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Hang in thereAlcaraz, AdrianMedical ClerkURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERTo be able to give an initial impression of the caseTo discuss the anatomy and physiology of the breastTo differentiate benign from malignant breast massTo present on Phyllodes Tumor To identify appropriate management

OBJECTIVES:URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERName: BAAge: 41year oldSex: FemaleAddress:Siay, ZSPCivil Status: Married

Occupation: NoneReligion: Born Again Nationality:FilipinoPersonal DataURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERRight Breast MassChief ComplaintURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER3 month PTC2cm x 2cm enlarging mass, right breast, tenderNo associated fever, weight loss, easy fatigability, nipple discharge, nipple retractionConsulted at ZCMCCore Needle Biopsy was doneHistory of Present IllnessURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER1 month PTCBiopsy result was consisted with Benign Phyllodes TumorWas scheduled for operationHistory of Present IllnessURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMedical Illness: No known morbidities; no asthmaHospitalization: No prior hospitalizationSurgical: No prior surgical operationMedications: No medical maintenanceAllergies: No known allergies to food or drugsPast Medical HistoryURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER(+) cancer (breast)(+) hypertension(-) diabetes mellitus(-) bronchial asthmaFamily HistoryURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERHousewife with 3 living children10 pack-year smoker Non-alcoholic beverage drinkerDoesnt use oral contraceptivesPersonal and Social HistoryURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERG4P4 (4 0 1 3)Menarche at 14years oldLMP: January 29, 2015, regular menstrual cycleOB-Gyne HistoryURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERNo other pertinent symptomsReview of SystemURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERGENERAL APPEARANCE:

ambulatory, response to questions and command; oriented to time, place, and name; not in cardio-respiratory distressPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERVITAL SIGNS: Blood Pressure: 120/110 mmHgPulse rate: 87 bpmRespiratory Rate: 18 cpmTemperature: 35CPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERSKIN/HAIR/NAILS:

Warm to touch; no jaundice; no pallor; no lesionsPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERHead: No scars; no lesions; normal hair distribution and texture; normocephalic; Eyes: Anicteric sclera; pink palpebral conjunctiva; pupils are round, regular, equally reactive to lightPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTEREars: Both pinna symmetrical; no lesion on auricle and both canalsNose/Sinuses: Symmetrical; septum midline Mouth/Throat: Pink buccal mucosa; tongue midline; no ulceration; no lesionsPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERNECK

No mass, lesion; no visible pulsation of jugular vein; no CLAD, mass; no tracheal deviation; no tendernessPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERTHORAX & LUNGS Inspection: No lesions; Symmetrical chest expansion; No intercostal retractions.Palpation: Non-tender on all lung fieldsPercussion: Resonant on all lung fieldsAuscultation: Equal clear breath sounds; no cracklesPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERBREASTInspection: Symmetric, pendulous, (-) peau dorange, no ulceration, skin lesions, or discharges.Palpation: Right Breast: 3cm x 3cm mass, lower outer at the peri-areolar area, round with regular border, hard, movable and tenderPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERAXILLAEInspection: No lesions, no signs of infection, no discolorationPalpation: No lymphadenopathiesPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERCARDIOVASCULAR adynamic precordium; normal rate, regular rhythm; no murmurPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERABDOMENflabby; normo-active bowel sounds; soft and non-tenderPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERGENITALIA: Not assessed RECTAL: Not assessedPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTEREXTREMITIES:

Warm skin, symmetrical, no atrophy, no clubbing, no cyanosis, no edema, CRT < 2secsPhysical Examination

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERPhyllodes Tumor, Benign Right Breast s/p Core Needle Biopsy (December 16, 2014)Pre-op DiagnosisURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERPartial MastectomyProposed Operation URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERUnremarkable hospital stayDischarged on the second post-op dayCourse in the WardURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERPhyllodes Tumor, Benign Right Breast s/p Core Needle Biopsy (December 16, 2014)Final DiagnosisURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERFibroademaBreast CarcinomaDifferential DiagnosisURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERCharacteristicBenign MassMalignant MassSigns and SymptomsMobile mass, usually painful Nipple dischargeChanges in size

