Fibroadenoma and Phyllodes TumorÕ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞

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°âÕπ∑’ˇμâ“π¡„πºŸâÀ≠‘ß«—¬√ÿàπÀ√◊Õ«—¬ºŸâ„À≠àμÕπμâππ—Èπ·¡â®–‰¡à¡’Õ“°“√·≈–

Õÿ∫—μ‘°“√≥å¢Õß¡–‡√Á߇μâ“π¡„πºŸâÀ≠‘ß°≈ÿà¡π’Èæ∫‰¥âπâÕ¬ ·μຟâªÉ«¬·≈–≠“μ‘¡—°¡’

§«“¡«‘μ°°—ß«≈«à“®–‡ªìπ¡–‡√Áß √«¡∑—Èß°—ß«≈«à“°âÕπ®–‚μ¢÷Èπ®π∑”„Àâ‡μâ“π¡

‡ ’¬√Ÿª√à“ß ·æ∑¬å®÷ßμâÕß„Àâ°“√¥Ÿ·≈∑’Ë∂Ÿ°μâÕ߇À¡“– ¡ ∑’Ë ”§—≠§◊Õ„Àâ°“√§«“¡

‡™◊ËÕ¡—Ëπ·°àºŸâªÉ«¬·≈–≠“쑇æ◊ËÕ„Àâ§≈“¬°—ß«≈„π°√≥’∑’ˉ¡à„™à‡π◊ÈÕ√⓬ ÷Ëß “¡“√∂

π—¥μ√«®μ‘¥μ“¡Õ“°“√‰¥âÕ¬à“ߪ≈Õ¥¿—¬‚¥¬‰¡à®”‡ªìπμâÕߺà“μ—¥‡Õ“°âÕπÕÕ°

∑ÿ°√“¬ ·≈–‡≈◊Õ°ºà“μ—¥‡©æ“–„π√“¬∑’ˇÀ¡“– ¡ ∫∑§«“¡π’È¡’‡π◊ÈÕÀ“‡°’ˬ«°—∫

°âÕπ‡μâ“π¡∑’Ëæ∫∫àÕ¬„πºŸâÀ≠‘ßÕ“¬ÿπâÕ¬§◊Õ fibroadenoma ·≈–°≈à“«∂÷ß‚√§∑’Ë

¡—°¡’≈—°…≥–§≈⓬ fibroadenoma §◊Õ phyllodes tumor ´÷Ëß¡’欓°√≥å‚√§·≈–

√“¬≈–‡Õ’¬¥°“√√—°…“∑’Ë·μ°μà“ß°—𠧫“¡ ”§—≠§◊ÕμâÕß«‘π‘®©—¬·¬°‚√§„À≥â

°àÕπ«“ß·ºπ°“√√—°…“À√◊Õºà“μ—¥

Fibroadenoma

Fibroadenoma ‡ªìπ benign fibroepithelial lesion ∑’Ëæ∫∫àÕ¬ ¡—°æ∫„π

ºŸâÀ≠‘ß™à«ßÕ“¬ÿ 20-30 ªï ¡’§«“¡™ÿ°¢Õß‚√§„π™à«ßÕ“¬ÿπ’Ȫ√–¡“≥ 2.2%1 ®“°

°“√»÷°…“™‘Èπ‡π◊ÈÕæ∫«à“ fibroadenoma ‡ªìπ°âÕπ¢Õ߇μâ“π¡∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥„πºŸâ

À≠‘ß«—¬√ÿàπ ‚¥¬æ∫ 44-94% ¢Õß°âÕπ„π‡μâ“π¡∑—ÈßÀ¡¥∑’ˉ¥â√—∫°“√ºà“μ—¥2

欓∏‘«‘∑¬“·≈–°“√®”·π°™π‘¥¢Õß fibroadenoma3

Fibroadenoma ¡’§«“¡º‘¥ª°μ‘∑—Èß„π à«π¢Õß epithelium ·≈– stroma

¿“§«‘™“»—≈¬»“ μ√å §≥–·æ∑¬»“ μ√å¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

