Ann Thorac Surg 2007;84:1750-1752. doi:10.1016/j.athoracsur.2007.06.014
© 2007 The Society of Thoracic Surgeons
Case Reports
Successful Resection of Giant Solitary Pulmonary Metastasis From a Phyllodes Tumor
Somshekar Ganti, FRCSa,*,
Eirik Svennevik, MDa,
Faisal S.M. Ali, MRCPathb,
Vladimir Anikin, FRCS(CTh)a
a Department of Thoracic Surgery, St. James’s University Hospital, Leeds, United Kingdom
b Department of Histopathology, Bradford Royal Infirmary, Bradford, West Yorkshire, United Kingdom
Accepted for publication June 5, 2007.
* Address correspondence to Dr Ganti, Department of Thoracic Surgery, St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF, United Kingdom (Email: gantisom{at}hotmail.com).
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Abstract
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Phyllodes tumors are rare fibroepithelial tumors that make up less than 1% of all breast tumors. Malignant phyllodes tumors are associated with a 25% incidence of distant metastasis, which is invariably fatal within 24 months. We report successful resection of a solitary pulmonary metastasis in the left chest in a 50-year-old woman 7 years after a right- sided mastectomy for malignant phyllodes tumor.
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Introduction
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Phyllodes tumors account for 0.3% to 0.9% of all breast tumors [1]. Histology of the phyllodes tumor reveals a stromal and epithelial component, and it is the stromal component that is responsible for local recurrence and distant metastasis. The World Health Organization defines three types of phyllodes tumors based on the histology: benign, low grade (borderline), and high-grade malignant phyllodes tumor [2]. Malignant phyllodes tumors comprise around 25% of all phyllodes tumors; the incidence of local recurrence and distant metastasis has been reported at 26% and 25%, respectively [3]. Metastatic phyllodes tumors are invariably fatal with very few reports of long-term survival [4].
A 50-year-old woman presented with rapidly increasing shortness of breath. Clinical examination revealed decreased breath sounds on the left side and a chest roentgenogram showed a complete opacification of the left chest (Fig 1A). A subsequent thoracic computed tomographic scan demonstrated a large, solitary soft-tissue mass encased within the chest and occupying and compressing most of the left upper lobe (Fig 1B). The only major significant past history in this patient was that she had undergone a right mastectomy for malignant phyllodes tumor 7 years prior to this presentation. The resection margins were reported to be clear. Computed tomographic-guided biopsy revealed the left chest mass to be a metastatic phyllodes tumor. In view of her good general fitness and lack of comorbidities, she was referred to the thoracic surgery unit by the regional multidisciplinary team for consideration of surgical resection of the phyllodes metastasis. She underwent a standard left posterolateral thoracotomy. At operation there was no evidence of mediastinal spread. Because of the size of the lesion, dissection of all the vascular lobar components was started posteriorly by first dividing the segmental arteries, which was followed by the left upper lobe bronchus. The superior pulmonary vein was short and it was divided flush with the pericardium. Despite the size of the tumor, dissection of all the vascular components was relatively straightforward. En bloc resection of the tumor-infiltrated left upper pulmonary lobe, along with a portion of involved chest wall, including the anterior portions of ribs 4, 5, and 6 was performed (Fig 2A). The tumor was entirely removed; the anterior chest wall defect was repaired with running polydioxanone sutures (Johnson & Johnson, New Brunswick, NJ). The patient was discharged home 7 days postoperatively after an uneventful hospital stay. Final histology revealed the lung tissue was almost entirely replaced by sheets of pleomorphic plump spindle cells with intervening collagen. The tumor was immunonegative for cytokeratin and the features are in keeping with a metastatic malignant phylliodes tumor (Fig 2B).
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Fig 1. (A) Chest x-ray film shows a mass in the left hemithorax. (B) Computed tomographic scan of the chest demonstrates a solid mass in the left hemithorax extending to the mediastinum.
