Laporan KasusGiant Phyllodes Tumor

Oleh:dr R Imam Muhajirin

Pembimbing:dr. Iskandar Ali Sp.B (K) Onk

PROGRAM PENDIDIKAN DOKTER SPESIALIS-IPROGRAM STUDI ILMU BEDAH UMUMUNIVERSITAS AIRLANGGA / RSU Dr. SOETOMOSURABAYA2015Giant Phyllodes TumorR Imam Muhajirin*. Iskandar Ali **.

Abstract Phyllodes tumor is rare breast fibroepithelial neoplasm that account for less than 1 percent of breast tumor. It is diagnosed in women between 30-70 years old. The tumours are histopathologically classified into benign, bordeline (low-grade malignant), and malignant (high-grade malignant).The article presents the case of a 30-years-old patient, sent to Dr. Soetomo hospital in Surabaya because of giant tumor of her right breast, from physical examination revealed a female with obvious mass of the right breast, the mass measured 50x30 cm with multiple ulcers. In additional investigation : anemia (9 g/dl) and hipoalbumin (1,8 g/dl) . After anemia & hipoalbumin been corrected, a simple mastectomy was performed , then pastient controlled at oncology polyclinic at dr Soetomo hospital .Keywords : Tumor Phyllodes, benign,borderline and malignant tumor*Resident of General surgery**Teacher of Oncology Surgery Departement of Airlangga University Medical Faculty/dr Soetomo Hospital Surabaya

BackgroundPhylloides tumor is a tumor of the fibroephitelial breast tissue which is rare with incidence rate of less than 1% of all breast tumors. This tumor is derived from intralobular stromal of the breast with morphologic characteristics such as the excessive growth of the stroma that is covered by epithelium and often shapes like a leaf.1 phyllodes tumors can be benign, borderline, or malignant.2 Most phyllodes tumor is benign, but 10-40% can be malignant. Distant metastases can be occurred by hematogenous, mainly found in the lungs, bones, abdominal viscera, and mediastinum. Local recurrence is a problem which can occur either on the benign phyllodes tumor or malignant at nearly 25% cases.5The main treatment of phyllodes tumor is surgery. The surgical treatment based on the principle of prevention of local recurrence, and mastectomy can be choosen as surgical treatment if the malignant phyllodes tumor is difficult to adequately excised.1Adjuvant radiation therapy and chemotherapy are still controversial, pyllodes tumor is believed to be resistant with radiation, but there are some reported cases ca be managed by administering radiotherapy. although some belief that Phyllodes tumor is resistant with chemotherapy, but there are some cases of patients with distant metastases showed clinical improvement after administration chemoterapy.1

Case ReportWe report a female patient, Mrs. S, 30 years old, with chief complain is there is a lump in the right breast since 2.5 years ago, initially she said that the lump size is like a marbles ( 1.5 cm) and progressively enlarged until now, its about like aqua gallon ( 50 cm), raised sores on the lump since 2 months ago, sometimes it bleed and produce the fluids, felt the pain on the skin of the lump, no tightness, no coughing, no headache, no bone pain. Previously patients treated the with traditional therapy for 2 years, and the lump is still growing larger and wound raisen on the lump, so the patient went to the Bangil Hospital and then she was referred to the Oncology departement (POSA) RSU Dr Soetomo.On physical examination found like anemia condition, and other condition is normal enough. Inspection on the right breast examination is obtained mass, the color of skin partly is same with normal skin and part one get hyperpigmentation, shiny, vein ectase, no peau d orange feature, satellite nodules, skin dimpling and papil retraction. Obtained multiple ulcers with an average 4cm diameter. On palpation obtained a mass with size 50x30 cm, dense chewy consistency and partly cystus, not obtained tenderness, mobile on the skin and chest wall, flat surface tumor, undifferentiated border of tumor, not warm, as shown in pictures 1dan 2. On left breast examinations are not obtained of the tumor mass. From the examination of the regional nodes not be obtained enlargement of regional nodes in the axilla, right and left supra and infraclavicula. The clinical diagnosis is suspected a malignant tumor phylloides.

