Case Presentation On Breast and Phyllodes Tumor

HANG IN
THERE
Alcaraz, Adrian
Medical Clerk
Z A M BOA N G A C I T Y M E D I C A L
CENTER
DEPARTMENT OF
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:
CENTER
DEPARTMENT OF
Name: BA
Age:
41year old
Sex:
Female
Address:Siay, ZSP
Civil Status: Married
Occupation: None
Religion:
Born Again
Nationality: Filipino
PERSONAL DATA
CENTER
DEPARTMENT OF
Right Breast Mass
CHIEF COMPLAINT
CENTER
DEPARTMENT OF
3 month PTC
2cm
x 2cm enlarging mass, right breast,

tender
No associated fever, weight loss, easy
fatigability, nipple discharge, nipple
retraction
Consulted at ZCMC
Core Needle Biopsy was done
HISTORY OF
PRESENT ILLNESS
CENTER
DEPARTMENT OF
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
CENTER
DEPARTMENT OF
(+)
cancer (breast)
(+) hypertension
(-) diabetes mellitus
(-) bronchial asthma
FAMILY HISTORY
CENTER
DEPARTMENT OF
Housewife with 3 living children

10 pack-year smoker
Non-alcoholic beverage drinker
Doesnt use oral contraceptives
PERSONAL AND
SOCIAL HISTORY
CENTER
DEPARTMENT OF
G4P4 (4 0 1 3)
Menarche at 14years old
LMP: January 29, 2015, regular menstrual cycle
OB-GYNE HISTORY
CENTER
DEPARTMENT OF
No other pertinent symptoms
REVIEW OF SYSTEM
CENTER
DEPARTMENT OF
GENERAL APPEARANCE:
ambulatory, response to
questions and command; oriented
to time, place, and name; not in
cardio-respiratory distress
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
VITAL SIGNS:
Blood Pressure: 120/110 mmHg
Pulse rate: 87 bpm
Respiratory Rate: 18 cpm
Temperature: 35C
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
SKIN/HAIR/NAILS:
Warm to touch; no jaundice; no
pallor; no lesions
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
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
CENTER
DEPARTMENT OF
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
CENTER
DEPARTMENT OF
NECK
No mass, lesion; no visible
pulsation of jugular vein; no CLAD,
mass; no tracheal deviation; no
tenderness
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
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
CENTER
DEPARTMENT OF
BREAST
Inspection: Symmetric, pendulous, (-)
peau dorange, 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
CENTER
DEPARTMENT OF
AXILLAE
Inspection: No lesions, no signs of
infection, no discoloration
Palpation: No lymphadenopathies
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
CARDIOVASCULAR
adynamic precordium; normal rate,
regular rhythm; no murmur
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
ABDOMEN
flabby; normo-active bowel sounds;
soft and non-tender
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
EXTREMITIES:
Warm skin, symmetrical, no
atrophy, no clubbing, no cyanosis,
no edema, CRT < 2secs
PHYSICAL
EXAMINATION
CENTER
DEPARTMENT OF
Phyllodes Tumor, Benign Right Breast

s/p Core Needle Biopsy (December 16, 2014)
PRE-OP DIAGNOSIS
CENTER
DEPARTMENT OF
Partial Mastectomy
PROPOSED
OPERATION
CENTER
DEPARTMENT OF
Unremarkable hospital stay

Discharged on the second post-op day
COURSE IN THE
WARD
CENTER
DEPARTMENT OF
Phyllodes Tumor, Benign Right Breast s/p Core

Needle Biopsy (December 16, 2014)
FINAL DIAGNOSIS
CENTER
DEPARTMENT OF
Characterist Benign Mass

ic
Mobile mass,
Signs and
Symptoms
usually painful
Nipple discharge
Changes in size
Mass Margin
Malignant Mass
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 dorange;
Weight loss;
Smooth and Round;
Irregular Borders; with no
Well demarcated; with Capsule
Fibrous Capsule
CENTER
BENIGN VS MALIGNANT
DEPARTMENT OF
Characterist Benign Mass

ic
Manner of
Grows by expanding
Growth
and pushing away and
against surrounding
tissue mobile mass
Metastasis
Never metastasize
Examples
Fibrocystic changes
Cysts
Fibroadenomas
Infection
Trauma
Phyllodes Tumor
Malignant Mass
Grows by invading and
sometimes destroying
surrounding tissue fix mass
Almost always metastasize
Ductal Carcinoma
Lobular Carcinoma
Phyllodes Tumor
BENIGN VS MALIGNANT
CENTER
DEPARTMENT OF
Intense and Uniform Hyperechogenicity

Ellipsoid shape and thin Echogenic
Capsule
Smooth margins
ULTRASOUND BENIGN
MASS Starvos, et al. Radiology 1995; 96:23-34
CENTER
DEPARTMENT OF
Thin
Echogenic
Capsule
Fibroadenoma
Ellipsoid Shape
(wider than tall)
ULTRASOUND BENIGN
CENTER
DEPARTMENT OF
Cyst
Ellipsoid Shape
(wider than tall)
Anechoic
Smooth
Surrface
ULTRASOUND BENIGN
CENTER
DEPARTMENT OF
Spiculation
Angular Margins
Hypoechogenicity
Shadowing
Calcification
Duct Extension
Branch pattern
Microlobulation
ULTRASOUND MALIGNANT
DEPARTMENT
CENTER
OF
Angular
Margin
Microlobulation
Hypoechoic
ULTRASOUND BENIGN
Irregular Margin
CENTER
DEPARTMENT OF
THE BREAST
CENTER
DEPARTMENT OF
2nd or 3rd Rib

