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Republic of the Philippines Dr Paulino J.

Garcia Memorial Research and Medical Center Cabanatuan City Department of Surgery CASE REPORT OBJECTIVES of this case report is to: 1. To present a rare case of malignant phylloides cystosarcoma, review of current literatures, management, update,. 2. To discuss the correlation between phylloides tumor and pregnancy 2. Discuss disease progression, prognosis, and prevent fatal outcome, 3.Promote patients education A case of P.H. 41 y/o female, single, roman catholic, presently residing in Lambakan, Jaen, Nueva Ecija, born on August 28, 1971 who came in with a chief complaint of right breast mass. The present condition started at about 8 years PTA, when the patient was diagnosed as Low Grade Phylloides Tumor and underwent Total Mastectomy right. Since then no follow-up was done and went unremarkable. Until 1 year PTA, when the patient became pregnant, G1P0, she noticed a mass on the previous incision site of her right chest areat no consult was done. Until 10 months PTA, patient had a spontaneous abortion at 16 weeks AOG, the mass progressively enlarged into 5x7 cm with ulceration and draining abscesses. She sought consult with an OB Gyne, completion curettage was done and was then referred at this institution for further management of tumor recurrence. But due to financial constraint, patient failed consult.

3 months PTA, patient breast mass size progressively enlarged to 12x15cm with ulcerations and draining sinuses. Still no consult was done. 1 month PTA, the size of the breast mass increased to 25x40cm with associated weight loss and body weakness. Patient sought consult at our institution. Incision biopsy of the mass was done revealing ____________________. Patient was advised for consult to oncologist for neoadjuvant therapy. But patient cannot afford for the therapy and patient was given an option of tumor rebulking. Patient was then cp cleared and was admitted for operation.

Past Medical History 8 years PTA, patient underwent total mastectomy right secondary to low grade phylloides, right. Patient was a diagnosed case of Diabetes mellitus 1 year prior to admission with maintenance medication of metformin 500mg TID 8 months prior to admission, patient admitted due to incomplete abortion PU+- 14 wks AOG and underwent completion curettage.

Obstetrics and Gynecologic History: revealed the following Data: LMP: April 14 2012, Menstruation: at 10 years of age, with irregular interval, for 3to5 days, amount varies from moderate-markedly soaked pad per period, no apparent symptoms of dysmenorrheal seen. Patient is a G1P0 (0-0-1-0) Incomplete abortion PU+ 14 weeks AOG underwent completion curettage (Npvember 2011). No history of oral contraceptive pill therapy. Family History: A known family of Diabetics: the patient is the eldest of four siblings. No history of breast cancer.

No other heredofamilial disease extracted. Social Environmental History: Subject is a non smoker and a non alcoholic beverage drinker graduate as an average student of high school at 16years old. Review of Systems revealed: GENERAL: (-) wt. loss, (-) anorexia ; HEENT: (-) icteric sclera (-) seizure, (-)changes in sensorium, (-) epistaxis, (-)ear discharge, deafness,

CARDIOVASCULAR: (-) chest pain, (-)chest heavines, (-) palpitation, CHEST AND LUNGS: (-) orthopnea, (-)Dyspnea, (-)shortness of breath, GASTROINTESTINAL: skip meals, (-)constipation (-) loose (-) occasionally (-)

stool, (-)black tarry stool, GENITOURINARY:

frequency,urgency, (-) hypogastric, (-)dysuria, (-) Discharges, MUSCULOSKELETAL: (-) joint and muscle pain, SKIN: (-) jaundice, HEMATOLOGIC:(-) bruise Physical Examination: At the ER: patient was conscious, coherent, awake, oriented, RR: 18

ambulatory not in cardio pulmonary distress, afebrile. Vital Signs: BP: 120/80 CR:84 T: 36.7C; Spo2: 98% at 2lpm, Wt= 59.2kg. SKIN : no pallor, no cyanosis, no jaundice, no active dermatoses,

HEENT: pinkish-white eyebrow, pale palpebral conjunctiva, anicteric sclerae, no nasoaural discharges, moist buccal mucosa, no gingival hemorrhages, no tonsilopharyngeal wall congestion, no cervical lymphadenopathy, no neck vein engorgement. BREAST: Right: 30x40cm movable, non tender, ulcerating with yellowish discharge breast mass with palpable axillary lymph nodes

