AJR 2005; 184:S115-S117
© American Roentgen Ray Society
Preoperative Embolization of Vascular Phyllodes Tumor of the Breast
Jessica W. T. Leung,
Michael B. Gotway and
Edward A. Sickles
Department of Radiology, University of California, San Francisco (UCSF)
Medical Center, San Francisco, CA.
Received January 16, 2004;
accepted after revision April 6, 2004.
Address correspondence to: J. W. T. Leung, Division of Breast Imaging, UCSF
Cancer Center, 1600 Divisadero St., Suite H-2801, San Francisco, CA 94115
(Jessica.Leung{at}ucsfmedctr.org).
Introduction
Tumors are often vascular compared with normal tissues because of
angiogenesis. In the breast, this principle forms the basis of MRI, Doppler
sonography, and contrast-enhanced digital subtraction mammography. Although
catheter embolization of tumor vessels has been reported in various organs,
most notably the liver, it is performed infrequently in the breast. When
catheter embolization is performed in the breast, it is almost always
performed for locally advanced malignancies. We report a highly vascular
benign phyllodes tumor for which catheter embolization was performed before
resection to decrease intraoperative bleeding and improve surgical
outcome.
Case Report
A 55-year-old postmenopausal woman presented with a 7-cm palpable mass in
the right outer breast. The patient first experienced focal pain 2 months
before presentation and identified a palpable mass 2 weeks later. On physical
examination, the mass was smooth and associated with a palpable thrill. No
evidence of axillary or supraclavicular lymphadenopathy was seen.
Mammography (Fig. 1A) and
sonography (Fig. 1B) revealed a
circumscribed solid mass. On Doppler interrogation, prominent vascularity was
identified within the mass (Fig.
1B) consistent with the clinical finding of a palpable thrill. MRI
revealed a large, heterogeneous, progressively enhancing mass
(Fig. 1C). On MR angiography,
feeding vessels from branches of the distal right subclavian artery were
identified, as were enlarged veins that drained into the right internal
mammary vein.
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Fig. 1A. —55-year-old postmenopausal woman with highly vascular
phyllodes breast tumor. Mammogram of right breast in mediolateral oblique
projection shows 7-cm circumscribed mass corresponding to presenting symptom
of palpable mass. Mass was located in outer aspect of breast in craniocaudal
projection (not shown).
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Fig. 1B. —55-year-old postmenopausal woman with highly vascular
phyllodes breast tumor. Transverse sonogram with color Doppler of palpable
mass shows large hypoechoic solid mass with robust vascularity.
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Fig. 1C. —55-year-old postmenopausal woman with highly vascular
phyllodes breast tumor. Contrast-enhanced MRI maximum-intensity-projection
image of right breast in sagittal projection shows multiple vessels feeding
intensely enhancing mass.
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Given the hypervascular nature of this mass, selective catheter
embolization was performed before surgical biopsy (Figs.
1D,
1E,
1F,
1G). A 5-French Berenstein
catheter was advanced over a Terumo guidewire into the right subclavian
artery. Selective injections were performed that revealed the dominant blood
supply to the mass was a lateral mammary artery. Injection of this vessel
produced a large tumor blush. A 3-French microcatheter was advanced through
the Berenstein catheter and the tumor was embolized using a combination of
Gelfoam (Pharmacia and Upjohn), 2-mm straight embolization particles, and 3-mm
tornado coil embolization particles. At the completion of the procedure, the
tumor blush resolved. Selective injection of the internal mammary artery
showed that it was widely patent, with no collateral supply to the tumor.
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Fig. 1D. —55-year-old postmenopausal woman with highly vascular
phyllodes breast tumor. Selective angiogram of subclavian artery shows
tortuous lateral mammary artery (arrow) providing dominant blood
supply to breast tumor.
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Fig. 1F. —55-year-old postmenopausal woman with highly vascular
phyllodes breast tumor. Embolization of feeding vessel performed using
microcatheter (arrow) advanced through Berenstein catheter
(arrowhead).
