Phyllodes Tumor

• The term Phyllodes originates from Greek word "phullon" which means a leaf.
• It is also called as Cystosarcoma phyllodes.
• Here is a picture of a Phyllodes tumor recently operated by us. 
• The patient was a 38 year old female with complaints of swelling in Left breast of 6 months duration which was fast growing in size.
• The tumor was excised through a submammary incision
• Phyllodes tumors are a fibroepithelial tumor composed of an epithelial and a cellular stromal component. 
• They may be considered benign, borderline, or malignant depending on histologic features including stromal cellularity, infiltration at the tumor's edge, and mitotic activity
• Predominantly a tumor of adult women
• Very fast-growing, and can increase in size in just a few weeks
• 10% of patients with phyllodes tumours can develop distant metastases 
• Commonest sites for distant metastases are the lung, bone, and abdominal viscera.
• Treatment : Wide Local Excision

6/24/2020 07:03:00 PM

Case History

A 32 year old female came with multiple lumps in her right breast which have been there from past 7 years and are increasing in size and number. Initially she was advised conservative management and observation. But the lesions were growing in size and she had started having occasional pain. So she decided to go for surgical removal.

Discussion: What is the best incision if multiple fibroadenomas have been identified?

Having multiple fibroadenomas in a single breast is a rare occurrence.

There are various available incision approaches like: 

• Periareolar
• Inframammary
• Radial
• Curvilinear. 

Each of these having their advantages and disadvantages. Utilising the mobility of the fibroadenomas, allows them to be excised through a single cosmetic circumareolar incision in each breast. Periareolar incision is not suitable when the diameter of the tumor is >5 cm or when the distance between the tumor and the areola is >3–4 cm, since the surgery would cause significant damage to the lactiferous ducts (Zhao XY).

Traditional surgical incision often chooses radial incision or curvilinear incision on the surface of the tumor. It is very favorable for the exposure and resection of the tumor, and the treatment effect is also good, but the postoperative scar is obvious and affects the cosmesis.

References

http://journals.sagepub.com/doi/abs/10.4137/BCBCR.S9512

https://onlinelibrary.wiley.com/doi/full/10.1046/j.1524-4741.2001.007003189.x

http://file.scirp.org/Html/5-2101137_57749.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5103926/

Zhao XY. Application value of areola incision at the edge of the benign breast tumor resection. Zhongguo Shiyong Yiyao. 2010;5:57–58

5/04/2018 11:01:00 AM

What is Aberration of Normal Development and Involution (ANDI) ?

Aberrations in the Normal Development and Involution of the breast (ANDI) is an all encompassing term that is used to describe a wide spectrum of the benign breast diseases. As the name suggests, it is based on the theory that most of the encountered benign breast disorders are essentially minor aberrations in the normal development process, hormonal response and involution of the breast.

How does the incidences across years of life varies for Fibroadenoma, Simple Cyst, Nodularity and Breast Ca ?

From which structure does a Fibroadenoma arise?

Arises from a single lobule and is composed of epithelial and fibrous components. Check out the anatomical origin of various breast pathologies in the figure below.

What is the relative risk of breast cancer in case of Proliferative breast disease with atypia?

Moderate Risk. (Relative risk >2)

6/17/2016 05:23:00 PM

What is Skin Involvement or T4b ?

Edema (including peau d’ orange) or ulceration of the skin of the breast or satellite skin nodules confined to the breast.

What is not Skin Involvement or T4b ?

Dimpling of the skin and nipple retraction is not considered skin involvement.

Skin involvement in breast showing a skin nodule 

surrounded by edema (peau d orange)

How does peau d’ orange appearance develop?

Localised edema (peau d’orange) develops when drainage of lymph fluid from the skin is disrupted by infiltration of lymphatics by metastatic cells.

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Read more about Ca Breast:

WHAT IS THE REASON FOR PUCKERING OR SKIN RETRACTION IN BREAST CANCER?
http://www.worldsurgeryforum.net/2016/05/what-is-reason-for-puckering-or-skin.html

SKIN PUCKERING AND PEAU D ORANGE APPEARANCE IN BREAST CANCER
http://www.worldsurgeryforum.net/2016/05/skin-puckering-and-peau-d-orange.html

WHAT IS THE ACCURACY OF CLINICAL DETERMINATION OF AXILLARY LYMPH NODE METASTASIS IN CA BREAST?
http://www.worldsurgeryforum.net/2016/06/what-is-accuracy-of-clinical.html

MECHANISM OF METASTASIS FROM CA BREAST TO BATSON'S PLEXUS AND LIVER
http://www.worldsurgeryforum.net/2016/06/mechanism-of-metastasis-from-ca-breast.html

6/12/2016 02:39:00 PM

How does metastatic lesion from Ca Breast reach vertebrae?

