History

Fact Explanation
Breast Lump Phyllodes tumors usually present as a painless, rapidly growing but clinically benign smooth breast lump. [2] The median size of phyllodes tumors is around 4 cm.[4]It can acquire any size and is sometimes even massive. Translucency of the overlying skin of an large tumor will allow visualization of veins which will lead to bluish discoloration of the skin.[1]They can be found as a breast lump at any age including adolescence. The peak incidence of this tumor in women is between 35 and 55 years of age, with only a few cases reported in men.[3] Phyllodes tumors are rare fibroepithelial lesions, they should be regarded as a spectrum of fibroepithelial neoplasms.At one extreme are malignant phyllodes tumors, then borderline tumors and at the other extreme benign phyllodes tumors. [1]
Necrosis of the skin This is due to pressure necrosis of the overlying skin of a large tumor.[1]
References
  1. PARKER S, S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Available from: doi:10.1136/pmj.77.909.428
  2. BROWSE Norman L., John BLACK, Kevin G. BURNAND, William E.G. THOMAS, Browse's Introduction to the Symptoms & Signs of Surgical Disease. 4th ed. London. Hodder Arnold, 2005
  3. MAJESKI James , Jason STROUD, Malignant Phyllodes Tumors of the Breast: A Study in Clinical Practice. International surgery. International College of Surgeons. April 2012. vol. 97. 95–98[viewed 3rd april 2014]. doi: 10.9738/CC79.1
  4. ILIANG, Margaret I.,Bhuvaneswari RAMASWAMY, Cynthia C PATTERSON, Michael T McKELVEY, Gayle GORDILLO, Gerard J NUOVO, William E CARSON. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology[online] biomed central. November 2008, vol. 6. 117[viewed 5th April 2014] Available from: doi: 10.1186/1477-7819-6-117

Examination

Fact Explanation
Breast lump Size of the lump is usually greater than 2 cm.It has a spherical or ovoid shape, smooth surface and rubbery consistency. It is freely mobile and not fixed or tethered to skin.[3]They are found more commonly in the upper outer quadrant.[1] It usually takes over a quarter or half of the affected breast[3]The skin over large tumors may have dilated veins and a blue discoloration but nipple retraction is rare.The diagnosis of a Phyllodes tumor should be considered in all women, particularly over the age of 35 years, who present with a rapidly growing but clinically benign breast lump.[1]
Necrosis of the skin This is due to pressure necrosis of the overlying skin.[2]
Palpable axillary lymph nodes. Palpable axillary lymphadenopathy can be identified in up to 20% of patients but nodal metastases are uncommon [1]
References
  1. PARKER S, S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Available from: doi:10.1136/pmj.77.909.428
  2. BROWSE Norman L., John BLACK, Kevin G. BURNAND, William E.G. THOMAS, Browse's Introduction to the Symptoms & Signs of Surgical Disease. 4th ed. London. Hodder Arnold, 2005
  3. STAMATAKOS Michael, Sofia TSAKNAKI, Konstantinos KONTZOGLOU, John GOGAS, Alkiviades KOSTASKIS Michael SAFIOLEAS. Phylloides tumor of the breast: a rare neoplasm, though not that innocent. International Seminars in Surgical Oncology[online].BioMed Central.February 2009, vol. 6(6). 1-4[viewed 5th april 2014.] Available from: doi:10.1186/1477-7800-6-6

Differential Diagnoses

Fact Explanation
Carcinoma of the breast Most important differential diagnosis to be excluded. Phyllodes tumor shares malignant features of breast ca like rapid growth, skin ulceration, axillary lymphadenopathy, But carcinomas will also has skin tethering, fixation to underling muscles, bloody nipple discharge, nipple retraction.[1]
Fibroadenoma Typically patient is less than 40 years old. Lump is smooth, rubbery in consistence and very mobile. No axillary lymphadenopathy or pressure necrosis of the skin.[3]
Fat necrosis of the breast Patient Usually gives a history of trauma to beast,radiotherapy,anticoagulation (warfarin), cyst aspiration, biopsy, lumpectomy, reduction mammoplasty, implant removal, breast reconstruction with tissue transfer,duct ectasia and breast infection or breast augmentation. Fat necrosis is common in peri menopausal women. It is usually a small to medium size firm lump with irregular borders. fat necrosis can have skin tethering but not in phyllodes tumors. But is doesn't gives rise to axillary lymphadenopathy like phyllodes tumors.[2]
Breast abscess Present as a recent onset painful breast lump. Affected area will be warm, tender and reddish. Lump will not have clearly defined margins. it has cystic consistency. It is not fixed to muscles or tethered to skin. occasionally can give rise to axillary lymphadenopathy.[3]
References
  1. BROWSE Norman L., John BLACK, Kevin G. BURNAND, William E.G. THOMAS, Browse's Introduction to the Symptoms & Signs of Surgical Disease. 4th ed. London. Hodder Arnold, 2005
  2. TAN P.H., LAI L.M., CARRINGTON E.V., OPALUWA A.S., RAVIKUMAR K.H., CHETTY N, KAPLAN V, KELLEY CJ, BABU ED. Fat necrosis of the breast—a review. The Breast[online]. Elsevier.July 2005, vol. 15(3), 313–318 [viewed1st April 2014]. doi:10.1016/j.breast.2005.07.003
  3. WILLIAMS,Norman S,Christopher JK BULSTRODE and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008