Lateral
Border of
the
Sternum
Anterior
Axillary
LIne
6th or 7th Rib
ANATOMY
CENTER
DEPARTMENT OF
Pectoralis
Major
Serratu
s
Anterior
ANATOMY
CENTER
DEPARTMENT OF
ANATOMY
CENTER
DEPARTMENT OF
Axillary
Artery
Lateral
thoracic a.
Lateral
mammary
Branches
Lateral mammary
Branches of lateral
cutaneous
branches of
posterior
intercostal aa.
ANATOMY
Subclavian
Artery
Internal
Thoracic a.
perforatin
g
branches
CENTER
DEPARTMENT OF
Axillary vein
(lateral)
nodes
drainage from the upper
extremity
Scapular
(posterior or
subscapular)
drainage principally from the

lower posterior neck, the
posterior trunk, and the
posterior shoulder
External
Mammary
(anterior or
drainage
from the lateral
pectoral)
ANATOMY
aspect of the breast
Central(anterior
or pectoral)
from the axillary vein,
external mammary, and
scapular groups of lymph
nodes, and directly from the
breast
Subclavicular
(apical)
drainage from all
of the other groups of axillary
lymph nodes
Interpectoral
CENTER
(Rotters)
DEPARTMENT OF
directly from the breast
Axillary vein
(lateral)
nodes
Scapular
(posterior or
subscapular)
External
Mammary
(anterior or
pectoral)
ANATOMY
Central(anterior
or pectoral)
Subclavicular
(apical)
Interpectoral
CENTER
(Rotters)
DEPARTMENT OF
Birth
2 years
After
Puberty
Estrogen
BREAST
DEVELOPMENT
Estrogen
CENTER
DEPARTMENT OF
Birth
2 years
After
Puberty
After
Pregnancy
Progesteron
e
Prolactin
Oxytocin
Estrogen
BREAST
DEVELOPMENT
Estrogen
CENTER
DEPARTMENT OF
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
PHYLLODES TUMOR
CENTER
DEPARTMENT OF
PATHOPHYSIOLOGY
CENTER
DEPARTMENT OF
Exclusively occur in the female breast

Can develop at any age, median age = 50s
EPIDEMIOLOGIC
CENTER
DEPARTMENT OF
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
MALIGNANT PHYLLODES
CENTER
DEPARTMENT OF
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
PRESENTATION
CENTER
DEPARTMENT OF
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
MANAGEMENT
CENTER
DEPARTMENT OF
No proven role for adjuvant chemotherapy or

radiotherapy
ADJUVANT THERAPY
CENTER
DEPARTMENT OF
Infection
Seroma formation
Local or distant recurrence
POST-OP COMPLICATION
CENTER
DEPARTMENT OF
Tissue
Involvement
Breast Tissue
Nipple-Areola
Complex
Scars
Skin
Level I nodes
Level II nodes
Level III nodes
Pectoralis Major
and Minor
Skin-sparing
Total (simple)
+
+
MASTECTOMY
CENTER
DEPARTMENT OF
Tissue
Involvement
Breast Tissue
Nipple-Areola
Complex
Scars
Skin
Level I nodes
Level II nodes
Level III nodes
Pectoralis Major
and Minor
Extended
Simple
+
Modified
Radical
+
+
+
+
+
+
+
+
MASTECTOMY
Halsted Radical
+
+
+
+
+
+/- Pectoralis
Minor
+
CENTER
DEPARTMENT OF
Borders
Laterally
Medially
Superiorly
Inferiorly
Modified Radical
Anterior margin of the Latissimus
dorsi muscle
Midline of the sternum
Subclavius muscle
Caudal extension; 2-3cm inferior to
the inframammary fold
MODIFIED RADICAL
MASTECTOMY
CENTER
DEPARTMENT OF
THANK YOU
CENTER
DEPARTMENT OF

Case Presentation On Breast and Phyllodes Tumor

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Case Presentation On Breast and Phyllodes Tumor

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HANG IN

To be able to give an initial impression of the case

Right Breast Mass

x 2cm enlarging mass, right breast,

Medical Illness: No known morbidities; no asthma

Housewife with 3 living children

No other pertinent symptoms

Head: No scars; no lesions; normal hair

Ears: Both pinna symmetrical; no lesion on

THORAX & LUNGS

Phyllodes Tumor, Benign Right Breast

Unremarkable hospital stay

Phyllodes Tumor, Benign Right Breast s/p Core

Characterist Benign Mass

Fixed mass, often painless;

Characterist Benign Mass

Intense and Uniform Hyperechogenicity

2nd or 3rd Rib

drainage principally from the

Aka. Cystosarcoma Phyllodes

Exclusively occur in the female breast

10-15% of Phyllodes tumor

Presents larger mass, and display rapid growth

Complete excision of the tumor

No proven role for adjuvant chemotherapy or

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