∫∑∑’Ë 7

Fibroadenoma and Phyllodes Tumor94

∫√‘‡«≥ terminal duct-lobular unit ¢Õ߇μâ“π¡ æ∫¡’ proliferation ¢Õß∑—Èß glan-

dular °—∫ stromal elements ≈—°…≥–°âÕπ¿“¬πÕ°¡’¢Õ∫‡¢μ™—¥‡®π º‘«‡√’¬∫

À√◊Õ‡ªìπ multinodular surface Àπâ“μ—¥°âÕπ¡’ ’¢“«-πÈ”μ“≈ÕàÕπ ·≈–πŸπÕÕ°

¡“®“°¢Õ∫‡≈Á°πâÕ¬

°“√®”·π°™π‘¥¢Õß fibroadenoma æ‘®“√≥“®“°≈—°…≥–∑“ß欓∏‘«‘∑¬“

√à«¡°—∫¢π“¥¢Õß°âÕπ ¥—ßπ’È

1. Conventional (typical, simple) fibroadenoma: ‡ªìπ™π‘¥∑’Ëæ∫

¡“°∑’Ë ÿ¥ æ∫∫àÕ¬„πÀ≠‘ß«—¬ºŸâ„À≠àμÕπμâπ°âÕπ¡—°¡’¢π“¥‰¡à„À≠à¡“°·≈–‚μ™â“

À√◊Õ¡’¢π“¥§ß∑’Ë¡“‡ªìπ‡«≈“π“π

2. Giant fibroadenoma: §◊Õ fibroadenoma ∑’Ë¡’¢π“¥„À≠à¡“°°«à“ 5

cm ‡ªìπ™π‘¥∑’Ëæ∫‰¥â‰¡à∫àÕ¬§◊Õ <4% ¢Õß∑—ÈßÀ¡¥ ¡—°æ∫„πºŸâÀ≠‘ß™à«ß«—¬√ÿàπ

·≈–‡ªì𠓇Àμÿ∫àÕ¬∑’Ë ÿ¥¢Õß°“√¡’‡μâ“π¡¢π“¥‰¡à‡∑à“°—π„πÀ≠‘ß«—¬√ÿàπ (unilat-

eral macromastia) ∂â“°âÕπ¡’¢π“¥„À≠à¡“°Õ“®°¥‡∫’¬¥º‘«Àπ—ß®πμ÷߇ÀÁπ

‡ âπ‡≈◊Õ¥¥”™—¥‡®π∑’˺‘«Àπ—ß À—«π¡°—∫≈“πÀ—«π¡¢¬“¬¢π“¥ ·≈–∂â“‚μ¡“°Ê

Õ“®∑”„À⇰‘¥·º≈∑’ˇμâ“π¡‰¥â·μàæ∫‰¡à∫àÕ¬ giant fibroadenoma ∑’Ë¡’¢π“¥

„À≠à¡“°®÷ß¡’≈—°…≥–§≈⓬°—∫ phyllodes tumor ‰¥â

3. Cellular fibroadenoma: ™π‘¥π’È¡’≈—°…≥–‡¥àπ§◊Õ¡’ spindle cells „π

stroma ®”π«π¡“°°«à“∑’Ëæ∫„π simple fibroadenoma cellular fibroadenoma

√Ÿª∑’Ë 1 Gross pathology of fibroadenoma Microscopic pathology of fibroadenoma

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 95

æ∫‰¥â 10% ¢Õß fibroadenoma ∑—ÈßÀ¡¥„πÀ≠‘ß«—¬√ÿàπ ·≈– à«π„À≠à¡’·π«‚πâ¡

®–¡’¢π“¥‚μ¢÷Èπ°≈“¬‡ªìπ giant fibroadenoma

4. Juvenile fibroadenoma : ™π‘¥π’È¡’≈—°…≥–‡¥àπ§◊Õ¡—°®–‚μ‡√Á« æ∫

