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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 135-137

Physiotherapy for simple mastectomy following phyllodes tumor: A case report


Department of Cardiovascular and Respiratory Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India

Date of Submission02-Jun-2021
Date of Acceptance19-Dec-2021
Date of Web Publication10-Feb-2022

Correspondence Address:
Dr. Zoha Badiuzzama Alvi
MGM Institute of Physiotherapy, N-6, Cidco, Aurangabad - 431 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_55_21

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  Abstract 


Phyllodes tumors are relatively rare breast tumors. Management of these tumors with surgical resection may cause postoperative complications. The purpose of this case study was to define the role of early postoperative physiotherapy in a patient with phyllodes tumor of the breast following simple mastectomy. A 50-year-old woman was brought to the outpatient department following a 1-year history of the lump in the right breast, worsening gradually in the preceding 2 months, and subsequently diagnosed to be a phyllodes tumor. She was treated with simple mastectomy followed by a drain insertion. Postoperatively, she presented with reduced chest expansion and functional mobility and postural impairments. Treatment protocol was set and follow-up was made on the 8th postoperative day. We conclude that early physiotherapy intervention can help in improving the functional mobility and preventing further postoperative complications.

Keywords: Mastectomy, phyllodes tumor, physiotherapy, postmastectomy exercises


How to cite this article:
Alvi ZB, Shukla MP, Mishra AS. Physiotherapy for simple mastectomy following phyllodes tumor: A case report. J Mahatma Gandhi Inst Med Sci 2021;26:135-7

How to cite this URL:
Alvi ZB, Shukla MP, Mishra AS. Physiotherapy for simple mastectomy following phyllodes tumor: A case report. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 May 24];26:135-7. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/135/337436




  Introduction Top


Phyllodes tumor of the breast is a rare fibro-epithelial neoplasm representing 0.3%–1% of all breast tumors that presents a morphologic continuum from benign to malignant. The tumor appears clinically as a round, mobile, and painless mass. They are typically large fast-growing masses that arise from the periductal stromal cells of the breast.[1] The tumor usually occurs in women between the ages of 35 and 55 years.[2]

Mammographic, sonographic, and magnetic resonance imaging may serve as an aid to identify phyllodes tumors. However, final diagnosis is confirmed only by histological examination. Surgical resection remains the gold standard of treatment. Wide local excision with 1–2 cm margins of normal breast is the treatment of choice for tumors which are less than 10 cm in size, and simple mastectomy for tumors larger than 10 cm.[3]

After simple mastectomy, patients may experience various complications such as restriction of the range of motion (ROM), retraction, fibrosis, seroma, lymphedema, muscular weakness, or postural deviations.[4] Physiotherapy plays a fundamental role in the rehabilitation after breast cancer surgery, helping in functional recovery, preventing complications, and enhancing the quality of life (QOL) of these women.[5] We report the case of a patient who developed recurrent phyllodes tumor and was operated with simple mastectomy. The purpose of this case study was to define the role of early postoperative physiotherapy in phyllodes tumor of the breast following simple mastectomy.


  Case Report Top


A 50-year-old, nulliparous woman with an enlarging right breast mass for 1 year presented to our oncology department. She reported that the lump was small and painless initially. In the last 2 months, the lump had grown rapidly. She complained of pain in her right breast. She also had surgical history of previous lumpectomy on the same side 15 years ago.

Mammography and ultrasonography showed a large lobulated mass in her right breast occupying all the quadrants and measuring 8 cm × 4 cm in size. No axillary lymph node was palpable. Examination of the left breast showed a small nodule measuring 3 mm × 4 mm size at the 3 o'clock position. Histopathologic analysis revealed that it was a benign recurrent phyllodes tumor. Due to the large size of the tumor (>10 cm), she was operated for phyllodes tumor with simple mastectomy. The procedure was performed using an elliptical incision 22 cm in length with 36 staplings along with 3 sutures [Figure 1].
Figure 1: Simple mastectomy scar with an elliptical incision

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Immediately after the surgery, a Romovac drain was connected to a single 600-ml suction bottle. After obtaining her consent, on postoperative days 1–4 (POD 1 to POD 4), the baseline parameters that could affect the outcomes of rehabilitation protocols were assessed. The parameters assessed included the following: scar examination, vital parameters, chest expansion, as well as clinical characteristics such as shoulder ROM, Numeric Pain Rating Scale for pain, and QOL [Table 1]. In order to assess and track the evolution of scars over time, we used the Manchester Scar Scale and Modified Scar Rating Scale. The total score for both scales was 8 in our patient.
Table 1: Evaluation of the clinical characteristics (pain, range of motion, and chest expansion) from POD 1 to POD 4

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A Functional Assessment of Cancer Therapy-Breast (FACT-B) QOL questionnaire was utilized for the assessment of QOL after breast surgery. In this patient, the total score for FACT-B was 56. The scores were unchanged in physical well-being, social, as well as emotional domains at the end of POD 5.

