Rapid-Growing Phyllodes Tumor after an Accidental Bump on the Breast: A Case Report

Phyllodes tumors are fibroepithelial lesions, which consist of both stromal and epithelial content. Tumor entities with diameters larger than 10 cm represent giant phyllodes tumors. Pathologists examine these lesions for atypia and stromal cellularity [1]. Phyllodes tumors are rare and are estimated to consist of less than 1% of all breast tumor masses [2]. They are classified as low-grade or benign, intermediate-grade or borderline, and high-grade or malignant, depending on atypical cells, the number of mitoses per 10 high-powered fields (hpf), and the infiltration of normal tissue [3]. These lesions are usually unilateral, with little possibility of axillary lymph node metastases [4]. Distant metastases can be found mainly in bones or lungs in less than 10% of the patients. Importantly, recurrences have been reported in the literature, ranging from 10 to 30% for benign to malignant tumors, respectively [1]. In this report, we describe the case of a young female patient, who presented with a rapid-growing phyllodes tumor after an accidental bump on the breast and who had to undergo mastectomy followed by breast reconstruction.

A 41-year-old female patient presented to our department with a painful mass in her left breast. The mass had appeared 3 months prior to the presentation in our department and gradually increased in size. Her medical history was uneventful and no prior breast surgeries were reported. During physical examination, no signs of infection were noticed. The mass presented as a firm yellow-brown mass with clear margins and superficial veins (Fig. 1). No swollen axillary lymph nodes or nipple discharge were observed clinically. A breast ultrasound was first performed, which revealed a round, delimited cystic lesion of 8.4 cm with hyperechoic content. Additionally, multiple cysts, increased vascularization, reactive axillary lymph nodes, thickening of the skin and subcutaneous tissue as signs of inflammation were observed. These findings were compatible with phyllodes tumor (Fig. 2). Mammographically, a breast asymmetry was revealed due to the presence of a well-emarginate large mass in the left breast (BIRADS IVb) (Fig. 3). Additional magnetic resonance imaging was requested for further clarification of the finding; however, it was never performed, as the patient had a car accident accompanied by a bump on the breast that led to swelling and pain, as well as hospital admission on an emergency basis (Fig. 4). The patient then underwent a second ultrasound with no evidence of hematoma but with enlargement of the lesion (up to 12.3 cm) (Fig. 5). A fine-needle aspiration biopsy was performed. A computed tomography (CT) scan of the thorax and abdomen was performed to investigate not only the trauma but also the biological behavior of the breast mass. CT did not reveal pathological findings. Blood tests indicated elevation of the serum inflammatory markers C-reactive protein, procalcitonin and ferritin (113.5 mg/dL, 0.57 ng/mL and 1,154 ng/mL, respectively). Consequently, due to pressure and pain in the breast, a mastectomy with primary breast reconstruction was performed, given that the rapid biopsy confirmed the fine-needle aspiration findings revealing a phyllodes tumor and CT did not reveal signs of distal metastases. The whole lesion was dissected and, macroscopically, the surgical margins were free. Breast reconstruction with tissue expander then followed. The skin flaps, used in the reconstruction, were closed under tension. No postoperative complications were noticed. The histopathological examination led to the diagnosis of a giant phyllodes tumor of 12 cm in maximum diameter, moderate stromal atypia and cellularity with 5–7 mitoses/hpf, moderate stromal overgrowth and no signs of invasion. According to the World Health Organization (WHO) criteria, this phyllodes tumor is characterized as borderline [5]. The Ki67 and p53 protein expression was marked. Finally, the patient did not undertake any adjuvant therapy. At the 32-month follow-up, she remains healthy with no evidence of relapse of the disease.

