Dr Phumudzo Ndwambi demystifies the mystical aggressor: phyllodes tumours.
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In a world where everything isn’t quite as it seems; where artificial intelligence has blurred the lines between virtual and real, it’s hard trying to ascertain what’s what. So, it’s important to look deeper into those things that may not present themselves as what they truly are. Phyllodes tumours are one of those things that due to its rare nature is often mistaken for other breast lesions. It’s part of a group of lesions known as fibroepithelial, which include fibroadenomas.
As with any breast mass, the journey often begins with a woman (and very rarely some men) feeling a lump and seeking advice and investigations from specialists. Because these tumours range from benign (non-cancerous), borderline, and malignant (cancerous), they are difficult to differentiate; imaging and careful histological examination is necessary to reach the correct diagnosis. Seventy-five percent of phyllodes tumours are benign, however, still warrant the full extent of investigation and treatment.
Who gets phyllodes?
Typically, a woman between the ages of 40-50 years old (but can occur at any age) may feel a lump and may rightfully feel anxious at the possibility of that lump being breast cancer. The lump may be rapidly growing and even reach sizes of up to 45cm, causing it to break through the skin resulting in bleeding, disfiguration, and inevitably great discomfort. Consultation with a breast surgeon will result in a thorough history and examination, counselling, request for mammogram and biopsy and then interpretation of those biopsy results.
Most patients will be curious to know what the cause of this rare tumour is, and the true answer is that the cause is largely unknown. There is a small genetic association in families known to have Li-Fraumeni syndrome. Some theories implicate the overgrowth of the normal breast tissue due to hormonal imbalance and increased oestrogen activity but the true nature of how these factors contribute isn’t well-understood.
The core biopsy is taken during the mammogram and ultrasound of the breast where the radiologist inserts a needle through the breast to the lump to take samples that can be examined under a microscope. The vast majority of breast lumps are benign, and this also holds true for phyllodes tumours, but the aim of the microscopic examination is to make sure that there are no cancerous cells in the samples taken. Once the pathologist has determined that this is a fibroepithelial lesion, they then classify it, then the phyllodes tumour is graded.
The best way to determine if that tumour truly is what the core biopsy represented, is to examine it in its entirety and that means the tumour needs to be fully excised. Based on the size of the tumour, breast-conserving surgery (where only the lump is removed) or mastectomy (removal of the whole breast) is chosen to remove the tumour ensuring that the margin around the tumour has normal breast tissue to a minimum of 1cm. It’s then that the true nature of the phyllodes can be graded into benign, borderline or malignant.
The malignant lesions pose the biggest concern and their management should be more vigilant and requires understanding that these lesions have a propensity to metastasise. These tumours, including the benign ones, tend to recur and potentially have to be re-excised. Radiation is added as part of the treatment plan after surgery to decrease the chances of the tumour recurring. Chemotherapy has minimal benefit and is thus not given.
Malignant tumours may metastasise to the lungs, bones or the brain if not managed appropriately.
Close monitoring and follow-up are essential after treatment and it must be understood that although this mystical aggressor has the potential to cause trauma and fear, vigilance in seeking consultation early yields positive outcomes in most people.
MEET THE EXPERT – Dr Phumudzo Ndwambi
Dr Phumudzo Ndwambi is a general surgeon with a special interest in breast surgery and expertise in oncoplastic procedures. She obtained her MBChB (UCT), FCS (SA) and MMed (Wits) as well as gained experience from the Western General Hospital in Edinburgh through the Royal College of Surgeons. She works at the Chris Hani Baragwanath Academic Hospital as well as Busamed Modderfontein Private Hospital.
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