∫àÕ¬„π™à«ß«—¬√ÿàπ ∫“ß ∂“∫—π®—¥„ÀâÕ¬Ÿà„π°≈ÿࡇ¥’¬«°—∫ celluar fibroadenoma

5. Complex fibroadenoma: §◊Õ fibroadenoma ∑’Ë¡’欓∏‘ ¿“æ

≈—°…≥–Õ◊ËπÊ¡“ª–ªπÕ¬Ÿà¥â«¬‡™àπ sclerosing adenosis, cysts, papillary apo-

crine metaplasia À√◊Õ¡’ epithelial calcification √à«¡Õ¬Ÿà¥â«¬ complex fibroad-

enoma æ∫‰¥â 15% ¢Õß∑—ÈßÀ¡¥ ¡—°æ∫„πºŸâÀ≠‘ßÕ“¬ÿ¡“°°«à“ fibroadenoma

™π‘¥Õ◊Ëπ ¡’°“√»÷°…“æ∫«à“ median age of diagnosis §◊Õ 47 ªï·¡â¡’°“√»÷°…“

æ∫«à“ fibroadenoma ™π‘¥π’È¡’§«“¡‡ ’ˬßμàÕ°“√°≈“¬‡ªìπ¡–‡√Áß ·μà∂◊Õ«à“πâÕ¬

¡“°§◊Õ 1.6% „π™à«ß 2 ªï·√°4 ·≈–·π«∑“ß°“√¥Ÿ·≈√—°…“ºà“μ—¥π—Èπ‰¡à·μ°μà“ß

®“° fibroadenoma ™π‘¥Õ◊Ëπ

 “‡Àμÿ°“√‡°‘¥ fibroadenoma

 “‡Àμÿ°“√‡°‘¥ fibroadenoma π—Èπ¬—߉¡à∑√“∫·πà™—¥ ¡’°“√»÷°…“æ∫«à“

√Ÿª∑’Ë 2 ¿“æ unilateral macromastia ¢ÕߺŸâªÉ«¬ giant fibroadenoma

Fibroadenoma and Phyllodes Tumor96

πà“®– —¡æ—π∏å°—∫°“√¡’ progesterone receptor ¡“°º‘¥ª°μ‘„π‡π◊ÈÕ‡¬◊ËÕ¢Õß fi-

broadenoma ‡¡◊ËÕ‡∑’¬∫°—∫‡π◊ÈÕ‡¬◊ËÕ‡μâ“π¡ª°μ‘ ÷Ëßπà“®–Õ∏‘∫“¬‡Àμÿ∑’Ë°âÕπ fibroad-

enoma ¡—°¡’¢π“¥‚μ¢÷Èπ„π™à«ß∑’˺ŸâªÉ«¬μ—Èߧ√√¿åÀ√◊Õ„Àâπ¡∫ÿμ√ ·≈â«¡’¢π“¥

‡≈Á°≈ß„π™à«ß«—¬À¡¥ª√–®”‡¥◊Õπ5 °“√»÷°…“∑“ßgenetic æ∫«à“ fibroadenoma

¡’°“√· ¥ßÕÕ°¢Õß p53 gene ¡“°°«à“ª°μ‘6 ´÷Ëß p53 protein ¡’∫∑∫“∑¬—∫¬—Èß

cellular proliferation ·≈–°√–μÿâπ„À⇰‘¥ apoptosis ∂â“¡’ DNA damage p53 gene

‡ªìπ tumor suppressor gene∂â“¡’mutation®–∑”„À⇰‘¥ cell proliferation º‘¥

ª°μ‘®π°≈“¬‡ªìπ tumor

°“√¥”‡π‘π‚√§¢Õß fibroadenoma

Fibroadenoma ¡’°“√¥”‡π‘π‚√§∑’ËÀ≈“°À≈“¬ ·μà‚¥¬∑—Ë«‰ª¡—°‚μ™â“Ê

