500 mg OD

(-) no food and drug allergies

(-) no previous hospitalization and
surgical history
 Family History

(+) Breast mass ( unrecalled dx) –

mother & sister
(-) HPN
(-) DM
(-) Cancer
(-) Other heredofamial diseases
 OB GYNE History

• G6P6 (5105)
• Menarche at 13 yo
• Interval: monthly (regular)
• Days: 3-4 days
• Amount: 2 pads/ day
• Symptoms: none
 OB GYNE History

• Coitarche at 23 yo
• Partner: 1
• Contraceptives: condom
• STD: none
• Menopause at 54 yo
 Personal & Social
• housewife
• living w/ her husband and their
youngest child
• non smoker; non alcohol drinker
• denied illicit drug use
• Diet : fatty foods, dried fish, sweety
foods, meat
 ,
“Breast
Mass”
Chief complaint
 History of Present Illness

20 years PTA
sudden palpable mass, hard , elevated,
non-movable, erythematous, non tender ,
measuring 5 cm at RUQ of the Left Breast,
no nipple discharges
 History of Present Illness

IN THE INTERIM
the mass was itchy, erythematous, increasing
in size and no other symptoms, patient self
medicated with herbal capsule, condition
tolerated, no consultation done
 History of Present Illness

3 MONTHS PTA
patient sought consult in VSMMC, FNAB
was done, results showed Fibroadenoma,
1st Core biopsy revealed Phyllodes tumor
 History of Present Illness

2 MONTHS PTA
enlarged palpable mass, hard, elevated,
non movable, tender, erythematous with
swelling but no nipple discharges on the
left breast
History of Present Illness

sought consult for follow up check up

at VSMMC CECAP, 2nd Core biopsy
done and revealed Fibroadenoma.

Patient was then advised for surgery

and thus this admission.
 Physical Examination

General Survey:
Conscious, responsive, cooperative, afebrile,
not in respiratory distress

Vital signs:
BP: 140/80 mmHg HR: 71 bpm
RR: 20 cpm T: 36.2 C/axilla O2Sat:99%

Weight: Height: BMI:

 Physical Examination

Skin:

warm, good senile turgor, dry,

(-) jaundice
 Physical Examination

HEENT:

Anicteric sclera, pink palpebral

conjunctiva, PERLA, no discharges
noted, no mass, no lesions.
 Physical Examination

Chest & Lungs:

Equal chest expansion, Clear

breath sounds
 Physical Examination

Breast:
Right – no mass, no lesions, no lumps,
no nipple discharge
Left – + mass (27 x 8.5cm) ,firm to
hard, non tender, non-movable, no
nipple discharge
 Physical Examination

Cardiovascular:

AP, distinct heart sounds

 Physical Examination

Abdomen:

Flat, NABS, soft, nontender, no

mass palpated
 Physical Examination

Musculoskeletal:

5/5 muscle strength on all

extremities, no limitation of
movement
 Physical Examination

GUT:

(-) kidney punch sign

 Physical Examination

Rectal:

no warts, no lesions, no lumps and

mass, no fecal component on
examining finger
 Physical Examination

Extremities:

warm, pinkish nailbeds, CRT < 2

seconds, strong peripheral pulses, no
pallor, no cyanosis
Summary
PRIMARY IMPRESSION

Fibroadenoma,
Left
Clinical Formulation
DIFFERENTIAL
DIAGNOSIS
At the
ER
 At the E.R. (1/20/19)

S: O:
(+) breast mass; awake, alert, coherent and
(-)fever; cooperative, NIRD
(-) dyspnea;
V/S:
(-)pain BP 140/80mmHg;
HR: 70bpm;
RR: 20cpm;
Temp: 36.4
At the E.R. (1/20/19)

O:
Breast: (+)left breast mass
34x38cm, smooth, well-
cicumscribed , with multiple
masses noted, non
erythematous, with visible veins
noted, no nipple discharges
noted
 CBC

WBC: 11.29 ↑ Neutrophil: 62.4

RBC: 4.67 Lymphocyte: 29.8
Hgb: 132 Monocyte: 3.7
Hct: 38 Eosinophil: 3.6
Platelet: 464 ↑ Basophil: 0.5
 Electrolytes & BUN, Crea

Electrolytes: BUN – 10.37

Na – 137.7 Crea- 0.73
Potassium – 3.88
Cl – 104.60
Ion Ca – 1.28
Chest X-ray
BT- Prothrombin
Type O positive Time:
13.10 sec
HBsAg -
nonreactive
 At theE.R. (1/20/19)

A: P:
Fibroadenoma, Surgical Management: Total
Mastectomy, Left
Left CP clearance
For laboratory work ups
VS q4hours; I&Oqshift
DAT temporarily
Course
in the
Wards.
Day 1
 Day One (1/21/19)

S: O:
(+) breast mass; awake, alert, coherent and
(-)fever; cooperative, NIRD
(-) dyspnea;
V/S:
(-)pain BP 140/80mmHg;
HR: 70bpm;
RR: 20cpm;
Temp: 36.4
Day One (1/21/19))

