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Documente Cultură
Oleh:
dr R Imam Muhajirin
Pembimbing:
dr. Iskandar Ali Sp.B (K) Onk
female with obvious mass of the right breast, the mass measured 50x30 cm with multiple
ulcers. In additional investigation : anemia (9 g/dl) and hipoalbumin (1,8 g/dl) . After anemia
& hipoalbumin been corrected, a simple mastectomy was performed , then pastient controlled
at oncology polyclinic at dr Soetomo hospital .
Keywords : Tumor Phyllodes, benign,borderline and malignant tumor
*Resident of General surgery
**Teacher of Oncology Surgery Departement of Airlangga University Medical Faculty/dr
Soetomo Hospital Surabaya
Background
Phylloides tumor is a tumor of the fibroephitelial breast tissue which is rare with
incidence rate of less than 1% of all breast tumors. This tumor is derived from intralobular
stromal of the breast with morphologic characteristics such as the excessive growth of the
stroma that is covered by epithelium and often shapes like a leaf. 1 phyllodes tumors can be
benign, borderline, or malignant.2 Most phyllodes tumor is benign, but 10-40% can be
malignant. Distant metastases can be occurred by hematogenous, mainly found in the lungs,
bones, abdominal viscera, and mediastinum. Local recurrence is a problem which can occur
either on the benign phyllodes tumor or malignant at nearly 25% cases.5
The main treatment of phyllodes tumor is surgery. The surgical treatment based on the
principle of prevention of local recurrence, and mastectomy can be choosen as surgical
treatment if the malignant phyllodes tumor is difficult to adequately excised.1
Adjuvant radiation therapy and chemotherapy are still controversial, pyllodes tumor is
believed to be resistant with radiation, but there are some reported cases ca be managed by
administering radiotherapy. although some belief that Phyllodes tumor is resistant with
chemotherapy, but there are some cases of patients with distant metastases showed clinical
improvement after administration chemoterapy.1
Case Report
We report a female patient, Mrs. S, 30 years old, with chief complain is there is a
lump in the right breast since 2.5 years ago, initially she said that the lump size is like a
marbles ( 1.5 cm) and progressively enlarged until now, its about like aqua gallon ( 50
cm), raised sores on the lump since 2 months ago, sometimes it bleed and produce the fluids,
felt the pain on the skin of the lump, no tightness, no coughing, no headache, no bone pain.
Previously patients treated the with traditional therapy for 2 years, and the lump is still
growing larger and wound raisen on the lump, so the patient went to the Bangil Hospital and
then she was referred to the Oncology departement (POSA) RSU Dr Soetomo.
On physical examination found like anemia condition, and other condition is normal
enough. Inspection on the right breast examination is obtained mass, the color of skin partly
is same with normal skin and part one get hyperpigmentation, shiny, vein ectase, no peau d
orange feature, satellite nodules, skin dimpling and papil retraction. Obtained multiple ulcers
with an average 4cm diameter. On palpation obtained a mass with size 50x30 cm, dense
chewy consistency and partly cystus, not obtained tenderness, mobile on the skin and chest
wall, flat surface tumor, undifferentiated border of tumor, not warm, as shown in pictures
1dan 2. On left breast examinations are not obtained of the tumor mass. From the
examination of the regional nodes not be obtained enlargement of regional nodes in the axilla,
right and left supra and infraclavicula. The clinical diagnosis is suspected a malignant tumor
phylloides.
Operation is carried out on 18 november 2014 and the operation lasted 2 hours, and it
is preceded by informed consent to patients and their families about the condition of the
patient, the procedure of operation and all possibilities that could occur either before, during
or after operation. The patient position is supine, with the ipsilateral arm to th operation side
is abduction position on 90o, shoulder ipsilateral to the operation side is propped up with
pillows thin, then carried out disinfection on the operation field, from top to the middle of the
neck, the bottom until the umbilicus, medial part until mid contra lateral of breast, part lateral
to the lateral edge of the scapula, upper arm up to the elbow circularly disinfected and then
wrapped in sterile doek to narrow the operation field.
Simple mastectomy is done with skin tumors ellipse incision, as shown in fig.3,
deeper incision and made flap, superior flap until below the clavicle, medial flap until
ipsilateral parasternal, inferior flap until to the inframammary fold, lateral flap until to the
anterior edge of the latissimus dorsi and then identificate vasa and N thoracalis dorsalis.
residual bleeding as shown in Figure 4, then the operation wound is sutured layer by layer,
and the operation lasted for 2 hours with about 700 cc of bleeding.
there may be some advantages for local control or borderline malignant disease, it does not
change the improvement of survival rate .1 From research conducted by Chaney et al, at the
University of Texas MD Anderson Cancer Center does not support the use of radiotherapy for
tumors phyllodes that has been resected with adequate.6
Recommendation of therapy can be vary, depending on prognosis marker. It did not
surprised that one of the main factors affected survival is the feature of a benign histology. 1 In
addition, local recurrence was associated with positif surgical margin. 11 Barrio et al also
found that local recurrence rates associated with necrosis and fibropoliferation of surrounding
breast tissue.5 Excessive growth of stromal tissue have been known to be associated with
local recurrence and distant metastases can predict. With numbers of metastases overall are
low, however it is difficult to take a definitive decision to this problem. 11 Barrio et al
proposed there are 6 factors that increase the high risk of metastases if there simultaneously,
namely: excessive stromal growth, large tumor size, cellularity stromal meaningful, high
mitotic count, and the presence of infiltration. Although local recurrence is considered to
relate to the further development of metastases, Chen et al. found no difference between the
two outcomes.11
Due to the rarity of this disease, there are not guidelines for phyllodes tumor
management yet. Overall good prognosis, with a 10-year survival rate of more than 95%.
Recent retrospective study with 752 cases of malignant phyllodes tumors found that the
survival rate reached a plateau at 5 years and 10 years, mortality rates equal to the population
umum.12 So follow-up is not too aggressive may be sufficient after five years. On the other
hand, the occurrence of local recurrence had a wide span of time with a significant number of
identified five years after the onset of tumor inisial.1
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