·≈–¡’¢π“¥„À≠à‰¡à‡°‘π 2-3 cm ·≈â«¢π“¥®–§ß∑’Ëπ“πÀ≈“¬ªï ‡¡◊ËÕÕ“¬ÿ¡“°¢÷Èπ

¡’‚Õ°“ ΩÉÕ¬ÿ∫≈߉¥â ¡’°“√»÷°…“æ∫ complete regression ‰¥â 10-40%7 ‚Õ°“ 

°≈“¬‡ªìπ¡–‡√Á߇μâ“π¡π—Èπæ∫‰¥âπâÕ¬¡“°§◊Õ ≤ 0.3%8 ·≈–‰¡à§àÕ¬æ∫„πºŸâÀ≠‘ß

∑’ËÕ“¬ÿμË”°«à“ 40 ªï

Õ“°“√∑“ߧ≈‘π‘°¢Õß fibroadenoma

Fibroadenoma  à«π„À≠àæ∫„πºŸâÀ≠‘ß«—¬√ÿàπμÕπª≈“¬∂÷ߺŸâ„À≠àμÕπμâπ

¡—°§≈”‰¥â°âÕπ¡“π“πÀ≈“¬‡¥◊ÕπÀ√◊Õπ“π‡ªìπªï‚¥¬∑’Ë°âÕπ¡’¢π“¥‡∑à“‡¥‘¡À√◊Õ

‚μ¢÷Èπ™â“Ê μ√«®§≈”°âÕπ®–¡’≈—°…≥– well circumscribed, rubbery, smooth sur-

face, mobile  “¡“√∂æ∫„π‡μâ“π¡∑—Èß Õߢâ“߉¥â 10-15%9 ‚¥¬ à«π„À≠à®–

‰¡à¡’°“√‡ª≈’ˬπ·ª≈ߢÕߺ‘«Àπ—ßÀ√◊ÕÀ—«π¡ ‰¡à¡’μàÕ¡πÈ”‡À≈◊Õß‚μ ∂â“μ√«®æ∫

≈—°…≥–º‘¥ª°μ‘¥—ß°≈à“«„Àâ ß —¬«à“πà“®–‰¡à„™à fibroadenoma ·≈–Õ“®®–‡ªìπ

°âÕπ¡–‡√Áß¡“°°«à“

°“√«‘π‘®©—¬·¬°‚√§

·¡â«à“ fibroadenoma ®–‡ªìπ°âÕπ‡π◊ÈÕ‡μâ“π¡∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥„πºŸâÀ≠‘ß

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 97

Õ“¬ÿπâÕ¬ Õ¬à“߉√°Áμ“¡·æ∑¬å§«√´—°ª√–«—μ‘ μ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥ ·≈–

æ‘®“√≥“ àßμ√«®‡æ‘Ë¡‡μ‘¡‡æ◊Ëՙ૬„π°“√«‘π‘®©—¬·¬°‚√§Õ◊Ëπ∑’Ëæ∫‰¥â ‡™àπ

- Phyllodes tumor - Inflammatory mass

- Fibrocystic change - Tubular adenoma

- Mammary harmatoma - Malignancies

°“√μ√«®‡æ‘Ë¡‡μ‘¡

Ultrasound ‡ªìπ°“√μ√«®«‘π‘®©—¬∑“ß√—ß ’∑’ˇÀ¡“– ¡∑’Ë ÿ¥ ”À√—∫°âÕπ‡μâ“

π¡„πºŸâÀ≠‘ßÕ“¬ÿπâÕ¬°«à“ 30 ªï „π¢≥–∑’Ë mammogram Õ“®®–‰¡à‡À¡“– ¡

‡æ√“–ºŸâÀ≠‘ß°≈ÿà¡π’ȇπ◊ÈÕ¢Õ߇μâ“π¡Àπ“·πàπ¡“°®÷ß≈¥§«“¡‰«·≈–§«“¡·¡àπ¬”