Borderline or malignant phyllodes tumors are usually unilateral, and their sizes range from few centimeters to more than 10 cm (giant). The malignant phyllodes tumors are usually bigger in size [4]. Our patient had a giant borderline phyllodes tumor, which grew rapidly in less than 3 months and rendered the skin thin and ischemic. This clinical presentation is atypical and renders other breast malignancies possible. Surgical excision with healthy margins of at least 1 cm is the cornerstone of the treatment [6]. Staging of axillary lymph nodes is not necessary in this type of breast tumor. As in our case, immediate breast reconstruction is the best option in patients who underwent mastectomy due to primary or recurrent tumor [4]. Radiotherapy is not usually used in this type of tumor. Its use can be implemented in patients with positive or close margins for intermediate or high-grade phyllodes tumors, in order to prevent local recurrences [7]. Local control in non-operable patients is the main use of radiotherapy [8]. Concerning chemotherapy, little is known. No antihormonal treatment is administrated to phyllodes tumors. Doxorubicin and ifosfamide can be used in case of distant metastases [9]. Our patient received neither radiotherapy nor chemotherapy due to clear margins and no signs of metastases. In this case report, we present the case of a female patient diagnosed with a giant phyllodes breast tumor who experienced a car accident resulting in rapid augmentation of the tumor and breast swelling necessitating mastectomy. The intriguing aspect of this case lies in exploring the potential correlation between the traumatic impact on the breast and the sudden increase in tumor dimensions. By thoroughly analyzing the temporal relationship between the accident and the tumor enlargement, we aim to shed light on whether external trauma could exacerbate tumor growth in phyllodes tumors, thus offering valuable insights into the pathophysiology of these rare neoplasms. This case underscores the importance of considering external factors in tumor progression and warrants further investigation into the interplay between trauma and tumor biology. Certainly, there are several possible explanations that could be explored to understand the correlation between the traumatic impact and the sudden increase in tumor dimensions including an inflammatory response leading to increased blood flow and cytokine release in the affected area [10]. Trauma-induced tissue damage might also stimulate angiogenesis, the formation of new blood vessels, in the vicinity of the tumor. Enhanced vascularization could provide the tumor with increased nutrient and oxygen supply, facilitating accelerated growth. The physical force exerted during the accident could disrupt the tumor microenvironment, potentially causing tumor cells to proliferate more rapidly [11]. This disruption may also compromise the integrity of tumor vasculature, leading to hemorrhage and subsequent tumor expansion. Trauma-induced stress responses could alter hormonal balance in the body, particularly adrenaline and cortisol levels. Hormonal fluctuations may influence tumor behavior, potentially promoting growth or altering the tumor microenvironment to favor aggressive tumor phenotypes. Additionally, trauma might compromise the local immune response, creating a permissive environment for tumor progression. Diminished immune surveillance could allow tumor cells to evade destruction, leading to unchecked growth. The physical impact of the accident could directly stimulate tumor cells, triggering signaling pathways associated with cell proliferation and survival [12]. This direct mechanical stimulation might accelerate tumor growth in susceptible individuals. Altogether, investigating these potential mechanisms through experimental studies or retrospective analyses could provide valuable insights into the complex interplay between trauma and tumor biology, ultimately informing clinical management strategies for patients with phyllodes breast tumors. However, the basic requirement for all the aforementioned is the accurate diagnostic process of phyllodes tumors and the correct differential diagnosis from other breast tumors, such as fibroadenomas, sarcomas, or metaplastic carcinomas, as these entities require different therapeutic approaches [13, 14].

In conclusion, the presented case of a 41-year-old woman with a giant borderline phyllodes tumor underscores the complex interplay between trauma and tumor biology in breast pathology. The rapid growth of the tumor following a traumatic incident highlights the potential influence of external factors on tumor progression. While the exact mechanisms remain to be fully elucidated, possible explanations include inflammatory responses, angiogenesis stimulation, mechanical disruption, hormonal fluctuations, compromised immune responses, and direct mechanical stimulation of tumor cells. This case emphasizes the importance of considering external factors in tumor progression and warrants further investigation into their impact on tumor biology. Ultimately, insights gained from such investigations could inform more effective clinical management strategies for patients with phyllodes breast tumors, potentially improving outcomes and patient care. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000539533).

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Ethical approval was not required for this study in accordance with local/national guidelines.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Christos Damaskos, Nikolaos Garmpis, and Iason Psilopatis contributed equally. Christos Damaskos and Nikolaos Garmpis provided clinical input to the case and wrote the manuscript. Iason Psilopatis revised the manuscript. Iason Psilopatis, Konstantinos Nikolettos, and Anna Garmpi performed the literature search and collected the data. Anna Kyriakopoulou performed the radiologic evaluation. Panagiotis Tsikouras, Dimitrios Dimitroulis, Nikolaos Nikolettos, and Dimitrios Papoutsas offered scientific advice. Kleio Vrettou performed the cytologic evaluation. Christos Damaskos, Nikolaos Garmpis, and Konstantinos Kontzoglou performed the surgical operation. Eleni I. Effraimidou was the supervisor and critically revised the manuscript.

Christos Damaskos and Nikolaos Garmpis contributed equally to this work.

The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author upon reasonable request.