Physiotherapy management

The main concern of the patient was pain at the site of incision which limited her mobility. Hence, she was educated about her surgery, postoperative complications, importance of postoperative exercises and arm elevation, skincare, and energy conservation techniques. Deep breathing (including diaphragmatic breathing and relaxation exercises, thoracic mobility exercises, and simple postural correction exercises to decrease apprehension and pain) improved postoperative pulmonary function, and prepared the patient for progression.

Shoulder ROM exercises were initiated – initially gentle passive ROM exercises were started, progressing to self-ROM, pendulum exercises, cane stretches, wall walking and pulleys, back climbing exercise, and chest wall stretches within comfort range. Repetitions were set according to the pain intensity tolerated by the patient. Progression was done by increasing the repetition, range, and hold time. She was given a home exercise programme regarding the scar massage and the strengthening protocol. Day-wise physiotherapy protocol is mentioned in [Table 2]. Outcomes and follow-up from POD 1 to POD 2 are mentioned in [Table 1].
Table 2: Day-wise physiotherapy management

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  Discussion Top


This case emphasizes the importance of physiotherapy in preventing early postoperative complications caused by simple mastectomy. The benefits of early interventional physiotherapy in postmastectomy patients have proven to be effective in reducing the postoperative complications.

In our case study, patient education played a very important role in improving all the outcomes of the patient. A recent review concluded that it is necessary to utilize multiple modalities of treatment to achieve adequate pain control of women postsurgery.[6] After simple mastectomy surgery, patients may experience tightness around the surgical site and cause by scar tissue formation resulting in a dense tissue under the incision, which is painful and can restrict the ROM. In our case, following the physiotherapy management, pain and ROM improved to a greater extent. A recent systematic review also suggested that ROM exercises improved shoulder ranges, however, their abduction and external rotation showed less recovery.[5] Chest expansion was reduced due to the incision and the presence of the drain on the right side of the chest. Deep breathing exercises along with thoracic mobility improved chest expansion to around 1–2 cm. Postural correction exercises were prescribed to the patient, but due to pain and muscle guarding, posture improvement was not seen to a greater extent.

On POD 4, her drain was removed and she was given discharge. She was prescribed a home exercise program. She was called for follow-up after 8 days to check for further improvement in the ROM, posture, and chest expansion and to prescribe further exercises. On POD 8, she did not complain of pain on activity, her ROM improved by 5° to 10°, and her posture was significantly corrected.

We found significant improvement in the ROM, chest expansion, and pain on POD 4. No other serious complications were noted. We conclude that early physiotherapy treatment helps in improving functional mobility and preventing postoperative complications of simple mastectomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rowell MD, Perry RR, Hsiu JG, Barranco SC. Phyllodes tumors. Am J Surg 1993;165:376-9.  Back to cited text no. 1
    
2.
Zhou ZR, Wang CC, Yang ZZ, Yu XL, Guo XM. Phyllodes tumors of the breast: Diagnosis, treatment and prognostic factors related to recurrence. J Thorac Dis 2016;8:3361-8.  Back to cited text no. 2
    
3.
Mishra SP, Tiwary SK, Mishra M, Khanna AK. Phyllodes tumor of breast: A review article. ISRN Surg 2013;2013:361469.  Back to cited text no. 3
    
4.
Ewertz M, Jensen AB. Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol 2011;50:187-93.  Back to cited text no. 4
    
5.
De Groef A, Van Kampen M, Dieltjens E, Christiaens MR, Neven P, Geraerts I, et al. Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: A systematic review. Arch Phys Med Rehabil 2015;96:1140-53.  Back to cited text no. 5
    
6.
Tait RC, Zoberi K, Ferguson M, Levenhagen K, Luebbert RA, Rowland K, et al. Persistent post-mastectomy pain: Risk factors and current approaches to treatment. J Pain 2018;19:1367-83.  Back to cited text no. 6
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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