Left: no palpable mass, no axillary lymph node CHEST: Symmetrical wall expansion, infection, no intercostals retraction, clear breath sounds, no crackles and wheezes noted HEART: Adynamic precordium, Normal rate regular rhythm, no murmur, PMI 5th ICS (L) MCL ABDOMEN: flabby, no previous surgical scar, normoactive bowel sounds NABS, soft, no tenderness elicited, no hepatosplenomegaly noted, DRE: good sphincter tone, no pararectal tenderness, no palpable mass, full rectal vault, no blood, no black tarry stool, positive stool on examining finger EXTREMITIES: full and equal pulses, No bipedal edema, all are gross normal Neurologic Examination revealed the following Cerebral: conscious, awake, coherent, in an appropriate mood, oriented to 3spheres cerebellar: no dysmetria, no dysdiadochokinesia, no intentional tremors, negative Rombergs sign Cranial Nerve test: CRANIAL NERVE I can smell; CRANIAL NERVE II: photophobia,

3to4mm OU, ERTLA; CRANIAL NERVE Ill. IV. Vl: intact EOMs; CRANIAL NERVE V : (+) corneal reflex; CRANIAL NERVE VII: no facial asymmetry; CRANIAL NERVE VIII: can

hear; VESTIBULAR DIVISION; CRANIAL NERVE IX ,X good swallow reflex; CRANIAL NERVE XI: shrugs shoulder full range; weakness noted; CRANIAL NERVE XII: no tongue deviation; no

Motor: 5/5, full ROM, against gravity and resistance in all extrimities ; Sensory: 100% sensation; Reflexes: ++/normoreflex; (-)babinski, (-)kernigs, (-)clonus.

Given the case presented: Salient points include:

Our initial impression: Malignant Phylloides Right s/p total mastectomy, right (2004; PJGMRMC) secondary to low grade Phylloides tumor right Differential Diagnosis: Conditions to consider in the differential diagnosis of phyllodes tumors include the following:

Angiosarcoma Breast cancer Juvenile fibroadenoma Giant fibroadenoma Inflammatory carcinoma Sclerosing adenosis Radial scar Fat necrosis Fibrocystic change Breast abscess Adenocarcinoma Mastitis

Figure 1. Diagnostic Algorithm Course in the ward:


Initial plan: For correction of anemia

For nutritional work up For possible Subtotal gastrectomy with billroth II reconstruction after Cardiopulmonary clearance Patient was admitted and managed as table below:

Diagnostics Cbc, blood typing, APC Ctbt PT, PTT CXR-pa 12lead ECG LIPID Profile FBS, BUN, CREA Serum Na/K

Therapeutics Pnss at KVO Celecoxib 200mg BID Coamoxiclav 625 mg BID Aminoblend OD Humulin R Glimeperide 20mg OD PO Diltiazem 30mg OD PO Phytomenadione 10mg q 6 hrs Ranitidine 50mg q 8 hrs

RESULTS: 1. Complete Blood Count Result: revealed anemia with, 5-09-12 Hgb Hct RBC ct WBC ct Neutro Lympho Plt ct BT 7.27 .68 .32 260 O+ 10 0.74 0.26 447 97 0.30 5-12-12 102 0.31

2. A. Protime : 15.3 secs (10-15 secs)

%activity: 50% ( 70-130%) B. APTT : 28.3 secs ( 27-38secs) 3. Clotting time: 6 mins ( 3-5minutes) Bleeding time: 4mins, 45 secs ( 2-6 minutes) 4. Lipid Profile cholesterol : 166.4 mg/dl (<200mg/dl) triglycerides: 120.3 mg/dl (60-150mg/dl) HDL cholesterol:29 mg/dl (40-70mg/dl) LDL cholesterol: 113.34 mg/dl (<150mg/dl) 5. Blood Chemistry: Fasting blood sugar: 107.9 mg/dl ( 70-105mg/dl) Creatinine: 1 mg/dl ( 0.5-1.7 mg/dl)

6. Serum electrolytes Sodium: 150.3 mmol/L (135-155mmol/L) Potassium: 3.14 mmol/L ( 3.4-5.3mmol/L)--------corrected to 3. 59mmol/L Chloride: 114. 9 mmo/L ( 96-106mmol/L) Calcium: 1.06mmol/L (1 -1.3 mmol/L) 7. Urinalysis: Glucose: negative 8. Chest Xray: Protein: positive 1 Pus cells : 10-15/hpf Red blood cells : 2-4/hpf