¢Õß mammogram ≈—°…≥–¢Õß fibroadenoma ∑’Ëμ√«®æ∫®“° ultrasound §◊Õ

well circumscribed iso or hypoechoic homogeneous mass with posterior

acoustic transmission ‚¥¬∑’Ë°âÕπÕ“®¡’√Ÿª√à“߉¥â∑—Èß oval, round À√◊Õ macro-

lobulated Õ¬à“߉√°Áμ“¡ ultrasound ‰¡à “¡“√∂·¬° fibroadenoma ÕÕ°®“°

‚√§Õ◊Ëπ‰¥â∑—ÈßÀ¡¥ ‚¥¬‡©æ“– phyllodes tumor ®÷ß®”‡ªìπμâÕß„™â°“√μ√«®™‘Èπ

‡π◊ÈÕ¡“™à«¬„π°“√«‘π‘®©—¬´÷Ëß«‘∏’°“√μ√«®∑’Ë·π–π”§◊Õ core needle biopsy

¢âÕ∫àß™’È„π°“√μ√«®™‘Èπ‡π◊ÈÕ„ÀâªØ‘∫—μ‘μ“¡ BIRADS ∑’ˉ¥â®“°°“√μ√«® ultra-

sound

°“√√—°…“ fibroadenoma

1. °“√‡ΩÑ“μ‘¥μ“¡Õ“°“√ (conservative and monitoring)  “¡“√∂‡ΩÑ“

μ‘¥μ“¡ —߇°μ°âÕπ fibroadenoma ‰¥â„πºŸâªÉ«¬Õ“¬ÿπâÕ¬∑’Ë¡’°âÕπ¢π“¥‡≈Á°°«à“ 5cm

‚¥¬μâÕ߉¡à¡’≈—°…≥–∑’Ëπà“ ß —¬«à“®–‡ªìπ°âÕπ‡π◊ÈÕ√⓬ ®“°Õ“°“√·≈– ultrasound

‚¥¬π—¥μ‘¥μ“¡Õ“°“√Õ’° 1-2 ‡¥◊Õπ‡æ◊ËÕ¥Ÿ«à“°âÕπ¡’·π«‚πâ¡‚μ¢÷ÈπÀ√◊Õ‡≈Á°≈ß

∂â“°âÕπ¡’¢π“¥‡≈Á°≈ß “¡“√∂‡ΩÑ“μ‘¥μ“¡‰¥â‚¥¬π—¥∑ÿ° 3-6 ‡¥◊Õπ„π™à«ß 1-2

ªï·√°·≈–æ‘®“√≥“∑” ultrasound ∑’Ë 6 ‡¥◊Õπ À≈—ß®“°π—Èπ„Àâπ—¥Àà“ßÕÕ°·≈â«

·μà°√≥’‚¥¬‰¡àμâÕߺà“μ—¥·μà∂â“°âÕπ¡’·π«‚πâ¡‚μ¢÷Èπ·π–π”„Àâæ‘®“≥“‡®“–

Fibroadenoma and Phyllodes Tumor98

μ√«®™‘Èπ‡π◊ÈÕ10,11

2. °“√ºà“μ—¥°âÕπÕÕ°∑—ÈßÀ¡¥ (excision) ¡’·π«∑“ßæ‘®“√≥“ºà“μ—¥°âÕπ

∑’Ë ß —¬ fibroadenoma ¥—ßπ’È12

- Rapidly growing mass

- Mass diameter > 5 cm (giant fibroadenoma)

- Mass causing distortion of breast architecture or overlying skin

changes

- Persistent mass without regression

- Multiple and bilateral breast masses

- Stromal hypercellularity or cystic change on ultrasound

- Symptoms and signs worrisome for malignancy

- Presence of a high-risk genetic mutation

- Histologically complex fibroadenoma

´÷Ëß°√≥’∑’ËÕ“°“√∑“ߧ≈‘π‘° ß —¬ phyllodes tumor À√◊Õ°âÕπ¡–‡√Áߧ«√

∑” CNB °àÕπ«“ß·ºπºà“μ—¥ À≈—ßμ—¥°âÕπÕÕ°·≈â« à«π„À≠à‰¡à®”‡ªìπμâÕ߇ √‘¡

‡μâ“π¡ (augmentation) ·¡â°√–∑—Ëß°√≥’ giant fibroadenoma ‡æ√“–‡π◊ÈÕ‡¬◊ËÕ

‡μâ“π¡∑’ˇ§¬∂Ÿ°°¥‡∫’¬¥®–¢¬“¬μ—«¡“‡μ‘¡‡μÁ¡™àÕß«à“ß∑’ˇ°‘¥¢÷ÈπÀ≈—ߺà“μ—¥

3. Vacuum-assisted ultrasound-guided percutaneous excision

‡ªìπ«‘∏’√—°…“∑’Ë∑”„À⇰‘¥∫“¥·º≈πâÕ¬ (minimally invasive technique)

‡À¡“–°—∫°âÕπ fibroadenoma ∑’Ë¡’¢π“¥‡≈Á° ‚¥¬„™â‡¢Á¡ vacuum biopsy ∑’Ë¡’

¢π“¥„À≠à·≈â«„™â ultrasound „π°“√π”∑“ß ¡’√“¬ß“πº≈ ”‡√Á® 75-100%13

·μà¡’°“√°≈—∫‡ªìπ´È”‰¥â ‡™◊ËÕ«à“‡°‘¥®“°‡»…°âÕπ‡π◊ÈÕ∑’Ë¡’¢π“¥‡≈Á°¡“°®π ultra-

sound ¡Õ߉¡à‡ÀÁπ ®÷ߥŸ¥ÕÕ°¡“‰¡àÀ¡¥ ‚¥¬æ∫«à“°“√°≈—∫‡ªìπ´È”¡—°‡°‘¥°—∫

°âÕπ∑’Ë¡’¢π“¥„À≠à°«à“ 2cm æ∫°≈—∫‡ªìπ´È”‰¥â 33% ‡¡◊ËÕμ‘¥μ“¡ºŸâªÉ«¬π“π 59

‡¥◊Õπ¥—ßπ—Èπ§«√‡≈◊Õ°„™â«‘∏’π’È„π°√≥’°âÕπ∑’Ë¡’¢π“¥‡≈Á°°«à“ 2cm ·≈–ºŸâªÉ«¬‰¡à

Õ¬“°‡ΩÑ“μ‘¥μ“¡Õ“°“√ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß°√≥’∑’Ë¡’À≈“¬°âÕπ√à«¡°—∫ºŸâªÉ«¬¡’