• The malignant cells from the breast reaches vertebrae via the intercostal veins.
• The intercostal vein will join the vertebral plexus of the veins. This is also called Batson’s plexus of veins. 
• The peculiarity of this plexus is that there are no valves and therefore the malignant cells can freely reach all the vertebrae from the base of the skull to the sacrum.
• 
  

How does a metastatic lesion from Ca Breast reach the liver ?

• The liver is involved in 2 ways. 
• The most important route is bloodstream spread. 
• The liver also can be involved by lymphatic route. 
• The lymphatics from the lower inner quadrant of the breast traverse the plexus in the rectus sheath and reach the subperitoneal plexus. From their along the falciform ligament it will reach the liver. 

6/10/2016 07:16:00 PM

The clinical stage of breast cancer is determined primarily through physical examination of the skin, breast tissue, and regional lymph nodes (axillary, supraclavicular, and internal mammary). The clinical determination of axillary lymph node metastases has an accuracy of:

1. Only 80%
2. Only 50%
3. Only 33%.
4. Only 10%

Answer in the comment section below. Detailed explanation will be posted.

6/08/2016 12:19:00 PM

Worldsurgeryforum.net

What is the most important prognostic correlate of disease-free and overall survival in Ca Breast?

A) Distant Metastasis
B) Size of the tumour
C) Skin involvement or Chest fixation
D) Axillary lymph node status   

Answer in the comment section below. Detailed explanation will be posted.

6/01/2016 01:58:00 PM

Invasive breast cancer and LCIS

Which of the following is true?

 A) Invasive cancer may develop in same breast which harbored the initial focus of LCIS

 B) Invasive cancer may develop in either breast, regardless of which breast harbored the initial focus of LCIS

 C) Invasive cancer does not develop in the breast which harbored the initial focus of LCIS

 D) Association between the laterality of Invasive cancer and LCIS is scientifically not significant      

Answer in the comment section below.

Detailed explanation here: http://www.worldsurgeryforum.net/2016/05/surgical-vignettes-lobular-carcinoma-in.html

6/01/2016 11:58:00 AM

A)Puckering in Breast Cancer B)Peau d' orange appearance

  What is the reason for puckering or skin retraction in Breast Cancer?

 1) Desmoplastic Response of tumor leading to shortening of cooper's ligaments
 2) Drainage of lymph fluid from the skin is disrupted
 3) Direct migration of tumor cells
 4) Satellite growth leading to retraction

Please leave your answer in the comment section below.

Click here for a detailed explanation.

Click here for more Freshly Brewed MCQs.    

5/26/2016 12:19:00 AM

Atypical Ductal and Lobular Hyperplasia of breast

What is the cancer risk for Atypical ductal hyperplasia?
What is the cancer risk for Atypical lobular hyperplasia?
What is the management if Atypical hyperplasia is found after surgery?
What is the management if Atypical hyperplasia is found after core needle biopsy?

5/14/2016 11:41:00 PM

A case of gynaecomastia with pectus excavatum

What are the criteria for diagnosis of Gynaecomastia?

In the nonobese male, breast tissue measuring at least 2 cm in diameter must be present before a diagnosis of gynecomastia may be made. Mammography and ultrasonography are used to differentiate breast tissues. 

What is the differential diagnosis of Gynaecomastia?

I. Estrogen excess states

  

A. Gonadal origin

    1. True hermaphroditism

    2. Gonadal stromal (nongerminal) neoplasms of the testis

       a. Leydig cell (interstitial)

       b. Sertoli cell

       c. Granulosa-theca cell

    3. Germ cell tumors

       a. Choriocarcinoma

       b. Seminoma, teratoma

       c. Embryonal carcinoma

  B. Nontesticular tumors

    1. Adrenal cortical neoplasms

    2. Lung carcinoma

    3. Hepatocellular carcinoma

  C. Endocrine disorders

  D. Diseases of the liver—nonalcoholic and alcoholic cirrhosis

  E. Nutrition alteration states

II. Androgen deficiency states

  A. Senescence

  B. Hypoandrogenic states (hypogonadism)

    1. Primary testicular failure

       a. Klinefelter's syndrome (XXY)

       b. Reifenstein's syndrome

       c. Rosewater-Gwinup-Hamwi familial gynecomastia

       d. Kallmann syndrome

       e. Kennedy's disease with associated gynecomastia

       f. Eunuchoidal state (congenital anorchia)

       g. Hereditary defects of androgen biosynthesis

       h. Adrenocorticotropic hormone deficiency

    2. Secondary testicular failure

       a. Trauma

       b. Orchitis

       c. Cryptorchidism

       d. Irradiation

  C. Renal failure

III. Drug effects

IV. Systemic diseases with idiopathic mechanisms

What are various grades of Gynaecomastia?

