case presentation - phyllodes tumor
TRANSCRIPT
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
HANG IN THERE…Alcaraz, Adrian
Medical Clerk
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
To be able to give an initial impression of the case To discuss the anatomy and physiology of the
breast To differentiate benign from malignant breast mass To present on Phyllodes Tumor To identify appropriate management
OBJECTIVES:
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Name: BA
Age: 41year old
Sex: Female
Address: Siay, ZSP
Civil Status: Married
Occupation: None
Religion: Born Again
Nationality: Filipino
PERSONAL DATA
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Right Breast Mass
CHIEF COMPLAINT
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
3 month PTC2cm x 2cm enlarging mass, right breast, tender
No associated fever, weight loss, easy fatigability, nipple discharge, nipple retraction
Consulted at ZCMCCore Needle Biopsy was doneHISTORY OF PRESENT ILLNESS
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Medical Illness: No known morbidities; no asthma
Hospitalization: No prior hospitalization
Surgical: No prior surgical operation
Medications: No medical maintenance
Allergies: No known allergies to food or drugs
PAST MEDICAL HISTORY
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
(+) cancer (breast)(+) hypertension(-) diabetes mellitus(-) bronchial asthma
FAMILY HISTORY
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Housewife with 3 living children 10 pack-year smoker Non-alcoholic beverage drinker Doesn’t use oral contraceptives
PERSONAL AND SOCIAL HISTORY
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
G4P4 (4 0 1 3) Menarche at 14years old LMP: January 29, 2015, regular menstrual cycle
OB-GYNE HISTORY
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No other pertinent symptoms
REVIEW OF SYSTEM
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
GENERAL APPEARANCE:
ambulatory, response to questions and command; oriented to time, place, and name; not in cardio-respiratory distress
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
VITAL SIGNS: Blood Pressure: 120/110 mmHg Pulse rate: 87 bpm Respiratory Rate: 18 cpm Temperature: 35ºC
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
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SKIN/HAIR/NAILS:
Warm to touch; no jaundice; no pallor; no lesions
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
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Head: No scars; no lesions; normal hair distribution and texture; normocephalic;
Eyes: Anicteric sclera; pink palpebral conjunctiva; pupils are round, regular, equally reactive to light
PHYSICAL EXAMINATION
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Ears: Both pinna symmetrical; no lesion on auricle and both canals
Nose/Sinuses: Symmetrical; septum midline
Mouth/Throat: Pink buccal mucosa; tongue midline; no ulceration; no lesions
PHYSICAL EXAMINATION
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NECK
No mass, lesion; no visible pulsation of jugular vein; no CLAD, mass; no tracheal deviation; no tenderness
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
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THORAX & LUNGS
Inspection: No lesions; Symmetrical chest expansion; No intercostal retractions.
Palpation: Non-tender on all lung fields
Percussion: Resonant on all lung fields
Auscultation: Equal clear breath sounds; no crackles
PHYSICAL EXAMINATION
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BREAST
Inspection: Symmetric, pendulous, (-) peau d’orange, no ulceration, skin lesions, or discharges.
Palpation: Right Breast: 3cm x 3cm mass, lower outer at the peri-areolar area, round with regular border, hard, movable and tender
PHYSICAL EXAMINATION
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AXILLAE
Inspection: No lesions, no signs of infection, no discoloration
Palpation: No lymphadenopathies
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
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CARDIOVASCULAR
adynamic precordium; normal rate, regular rhythm; no murmur
PHYSICAL EXAMINATION
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ABDOMEN
flabby; normo-active bowel sounds; soft and non-tender
PHYSICAL EXAMINATION
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EXTREMITIES:
Warm skin, symmetrical, no atrophy, no clubbing, no cyanosis, no edema, CRT < 2secs
PHYSICAL EXAMINATION
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Phyllodes Tumor, Benign Right Breast
s/p Core Needle Biopsy (December 16, 2014)
PRE-OP DIAGNOSIS
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Partial Mastectomy
PROPOSED OPERATION
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Unremarkable hospital stay
Discharged on the second post-op day
COURSE IN THE WARD
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
Phyllodes Tumor, Benign Right Breast s/p Core Needle Biopsy (December 16, 2014)
FINAL DIAGNOSIS
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
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Characteristic
Benign Mass Malignant Mass
Signs and Symptoms
Mobile mass, usually painful
Nipple discharge Changes in size
Fixed mass, often painless; Nipple discharge or
bleeding; Changes in the size or
contour of the breast; Changes in color or
appearance of areola; Peau d’orange; Weight loss;
Mass Margin Smooth and Round; Well demarcated; with Fibrous Capsule
Irregular Borders; with no Capsule
BENIGN VS MALIGNANT
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URGERYD E P A R T M E N T O F
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Characteristic
Benign Mass Malignant Mass
Manner of Growth
Grows by expanding and pushing away and against surrounding tissue → mobile mass
Grows by invading and sometimes destroying surrounding tissue → fix mass
Metastasis Never metastasize Almost always metastasize
Examples Fibrocystic changesCystsFibroadenomasInfectionTraumaPhyllodes Tumor
Ductal CarcinomaLobular CarcinomaPhyllodes Tumor
BENIGN VS MALIGNANT
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERULTRASOUND – BENIGN
MASS
Intense and Uniform Hyperechogenicity Ellipsoid shape and thin Echogenic Capsule
Smooth margins
Starvos, et al. Radiology 1995; 96:23-34
URGERYSD E P A R T M E N T O F
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Thin Echogenic Capsule
Ellipsoid Shape (wider than tall)
Fibroadenoma
ULTRASOUND – BENIGN MASS Starvos, et al. Radiology 1995; 96:23-34
URGERYSD E P A R T M E N T O F
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Anechoic
Ellipsoid Shape (wider than tall)
Smooth Surrface
Cyst
ULTRASOUND – BENIGN MASS Starvos, et al. Radiology 1995; 96:23-34
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Spiculation Angular Margins Hypoechogenicity Shadowing Calcification Duct Extension
Branch pattern Microlobulation
ULTRASOUND – MALIGNANT MASS Starvos, et al. Radiology 1995; 96:23-34
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Angular Margin
Microlobulation
Hypoechoic
ULTRASOUND – BENIGN MASS Starvos, et al. Radiology 1995; 96:23-34
Irregular Margin
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERTHE BREAST
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERANATOMY
2nd or 3rd Rib
6th or 7th Rib
Lateral Border of
the Sternum
Anterior Axillary
LIne
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URGERYD E P A R T M E N T O F
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Pectoralis Major
Serratus
Anterior
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ANATOMY
Subclavian Artery
Internal Thoracic a.
