Journal of Thoracic Oncology:
Image of the Month
Rutzick, Aaron D. MD; Davies, Scott F. MD
Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, Minnesota.
Disclosure: The authors declare no conflict of interest.
Address for correspondence: Aaron D. Rutzick, MD, Department of Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. E-mail: email@example.com
Phyllodes tumor (PT) of the breast is an uncommon fibroepithelial tumor accounting for 0.37% of primary breast cancers. Most PT are <5.0 cm, averaging 4–7 cm. We present a case of PT measuring 28 cm in diameter with an extreme computed tomography image with tumor size larger than the adjacent thoracic circumference. A 59-year-old uninsured woman without significant medical history presented with a massive ulcerated chest wall tumor. The mass was resected, and microscopic examination demonstrated spindled cells within a myxoid stroma, consistent with PT.
Phyllodes tumor of the breast is unusual and can present with impressive size. We report the case of a phyllodes tumor (PT) growing to a massive size in a woman without health insurance.
A 59-year-old woman was directed to our hospital from an outside clinic with dizziness, hypotension, and a huge right-sided breast mass. For 3 years, she had tolerated this mass as it grew to extreme size, requiring the patient to cradle it with both arms as she walked (Figures 1 and 2). The patient lacked health insurance and feared that an interface with the medical establishment would lead to the loss of her savings and her house. The mass itself had not prompted her to seek medical attention. Rather, it was symptomatic hypotension related to bleeding and infection of the necrotic tumor. She improved after transfusion and treatment with antibiotics. The mass was resected, and histopathology demonstrated PT.
On gross examination, the tumor measured 28 × 21 × 21 cm with multiple ulcerated areas and a large central cavity. It was multinodular with mucoid consistency. Microscopic examination displayed spindled cells within a myxoid stroma. The spindled cells showed moderate nuclear atypia, suggesting an intermediate grade tumor. Only a tiny amount of benign breast tissue remained between lobules of tumor. Skeletal muscle was impinged on but not infiltrated by the mass. Given the tumor size and narrow margins of resection, it was difficult to totally exclude local invasion, and malignancy was a concern. The patient was offered radiation therapy to the chest wall; however, she declined that treatment pending improvement in her postsurgical lymphedema.
PT is an uncommon fibroepithelial breast tumor, making up less than 0.5% of breast malignancies.1 The median age is 42, and the incidence of PT is estimated to be 2.1 per one million.2 The term “phyllodes” means leaf and refers to the typical papillary pattern seen on histologic examination. Clinically, PT typically presents as a painless breast lump with variable tumor size, averaging 4 to 7 cm.2 It is often multilobular and painless. Benign, intermediate, and malignant tumors are classified according to degree of cellular atypia, mitotic activity, infiltration of tumor into surrounding tissue, and the presence or absence of stromal overgrowth. This last criterion is the only one associated with metastatic disease. Breast conserving therapy with wide local excision is the treatment of choice for benign tumors. Current data do not support radiation therapy in cases with clear margins. Recent data have shown that radiation therapy should be considered in patients with malignant PT >2 cm.3
The patient avoided medical care out of fear of the financial hardship she would accrue without any health insurance. She was not in denial of her condition, and she suffered no psychiatric illness. Because her pension income was very low, she did qualify for emergency general medical assistance, which was funded by the State of Minnesota. Her medical bills were paid. She was totally unaware of this program until her urgent hospitalization. So far, she has been able to keep her house, but she is financially burdened by significant credit card debt that accumulated as her disability increased. She needs to supplement her pension to meet expenses, and she plans to return to work as soon as possible.
Long-term uninsured patients, especially those in poor health (tobacco dependence, obesity, alcohol abuse, hypertension, elevated cholesterol, diabetes, and human immunodeficiency virus risk factors) are much less likely to have routine medical care than insured patients. Not surprisingly, this group of patients is also less likely to participate in cancer screening, cardiovascular risk reduction, or diabetes management than patients with health insurance.4 Late presentation for various conditions also occurs.
1. Geisler DP, Boyle MJ, Malnar KF, et al. Phyllodes tumors of the breast: a review of 32 cases. Am Surg 2000;66:360–366.
2. Barrio AV, Clark BD, Goldberg JI, et al. Clinicopathologic features and long-term outcomes of 293 phyllodes tumors of the breast. Ann Surg Oncol 2007;14:2961–2970.
3. Penzer RD, Schultheiss TE, Paz IB. Malignant phyllodes tumor of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Phys 2008;71:710–713.
4. Ayanian J, Weissman J, Schneider E, Ginsburg J, Zaslavsky A. Unmet health needs of uninsured adults in the United States. JAMA 2000;284:2061–2069.