Introduction

Phyllodes tumour are rare breast tumours. They account for less than 1% of all breast neoplasms. Both malignant and benign forms have been reported. 20% of patients with malignant phyllodes tumours develop distant metastases, which is commonly spread by the haematogenous route. ¹ The usual sites of metastases are the lung, abdomen and bone. Long term survival with distant metastases is rare. Here we report a case of metastatic malignant phyllodes tumour to the nasal cavity.

Case Report

A 58 year old Chinese woman presented to the ENT clinic with a two week history of left sided epistaxis, associated with unilateral left sided nasal obstruction. She also complained of diplopia and drooping of her left eyelid with a two month history of persistent left sided headache. This patient had a past history of malignant phyllodes tumour of her right breast for which she underwent a right mastectomy with post operative radiotherapy two months prior to her presentation at the ENT clinic.

On examination, she was noted to have an obvious ptosis of her left eyelid with a left oculomotor nerve and left maxillary nerve palsy. Her visual acuity was normal. Examination of the left nasal cavity, revealed a soft friable mass arising superior and medial to the middle turbinate. It was occupying the entire floor of the nasal cavity and extending to the posterior choanae. The left fossa of Rossenmuller was clear. However there was no evidence of recurrence at the primary site.

A CT scan of paranasal sinus was done and showed an enhancing mass in the sphenoid, ethmoid and nasal cavity extending to the suprasellar region. There was also erosion of the floor of the pituitary fosse (Fig 1). A biopsy of the mass under local anaesthetic revealed a plemorphic hyperchromatic and vesicular nuclei against a loose myxoid background. Immunohistochemistry showed tumour cells expressing vimentin, actin, myoglobin with focal expression of desmin and MNF116. The histopathological picture was also similar to the histopathology of the mastectomy specimen, consistent with a metastatic malignant phyllodes tumour.

Figure 1

A diagnosis of metastatic malignant Phyllodes tumour of the breast to the nasal cavity was made. Ultrasound of the liver, liver function test chest X-ray and bone scan did not reveal any other metastatic lesions.

In view of the aggressive nature of this metastatic lesion and the pathological findings, no surgical intervention was made. The patient opted for palliative care and succumbed to the disease within one month.

Discussion

Phyllodes tumours are rare fibroepithelial lesions that account for less than 1% of all breast neoplasms. ₁ Malignant phyllodes have a propensity for rapid growth and metastatic spread usually through the haematogenous route. ₂ Usually 10% of patients with phyllodes tumour develop distant metastases and these eventually occur in approximately 20% of patients with histologically malignant tumours . ₃ Most distant metastases develop without evidence of local recurrence. ₄ This finding is in keeping with our case. This patient did not show any evidence of local recurrence despite having such an extensive metastastic lesion. The commonest sites for metastases are the lung, bone and abdominal viscera. ₅ However other rare sites of metastases have also been reported such as the pancreas ₆ and the forearm. ₇ A search of the literature through Medline revealed that metastatic malignant phyllodes tumour to the nasal cavity has not been reported before. We believe this is the first case of a malignant phyllodes tumour of the breast metasizing to the nasal cavity.

Metastatic phyllodes tumour generally have a poor prognosis and no long term survival has been reported. ⁵ Isolated reports have been published of good palliation of metastatic disease from single agent and combination chemotherapy. ₈ However the exact role of chemotherapy, radiotherapy and hormonal manipulation in metastatic phyllodes remains undefined.

Correspondence to

Dr Muthu Kumar Department Of Otorhinolaryngology University Malaya Medical Center 50603 Kuala Lumpur Malaysia Tel:603-79502062 Fax:603-79556963 muthukm@yahoo.com