O:
Breast: (+)left breast mass
34x38cm, smooth, well-
cicumscribed , with multiple
masses noted, non
erythematous, with visible veins
noted, no nipple discharges
noted
 Day One. (1/21/19)

A: P:
Fibroadenoma, Surgical Management: Total
Mastectomy, Left
Left CP clearance
For laboratory work ups
VS q4hours; I&Oqshift
DAT temporarily
Day 2
Day 3
 Day Three (1/23/19)

S: O:
post op site pain awake, alert, coherent and
PS 3-4/10 cooperative, NIRD
(+) N& ~ x3epi –
V/S:
nonbilous; saliva;
BP 130/90mmHg;
(-)fever episodes;
HR: 79bpm;
(-) dyspnea RR: 19cpm;
Temp 36.8
Day Three (1/23/19)

O:
Breast: (+)post op incision
on left chest - ~10-
12inches- sutures intact
&dry;
(+)JP drain-intact&patent
 Day Three (1/23/19)

A: P:
S/P Total -Daily wound dressing
Mastectomy – -Continue post op
Left; Day 0 medications
Day 4
 Day Four (1/24/19)

S: HD4 SP1
O:
(+)dizziness, awake, alert, coherent and
(+) n& v x2epi – cooperative, NIRD
nonbilous; saliva;
V/S:
(-)fever episodes;
BP 140/80mmHg;
(-) dyspnea;
HR: 75bpm;
(-) pain on postop
RR: 20cpm;
site;
Temp: 36.0
Day Four (1/24/19)

O:
Breast: (+)post op incision
on left chest - ~10-
12inches- sutures intact
&dry;
(+)JP drain-intact&patent
 Day Four (1/24/19)

A: P:
S/P Total -Daily wound dressing
-Continue post op medications
Mastectomy – -Metoclopramide IVTT
Left; Day 1 -Bed side kidney basin for
vomitus
-secure patient’s safety;
-bed rest without BR privileges
Day 5
 Day Five (1/25/19)

S: HD5 SP2
O:
(+) swelling on left awake, alert, coherent and
arm; cooperative, NIRD
(+) n&V x2ep–
nonbilous; saliva; V/S:
(-)fever episodes; BP 140/80mmHg;
(-) dyspnea; HR: 80bpm;
(-)pain on postop RR: 19cpm;
(-)dizziness,
Temp: 37.0
Day Five (1/25/19)

O:
Breast: (+)post op incision
on left chest - ~10-
12inches- sutures intact
&dry;
(+)JP drain- intact and
patent
 Day Five (1/25/19)

A: P:
S/P Total -Wound dressing daily
Mastectomy – -Continue post op meds -
Elevate left hand
Left; Day 2
-Start warm compress on
affected arm
Day Five (1/25/19)

P:
-Metoclopramide IVTT
-Bed side kidney basin for
vomitus
-Secure patient’s safety;
bed rest without BR
privileges
Day 6
 Day Six (1/26/19)

S: HD6 SP3
O:
(+) swelling on left awake, alert, coherent and
arm; cooperative, NIRD
(-)fever episodes;
V/S:
(-) N &V;
BP 130/80mmHg;
(-) dyspnea;
HR: 65bpm;
(-)pain on postop
RR: 18cpm;
site
Temp 36.0
Day Six (1/26/19)

O:
Breast: (+)post op incision
on left chest - ~10-
12inches- sutures intact
&dry;
(+)JP drain?
 Day Six (1/26/19)

A: P:
S/P Total -Daily wound dressing
Mastectomy – -Continue post op
medications
Left; Day 3
-Elevate left arm;
Clinically stable
-Start warm compress
Day Six (1/26/19)

P:
-Wound dressing daily
-Continue post op meds
(antibiotics & PRN pain meds)
-Elevate left hand
-Continue warm compress on
affected arm
Day Six (1/26/19)

P:
-MGH and with home
medications
-Instructions on follow up
at OPD given – as ordered
FINAL DIAGNOSIS

Phyllodes Tumo
Left;
s/p Total Mastectomy
Left (1/23/19)
Discussion.
DIAGNOSTIC
&TREATMENT
Diagnostic & Treatment

DIAGNOSTIC CHALLENGE

FIBROADENOMA, BENIGN OR
MALIGNANT?
 Diagnostic & Treatment
Phyllodes are distinguished from fibroadenomas
on the basis:

 higher cellularity
Higher mitotic rate
Nuclear pleomorphism
Stromal overgrowth
Infiltrative borders
 Imaging: UTZ

Connective tissue composes bulk which have mixed

gelatinous, solid and cystic area.
Cystic areas represent the sites of infraction and
necrosis.
A solid mass containing single or multiple, round or
cleft like cystic spaces and demonstrating posterior
acoustic enhancement strongly suggests the diagnosis
of phyllodes tumor.
 Mammogram

Mammographic evidence of calcifications and

morphologic evidence of necrosis do not distinguish
between benign, borderline and malignant variant
and from fibroadenoma.
Typically seen as non-specific large rounded oval or
lobulated, generally well circumscribed, lesions with
smooth margins. A radiolucent halo may be present.
 Biopsy
• Gross cut tumor surface its classical leaf
like(phyllodes) appearance

• Microdissection harvest cluster of stromal cells

monoclonal
 Biopsy
• Evaluation of numbers of mitoses and
presence/absence of invasive foci at the tumor
margins my help to identify a malignant tumor.