Figure 1. Anterior view of phyllodes tumor

Figure 2. Inferolateral view of phylldes tumorRadiological investigations with plain thorax is normal and not found metastases. Abdominal ultrasound examination is not found metastases in the liver and paraaorta. Ct-scan of the thorax examination obtained solid mass with cystic components and multiple calcified amorphous that enhance the limit solid portion. The border size at right side of the thorax region is 24,2x30,5x35,2cm, the mass attach to the right breast, and make infiltraton to the right pectoralis major muscle and right intercostal muscle, and obtained enlargement on right axilla lymph nodes multiple with the largest size 1,8 x 1,2cm that confirm phylloides is suspected a malignant tumor, hepatomegaly, bilateral pleural effusions. Multiple varying size nodules in left side can be suspected metastases process.Incisional biopsy of anatomical pathology examination is found pieces of tissue that composed of spindle cell proliferation, spindle core, fine chromatin, elongated eosinophilic cytoplasm, partly solid composed partly loose, between myxoid matrix and collagen. Looks several glands are squeezed diantranya. Mitosis 0/10 HPF. The anatomical pathology examination conclusion is according to Phyllodes tumor, and malignancy feature is not found in this material.Haematological examination is obtained anemia (Hb 9 g / dl), hipoalbumin (alb 1.8 g / dl), and the others are in the normal range. Kidney and liver function is also within normal limits, no abnormality with the physiology of hemostasis.Operation is carried out on 18 november 2014 and the operation lasted 2 hours, and it is preceded by informed consent to patients and their families about the condition of the patient, the procedure of operation and all possibilities that could occur either before, during or after operation. The patient position is supine, with the ipsilateral arm to th operation side is abduction position on 90o, shoulder ipsilateral to the operation side is propped up with pillows thin, then carried out disinfection on the operation field, from top to the middle of the neck, the bottom until the umbilicus, medial part until mid contra lateral of breast, part lateral to the lateral edge of the scapula, upper arm up to the elbow circularly disinfected and then wrapped in sterile doek to narrow the operation field. Simple mastectomy is done with skin tumors ellipse incision, as shown in fig.3, deeper incision and made flap, superior flap until below the clavicle, medial flap until ipsilateral parasternal, inferior flap until to the inframammary fold, lateral flap until to the anterior edge of the latissimus dorsi and then identificate vasa and N thoracalis dorsalis.

Figure 3. Post mastectomy with elips incision (cranial-caudal)Durante operations is obtained a solid tumor mass, partially cystic, encapsulated with size 50x30 cm, strict border and attached on the base of pectoralis major and minor muscles, mastectomy is started from the medial towards lateral while bleeding control, especially branch of intrercostal vessels in parasternal region, and in the lateral edge of the pectoralis major, mammary tissue is removed from m.pectoralis minor and serratus anterior by haak, ligated the veins, further identificate nerves and vessels of thoracalis longus, thoracalis dorsalis and intercostobrachialis. After all the above structures can be identified, then removed all of breast tissue with removed the partial the pectoralis muscle too, treated bleeding well, mounted 2 pieces redon drain number 14 which is placed under the axillar vasa in lateral and second drain is directed to the medial to ensure draination the seroma and residual bleeding as shown in Figure 4, then the operation wound is sutured layer by layer, and the operation lasted for 2 hours with about 700 cc of bleeding.

