Phyllodes tumour initially diagnosed as keloid

Abstract

It is unusual to find a breast tumour in a keloid, as the management of both is distinct. In this case, a young woman was operated on 4 years ago, for a right chest wall swelling, situated near the inframammary fold. The histopathological report revealed a granuloma, for which anti-tuberculosis treatment was given. However, the swelling recurred and progressed in size over the next 3 years. Then, she consulted the dermatology department, where the swelling was managed as a keloid. There was no remission. Consequently, the possibility of a breast tumour was suspected, and the patient was referred to breast services (subdivision of the surgery department).

Triple assessment of the breast lump was suggestive of a phyllodes tumour (PT). Surgical excision of the tumour was done, which showed a malignant PT. Radiotherapy was given and delayed breast reconstruction was planned.

Background

Malignant phyllodes tumour (PT) is one of the rare tumours (0.3%–0.9% of all breast cancers) that is difficult to diagnose.¹ High-grade PT is commonly seen in the elderly but can also occur in young patients, as reported in this case of a woman in her 20s.

Preoperative diagnosis helps in planning the line of management. The treatment protocol varies between benign, borderline and malignant PT in terms of surgical management and need of radiotherapy.

Case presentation

A young woman was clinically diagnosed as a case of keloid in the right breast of 3-year duration in the dermatology department (figure 1). Intralesion triamcinolone was injected twice in the keloid at an interval of 1 month. There was no reduction in size, rather it enlarged progressively. The patient was then referred to breast services for further evaluation.

Figure 1.

Breast lump in the lower inner quadrant of the right breast.

The patient gave a history of excision of right chest wall swelling, near inframammary fold, and histopathology showed granuloma. She completed 6 months of anti-tuberculosis treatment through the Revised National Tuberculosis Control Programme. The swelling recurred within 6 months and progressed to the current size over the next 3 years.

On clinical examination, there was a solitary 8×8 cm globular swelling in the lower inner quadrant of her right breast, with three satellite lesions at 5, 6 and 12 o’clock position. It was firm in consistency, with pink surface and ulceration over the dome of the swelling (figure 2).

Figure 2.

Breast lump with satellite lesions at 5, 7 and 12 o’clock position (features of keloid) extending into the chest.

Investigation

The sonomammography showed five hypoechoic masses situated from 3 to 6 o’clock position. Two masses were exophytic in nature, situated over the skin, medial and inferior to the right breast. Three masses were within the breast parenchyma, adjacent to each other.

A trucut biopsy showed fibroepithelial neoplasm favouring PT. Chest radiography had no significant findings.

Treatment

As trucut biopsy was suggestive of a low-grade PT and the breast-to-tumour ratio being favourable, wide local excision was done (figure 3). Histopathology showed a multinodular mass of size 10×4.5×6 cm diagnosed as a malignant PT (figure 4) with high mitotic index of 6–7/high-power field. The tumour showed invasive borders and positive basal resection margin (figure 5). Completion mastectomy was done.

Figure 3.

Postoperative view after wide local excision.

Figure 4.

Cut section of the tumour showing a solid, grey-white, firm tumour.

Figure 5.

Microscope view showing a malignant phyllodes tumour.

Outcome and follow-up

The patient was given radiotherapy for the high-grade nature of the tumour. Breast reconstruction was delayed as radiotherapy leads to graft contraction. Follow-up ultrasonography was done after 6 months, which revealed no metastatic lymph nodes or local recurrence.

Discussion

The WHO classified PT into benign, borderline and malignant categories based on the degree of stromal cellular atypia, mitotic activity per 10 high-power fields, degree of stromal overgrowth and margin appearance.² Unlike fibroadenomas, PT is composed of higher stromal cellularity.³

Triple assessment, as the name indicates, includes three components: physical examination, imaging (mammography or ultrasound) and biopsy (fine-needle aspiration cytology and core biopsy). These different methods of investigation, when used separately, give less reliable results, but when performed adequately, diagnostic accuracy reaches up to 100%, thus making it a gold standard in the management of a breast lump. It is a great example for a multistep or multidisciplinary approach. Lack of any of these at a single centre may lead to delay in diagnosis and treatment of the breast lump.

Tumours 3 cm or greater in diameter on mammography are more likely to be malignant.³ According to Ramakant et al, a large or giant PT (>10 cm) has higher cancer rates (42.5%) and recurrence rates (41%) than smaller tumours (21% malignancy rate and 29% recurrence rate).⁴

Most studies recommend a more than 1–2 cm excision margin based on the evidence that local recurrence occurs more frequently in patients with surgical margins less than 1–2 cm.⁵ So, aggressive management and adequate resection margins are vital. However, mastectomy significantly reduces the risk of recurrence.⁵

Radiotherapy has been used with good results for local control of the disease and it may be considered for high-risk PT, including those greater than 5 cm, with stromal overgrowth, with more than 10 mitoses per high-power field, or with positive margins (Breast conservative surgery).⁶ The optimal approach is delayed autologous tissue reconstruction in patients who have taken radiotherapy, as it prevents autologous graft contraction and interference with radiation therapy.⁷ The use of adjuvant chemotherapy is not beneficial.⁸

Patient’s perspective.

This swelling in my chest was persistent and worrisome despite many modalities of treatment. I was very much concerned regarding the nature of tumour and its recurrence. The treatment given to me was clearly elaborated and discussed with me and my husband, and also amongst the various treating doctors (General surgery, Plastic surgery, Radiotherapy, Onco-medicine). The idea of delayed breast reconstruction made sense to me, so I will consider it in future. My fear of conceiving, breast feeding etc. was alleviated. I got a comprehensive solution to this problem from this hospital. They made me mentally and socially strong, and I had a very non-traumatic experience throughout.

Learning points.

• The difficulty in distinguishing between phyllodes tumour (PT)/fibroadenoma and keloid, as in this case, may lead to mismanagement, so triple assessment is the key.

• Lack of awareness of triple assessment and availability of various diagnostic tools in a healthcare facility adds to the problem.

• Attaining negative margins in the primary excision followed by radiotherapy is mainstay of treatment for a malignant PT.

Ethics statements

Patient consent for publication

Obtained.