Dome shaped soft tissue density noted at the lower 2/3 of right chest area obliterating the right cardiac border, right hemidiaphragm and costophrenic sinus. 9. 12Lead ECG normal sinus rhythm 10. Mammography of left breast: small breast nodule left lateral aspect; axillary lymphadenopathies

Intraoperative

FINAL DIAGNOSIS _____________________________________________________________________________ _ Case Discussion: Introduction: The cysto-sarcoma phylloides (CP) tumors of the breast are fibroepithelial tumors which are rarely seen and have potential recurrence [1-4]. Its name is derived from the Greek words sarcoma, meaning fleshy tumor, and phyllo, meaning leaf. CP tumors about which a great deal of studies have been done, was clinically identified first by Muller in 1838. Less than 1 % of all the breast tumors consist of CP tumors [4]. Phyllodes tumors can appear in any age group of women, although it is seldom seen in girls [5,6,]. CP tumors are the ones which are not considered initially in clinical diagnosis, show slow or rapid growth pattern, and are diagnosed after biopsy. These rarely encountered tumors are typically seen as mobile masses in the diameter of 5 centimeters and more. Nevertheless, CPs with diameter of 40centimeters are reported in the literature [7]. CP tumors which are clinically similar to fibroadenomas are distinguished

histopathologically by their cellular pattern, having increased cellular atypical changes and excessive stromal growth. CP tumors typically have more frequent local recurrence and higher malignancy compared with fibroadenomas. Grossly, the tumor displays characteristics of a large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial, cystlike spaces when viewed histologically. The malignant variety of the phylloides tumor is rare with <1% occurrence. Metastasis is usually hematogenous, and axillary lymph node dissection is not routinely performed. [8] Phyllodes tumor during pregnancy grows fast and its size is relatively big. Malignant phylloides tumors are exceedingly rare with few cases being reported in pregnancy. Blaker et al describe the first case ever reported of a malignant phylloides tumor presenting in the first trimester of pregnancy and provide insight into the complexities of management as well as a review of the known literature. Six other cases of phylloides tumor presenting in pregnancy have been reported in the literature, one of which had bilateral disease. Of these, the average patient age was 32 years (range, 28 to 35 years). The majority of these patients presented in their third trimester (mean, 29 weeks; range, 20 to 36 weeks) and often had large tumors (mean, 15 cm; range, 5 to 21 cm). Four of the seven tumors (57%) required a mastectomy. Previous cases have shown phylloides tumors to present in the third trimester as large masses that require mastectomy. With early detection, malignant phylloides tumors can present in the first trimester of pregnancy at smaller sizes; in these patients, breast-conserving surgery is possible. [9]

DIAGNOSTIC CRITERIA Usually large and grossly circumscribed

Fibroepithelial proliferation with broad "leaf-like" papillae inserting into slit-lilke or cleft-like spaces - Exaggerated intracanalicular pattern Cellular stroma - Periductal stromal condensation may seen Frankly sarcomatous stroma may be seen in malignant phyllodes tumor Heterologous differentiation may occur in malignant phyllodes tumor A. Liposarcoma B. Osteosarcoma C. Chondrosarcoma D. Rhabdomyosarcoma Grading determined by presence or absence of atypical stromal features

Benign Versus Malignant Phyllodes Tumors Because of limited data, the percentage of benign versus malignant phyllodes tumors is not well defined. Reports suggest, however, that about 85-90% of phyllodes tumors are benign and that approximately 10-15% are malignant.[4-10]

Although the benign tumors do not metastasize, they have a tendency to grow aggressively and can recur locally.[2-11] Similar to other sarcomas, the malignant tumors metastasize hematogenously. Unfortunately, the pathologic appearance of a phyllodes tumor does not always predict the neoplasm's clinical behavior; in some cases, therefore, there is a degree of uncertainty about the lesion's classification. The characteristics of a malignant phyllodes tumor include the following[5-12] :

Recurrent malignant tumors seem to be more aggressive than the original tumor The lungs are the most common metastatic site, followed by the skeleton, heart, and liver Symptoms of metastatic involvement can arise from as early as a few months to as late as