§«“¡‡ ’ˬߠŸß„π°“√‡°‘¥·º≈‡ªìπ™π‘¥ keloid

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 99

Phyllodes tumorPhyllodes tumor ‡ªìπ fibroepithelial lesions ∑’Ëæ∫‰¡à∫àÕ¬§◊Õ 0.3-0.5%

¢Õß°âÕπ‡π◊ÈÕ‡μâ“π¡„π‡æ»À≠‘ß14 ·≈–¡’Õÿ∫—μ‘°“√≥åª√–¡“≥ 2.1 §πμàÕºŸâÀ≠‘ß

Àπ÷Ëß≈â“π§π‚¥¬™à«ßÕ“¬ÿ∑’Ëæ∫∫àÕ¬§◊Õ 45-49 ªï15 ‰¡à§àÕ¬æ∫„π°≈ÿà¡«—¬√ÿàπ·≈–

ºŸâ ŸßÕ“¬ÿ ≈—°…≥–°“√¥”‡π‘π‚√§·≈–欓°√≥å‚√§¢Õß phyllodes tumor ¡’

§«“¡À≈“°À≈“¬¢÷Èπ°—∫≈—°…≥–欓∏‘«‘∑¬“¢ÕߺŸâªÉ«¬·μà≈–√“¬ §«“¡ ”§—≠

„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ phyllodes tumor §◊Õ°“√«‘π‘®©—¬∑’Ë∂Ÿ°μâÕß·¡à𬔰àÕπ∑’Ë

®–«“ß·ºπ°“√ºà“μ—¥‰¥â‡À¡“– ¡ ≈¥‚Õ°“ °“√‡°‘¥‡ªìπ È” ·≈–≈¥°“√ºà“μ—¥ È”

§«“¡¬“°Õ¬Ÿà∑’Ë¡—°®–‰¡à “¡“√∂·¬°‚√§ phyllodes tumor (‚¥¬‡©æ“–™π‘¥ be-

nign) ÕÕ°®“° fibroadenoma ‰¥â°àÕπºà“μ—¥ ∫àÕ¬§√—Èß∑’Ë»—≈¬·æ∑¬å§‘¥«à“‡ªìπ

fibroadenoma ®÷ß∑”·§à excision μ—¥™‘¥°âÕπ‰¡à„™à wide excision ∑”„Àâ¡’

‚Õ°“ μ—¥‰¥â¢Õ∫‡¢μ‰¡àÀ¡¥À√◊Õ‰¡à°«â“ßæÕ¡’‚Õ°“ °≈—∫‡ªìπ È” Ÿß‚¥¬‡©æ“–

™π‘¥ borderline °—∫ malignant phyllodes tumor ÷Ëß¡’º≈‡ ’¬μàÕºŸâªÉ«¬∑’Ë®–μâÕß

¡“ºà“μ—¥Õ’°§√—È߇æ◊ËÕ„À≥â¢Õ∫‡¢μ∑’Ë°«â“߇撬ßæÕ

 “‡Àμÿ°“√‡°‘¥ phyllodes tumor

ªí®®ÿ∫—π¬—߉¡à∑√“∫ “‡Àμÿ°“√‡°‘¥ phyllodes tumor ·≈–§«“¡‡°’ˬ«æ—π

°—∫ fibroadenoma ∑’Ë·πà™—¥ ¡’À≈“¬ ¡¡ÿμ‘∞“π‡°’Ë¬«°—∫ “‡Àμÿ¢Õß phyllodes tumor

‡™àπ

- ‡°‘¥®“°§«“¡º‘¥ª°μ‘¢Õß‚§√‚¡‚´¡ μ—«Õ¬à“ߧ◊Õ germline mu-

tation ¢Õß TP53 gene „πºŸâªÉ«¬ Li-fraumeni syndrome ·μஓ°°“√»÷°…“æ∫«à“

‡ªìπ°≈ÿà¡πâÕ¬¢ÕߺŸâªÉ«¬phyllodes tumor ∑—ÈßÀ¡¥16

- Phyllodes tumor ‡ª≈’ˬπ·ª≈ß¡“®“° fibroadenomas ‡æ√“–∑—Èß

 Õß‚√§¡’ histology ·≈–≈—°…≥–∑“ß molecular∑’Ë„°≈⇧’¬ß°—π17 Memorial Sloan

Kettering Cancer Center ‰¥â‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈ºŸâªÉ«¬ phyllodes tumor 293