perforating
branches
Axillary Artery
Lateral thoracic a.
Lateral mammary Branches
Lateral mammary Branches of lateral
cutaneous branches of
posterior intercostal aa.
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERANATOMY
Axillary vein (lateral) nodes
drainage from the upper extremity
External Mammary
(anterior or pectoral)
Scapular (posterior or subscapular)
drainage from the lateral aspect of the breast
drainage principally from the lower posterior neck, the posterior trunk, and the
posterior shoulder
Central(anterior or pectoral)
from the axillary vein, external mammary, and scapular groups of lymph
nodes, and directly from the breast
Subclavicular (apical)
Interpectoral (Rotter’s)
directly from the breast
drainage from allof the other groups of axillary
lymph nodes
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERANATOMY
External Mammary
(anterior or pectoral)
Scapular (posterior or subscapular)
Axillary vein (lateral) nodes
Central(anterior or pectoral)
Subclavicular (apical)
Interpectoral (Rotter’s)
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERBREAST
DEVELOPMENT
Birth 2 yearsAfter
Puberty
Estrogen
↑Estrogen
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERBREAST
DEVELOPMENT
Birth 2 yearsAfter
PubertyAfter
Pregnancy
Estrogen
↑Estrogen
Progesterone
Prolactin
Oxytocin
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERPHYLLODES TUMOR
Aka. Cystosarcoma Phyllodes Derived from the Greek words sarcoma (“fleshy
tumor”), and phyllon (“leafy”) Rare (1% of breast tumor), predominantly
benign tumor Composed mainly of connective tissue Benign Phyllodes do not metastasize, but can
grow aggressively, can recur locally
URGERYSD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
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URGERYD E P A R T M E N T O F
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Exclusively occur in the female breast Can develop at any age, median age = 50s
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URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERMALIGNANT PHYLLODES
10-15% of Phyllodes tumor Matastasize hematogenously Recurrent malignant tumors seem to be more
aggressive Lung, skeleton, heart, and liver – most common
metastatic site Roughly 30% of patient with malignant Phyllodes die
from this disease May present with dyspnea, fatigue, and bone pain
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERPRESENTATION
Presents larger mass, and display rapid growth Rarely involves the nipple-areola complex or ulcerate
the skin Frim, mobile, well-circumscribed, nontender breast
mass Overlying skin may display shiny appearance and be
translucent enough to reveal underlying breast veins Very large Phyllodes may erode through overlying
skin
URGERYSD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
ZAMBOANGA CITY MEDICAL CENTERMANAGEMENT
Complete excision of the tumor 2cm margin for small tumors 5cm margin for large tumor > Tumor-to-breast ratio – total mastectomy Axillary dissection – not recommended
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URGERYD E P A R T M E N T O F
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No proven role for adjuvant chemotherapy or radiotherapy
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Infection Seroma formation Local or distant recurrence
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Tissue Involvement
Skin-sparing Total (simple)
Breast Tissue + +
Nipple-Areola Complex
+ +
Scars + +
Skin +
Level I nodes
Level II nodes
Level III nodes
Pectoralis Major and Minor
MASTECTOMY
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ZAMBOANGA CITY MEDICAL CENTER
URGERYD E P A R T M E N T O F
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Tissue Involvement
Extended Simple
Modified Radical
Halsted Radical
Breast Tissue + + +
Nipple-Areola Complex
+ + +
Scars + + +
Skin + + +
Level I nodes + + +
Level II nodes + +
Level III nodes +
Pectoralis Major and Minor
+/- Pectoralis Minor
+
MASTECTOMY
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URGERYD E P A R T M E N T O F
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Borders Modified RadicalLaterally Anterior margin of the Latissimus
dorsi muscleMedially Midline of the sternumSuperiorly Subclavius muscleInferiorly Caudal extension; 2-3cm inferior to
the inframammary fold
MODIFIED RADICALMASTECTOMY
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