Investigations - for Diagnosis

Fact Explanation
Mammography Phyllodes tumours are mammographically well defined with a smooth and occasionally lobulated border.A radiolucent “halo” may be seen around the lesion, due to compression of the surrounding breast stroma. No mammographic indicators have been identified that allow for differentiation between benign and malignant tumors[1]
Ultrasound scan On ultrasound examination, phyllodes tumors often show smooth contours with low level homogenous internal echoes, intramural cysts, and the absence of posterior acoustic enhancement.[1]
Fine Needle Aspiration Cytology (FNAC) Cytologically, it is often easier to differentiate benign from malignant phyllodes tumours than to separate benign phyllodes tumours from fibroadenomas[2]
Core biopsy This is require to differentiate phyllodes tumors from the fibroadenomas which is difficult in fine needle aspiration cytology.[2]
References
  1. PARKER S, S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Available from: doi:10.1136/pmj.77.909.428
  2. MAJESKI James , Jason STROUD. Malignant Phyllodes Tumors of the Breast: A Study in Clinical Practice. International surgery. International College of Surgeons. April 2012. vol. 97. 95–98[viewed 3rd april 2014]. Available from; doi: 10.9738/CC79.1

Investigations - Fitness for Management

Fact Explanation
Full blood count This is a slandered preoperative investigation for any patient who wish to undergo surgical treatment. Can asses Hb level, platelet counts and blood cell counts which will help to identify anemia, thrombocytopenia.[1]
ECG Done as a routine investigation to find out any cardiac compromise. if there any ECG changes exercise ECG will be indicated. [1]
Blood urea and electrolyte Not routinely done, but if patient has any underlying disease such as hypertension, cardiac diseases, renal disease, diabetes mellitus or if age is more than 65 years. [2]
Echocardiogram Only indicated if there any ECG changes or in diagnosed cardiac disease patient.[1]
Chest x ray. To asses respiratory functions. this will also indicated in malignant phylloides tumors to asses complications like plural effusions, bone deposits etc.[2]
Fasting Blood Sugar To asses to preoperative blood sugar control as uncontrolled diabetes will give rise to lot of surgical complications. [1]
References
  1. Milner QUENTIN. Fit for Anaesthesia?,Surgery [online]. Elsevier. March 2002. Vol. 20(2). 49-53[viewed april 4th 2014], Available from: DOI: 10.1383/surg.20.3.49.14618.
  2. WILLIAMS,Norman S,Christopher JK BULSTRODE and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008

Investigations - Followup

Fact Explanation
Mammography 15% of patients develop local recurrence. Local recurrence usually occurs within the first few years of surgery. So women who undergo surgery for removal of a phyllodes tumor require close surveillance with a follow-up mammogram and physical examination at regular intervals.[1]
References
  1. PARKER S, S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Availble from: doi:10.1136/pmj.77.909.428

Management - General Measures

Fact Explanation
Non surgical watchful waiting The natural history of fibroadenomas has recently been clearly defined.With the negligible increased risk of malignancy and the recognition that 40% of fibroadenomas reduce in size over a two year period, non-operative management has been widely adopted.[1] But many patients wish lump to be removed even after informing that it is benign.
References
  1. PARKER S., S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Availble from: doi:10.1136/pmj.77.909.428

Management - Specific Treatments

Fact Explanation
Wide local excision wide excision with a margin of at least 1 cm of normal breast tissue is required, particularly for borderline and malignant tumours to prevent local recurrence. If recurred,re-excision of borderline and malignant phyllodes tumours identified after local excision should be considered.[4]
Mastectomy Mastectomy is now not routinely done for phyllodes tumors.[1] It is done if histology shows malignant features. But mastectomy for malignant tumours offers no survival advantage. Axillary nodal dissection is not required[2]
Radiotheraphy The role of adjuvant radiotherapy is unclear.[3]
References
  1. MANGI AA, SMITH BL, GADD MA, TANABE KK, OTT MJ, SOUBA WW. Surgical Management of Phyllodes Tumors. Archives of Surgery[online].jamanetwork. May 1999, vol. 134(5), 487-493[viewed 3rd april 2014] Available from: doi: 10.1001/archsurg.134.5.487
  2. WILLIAMS,Norman S,Christopher JK BULSTRODE and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008
  3. PARKER S , S HARRIES. Phyllodes tumours. Postgraduate medical journal [online]. BMJ. July 2001, vol. 77. 428-435 [viewed 1st april 2014]. Available from: doi:10.1136/pmj.77.909.428
  4. LIANG, Margaret I.,Bhuvaneswari RAMASWAMY, Cynthia C PATTERSON, Michael T McKELVEY, Gayle GORDILLO, Gerard J NUOVO, William E CARSON. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology[online] biomed central. November 2008, vol. 6. 117[viewed 3rd April 2014] Available from: doi: 10.1186/1477-7819-6-117