Fixed mass, often painless; Nipple discharge or bleeding;Changes in the size or contour of the breast; Changes in color or appearance of areola; Peau dorange; Weight loss; Mass MarginSmooth and Round; Well demarcated; with Fibrous CapsuleIrregular Borders; with no CapsuleBenign vs malignantURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERCharacteristicBenign MassMalignant MassManner of GrowthGrows by expanding and pushing away and against surrounding tissue mobile massGrows by invading and sometimes destroying surrounding tissue fix massMetastasisNever metastasizeAlmost always metastasizeExamplesFibrocystic changesCystsFibroadenomasInfectionTraumaPhyllodes TumorDuctal CarcinomaLobular CarcinomaPhyllodes TumorBenign vs malignantURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERBENIGN CONDITIONSFibrocystic changes: Lumpiness, thickening and swelling, often associated with a womans periodCysts: Fluid-filled lumps can vary in sizeFibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occuring most in young womenURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERBENIGN CONDITIONSInfections: The breast will likely be red, warm, tender and lumpyTrauma: a blow to the breast or a bruise can cause a lumpPhyllodes: Large bulky mass of connective tissue and cysts. Leaf-like projections.URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERBENIGN CONDITIONSMicrocalcifications: Tiny deposits of calcium in the breastMost women have one or more areas of microcalcifications of various sizesMajority of calcium deposits are harmlessA small percentage may be precancerous or cancer (biopsy is sometimes recommended)URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMalignantCONDITIONSDuctal CarcinomaLobular CarcinomaURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERULTRASOUND Benign MassIntense and Uniform HyperechogenicityEllipsoid shape and thin Echogenic CapsuleSmooth marginsStarvos, et al. Radiology 1995; 96:23-34URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER

Thin Echogenic CapsuleEllipsoid Shape (wider than tall)FibroadenomaULTRASOUND Benign MassStarvos, et al. Radiology 1995; 96:23-34URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER

AnechoicEllipsoid Shape (wider than tall)Smooth SurrfaceCystULTRASOUND Benign MassStarvos, et al. Radiology 1995; 96:23-34URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERSpiculationAngular MarginsHypoechogenicityShadowingCalcificationDuct ExtensionBranch patternMicrolobulationULTRASOUND Malignant MassStarvos, et al. Radiology 1995; 96:23-34URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER

Angular MarginMicrolobulationHypoechoicULTRASOUND Benign MassStarvos, et al. Radiology 1995; 96:23-34Irregular MarginURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERThe BreastURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER

Anatomy2nd or 3rd Rib6th or 7th RibLateral Border of the SternumAnterior Axillary LIne URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERThe breast is prominent superficial structured in the anterior thoracic wall, especially in women.

The mature breast is bordered superficially by the 2ND OR 3RD RIB and extends to the inframammary fold at the 6TH OR 7TH RIB. Medially bordered by the LATERAL BORDER OF THE STERNUM and Laterally bordered by the ANTERIOR AXILLARY LINE.

It rest on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. The retromammary bursa lies between the posterior aspect of the breast and fascia of the pectoralis major muscles.

The AXILLARY TAIL OF SPENCE extends laterally across the anterior axillary fold.

The breast is mainly composed of fat surrounding the glandular tissues. And it contains 15 to 20 lobes, each composed of several lobules. And is supported by fibrous bands of connective tissues called the Coopers suspensory ligaments, that travel through the breast and insert perpendicularly into the dermis and provide structural support

42

AnatomyPectoralis MajorSerratus AnteriorURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERThe breast is prominent superficial structured in the anterior thoracic wall, especially in women.

The mature breast is bordered superficially by the 2ND OR 3RD RIB and extends to the inframammary fold at the 6TH OR 7TH RIB. Medially bordered by the LATERAL BORDER OF THE STERNUM and Laterally bordered by the ANTERIOR AXILLARY LINE.

It rest on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. The retromammary bursa lies between the posterior aspect of the breast and fascia of the pectoralis major muscles.

The AXILLARY TAIL OF SPENCE extends laterally across the anterior axillary fold.

The breast is mainly composed of fat surrounding the glandular tissues. And it contains 15 to 20 lobes, each composed of several lobules. And is supported by fibrous bands of connective tissues called the Coopers suspensory ligaments, that travel through the breast and insert perpendicularly into the dermis and provide structural support

43

AnatomyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERThe breast is prominent superficial structured in the anterior thoracic wall, especially in women.

The mature breast is bordered superficially by the 2ND OR 3RD RIB and extends to the inframammary fold at the 6TH OR 7TH RIB. Medially bordered by the LATERAL BORDER OF THE STERNUM and Laterally bordered by the ANTERIOR AXILLARY LINE.

It rest on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. The retromammary bursa lies between the posterior aspect of the breast and fascia of the pectoralis major muscles.

The Breast is a circular modified sebaceous gland with an lateral extension crossing the anterior axillary fold called the AXILLARY TAIL OF SPENCE.