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Fig 2. (A) Gross specimen of the excised tumor. (B) Histology of the tumor reveals a cellular spindle cell tumor with no epithelial component (x50). On high power (inset), there is mild to moderate nuclear pleomorphism with scattered mitotic figures evident (center) (x200).
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Comment
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Metastatic phyllodes tumor is reported in the literature to occur in approximately 10% of all patients with phyllodes tumor and in 10% to 25% of high-grade malignant phyllodes tumors [4]. Metastasis occurs invariably by hematogenous spread with the commonest sites being the lung (70% to 80%), pleura (60% to 70%), and bone (20% to 30%) [1]. The risk of metastatic spread seems to not be influenced by the extent of initial surgery, but to be predetermined by tumor biology [5]. The literature review has shown that the metastatic phyllodes tumor occurs within the first 3 years of primary resection and is invariably fatal with a mean survival of 4 months from the time of diagnosis [5]. There are only three previous reports of successful resection of metastatic phyllodes tumor in the chest owing to the fact that these metastases are invariably multiple and generally involve mediastinal structures precluding surgical intervention. The first documented successful excision of pulmonary metastasis of metastatic phyllodes tumor was by Hart and colleagues [6] in 1978; their patient was reported to be surviving 16 years after lobectomy with removal of the metastasis. Second, a giant (>20 cm) metastatic phyllodes tumor in the lung was resected and reported by Takahashi and colleagues [7] in 1992. The third and latest report was a successful excision of a giant phyllodes pleural metastasis in 2005 by Filosso and colleagues [8] who reported an otherwise healthy patient presenting 9 years after mastectomy. We believe our case to be the fourth such reported case of successful resection of a solitary chest phyllodes metastasis. Our case is unique as it also involved chest wall resection, which we believe has not been previously reported. Although Hawkins and colleagues [9] reported some long-term remissions at 26 and 61 months using combinations of ifosfamide and doxorubicin to treat distal phyllodes metastases, we believe that this success with chemotherapy has not been reported elsewhere in the literature. In addition, the role of radiotherapy is still not clear, because experience is usually limited to a few cases in most series. In light of the good clinical response to complete extirpation of a giant solitary thoracic phyllodes metastasis of our patients and the surprisingly successful outcomes in the few documented patients who have undergone resection of similar lesions, we recommend surgical resection of these metastases in appropriate candidates.
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References
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- Kapiris I, Nasiri N, A’Hern R, Healy V, Gui GP. Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phyllodes tumors of the breast Eur J Surg Oncol 2001;27:723-730.
- World Health Organization Histological typing of breast tumors Tumori 1982;68:181-198.
- Barth Jr RJ. Histologic features predict local recurrence after breast conserving therapy of phyllodes tumors Breast Cancer Res Treat 1999;57:291-295.
- Parker SJ, Harries SA. Phyllodes tumors Postgrad Med J 2001;77:428-435.
- Reinfuss M, Mitus J, Duda K, et al. The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases Cancer 1996;77:910-916.
- Hart WR, Bauer RC, Oberman HA. Cystosarcoma phyllodesA clinicopathologic study of twenty-six hypercellular periductal stromal tumors of the breast. Am J Clin Pathol 1978;70:211-216.
- Takahashi M, Murata K, Mori M, et al. Giant metastatic cystosarcoma phyllodes to the lung: CT and MR findings Radiat Med 1992;10:210-213.
- Filosso PL, Turello D, Pernazza F, Ruffini E, Oliaro A. Radical surgical resection of a giant pleural metastasis of a malignant phyllodes tumor of the breast J Thorac Cardiovasc Surg 2005;130:1707-1708.
- Hawkins RE, Schofield JB, Wiltshaw E, Fisher C, McKinna JA. Ifosfamide is an active drug for chemotherapy of metastatic cystosarcoma phyllodes Cancer 1992;69:2271-2275.
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Abstract
Introduction