12 years after the initial therapy

Most patients with metastases die within 3 years of the initial treatment[6-13] No cures for systemic metastases exist Roughly 30% of patients with malignant phyllodes tumors die from the disease

Frequency Phyllodes tumors account for less than 1 percent of all breast tumors. The malignant variety of the phylloides tumor is rare with <1% occurrence. Race As far as is known, phyllodes tumors occur with the same frequency in women of all races and in all parts of the world. Sex- and age-related demographics Phyllodes tumors occur almost exclusively in females, although rare case reports have been described in males. The tumors can develop in people of any age; however, the median age is the fifth decade of life. History Phyllodes tumors generally manifest as larger masses and display rapid growth. A small mass may rapidly increase in size in the few weeks before the patient seeks medical attention.Phyllodes tumor include the rapid but painless growth of a smooth, bulky mass within the affected breast. The patient may notice that her entire breast is enlarged and its shape distorted. The skin over-lying the tumor may feel warm to the touch and develop a shiny appearance; it may also become translucent. Tumors rarely involve the nipple-areola complex or

ulcerate to the skin. Patients with metastases may present with such symptoms as dyspnea, fatigue, and bone pain.

Physical examination A firm, mobile, well-circumscribed, nontender breast mass is appreciated. Curiously, cystosarcoma phyllodes tends to involve the left breast more commonly than the right one. Overlying skin may display a shiny appearance and be translucent enough to reveal underlying breast veins. Physical findings (ie, the occurrence of mobile masses with distinct borders) are similar to those of fibroadenoma.[3-14] The median size of phyllodes tumors is around 4 cm [1]. Twenty percent of tumors grow larger than 10 cm, the arbitrary cut off point for the designation as a giant tumor. These tumors can reach sizes up to 40 cm in diameter [2].

Journal of Surgical Oncology 2008, 6:117 doi:10.1186/1477-7819-6-117 Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature Margaret I Liang1, Bhuvaneswari Ramaswamy2, Cynthia C Patterson1, Michael T McKelvey3, Gayle Gordillo4, Gerard J Nuovo5 and William E Carson III*6 Address: 1The Ohio State College of Medicine, Columbus, Ohio, USA, 2The Ohio State University Department of Haematology-Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Division of Internal Medicine, Columbus, Ohio, USA, 3The Ohio State University Division of Dermatology, Columbus, Ohio, USA, 4The Ohio State University Division of Plastic Surgery, Columbus, Ohio, USA, 5The Ohio State University Department of Pathology, Columbus, Ohio, USA and 6The Ohio State University Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Division of Surgical Oncology, Columbus, Ohio, USA

Differential Diagnosis Conditions to consider in the differential diagnosis of phyllodes tumors include the following:

Angiosarcoma Breast cancer Juvenile fibroadenoma

Giant fibroadenoma Inflammatory carcinoma Sclerosing adenosis Radial scar Fat necrosis Fibrocystic change Breast abscess Adenocarcinoma Mastitis

Juvenile Fibroadenoma Low Grade Phyllodes Tumor No leaf-like architecture Prominent leaf-like architecture No condensation around ducts Stromal condensation around ducts Does not infiltrate May infiltrate surrounding breast ***The histologic border between these two is not always sharp Juvenile Fibroadenoma High Grade Phyllodes Tumor No stromal atypia Atypical stroma Stromal mitotic rate < 3/hpf Elevated stroma mitotic rate No stromal overgrowth Stromal overgrowth Does not infiltrate May infiltrate surrounding breast ***Stromal overgrowth defined as at least one low power field (40x total magnification) composed entirely of stroma Fibroadenoma Low Grade Phyllodes Tumor Lacks significant stromal hypercellularity Hypercellular stroma is prominent No stromal overgrowth May have stromal overgrowth No leaf-like architecture Prominent leaf-like architecture No condensation around ducts Stromal condensation around ducts Does not infiltrate May infiltrate surrounding breast ***The histologic border between these two is not always sharp Metaplastic Carcinoma Spindled component may be positive for high molecular weight keratin or p63 Epithelial component is malignant Squamous differentiation may be present Phyllodes Tumor Stromal component negative for high molecular weight keratin and p63 Epithelial component is benign No squamous differentiation

