A giant phyllodes tumour with sepsis

Abstract

able to withstand major surgery; (ii) possess a ductal anatomy that allows the bypass procedure to drain at least one-third of the functioning liver; 1 and (iii) ipsilateral liver atrophy is absent.Surgical techniques adopted to bypass the obstruction depend on the tumour location, which includes either segment III or right sectoral intrahepatic cholangiojejunostomy. Surgical palliation to the left liver is a far commoner procedure. This is because the left hepatic duct has a long extrahepatic course that makes dissection and anastomosis much easier. Together with the left portal vein and hepatic artery, this triad lies just under the base of segment IV.On the other hand, the extrahepatic course of the right main duct is short; therefore, a biliary enteric anastomosis to the right extrahepatic duct would result in early tumour invasion and subsequently, obstruction.In a study carried out by Memorial Sloan-Kettering 2 of 58 patients with either cholangiocarcinoma or gallbladder cancer, whom were treated with either a segment III or a right sectoral hepatic duct bypass, the group experienced an overall procedure-related morbidity of 45% and a 30-day mortality of 11%. In terms of bypass patency, there was a greater actuarial patency in patients who underwent segment III cholangiojejunostomy.In our patient, a curative resection is not possible due to bilateral disease. A left cholangiojejunostomy would not adequately provide relief to the obstruction, as the volume of the liver is insufficient. A right sectoral biliary enteric bypass could have been an option in this patient; however, in the presence of segment V disease, the patency of this anastomosis is doubtful. Therefore, an intrahepatic approach to segment V was necessary in order to relieve the patient from recurrent biliary sepsis. References1. Connor S, Barron E, Redhead DN et al. Palliation for suspected unresectable hilar cholangiocarcinoma. Eur. J. Surg. Oncol. 2007; 33: 341-5. 2. Jarnagin WR, Burke E, Powers C, Fong Y, Blumgart LH. Intrahepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the hepatic duct confluence.A 48-year-old female from regional Australia presents with a 12-month history of an enlarging lump in her left breast (Fig. 1). She had a sister who developed breast cancer in her 40s but otherwise did not have any significant past medical history or risk factors for breast malignancy. The lesion was slow growing until 2 months preceding her presentation when there was an onset of rapid growth with the mass doubling in size in that period. Ultrasound and computed tomography (CT) demonstrated a large fluid collection within the breast.Three litres of turbid fluid was drained with growth of methicillinsensitive Staphylococcus aureus and inflammatory changes (Fig. 2). Core biopsy showed changes consistent with pseudoangiomatous stromal hypertrophy (PASH).While awaiting further investigations, the patient developed fevers, rigors and diaphoresis. Clinical examination at this time demonstr...