Heller D R, Rohde C, Ananthakrishnan P
College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
Plastic Surgery Section, Columbia University Medical Center, New York, NY, USA.
Int J Surg Case Rep. 2015;6C:84-7. doi: 10.1016/j.ijscr.2014.12.014. Epub 2014 Dec 12.
Cystosarcoma phyllodes (CP) is a rare breast tumor occurring most often in females in their fifth decade. While usually benign, some CP tumors exhibit aggressive growth patterns and extensively invade chest wall structures; resecting these tumors to negative surgical margins can be challenging. We present a case of malignant CP involving the chest wall where using a negative pressure vacuum-assisted closure (VAC) system after resection enabled complete histopathologic margin assessment prior to reconstruction. This is the first known report of staged breast tumor resection and reconstruction with interim VAC coverage.
A 48 year-old woman presented with rapidly increasing left breast size, fevers, and fatigue. On examination, the left breast was massively enlarged with engorged vessels and skin necrosis. Lab analyses revealed unusual metabolic abnormalities requiring preoperative hospitalization. We performed a left modified radical mastectomy with partial resection of pectoralis major and minor muscles, temporarily sealing the wound with a VAC due to concern for deeper tumor extension that could require further resection. Pathology revealed malignant CP with a negative deep margin. The 38cm defect was then repaired with latissimus myocutaneous flap plus skin graft. At three-year follow up the patient remains free of disease.
In cases of malignant CP involving the chest wall, minimizing the extent of chest wall resection is critical for reducing morbidity, while completely clearing tumor margins is essential for reducing recurrence risk. Using temporary wound VAC coverage enables cautious debulking followed by histopathologic margin assessment prior to definitively reconstructing the breast.
叶状囊肉瘤（CP）是一种罕见的乳腺肿瘤，最常发生于50岁左右的女性。虽然通常为良性，但一些CP肿瘤表现出侵袭性生长模式，并广泛侵犯胸壁结构；将这些肿瘤切除至手术切缘阴性具有挑战性。我们报告一例累及胸壁的恶性CP病例，在切除术后使用负压真空辅助闭合（VAC）系统，能够在重建前进行完整的组织病理学切缘评估。这是已知首例关于分期乳腺肿瘤切除及重建并采用临时VAC覆盖的报告。
一名48岁女性因左乳迅速增大、发热和疲劳就诊。检查发现左乳明显肿大，血管充血，皮肤坏死。实验室分析显示有异常代谢异常，需要术前住院治疗。我们进行了左乳改良根治术，部分切除胸大肌和胸小肌，由于担心肿瘤深部扩展可能需要进一步切除，用VAC临时封闭伤口。病理显示为恶性CP，深部切缘阴性。然后用背阔肌肌皮瓣加植皮修复38cm的缺损。三年随访时患者无疾病复发。
在累及胸壁的恶性CP病例中，尽量减少胸壁切除范围对于降低发病率至关重要，而彻底清除肿瘤切缘对于降低复发风险至关重要。使用临时伤口VAC覆盖可谨慎减瘤，然后在最终重建乳房之前进行组织病理学切缘评估。
