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Difficulty: HardBreast Disorders

A 45-year-old woman is evaluated in the surgical clinic for a rapidly enlarging mass in her right breast. She first noticed a small lump approximately 4 months ago, but it has doubled in size over the past 4 weeks. She reports no pain, fever, or nipple discharge. Her medical history is unremarkable, and she takes no medications. On physical examination, the breasts appear asymmetric. A 7-cm, firm, smooth, and mobile mass is palpable in the upper half of the right breast. The overlying skin is stretched and shiny with prominent superficial veins, but there is no erythema, dimpling, or nipple retraction. No axillary or supraclavicular lymphadenopathy is appreciated. Breast ultrasonography demonstrates a large, solid, hypoechoic mass with internal cleft-like cystic spaces. A subsequent core needle biopsy reveals a biphasic proliferation consisting of benign epithelial elements and a hypercellular stroma with leaf-like architectural patterns. There are 6 mitoses per 10 high-power fields and moderate stromal atypia. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Estrogen receptor testing followed by initiation of endocrine therapy
  2. B
    Observation with repeat clinical examination and ultrasonography in 3 months
  3. Surgical removal of the mass with at least 1-cm tumor-free marginsAnswer
  4. D
    Total mastectomy combined with sentinel lymph node evaluation
  5. E
    Administration of neoadjuvant doxorubicin-based chemotherapy

Answer

Surgical removal of the mass with at least 1-cm tumor-free margins
The correct answer is surgical removal of the mass with at least 1-cm tumor-free margins. This patient's clinical presentation (a rapidly growing, large breast mass) and biopsy findings (biphasic proliferation with a hypercellular stroma and 'leaf-like' architecture) are diagnostic of a phyllodes tumor. The increased mitotic rate (6 per 10 high-power fields) and stromal atypia suggest a borderline or malignant variant. Because phyllodes tumors have a high propensity for local recurrence, standard management for all grades involves complete surgical excision with wide, grossly negative margins (typically at least 1 cm).

Step-by-Step Solution

1
Analyze the patient's clinical presentation and imaging findings.
A 45-year-old woman presents with a rapidly growing, large (7-cm) breast mass. Imaging shows a solid mass with cystic clefts.
To synthesize the initial clinical picture, which is highly suspicious for a rapidly proliferating neoplasm.
2
Interpret the core needle biopsy results.
The biopsy shows a biphasic tumor with a hypercellular stroma, leaf-like architecture, and increased mitoses.
To establish the definitive diagnosis of a borderline or malignant phyllodes tumor, which is distinctly characterized by these histological features.
3
Determine the appropriate surgical or medical management based on the tumor's biology.
The standard of care is surgical excision with wide margins (at least 1 cm) without routine axillary staging.
Phyllodes tumors have a high risk of local recurrence if not fully excised. However, unlike adenocarcinomas, they spread hematogenously rather than lymphatically, making axillary staging unnecessary.

Key Concept

Phyllodes tumors are rare, rapidly growing fibroepithelial breast tumors characterized by a leaf-like stromal architecture. The mainstay of treatment is wide local excision with margins of at least 1 cm to prevent recurrence; axillary lymph node staging is generally not required because these tumors spread hematogenously.
Estimated Time:1m 30s
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Topics

Breast Disorders

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