§πæ∫«à“¡’ºŸâªÉ«¬ 37% (109 §π)∑’Ë¡’ª√–«—쑇§¬‡ªìπ fibroadenoma ¡“°àÕπ∑’Ë

®–μ√«®æ∫‡ªìπ phyllodes tumor18

Fibroadenoma and Phyllodes Tumor100

- ‡™◊ËÕ«à“¿“«–ª°μ‘ epithelium °—∫ stroma ®–¡’°“√§«∫§ÿ¡´÷Ëß°—π·≈–

°—π‰¡à„À⇮√‘≠º‘¥ª°μ‘ (interactions between the epithelium and stroma)

·μà‡¡◊ËÕ¡’§«“¡º‘¥ª°μ‘ ‡ ’¬°“√§«∫§ÿ¡π’È (loss of the stromal-epithelial inter-

dependency) ®–∑”„Àâ stromal cells ¡’°“√·∫àßμ—«¡“°º‘¥ª°μ‘‰¥â19

欓∏‘«‘∑¬“¢Õß phyllodes tumor

Phyllodes tumor ¡’欓∏‘ ¿“æ∑’Ë·μ°μà“ß®“° breast carcinoma §◊Õ

phyllodes tumor ‡®√‘≠º‘¥ª°μ‘¡“®“° stroma ´÷Ë߇ªìπ connective tissues ∑’Ë

Õ¬Ÿà≈âÕ¡√Õ∫ ducts ·≈– lobules ¢Õ߇μâ“π¡

Gross pathology : phyllodes tumor ‡ªìπ°âÕπ∑’Ë¡’¢Õ∫‡¢μ™—¥‡®π·¡â‰¡à¡’

capsule ∑’Ë·∑â®√‘ß ¡’√Ÿª√à“ß°≈¡À√◊Õ√’ æ◊Èπº‘«‰¡à‡√’¬∫ (multinodular mass)