Grade I	Mild breast enlargement without skin redundancy
Grade IIa	Moderate breast enlargement without skin redundancy
Grade IIb	Moderate breast enlargement with skin redundancy
Grade III	Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

What is the surgical management of Gynaecomastia?

The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion.

Webster's Incision

5/14/2016 08:44:00 PM

Breast Implants

Below are a few specific points to remember related to breast cancer in patients with cosmetic breast implants:

1. Breast Implants and Risk of Breast Cancer: Women who have undergone cosmetic breast implantation do not have an increased risk of breast cancer. [1]
2. Breast Implants and Breast Cancer Survival: A meta-analysis showed reduced survival after breast cancer among women who had implants compared with those who did not (overall hazard ratio for breast cancer specific mortality 1.38, 95% confidence interval 1.08 to 1.75) [2]. This can be due to the delayed detection of breast cancer in these patients because implants can interfere with mammography
3. Mammography and Silicon Implants: The presence of silicone gel-filled breast implants may interfere with standard mammography since silicone is radiopaque, and the physical presence of the implant compresses fat and glandular tissues, creating more homogeneous dense tissue that frequently lacks the contrast needed to detect subtle early features associated with breast cancer [3]
4. Breast Implants and Stage at Diagnosis:  A 2013 systematic review of 12 studies found that women with breast cancer who had breast implants are diagnosed with later-stage cancers than women with breast cancer who did not have implants [4]
5. Breast cancer screening schedule and Breast Implants: Though breast augmentation decreases the sensitivity of screening mammography among asymptomatic women but does not increase the false-positive rate [5]. Thus it is advised that women with breast implants should undergo screening at the same schedule as women without breast implants.

References

[1] Noels EC, Lapid O, Lindeman JH, Bastiaannet E. Breast implants and the risk of breast cancer: a meta-analysis of cohort studies. Aesthet Surg J. 2015 Jan;35(1):55-62. doi: 10.1093/asj/sju006. PMID:25568234
[2] Lavigne Eric, Holowaty Eric J, Pan Sai Yi, Villeneuve Paul J, Johnson Kenneth C, Fergusson Dean A et al. Breast cancer detection and survival among women with cosmetic breast implants: systematic review and meta-analysis of observational studies BMJ 2013; 346 :f2399
[3] Institute of Medicine (US) Committee on the Safety of Silicone Breast Implants; Bondurant S, Ernster V, Herdman R, editors. Safety of Silicone Breast Implants. Washington (DC): National Academies Press (US); 1999. 12, Silicone Implants and Breast Imaging.Available from: http://www.ncbi.nlm.nih.gov/books/NBK44781/
[4] Lavigne E., Holowaty EJ, Pan SY, Villeneuve PJ, Johnson KC, Fergusson DA, Morrison H, & Brisson J. Breast cancer detection and survival among women with cosmetic breast implants: Systematic review and meta-analysis of observational studies
[5] Handel N. The effect of silicone implants on the diagnosis, prognosis, and treatment of breast cancer. Plast Reconstr Surg. 2007 Dec;120(7 Suppl 1):81S-93S. Review. PubMed PMID: 18090817
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5/13/2016 07:46:00 PM

Poland’s syndrome consists of hypoplasia or complete absence of the breast, costal cartilage and rib defects, hypoplasia of the subcutaneous tissues of the chest wall, and brachysyndactyly.

The cause of Poland syndrome is unknown. However, an interruption of the embryonic blood supply to the arteries that lie under the collarbone (subclavian arteries) at about the 46th day of embryonic development is the prevailing theory.

Poland's Syndrome

    Image above shows a 15-year-old girl with Poland's syndrome of left breast. A, With shoulder girdle musculature actively contracted. B, There is accentuation of the left hypoplastic breast. There is absence of the sternal head of the pectoralis major although the clavicular head is present.      (Image Courtesy of Dr. Hollis H. Caffee, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, FL.)

5/10/2016 05:32:00 PM

Ref: Schwartzs 10th ed (http://amzn.to/1q10JSc)

Image Source: Wikipedia

   

• Calcifications associated with LCIS typically occur in adjacent tissues. This neighbourhood calcification is a feature that is unique to LCIS and contributes to its diagnosis.
• The average age at diagnosis is 45 years, which is approximately 15 to 25 years younger than the age at diagnosis for invasive breast cancer
• Invasive breast cancer develops in 25% to 35% of women with LCIS. 
• Invasive cancer may develop in either breast, regardless of which breast harbored the initial focus of LCIS, and is detected synchronously with LCIS in 5% of cases. 
• In women with a history of LCIS, up to 65% of subsequent invasive cancers are ductal, not lobular, in origin. 
• For these reasons, LCIS is regarded as a marker of increased risk for invasive breast cancer rather than as an anatomic precursor

5/06/2016 10:42:00 PM