The breast is mainly composed of fat surrounding the glandular tissues. And it contains 15 to 20 lobes, each composed of several lobules. Connected with ducts into an opening in the nipple. And is supported by fibrous bands of connective tissues called the Coopers suspensory ligaments, that travel through the breast and insert perpendicularly into the dermis and provide structural support

44Anatomy

Subclavian ArteryInternal Thoracic a.perforatingbranchesAxillary ArteryLateral thoracic a.Lateral mammary BranchesLateral mammary Branches of lateral cutaneous branches of posterior intercostal aa.URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMedially supplied by the arteries arising form the subclavian artery. Internal thoracic artery with it perforating branches

Laterally supplied by the axillary artery which give rise to the lateral thoracic artery with its lateral mammary branches. And the lateral mammary branches from the lateral cutaneous branches of posterior intercostal arterioles45Anatomy

Axillary vein (lateral) nodesdrainage from the upper extremityExternal Mammary (anterior or pectoral)Scapular (posterior or subscapular)drainage from the lateral aspect of the breastdrainage principally from the lower posterior neck, the posterior trunk, and the posterior shoulderCentral(anterior or pectoral)from the axillary vein, external mammary, and scapular groups of lymph nodes, and directly from the breastSubclavicular (apical)Interpectoral (Rotters) directly from the breast drainage from allof the other groups of axillary lymph nodesURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMedially supplied by the arteries arising form the subclavian artery. Internal thoracic artery with it perforating branches

Laterally supplied by the axillary artery which give rise to the lateral thoracic artery with its lateral mammary branches. And the lateral mammary branches from the lateral cutaneous branches of posterior intercostal arterioles46Anatomy

External Mammary (anterior or pectoral)Scapular (posterior or subscapular)Axillary vein (lateral) nodesCentral(anterior or pectoral)Subclavicular (apical)Interpectoral (Rotters)URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMedially supplied by the arteries arising form the subclavian artery. Internal thoracic artery with it perforating branches

Laterally supplied by the axillary artery which give rise to the lateral thoracic artery with its lateral mammary branches. And the lateral mammary branches from the lateral cutaneous branches of posterior intercostal arterioles47Breast DevelopmentBirth2 yearsAfter PubertyEstrogenEstrogenURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERDuctal development occurs mainly after BIRTH48Breast DevelopmentBirth2 yearsAfter PubertyAfter PregnancyEstrogenEstrogenProgesteroneProlactinOxytocinURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERDuctal development occurs mainly after BIRTH49Phyllodes tumorAka. Cystosarcoma PhyllodesDerived from the Greek words sarcoma (fleshy tumor), and phyllon (leafy)Rare (1% of breast tumor), predominantly benign tumorComposed mainly of connective tissueBenign Phyllodes do not metastasize, but can grow aggressively, can recur locallyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERpathophysiology

URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERepidemiologicExclusively occur in the female breastCan develop at any age, median age = 50sURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERMalignant phyllodes10-15% of Phyllodes tumorMatastasize hematogenouslyRecurrent malignant tumors seem to be more aggressiveLung, skeleton, heart, and liver most common metastatic siteRoughly 30% of patient with malignant Phyllodes die from this diseaseMay present with dyspnea, fatigue, and bone painURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERpresentationPresents larger mass, and display rapid growthRarely involves the nipple-areola complex or ulcerate the skinFrim, mobile, well-circumscribed, nontender breast massOverlying skin may display shiny appearance and be translucent enough to reveal underlying breast veinsVery large Phyllodes may erode through overlying skinURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERmanagementComplete excision of the tumor2cm margin for small tumors5cm margin for large tumor> Tumor-to-breast ratio total mastectomyAxillary dissection not recommendedURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERAdjuvant therapyNo proven role for adjuvant chemotherapy or radiotherapyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERPost-op complicationInfectionSeroma formationLocal or distant recurrenceURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERTissue InvolvementSkin-sparingTotal (simple)Breast Tissue++Nipple-Areola Complex++Scars++Skin+Level I nodesLevel II nodesLevel III nodesPectoralis Major and MinorMastectomyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERTissue InvolvementExtended SimpleModified RadicalHalsted RadicalBreast Tissue+++Nipple-Areola Complex+++Scars+++Skin+++Level I nodes+++Level II nodes++Level III nodes+Pectoralis Major and Minor+/- Pectoralis Minor+MastectomyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERBordersModified RadicalLaterallyAnterior margin of the Latissimus dorsi muscleMediallyMidline of the sternumSuperiorlySubclavius muscleInferiorlyCaudal extension; 2-3cm inferior to the inframammary foldModified RadicalMastectomyURGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER Thank you URGERYDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTERURGERYSDEPARTMENT OFZAMBOANGA CITY MEDICAL CENTER