Phyllodes tumor is uncommon benign tumor of breast with a risk of malignant transformassion. Malignant phylloies tumors originates from the connective tissue of the breast therefore these tomors are sarcomas on histology.  A 37 years old married woman presented with painless slowly progressive enlargement of right breast for two years duration. On physical examination confirmed the presence of a large size lobulated well defined mass lesion in occupying in UIQ, UOQ & LOQ of right breast. Ultrasonography of breast and Mammography revealed mass lesion. FNAC from the lesion & subsequently histopathology confirmed the diagnosis of benign phyllodes tumor of breast.

Overlying skin was normal. There was no discharge from the nipple. No lymph nodes were palpable in right axilla. Left breast and left axilla were unremarkable. Her systemic examination was normal. The present case report describes a case of begin phyllodes tumor of breast in a 37-year-old female and its clinical, ultrasonographic, cytological and histopathological correlation.

Case Presentation:

A middle aged woman presented with complaints of progressive enlargement of right breast of 2 years duration, not associated with pain.No H/o- oral contraceptive intake with normal menstrual cycle.No positive family history for breast neoplasms.Had history of normal vaginal delivery of 2 children. On local examination, Enlargement of right breast as compare to left breast with bulge on contour. Nipple areola was normal. Skin appear normal with livid discoloration. Large sized approximately 12 x 8 cm, mass lesion felt on palpation involving all quadrants of right breast mainly upper outer quadrant. Lesion was mobile and non-tender. No palpable lymph nodes in axilla. Systemic examination was insignificant.

Figure 1: clinical image showing enlargement and disfigurement of right breast.

Imaging findings: 

Mammographic findings:

Well defined large sized encapsulated, lobulated high density mass lesion with well-defined margins occupying right breast. A radiolucent halo is seen around the lesion.No evidence of pleomorphic microcalcifications seen.

Figure 2, 3, 4: mammographic CC, LAT & OBL projections showing well defined, encapsulated, lobulated high density lesion in right breast.

Breast Ultrasonographic findings:

Well defined heterogenous hypoechoic mass lesion with clefts occupying entire breast mainly upper outer and central quadrant with posterior acoustic shadow.No evidence of internal vascularity seen.No significant lymphnodes seen in right axilla. Left breast was normal.

Figure 5: USG findings shows well defined heterogenous,hypoechoic mass lesion with clefts and posterior acoustic shadows.

Figure 6: USG DOPPLER study showing minimal internal vascularity.

Figure 7: cli nical specimen after surgical removal.

Histotopathological finding:

Benign Phyllodes tumor grade I with low rate of local recurrence.

Discussion:

Phyllodes tumour is a rare fibroepithelial neoplasm.1:6300 examinations; 0.3-1.5 % of all breast tumors [1, 2], 3% of all fibroadenomas.Most of the tumours occur in females of a median age [2,3,4]. 5th -6th decade, mean age of 45 years [5],occasionally in women < 20>

 Approximately 20-30% of phyllodes tumours are malignant and thus cannot be safely followed or simply enucleated. The malignancy grade is categorised as benign, borderline
and malignant based on tumour margins, stromal cellularity and overgrowth stromal cell atypia and mitotic activity.Even benign tumours recur(20%) and they may be accompanied by a change to a more malignant status.

Mammographic appearance:

Phyllodes tumours are usually larger than fibroadenomas. Both tumours present as well circumscribed, oval or lobulated masses, but phyllodes are reported to have a higher density.Small tumours tend to have more smooth edges, while the greater ones are more irregular and lobulated. Illdefined borders may be due to invasion of surrounding breast tissue.Even malignant phyllodes are usually nonspiculated. Very large size and rapid growth are in favor of phyllodes rather than fibroadenoma. 

Breast ultrasonographic appearance:

The modality of choice for the diagnosis reveals well-circumscribed, lobulated masses with heterogeneous internal echogenicity, including solid and cystic components. There are several imaging features that are more frequently encountered in phyllodes tumours than fibroadenonomas. These are lobulations,heterogeneous internal texture, cystic components, horizontal linear clefts, rich vascularisation and irregular margins. Posterior enhancement has also been reported to represent a commonly detected feature in phyllodes tumours, at rates between 50 and 77% in different studies. 

MRI appearance:

Well -defined lobulated masses with cystic components, either due to degeneration or necrosis, which tend to have a cleft-like shape.The presence of internal cystic areas was significantly different between phyllodes tumours and fibroadenomas .The latter are more commonly associated with septations. Solid parts are iso- to high signal on T2WI, but also foci of dark signal can appear, representing areas of haemorrhage or calcification. Breast phyllodes tumour is of low-signal intensity on plain scan T1WI and of   higher signal intensity on T2WI. Previous studies described slowly enhancing (type 1) and suspiciously enhancing (types 2 and 3) phyllodes tumours. Wurdinger et al reported that one-third of phyllodes tumours showed a typical malignant enhancement pattern. 

Follow up:

Patient is adv. for follow up with every 3 months in 1st year, every 6 month in 2nd year then yearly onwards and Self Breast Examination.

Imaging helps in preoperative diagnosis of phyllodes tumor however a final diagnosis remains on histopathology.

As chances of local recurrence and spread out of malignant phyllodes tumor is considerable therefore radiological and histopathological correlation is important in diagnosis and treatment of phyllodes tumor.

Our case was proven low grade benign phyllodes tumor still we recommended patient for follow up examination.

We are thankful to Dean, Medical Director and Department of Surgery, and     Pathology, LN Medical College and J K Hospital for allowing us to use data from the hospital   for this case report publication.

Nil

There are no conflicts of interest.