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BLOCK 10 A TINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA

BLOCK 10 A TINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA. HISTORY. PROFILE. M.P. 52/F San Dionisio, Paranaque Single, works as a vollunteer at the cemetery Admitted 01/08/12. HISTORY OF PRESENT ILLNESS.

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BLOCK 10 A TINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA

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  1. BLOCK 10 A TINDOC, TUGANO, URQUIZA, UY, VELASCO, VENTIGAN, VENTURA, VERDOLAGA

  2. HISTORY

  3. PROFILE • M.P. • 52/F • San Dionisio, Paranaque • Single, works as a vollunteer at the cemetery • Admitted 01/08/12

  4. HISTORY OF PRESENT ILLNESS • 7 years PTA: palpable mass, R breast: ~<1cm in greatest diameter, firm, movable, nontender, with no note of skin changes/ nipple discharge. No consult done. • Interim: Progressive enlargement of mass; (+) occasional pain described as “tumutusok-tusok” VAS 2/10 (1 year PTA) and erythema and pruritus on the skin overlying the mass.

  5. HISTORY OF PRESENT ILLNESS • 2 months PTA: consulted at PGH-OPD  biopsy of the mass was done A> PHYLLODES TUMOR R Breast  scheduled for elective surgery

  6. REVIEW OF SYSTEMS • (-) wt. loss, easy fatigability, fever • BOV, tinnitus, dysphagia • Dyspnea, chest pain, palpitations, orthopnea, PND • Bowel and bladder changes • Polyuria, polydipsia, polyphagia • Heat and cold intolerance

  7. PAST MEDICAL HISTORY • (-) previous hospitalizations/ surgical procedures • (-)comorbidities

  8. FAMILY MEDICAL HISTORY • (-)Benign/Malignant breast neoplasia • (-) other CA • (+) HPN, sibling • (-)DM • (+) BA, both parents

  9. PERSONAL AND SOCIAL HISTORY • (+) Smoker, 22 pack years • (+) Alcoholic beverage drinker, 1x a week, 2-3 bottles of beer

  10. OB-GYN HISTORY • Menarche: 16y/o • Regular monthly period, lasting 5 days, consuming 4-5 ppd • (+) dysmenorrhea • LNMP: 1st week Dec 2011 • OB Score: G5P4 (4012) • (-)OCP/IUD use

  11. PHYSICAL EXAMINATION

  12. BP 140/80 HR 70 RR 20 Temp 36.7 • Systemic PE: E/NHEENT: (-) CLAD, NVE • Chest: ECE, CBS, NRRR, Distinct S1 and S2 • Abdomen: soft and flabby, NABS • Extremity: FEP, PNB, (-) cyanosis, edema

  13. The R breast is converted into a 8cm x 24cm x 10cm , firm, nodular, well-circumscribed, movable, non-tender mass. Overlying skin is shiny with a patch of erythema. (-) nipple discharge L breast: (-)masses/tenderness/skin changes/nipple discharge

  14. Considerations

  15. DIAGNOSTICS

  16. Imaging of giant breast masses • with pathological correlation • M Muttarak, B Chaiwun • Department Mammography is always the imaging modality of choice for breast masses specially in ages 35 years and above. M Muttarak, B Chaiwun.Imaging of giant breast masses with pathological correlation. Singapore Med J 2004 Vol 45(3) : 132

  17. FNA Biopsy: Smears disclose cohesive clusters of uniformly sized ductal cells many of which are arranged in knobby short branching patterns. Portions of fibromyxoidstroma can be observed in fields. Histopathologic Diagnosis: Negative for malignant cells, right breast mass Cytomorphologic features consistent with phyllodestumor Recommend tissue biopsy for a more definitive diagnosis

  18. DIAGNOSIS PHYLLODES TUMOUR

  19. Phyllodes Tumour • a.k.a. Phylloides tumours, cystosarcoma phyllodes • Cystosarcoma phyllodes– used to indicate only the tumour’s leaf-like fleshy appearance and propensity to contain macroscopic cyst and a misnomer since most PTs are benign • Cause: unknown, p53 defect MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

  20. Clinical Presentation: • Unilateral, painless, palpable, firm and well circumscribed, variable size • Rapid growth and skin ulceration can occur (ischemia from pressure and stretching) MI Liang, et al. Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. World Journal of Surgical Oncology 2008, 6:117

  21. Rare, < 1 % of all breast neoplasm and 2-3 % of all fibro-epithelial breast tumors • 35-54 y/o • 3 Histopathologic types: benign, borderline and malignant (20%) L-R Benign, Borderline, Malignant Satyajeet Verma, et al. Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India. Journal of Cancer Research and Therapeutics 2010. Vol. 6, Issue 4. 511-515

  22. Histologic Classification: Based on: infiltrative margin, stromal overgrowth, stromal atypia and cellularity, and mitotic activity Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

  23. Phyllodes Tumour • Core biopsy is better than FNAC yielding about 65% of correct diagnosis • No distinct imaging characteristics distinguish it from fibroadenoma

  24. Phyllodes Tumor Ian K. Komenaka; Mahmoud El-Tamer; Eliza Pile-Spellman; HaninaHibshoosh. Core Needle Biopsy as a Diagnostic Tool to Differentiate PhyllodesTumor From Fibroadenoma. ARCH SURG/VOL 138, SEP 2003. 987-990

  25. Phyllodes Tumour Fibroadenoma

  26. MANAGEMENT

  27. Treatment is surgical, regardless of classification • Wide excision and simple mastectomy (radical not done), surgical margin of at least 1 cm (1-2 cm) to prevent local recurrence • Mastectomy: > 10 cm, malignant, recurrent • Axillary lymphadenectomy is considered for clinically suspicious cases and sometimes not warranted since spread is hematogenous (metastatic) Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

  28. Final assessment will depend on pathology report after complete surgical removal of the mass

  29. Specific management (histologic consideration): • Benign and borderline: wide local excision • Malignant: simple mastectomy with or without reconstruction SatyajeetVerma, et al. Extent of surgery in the management of phyllodestumor of the breast: A retrospective multicenter study from India. Journal of Cancer

  30. Controversial • Radiotherapy: adjuvant for high risk patients, >5 cm, with stromal overgrowth, with 10 mitotic elements/hpf, or with infiltrating margins • Chemotherapy: Doxurubicin and ifosfamide for metastatic spread • Hormonal management (ER/PR) still on research Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

  31. PROGNOSIS

  32. Recurrence and Survival Rate • Local recurrence for high-grade malignant lesions is 26% (12-65%): (+) stromal overgrowth, large size tumor, and involved margin • 5 yr survival rate (malignant): 54-82% • 10 yr survival rate : 23-42% Harris JR et al. Diseasesof the breast. 4th Ed. Vol 2. 781-791

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