• Most malignant phyllodes tumor contain

liposarcomatous/rhabdomyosarcomatous
element rather than fibrosarcomatous elements.
 TREATMENT

WIDE EXCISION AND TOTAL

MASTECTOMY
 WIDE EXCISION AND
TOTAL MASTECTOMY

• Small phyllodes tumor excised with margin of

normal appearing breast tissue.

• Reexcision of the biopsy specimen site to ensure

complete excision of the tumor with a 1cm
margin of normal appearing breast tissue.
 WIDE EXCISION AND
TOTAL MASTECTOMY

• Large phyllodes tumors may require mastectomy

• Axillary dissection is not recommended because

axillary lymph node metastases rarely occur.
 TOTAL MASTECTOMY
INDICATION:
patients who are not candidates for breast-
conserving (lumpectomy) operations.

The principal indications are for large cancers that

persist after adjuvant therapy, especially in a
smaller breast, in multicentric disease, and in
elderly poor-risk patients with localized lesions.
 TOTAL MASTECTOMY
PREOPERATIVE PREPARATION ANESTHESIA

General anesthesia is given via an endotracheal

tube. Short acting muscle depolarizing agents are
used for the intubation
 TOTAL MASTECTOMY
POSITION:

The patient is placed in a comfortable supine

position with the arm on the involved side
abducted approximately 90 degrees, in order to
give maximum exposure of the region.
 TOTAL MASTECTOMY

OPERATIVE PREPARATION

A routine skin prep is performed and the area is

draped in a sterile manner.
 TOTAL MASTECTOMY
INCISION AND EXPOSURE

A horizontal elliptical incision is inked so as to

include the entire areolar complex. The two skin
edges should be of equivalent length, as measured
with a free suture between hemostats at each end.
The two incisions should come together without
tension
 TOTAL MASTECTOMY
DETAILS OF PROCEDURE

The skin incision is made sharply with the scalpel

for the depth of 1 cm or so. Any significant vessels
should be secured with fine ligatures.
The skin flaps are elevated with large skin hooks
that are lifted vertically so as to provide
 TOTAL MASTECTOMY
countertraction as the surgeon pulls the specimen
away from the skin flap.

The dissection proceeds superiorly almost to the

clavicle, medially to the sternal edge, and inferiorly
to the costal margin near the insertion of the
rectus sheath.
 TOTAL MASTECTOMY
The lateral flap dissection is carried to the edge of
the pectoralis major muscle.

This leaves the axillary fat and lymph nodes for a

separate dissection.
 TOTAL MASTECTOMY
A subfascial dissection is performed, lifting the
breast off of the pectoralis major muscle.

It is easier to begin superiorly.

As the dissection continues medially, the

perforating internal branches of the mammary
vessel are controlled with electrocautery or
ligature, using fine silk.
 TOTAL MASTECTOMY

Last, the axillary flap is developed such that the

breast is removed from the lateral chest wall.
 JOURNAL

Prognostic factors in breast phyllodes tumors: a

nomogram based on a retrospective cohort study
of 404 patients.
 ABSTRACT

The aim of this study was to explore the independent

prognostic factors related to postoperative
recurrence‐free survival (RFS) in patients with breast
phyllodes tumors (PTBs). A retrospective analysis was
conducted in Fudan University Shanghai Cancer Center.
According to histological type, patients with benign PTBs
were classified as a low‐risk group, while borderline and
malignant PTBs were classified as a high‐risk group.
 ABSTRACT

Among the 404 patients, 168 (41.6%) patients had benign

PTB, 184 (45.5%) had borderline PTB, and 52 (12.9%) had
malignant PTB. Fifty‐five patients experienced
postoperative local recurrence, including six benign cases,
26 borderline cases, and 22 malignant cases; the three
histological types of PTB had local recurrence rates of
3.6%, 14.1%, and 42.3%, respectively
 ABSTRACT

nomogram developed based on clinicopathologic features

and surgical approaches could predict recurrence‐free
survival at 1, 3, and 5 years. For high‐risk patients, this
predictive nomogram based on tumor border, tumor
residue, mitotic activity, degree of stromal cell hyperplasia,
and atypia can be applied for patient counseling and
clinical management. The efficacy of adjuvant
radiotherapy remains uncertain.
 ABSTRACT

Zhi‐Rui Zhou Chen‐Chen Wang Xiang‐Jie Sun Zhao‐Zhi

Yang …
First published: 26 February 2018
https://doi.org/10.1002/cam4.1327