Pure Sarcoma of the Breast Very rare The presence of an epithelial component defines phyllodes tumor Fibromatosis Bland spindle cells Stellate configuration Absence of intrinsic epithelial component May entrap normal breast lobules Myofibroblastoma Resembles solitary fibrous tumor Lacks intrinsic epithelial component

Biopsy and Histology Open excisional breast biopsy for smaller lesions and incisional biopsy for large lesions are the definitive methods for diagnosing phyllodes tumors. Fine-needle aspiration for cytologic examination usually is inadequate for the diagnosis of phyllodes tumors. Core biopsy is more reliable, but there still can be sampling errors and difficulty in distinguishing the lesion from a fibroadenoma. All phyllodes tumors contain a stromal component that can vary significantly in histologic appearance from one lesion to another.[7] In general, benign phyllodes tumors demonstrate a markedly increased number of regular fusiform fibroblasts in the stroma. Occasionally, highly anaplastic cells with myxoid changes are observed. A high degree of cellular atypia, with increased stromal cellularity and an increased mitotic count, is almost always observed in the malignant form of cystosarcoma phyllodes.

Micrograph of a phyllodes tumor (right of image) with the characteristic long clefts and myxoid cellular stroma. Normal breast andfibrocystic change are also seen (left of image). H&E stain

Fig.1. Panoramic view of the tumor showing tubular and malignant adipose components (H&E, x 40) Fig.2.

Fig.2. Stromal component with liposarcomatous differentiation (H&E, x 100)

Fig.3. Leaf-like projections characteristic of phyllodes tumor (H&E, x 40)

Fig.4. Tubular component with juxtaposed regular mammary lobules (H&E, x 40)

Ultrastructurally, in the benign and malignant forms of phyllodes tumors, nucleoli may reveal a coarsely meshed nucleolonema and abundant cisternae in the endoplasmic reticulum.

Laboratory and Imaging Studies Laboratory studies No specific hematologic tumor markers or other blood tests can be used to diagnose cystosarcoma phyllodes.[7] Imaging studies Although mammography and ultrasonography generally are important in the diagnosis of breast lesions, they are notoriously unreliable in differentiating benign cystosarcoma phyllodes from the malignant form of the condition or from fibroadenomas. (The phyllodes tumors mammographic appearance, as a round density with smooth borders, is similar to that of fibroadenoma.) Thus, findings on imaging studies are not definitively diagnostic of phyllodes tumors.[8] Clinical Staging, Treatments, and Prognosis Staging Phyllodes tumors are not staged in the usual sense; they are classified on the basis of their appearance under the microscope as benign, borderline (or indeterminate), or malignant. The pathologist makes the decision on the basis of the cells' rate of division (mitosis) and the number of irregularly shaped cells in the biopsy sample. In one series of 101 patients with phyllodes tumors, 58 percent were identified as benign, 12 percent as borderline, and 30 percent as malignant.

Grading Adverse features Stromal overgrowth (> one 40x field without epithelium) High mitotic index (>10 /10 hpf) Sarcomatous stroma (stromal nuclear pleomorphism and atypia) Infiltrative margin Benign No adverse features 20% recurrence rate after local excision 10% recurrence rate after wide excision (at least 1 cm margin) No reported metastases Borderline One or more adverse features but short of definition for malignant (see below) 45% recurrence rate after local excision 30% recurrence rate after wide excision (at least 1 cm margin) No reported metastases Malignant High mitotic index and sarcomatous stroma OR Stroma overgrowth and either high mitotic index or sarcomatous stroma 65% recurrence rate after local excision 35% recurrence rate after wide excision (at least 1 cm margin) 30% metastatic rate Staging Not applicable Report Grade Size Margin status Presence and type of heterologous differentiation

Treatments Multidisciplinary approach

The treatment team for a patient with a phyllodes tumor will usually include a diagnostic radiologist, a gynecologist, a general surgeon, oncologist and a pathologist

Surgical excision is the usual treatment for phyllodes tumors, whether benign or malignant. In the case of benign tumors, the surgeon will usually try to spare as much breast tissue as possible, generally removing about 1 in (2 cm) of normal breast tissue from the area around the tumor as well as the tumor itself. If the tumor is very large, however, the doctor may remove the entire breast.

