Omental Metastasis of Malignant
Phyllodes Tumor: A Case Report
Bhambhani N1, Gori J2, CS
Pramesh3, Kulkarni C4, Dr. Nambiar A5, Badwe RA6
1Dr. Navin Bhambhani, MS, DNB, Consultant Surgical Oncologist, Jupiter
Hospital, Thane, Maharastra, India, 2Dr. Jayesh Gori, MS, Registrar,
Department of Surgical Oncology, Fortis hospital, Mulund (w), Mumbai,
Maharastra, India, 3Dr. CS Pramesh, MS, FRCS, Department of
Surgical Oncology, 4Dr. Chandrashekar Kulkarni, MS, Department of
Surgical Oncology, 5Dr. Ajit Nambiar, MD, DNB, Department of
Pathology, 6Dr. RA Badwe, MS, FICS, Department of Surgical Oncology
all are affiliated to Tata Memorial Hospital and Research Center,
Parel, Mumbai, Maharastra, India.
Corresponding Author: Dr.
Jayesh Jayantilal Gori, E-mail - jayeshgori26feb@gmail.com
Abstract
Malignant Phyllodes tumor behaves like sarcomas and has a tendency for
local spread and for local recurrence. The metastasis commonly known is
blood borne and is usually to the lungs, mediastinum and skeleton
rather than to the axillary lymph nodes. In present case of malignant
phyllodes tumor there was metastasis to omentum, probably the only
reported case in English literature.
Keywords:
Malignant Phyllodes Tumor, Omentum, Metastasis, Spindle-Cell Sarcoma
Manuscript received: 25th Jan 2015, Reviewed: 4th Feb
2015
Author Corrected: 19th
Feb 2015, Accepted for
Publication: 14th Mar 2015
Introduction
Cystosarcoma phyllodes constitutes only 0.3–0.9% of all
breast tumors also called, in modern terminology as Phyllodes tumor
(PT). The term Phyllodes tumor includes a group of lesions varying from
benign and locally recurrent to malignant and metastatic. In a recent
surgical series, 6.2% of the tumors were malignant[1,2]. The metastatic
potential of the tumor cannot be accurately determined by gross and
microscopic pathologic findings but the clinical course is the only
sure means of determining it at present .Metastases consists only of
stromal tissue and can occur in any area of the body. Most commonly
reported are to the lungs and skeleton[2,3]. Here we present a case of
metastases of malignant Phyllodes tumor to the omentum probably the
only reported case in English literature.
Case
History
A 26 year old unmarried woman presented to us with a recurrent right
breast lump. She had a history of lumpectomy done twice before; two and
four years back respectively, the histopathology on both occasions
being benign fibroadenoma. Clinical examination revealed a single, 15cm
x 15cm, bosselated, mobile lump in the right breast. The opposite
breast, both axillae and supraclavicular fossae were normal. A tru-cut
biopsy from the lump revealed a stromal cell sarcoma of the breast.
Awaiting surgery the tumor had rapidly progressed and fungated. A
simple mastectomy with axillary node sampling was done. The
histopathology revealed a malignant cystosarcoma Phyllodes with free
margins and negative nodes in the axilla. After a disease free interval
of 11 month patients presented with abdominal distension associated
with anorexia and constipation. There was no evidence of loco-regional
recurrence. Ultrasonography of the abdomen revealed loculated ascites.
The liver, ovaries and retro peritoneum were reported normal.
The patient progressively deteriorated while investigating the cause of
ascites, diagnosis and the clinical picture suggesting intestinal
obstruction, an exploratory laparotomy was performed. This revealed the
greater omentum encasing a large mass occupying the whole of the
abdomen with multiple cystic spaces and adherent small bowel loops. The
liver, ovaries and retro peritoneum were normal. Debulking of the mass
with about one foot of adherent jejunum were removed and an anastomosis
of the small bowel performed. However, it was not feasible to achieve
complete clearance of the disease. The patient expired on the first
postoperative day in the intensive care unit, probably consequent to
the extremely poor general condition pre-operatively with the
subsequent stress of surgery.
The Histopathological analysis of the debulked omentum showed a
spindle-cell sarcoma consistent with metastases in a known case of
malignant Phyllodes tumor of the breast [fig. A and B]. The sections
from the intestine were unremarkable except for occasional evidence of
inflammation.
Fig 1: Showing
at 100X magnification
Omental
Fig 2:
(400X) Stroma shows cellular pleomorphism
fat with multiple spindle
cells nuclear
atypia, high mitotic activity, increase in nuclear
cytoplasmic ratio.
Discussion
The percentage of Phyllodes tumors classified as malignant ranges from
23% to 50% [4, 5]. Axillary metastases are reported in less than 5% of
cases, but are a poor prognostic sign when present [6]. Formal axillary
dissection seems to be unnecessary, but removal of low axillary lymph
nodes cannot be criticized. Metastases commonly follow the pattern seen
with sarcomas with the lung as the most common site in 6-22% [5, 7].
Phyllodes tumor akin to sarcomas has a tendency for local spread
causing fungation of skin and tendency for local recurrence. The
metastasis commonly is blood borne and not lymphatic as metastases is
usually to the lungs, mediastinum and skeleton rather than to the
axillary lymph nodes. Our surmise is that the Omental spread too must
be blood borne.
The optimal treatment for metastatic Phyllodes tumor has not been found
but is commonly based on the guidelines for treating sarcomas.
Effective palliation is achieved by few. Radiation to symptomatic
metastases was helpful. Occasionally these tumors contain estrogen and
progesterone receptors, although hormone manipulation was ineffective.
In metastatic condition role of various modality like chemotherapy,
radiotherapy and hormonal therapy in both the adjuvant and palliative
settings remain to defined[8].
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Bhambhani N, Gori J, CS Pramesh, Kulkarni C, Nambiar A, Badwe RA.
Omental Metastasis of Malignant Phyllodes Tumor: A Case Report. Int J
Med Res Rev 2015;3(2):243-245. doi: 10.17511/ijmrr.2015.i2.042.