Ann Thorac Surg 2007;83:2196-2197
© 2007 The Society of Thoracic Surgeons
Case Reports
Full-Thickness Chest Wall Resection for Recurrent Breast Phyllodes Tumor
Jose D. Andrade Neto, MDa,
Ricardo M. Terra, MDa,*,
Angelo Fernandez, MD, PhDa,
Viviane Rawet, MDb,
Fabio B. Jatene, MD, PhDa
a Department of Thoracic Surgery, Hospital das Clinicas, University of São Paulo Medical School, São Paulo-SP, Brazil
b Department of Pathology, Hospital das Clinicas, University of São Paulo Medical School, São Paulo-SP, Brazil
Accepted for publication January 2, 2007.
* Address correspondence to Dr Terra, Av. Dr. Enéas de Carvalho Aguiar, 255 Sala 9117, São Paulo-SP, CEP 05403-000, Brazil (Email: rmterra{at}uol.com.br).
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Abstract
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Phyllodes tumor is a rare breast neoplasm. We present the case of a woman who underwent multiple surgical procedures for phyllodes tumor treatment. Even after bilateral mastectomy and radiotherapy, local recurrences developed. We performed a full-thickness chest wall resection with wide margins, a procedure rarely reported in medical literature for this purpose. Only after this approach did we obtain disease control, with no signs of further recurrence at 4 years’ follow-up.
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Introduction
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Phyllodes tumor, or cystosarcoma phyllodes, is a rare neoplasm that represents 3% of fibroepithelial breast tumors. Wide local excision is the mainstay of the disease treatment, and free surgical margins are of crucial importance because recurrence is strongly correlated with inadequate margins. In large tumors and multiple recurrences, mastectomy may be necessary to provide adequate margins [1, 2].
Some patients have recurrent disease even after mastectomy, however, and their treatment is challenging. We report a patient who underwent several procedures for breast phyllodes tumor treatment. Despite bilateral mastectomy, right-sided local recurrences developed. The disease was only controlled after full-thickness chest wall resection, a procedure rarely reported in medical literature for this purpose.
A 43-year-old woman was referred in 2002 with a recurrent breast tumor after having had multiple previous breast operations. She first noticed a 2-cm nodule on her right breast when she was 18 years old. A nodulectomy was performed at that time, and histopathologic examination revealed fibroadenoma. Six years later, a recurrent nodule was found; again, a complete excision was performed and benign phyllodes tumor was histologically diagnosed. After 3 years, a second recurrent tumor was detected, followed by 15 local excisions over a subsequent 9-year period before a right mastectomy.
In 1995, after the mastectomy, the patient received 50 Gy of radiation. Despite mastectomy and radiation, a right chest wall recurrence developed, and again, a local excision was performed. During the next 7 years, five local recurrences on the right side were treated with local excision.
At age 40, 4 years after the right mastectomy, a similar tumor developed in the left breast, which was resected locally. After two additional left breast recurrences, she underwent a left mastectomy in 2001. Unlike the right side, she had no further recurrences on the left side.
On examination, she had a firm and irregular tumor at the right anterolateral chest wall, about 7 cm in diameter (Fig 1), and no evidence of recurrent disease on the left side. Thoracic computed tomography (CT) showed an anterior wall lesion involving soft tissues, and metastatic disease was ruled out on the basis of her symptoms and CT scans of the brain, chest, and superior abdomen.
Because of the multiple recurrences and apparent adherence to the ribs, we recommended wide excision (4-cm margins), with full-thickness chest wall resection, as our routine for other chest wall malignant tumors. Bony thorax reconstruction and stabilization was accomplished with a polypropylene synthetic mesh and soft tissue reconstruction with a musculocutaneus flap with rectus abdominis muscle (Fig 2).
The histopathologic examination demonstrated a 7.0 x 4.0 x 3.5 cm low-grade phyllodes tumor. It showed less than 4 mitoses per 10 high-power fields and moderate atypia (Fig 3). A negative margin was obtained after excision.
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Fig 3. Benign phyllodes tumor (<4 mitoses per 10 high-power fields and moderate atypia). (H.E. stain, original magnification 100x[left] and 400x[right].)
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The patient had a good postoperative outcome. At the 4-year follow-up, no evidence of tumor recurrence was noted at the physical examination or on the chest CT.
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Comment
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Standard surgical treatment for phyllodes tumor consists of complete tumor excision with wide radial margins of at least 1 to 2 cm [1–3]. Mastectomy is recommended for large tumors (>10 cm diameter), multiple recurrences, and tumors of less than 10 cm diameter in patients with a very small breast [2]. Axillary lymph node dissection is not routine unless nodes are enlarged [1, 2]. With adequate treatment, patients remain free of disease for a long term [1, 2]. The feature most closely related to local recurrence, more than histologic type, is the presence of tumor at surgical margins.
The patient in this case underwent several surgical procedures owing to local recurrence. She was probably treated with inadequate surgical margins on the previous resections, including the right mastectomy. On the left side, she also had recurrences; however, the mastectomy was performed earlier and offered wide disease-free margins allowing neoplasm control, confirming the importance of wide local excisions.
Radiotherapy is occasionally but rarely used when it is impossible to obtain a 1-cm free margin and in cases of multiple local recurrences or bone metastasis [1, 3]. Chemotherapy and hormone therapy have not been established, even for high-grade tumors [1, 3]. Experience with these therapeutic options in recurrent disease is limited and results are poor.
Full-thickness chest wall resection as a palliative or curative treatment for other breast malignances, such as desmoids tumors, has been reported [4, 5]. Our aggressive approach for phyllodes tumor recurrence, which involved full thickness chest wall resection and reconstruction, appears to have been successful in this patient. She has now been monitored for 4 years, the longest period she has had without recurrences.
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References
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- Guerrero MA, Ballard BR, Grau AM. Malignant phyllodes tumor of the breast: review of the literature and case report of stoma overgrowth Surg Oncol 2003;12:27-37.[Medline]
- Mangi A, Smith B, Gadd M, et al. Surgical management of phyllodes tumors Arch Surg 1999;134:487-491.[Abstract/Free Full Text]
- Soumarová R, SeneKlová Z, Horov H, et al. Retrospective analysis of 25 women with malignant cystosarcoma phyllodes—treatment results Arch Gynecol Obstet 2004;269:278-281.[Medline]
- Pameijer CRJ, Smith D, Maccahill LE, et al. Full-thickness chest wall resection for recurrent breast carcinoma: institutional review and meta-analysis Am Surg 2005;71:711-715.[Medline]
- Povoski SP, Marsh Jr WL, Spigos DG, Abbas AE, Buchele BA. Management of a patient with multiple recurrences of fibromatosis (desmoid tumor) of the breast involving the chest wall musculature World J Surg Oncol 2006;4:32.[Medline]
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Abstract
Introduction
