case report

Malignant Phyllodes: Report of Three Cases and Review of the Literature

Hiyam Al Haddad1, Anwar AlZahrani1*, Khaled Alhizami1, Liqa Al Mulla2, Roaa Al Goweiz3, Mariam Al Qurashi1, Maha Abdel Hadi1

1Department of Surgery, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia

2Department of Pathology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia

3Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia

*Corresponding author: Anwar Saeed Al Zahrani, Department of Surgery, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia

Received Date: 19 April 2023

Accepted Date: 24 April 2023

Published Date: 26 April 2023

Citation: Al Haddad H, Al Zahrani A, Alhizami K, Al Mulla L, Al Goweiz R, et al. (2023) Malignant Phyllodes: Report of Three Cases and Review of the Literature. Ann Case Report 8: 1276. DOI: https://doi.org/10.29011/2574-7754.101276

Abstract

Phyllodes tumors (PT) accounts for up to 1% of all breast tumors. Although it is considered to be a rare tumor which is mostly benign. Some of the Phyllodes tumors could be malignant, which are characterized by aggressiveness in biological behavior with the chance of local recurrence or metastasis. In this presentation, we report three cases of large malignant PT.

Keywords: Phyllodes; Breast; Fibroepithelial Tumors.

Introduction

Phyllodes tumors (PT) previously known as Cystsarcoma Phyllodes are rare tumors that arise from the connective tissue and periductal stroma of the breast sparing the ducts and the glands. Thus, it is categorized as fibroepithelial tumors of the breast accounting for 0.3% to 1% of all breast tumors [1,2]. The World Health Organization in 2003 has classified Phyllodes tumors into three mains categories based on their histological features, benign, borderline, or malignant [3]. Phyllodes tumors are commonly benign (35% to 64%) with documented malignancy ranging between 10% - 30% [4].

The clinical features of PT carry resemblance to fibroadenomas with variable sizes. However, it has the tendency of rapid growth, multiplicity, active biological behavior, local recurrence, or distal metastasis [5]. The challenge is to achieve accurate diagnosis and be able to perform surgical excision with safety margins. Hereby, we report three cases of Asian women presenting with extreme sizes of PT.

Case presentation

Case 1

40 years old Pilipino a mother of 2 children who lost followup after wide local excision with safe margins of borderline PT in 2018. She presented at this time to the Breast Clinic with a left breast mass of 3 months duration. There was a progressive increase in size associated with pain, skin redness, and a foulsmelling bloody nibble discharge. No other associated symptoms. Menarche at 16 years, strong positive family history of breast cancer was documented. 

Local examination revealed marked asymmetry, enlarged left breast with overlying stretched skin, erythema, and peau d’orange with distortion of nipple and areola complex with ulceration. On palpation confirmed the presence of the mass occupying the center of the left breast, hard in consistency measuring 10x10 cm. with no palpable axillary nodes. (Figure 1a)

Ultrasound demonstrated a large lobulated hypoechoic mass with an angular margin occupying nearly all the breast extending to the nipple, associated with overlying skin thickening and nipple distortion. Multiple axillary lymph nodes with diffused cortical thickening, measuring 13.1x8.7mm, same findings were confirmed by mammogram and was reported BI-RADS 5. (Figure.1b)

Metastatic workup utilizing CT-CAP scan (for chest, abdomen, and pelvis) and the Bone scan was reported as negative. Ultrasound-guided core biopsy of the left breast mass and left axillary lymph node (LN) reported malignant PT of left breast mass and reactive axillary lymphoid tissue.

Mastectomy was the consensus by the Multidisciplinary team (MDT) meeting. The patient underwent left mastectomy and axillary sampling of the enlarged lymph nodes. Breast tissue measured around 26x26 cm and weighed 3.5 kg (Figure 1c)

Immunohistochemical stains showed, Pan-CK highlight limited epithelial elements and marked stromal expansion, Ki-67: 3040 %, ER: positive, CK5/6: weak, P63: highlight myoepithelial cells, Calponin: highlight the myoepithelial cells (Figure 2) The diagnosis was reported as Malignant PT with uninvolved axillary nodes.