Figure 4. Post operative woundAnalysis of macroscopic tumor is obtained right mammary tumor, weight 15 kg, size of 50x30x20 cm, skin cover size 73x50 cm, mammary papilla on the skin of tumor, multiple ulcers with an average diameter of 4 cm. On slices obtained mass 50x30x20 cm size, white color solid gray chewy, filled the entire section of mammary, and also appeared multiple cystic necrosis area with size of an average diameterfrom explorati of 0.5 cm, containing clear liquid yellowish green. The distance tumor with skin, base, lateral, medial, superior and inferior coincide, base operation is mostly formed by muscle, partly formed by a tumor mass. obtained axillar tail with 11x6x1,5 cm size, and from exploration is obtained 13 cm yellow rubbery solid with the size of the nodule 0,5x0,5x0,1-1x0,5x0,2.In a microscopic piece of tissue is obtained mamma with tumor growth consisting of proliferation of anaplastic cells nucleus spindle-plump, coarse chromatin, nucleolus arranged fascicles. Among is obtained the feature ductuli wedged shape leaf like appearance, mitosis 15/10 HPF, the distance tumor resection coincide with the edge, no infiltration feature of tumors in 13 lymph node, region of calcification. Conclusion: malignant phyllodes tumor, tumor diameter of 50 cm, the distance to the edge of the tumor resection and base of operation coincide, no metastases feature in 13 lymph node.Post operation, patients is treated for 5 days, the condition of the patient improved clinically as shown in Figure 5, then the patient is discharged and she subsequently controls to POSA Surgery Dr Soetomo Hospital for post operation wound care and further evaluation.

Picture 5. Post operatif 5th day

Discussion Phylloides tumor is a rare tumor of the fibroephitelial breast tissue with incidence rate of less than 1% of all breast tumors. These tumors are derived from stromal intralobular breast and morphologic characteristics such as the excessive growth of the stroma that covered by epithelium and often shaped like a leaf.1 Phyllodes tumors can be benign, borderline, or malignant.2 Most phyllodes tumor is benign, but 10-40% including malignant. Distant metastases occur with hematogenous, mainly found in the lungs, bones, abdominal viscera, and mediastinum. Local recurrence is a problem which can occur either on the phyllodes tumor is benign or malignant at nearly 25% cases.5Surgical intervention is the gold standard for the treatment of phyllodes tumor. Comparation of indications for breast-conserving surgery or mastectomy is still controversial. There is general consensus that pyloides benign tumors can be treated conservatively with the good result.1 Some researchers also found that breast conserving surgery with a clean boundary is also an appropriate therapy for tumor pyloides maligna.11 Belkacemi et al reported that total mastectomy provide better survival for malignant tumors and considered borderline.1 mastectomy can provide better local control, but in a study that has been conducted by Asoglu et al, the type of surgery did not affect the rate of local recurrency.3 Lymph node resection is not performed routinely because of the spreading of distant metastases phyllodes tumor is haematogenously. The radiotherapy still can not be determined, there may be some advantages for local control or borderline malignant disease, it does not change the improvement of survival rate .1 From research conducted by Chaney et al, at the University of Texas MD Anderson Cancer Center does not support the use of radiotherapy for tumors phyllodes that has been resected with adequate.6Recommendation of therapy can be vary, depending on prognosis marker. It did not surprised that one of the main factors affected survival is the feature of a benign histology.1 In addition, local recurrence was associated with positif surgical margin.11 Barrio et al also found that local recurrence rates associated with necrosis and fibropoliferation of surrounding breast tissue.5 Excessive growth of stromal tissue have been known to be associated with local recurrence and distant metastases can predict. With numbers of metastases overall are low, however it is difficult to take a definitive decision to this problem.11 Barrio et al proposed there are 6 factors that increase the high risk of metastases if there simultaneously, namely: excessive stromal growth, large tumor size, cellularity stromal meaningful, high mitotic count, and the presence of infiltration. Although local recurrence is considered to relate to the further development of metastases, Chen et al. found no difference between the two outcomes.11Due to the rarity of this disease, there are not guidelines for phyllodes tumor management yet. Overall good prognosis, with a 10-year survival rate of more than 95%. Recent retrospective study with 752 cases of malignant phyllodes tumors found that the survival rate reached a plateau at 5 years and 10 years, mortality rates equal to the population umum.12 So follow-up is not too aggressive may be sufficient after five years. On the other hand, the occurrence of local recurrence had a wide span of time with a significant number of identified five years after the onset of tumor inisial.1

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