Tumor Excision and Mastectomy Complete excision, with accurate histologic examination and continued follow-up care, is the best way to treat phyllodes tumors. In most cases of cystosarcoma phyllodes, perform wide local excision, with a rim of normal tissue included.[9, 10, 11] No absolute rules on margin size exist. However, a 2cm margin for small (< 5cm) tumors and a 5cm margin for large (>5cm) tumors have been advocated. The lesion should not be "shelled out," as might be done with a fibroadenoma, or the recurrence rate will be unacceptably high.[6] If the tumor-to-breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision, total mastectomy, with or without reconstruction, is an alternative. More radical procedures are generally not warranted.[10] Perform axillary lymph node dissection only for clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells.[12]

Postoperative complications As with most breast surgery, postoperative complications from the surgical treatment of phyllodes tumors include the following:

Infection Seroma formation Local and/or distant recurrence

Adjuvant therapy There is no proven role for adjuvant chemotherapy or radiation therapy in the treatment of phyllodes tumors. Response to chemotherapy and radiotherapy for recurrences and metastases has been poor, and no success with hormonal manipulation has been documented.

Alternative and Complementary Therapies Women who have had surgery for removal of a phyllodes tumor appear to use CAM therapies as often and for the same reasons as women treated for breast cancer. According to the Behavioral Research Center of the American Cancer Society, breast cancer survivors are highly likely to use some form of alternative or complementary therapy during cancer treatment or within a year or two of completing conventional treatment. A survey of 608 longer-term (8 years or longer) breast cancer survivors reported in early 2005 that the majority were still using CAM therapies. The survey respondents gave four reasons for using alternative treatments:

To maintain an active role in recovery from cancer.

To reduce their stress level. To reduce the risk of recurrence. To maintain hope.

Specific CAM therapies mentioned by the women in the ACS survey included exercise, humor, self-help books (bibliotherapy), prayer or spiritual practice, vitamin treatments, relaxation exercises, and support groups. Dr. Kenneth Pelletier, the former director of the program in complementary and alternative medicine at Stanford University School of Medicine, lists hypnosis, visualization, naturopathy, and journaling as other alternative approaches that breast cancer patients find helpful. Acupuncture is frequently mentioned as a useful method of pain control. Coping With Treatment Coping with the aftereffects of surgery for a phyllodes tumor is similar to coping with the effects of surgery for breast cancer. Patients who have had a complete mastectomy may experience pain, limited range of motion or weakness in the affected arm, scarring, or swelling. Exercises, outpatient physical therapy, and massage help to relieve these side effects of breast surgery. In terms of follow-up, most patients treated for phyllodes tumors are scheduled for a postoperative visit with the surgeon 12 weeks after surgery, with periodic checkups thereafter. Clinical Trials The National Cancer Institute (NCI) is not conducting any clinical trials involving phyllodes tumors as of 2005. There is, however, an ongoing study at the Dartmouth-Hitchcock Medical Center in New Hampshire of the effectiveness of radiation therapy in preventing recurrences of borderline or malignant phyllodes tumors in patients who have been treated with local excision

of the tumor. Women who have had a borderline or malignant phyllodes tumor removed within the past three months may wish to consider participating in this study.

Prognosis The prognosis for benign phyllodes tumors is good following surgical removal, although there is a 2035 percent chance of recurrence, particularly in patients over the age of 45. Recurrence is usually treated with further surgery, either another local excision or a complete mastectomy. The prognosis for patients diagnosed with borderline or malignant phyllodes tumors is more guarded. About 4 percent of borderline tumors will eventually metastasize. A Mayo Clinic study of 50 patients with malignant tumors found that 32 percent had a recurrence within two years after surgery; 26 percent developed metastases, and 32 percent of the group died from their malignancy. The most common sites for metastases from malignant phyllodes tumors are the lungs, bones, liver, and chest wall, although metastases to the lymph nodes have also been reported. Most patients with metastases from a malignant phyllodes tumor die within three years of their first treatment. Prevention There is no way to prevent phyllodes tumors as of the early 2000s because their cause is not yet known.

Outpatient Care

Although specific guidelines regarding follow-up care for phyllodes tumors are limited because of the rarity of these lesions, regular, long-term follow-up care should be performed to detect possible local recurrences. An initial visit 1-2 weeks after surgery to detect any initial complications should be followed by periodic visits as determined by the patient's surgeon. A reasonable schedule might be physical examinations every 6 months and mammograms yearly for at least 5 years. Carefully observe patients for any possible recurrence.

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