Gaint phyllodes tumour with axillary & interpectoral lymph node metastasis; A rare presentation

Phyllodes tumors are rare fibroepithelial neoplasms of the breast, account for less than 1 % of all breast neoplasms, lymph node metastasis is even rare and routine axillary dissection is not recommended. Approximately 20 % of patients with malignant phyllodes tumors develop distant metastasis.

A 45 years old premenopausal female, presented with a huge right breast mass for 3 years. Physical examination revealed a 40 × 46 cm, lobulated mass, fixed to the chest wall and multiple enlarged and mobile ipsilateral axillary lymphadenopathy. Core tissue biopsy revealed fibroepithelial & stromal proliferation suggestive of phyllodes tumor. The CT scan of the chest and the abdomen revealed bilateral pulmonary metastasis. She underwent palliative Modified Radical Mastectomy. Pathology demonstrated malignant phyllodes with osseous and chondroid metaplasia, the resection margins were clear and 6 out of 25 nodes were positive. Her post-operative recovery was uneventful and she received adjuvant chemo-radiotherapy. During 12 months follow up, no local recurrence was noted, but despite chemotherapy her pulmonary disease was increasing.

Only a few cases of cystosarcoma phyllodes with lymph node involvement have been reported in the literature. Treves, Norris and Taylor's series have demonstrated the axillary node metastasis of less that 1 %. Since most sarcomas metastasize hematogenously, this finding explains why axillary metastasis is so rare. Hence most authors have concluded that removal of axillary lymph nodes is not warranted unless there are pathologically involved.

Management of Phyllodes tumor presents the surgeon with challenges. Core tissue biopsy is a reliable method for pre-operative diagnosis. Imaging like CT scan and MRI help to evaluate the primary lesion as well as distant metastasis. The majority of these cases can be managed by simple mastectomy. Axillary lymph node metastasis is rare and dissection should be limited to patients with pathological evidence of tumor in the lymph nodes.