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An incisional surgical biopsy was performed 3 days after embolization that
revealed a phyllodes tumor with intermediate mitotic activity (4 mitoses per
10 high-power fields). The patient underwent lumpectomy 23 days after
embolization. Pathologic examination of the lumpectomy specimen revealed a
low-grade phyllodes tumor with low mitotic activity (0-1 mitosis per 10
high-power fields). Tumor was identified pathologically at the inked margins.
Reexcision surgery performed 49 days after embolization showed no evidence of
tumor.
The patient tolerated the embolization procedure and subsequent surgeries
well. Negligible blood loss was reported at each surgery and hemostasis was
easily achieved with electrocautery and thrombin spray. She returned for
follow-up mammography 1 year after the lumpectomy with no evidence of
recurrence.
Discussion
Catheter embolization for breast lesions has been reported but not
specifically as a means of minimizing bleeding during surgery. Sonographically
guided embolization has been used for percutaneous repair of breast
pseudoaneurysm [1]. The more
common use of catheter embolization in the breast is for therapeutic occlusion
of vascular supply of breast tumors, resulting in ischemia and, hence, tumor
cell death. This technique is usually performed in conjunction with local
delivery of chemotherapy
[2-5]
and response has been reported in both the primary tumor and metastatic
regional lymph nodes [3,
4]. Vascular occlusion by means
of embolization also has been used to control severe or recurrent bleeding in
fungating breast cancers [6,
7]. Embolization has been
effective in controlling such bleeding
[6] and lifesaving in cases
involving sternal erosion
[7].
To our knowledge, this is the first report of the use of embolization to
minimize bleeding of a breast tumor during surgery and improve surgical
outcome. The presence of a palpable thrill was the first indication that the
lesion could be extremely vascular, and the highly vascular nature of the
tumor was confirmed by sonogram, MRI, and MR angiography. Preoperative
embolization was performed to minimize intraoperative bleeding. The lesion was
successfully embolized with resolution of tumor blush using Gelfoam,
particles, and coils. Other agents used in previous reports include blood
clotting factors [3,
5,
7] and polyvinyl alcohol
[6]. The use of a microcatheter
allowed for embolization of the specific vessel supplying the tumor without
damage to noninvolved tissues.
Although intermediate mitotic activity (4 mitoses per 10 high-power fields)
was detected in the incisional surgical biopsy specimen, the mitotic activity
of the lumpectomy specimen was much lower (0-1 mitoses per 10 high-power
fields). This difference may be attributed to the intervening embolization
procedure, suggesting that vascular occlusion through embolization may be
effective to decrease tumor volume preoperatively.
Pathologic examination of the incisional surgical biopsy and lumpectomy
specimens revealed a low-grade phyllodes tumor. Phyllodes tumor is a rare
fibroepithelial neoplasm and accounts for approximately 1% of breast cancers
[8]. It was initially termed
cystosarcoma phyllodes because of its leaflike, papillary projections into
cystic spaces. Compared with benign fibroadenoma, phyllodes tumor has
hypercellular stroma, cytologic atypia, and a high mitotic index, but the
distinction between fibroadenoma and phyllodes tumor may be difficult to make
with limited samples such as those obtained at percutaneous core biopsy.
Phyllodes tumor has been reported in women ranging in age from 30 to 70
years [9]. It usually presents
as a large, palpable mass. Treatment is complete surgical excision with wide
margins. Axillary nodal dissection is usually not indicated, as the high-grade
phyllodes tumor metastasizes hematogenously, often to the lungs, rather than
via lymphatics to the axillary nodes.
On mammography, phyllodes tumor presents as a circumscribed mass, usually
lobulated, round, or oval in shape. Sonography normally shows a well-defined
solid mass with homogeneous or heterogeneous internal echotexture. On MRI,
phyllodes tumor shows robust contrast enhancement and fluid-filled clefts that
are hyperintense on T2-weighted imaging
[9].
Breast imaging has become a multimodality specialty. This case showed how
several imaging techniques were used to fully evaluate a large breast mass
associated with a palpable thrill. Multimodality imaging, including
angiography, provided a detailed examination of the morphology and vascular
anatomy of this mass, while catheter embolization improved the surgical
outcome. Because of the highly selective nature of the embolization procedure,
this technique also may prove useful for intratumoral drug delivery, including
antiangiogenic agents.
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Introduction
Case Report