¢π“¥¢Õß°âÕπæ∫‰¥âμ—Èß·μà¢π“¥‡≈Á°°«à“ 1cm ®π∂÷ß¢π“¥„À≠à 40 cm20 Àπâ“

μ—¥¢Õß°âÕπ “¡“√∂æ∫∫√‘‡«≥∑’Ë¡’ necrosis À√◊Õhemorrhage‰¥â‚¥¬‡©æ“–

°âÕπ∑’Ë¡’¢π“¥„À≠à·≈–‚μ‡√Á« ·μà‚¥¬∑—Ë«‰ª‡√“¡—°‰¡à “¡“√∂·¬°√–À«à“ß phyl-

lodes tumor °—∫ fibroadenoma ‰¥â®“° gross pathology

Microscopic pathology : phyllodes tumor ¡’≈—°…≥–‰¥âÀ≈“¬·∫∫ μ—Èß

·μà¡’®”π«π‡´≈≈åπâÕ¬§≈⓬ fibroadenoma ®π∂÷ß¡’‡´≈≈庑¥ª°μ‘®”π«π¡“°

§≈⓬°—∫ sarcoma Õ¬à“߉√°Áμ“¡ phyllodes tumor ¡—°®–¡’≈—°…≥–‡©æ“–§◊Õ

¡’™àÕß«à“߇ªìπ√àÕ߬“«·∑√°Õ¬Ÿà¿“¬„π‡π◊ÈÕ°âÕπ ‚¥¬„π√àÕßπ’È®–¡’ papillary pro-

jections ∑”„Àâ√Ÿª√à“ߧ≈⓬„∫‰¡â ®÷߇√’¬°≈—°…≥–‡©æ“–π’È«à“ leaf-like architec-

ture21

‡´≈≈å¿“¬„π stroma ®–¡’≈—°…≥– hyperplasia ·≈– atypia ∑’Ë·μ°μà“ß

°—π„π·μà≈–°≈ÿà¡¢Õß phyllodes tumor 欓∏‘·æ∑¬å„™â≈—°…≥–¢Õß stromal

cells„π°“√·¬°‚√§√–À«à“ß fibroadenoma °—∫ phyllodes tumor √«¡∑—Èߙ૬

·¬°™π‘¥¢Õß phyllodes tumor ÕÕ°‡ªìπ 3 °≈ÿà¡μ“¡ WHO classification (μ“√“ß∑’Ë

1) °“√æ∫ stromal overgrowth ¬—ߙ૬∫հ欓°√≥å‚√§«à“¡’‚Õ°“ ‡°‘¥ local

recurrence ·≈– distance metastasis ‰¥â Ÿß¡’√“¬ß“πæ∫°“√‡ª≈’ˬπ·ª≈ß®“°

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 101

phyllodes tumor °≈“¬‡ªìπ sarcomas (sarcomatous differentiation) ‰¥â·μà

πâÕ¬§◊Õ< 5% ¢Õß phyllodes tumor ∑—ÈßÀ¡¥22

°“√®”·π°™π‘¥¢Õß phyllodes tumor

„πªï §.». 1981 Õߧ尓√Õπ“¡—¬‚≈°‰¥â·∫àß phyllodes tumor ÕÕ°‡ªìπ

3 °≈ÿࡧ◊Õ benign, borderline ·≈– malignant phyllodes tumor ‚¥¬Õ“»—¬

‡°≥±å∑“ß欓∏‘«‘∑¬“23 benign phyllodes tumor æ∫‡ªìπ —¥ à«π¡“°∑’Ë ÿ¥§◊Õ

35-64% ∑’ˇÀ≈◊ÕÕ¬à“ß≈–§√÷Ëß®–‡ªìπ™π‘¥ borderline °—∫ malignant24

μ“√“ß∑’Ë 1 Histologic features for classification of phyllodes tumor subtypes.

Histologic Features Benign Borderline Malignant

Mitotic activity <4/10 hpf 4-9/10 hpf ≥10/10 hpfStromal cellular atypia Mild Marked MarkedStromal overgrowth Absent Absent PresentTumor margins Circumscribed Circumscribed or Infiltrative

Infiltrative

hpf = high power field.

√Ÿª∑’Ë 3 Gross and microscopic pathologies of phyllodes tumor

Fibroadenoma and Phyllodes Tumor102

Õ“°“√∑“ߧ≈‘π‘°¢Õß phyllodes tumor25

- ¡—°æ∫„πºŸâÀ≠‘ß™à«ßÕ“¬ÿ 35-55 ªï (¡“°°«à“°≈ÿà¡ fibroadenoma

ª√–¡“≥ 20 ªï)

- °âÕπ‚μ‡√Á«¿“¬„π√–¬–‡«≈“‡ªìπ‡¥◊Õπ À√◊Õ‡ªìπ°âÕπ∑’˧≈”æ∫¡“

À≈“¬ªï°àÕπ∑’Ë®–‚μ‡√Á«¢÷Èπ„π™à«ß√–¬–À≈—ß

- °âÕπ¡—°§≈”‰¥â¢Õ∫‡¢μ™—¥‡®π‚¬°°âÕπ‰¥âßà“¬ ‰¡àμ‘¥°—∫‡π◊ÈÕ‡¬◊ËÕ¢â“ß

‡§’¬ß ´÷Ëߧ≈⓬°—∫ fibroadenoma

- °âÕπ¡’¢π“¥‰¥âμ—Èß·μà 1-40 cm ‚¥¬∂â“°âÕπ¡’¢π“¥„À≠à¡“°®–

‡∫’¬¥∑”„Àâ‡μâ“π¡º‘¥√Ÿª º‘«Àπ—ß¡’ ’§≈È” ‡ÀÁπ‡ âπ‡≈◊Õ¥¥”∑’˺‘«Àπ—ߢ¬“¬¢π“¥

·≈–Õ“®‡°‘¥·º≈°¥∑—∫∑’˺‘«Àπ—߉¥â ÷Ëß·º≈∑’˺‘«Àπ—ßæ∫‰¥â‰¡à∫àÕ¬„π phyllodes tu-

mor

- æ∫¡’μàÕ¡πÈ”‡À≈◊Õß∑’Ë√—°·√â‚μ√à«¡¥â«¬πâÕ¬¡“° ‰¡à‡°‘π 10-15%

·≈–‡ªìπ pathologic node < 1%

- °√≥’∑’Ë°âÕπ≈ÿ°≈“¡‡¢â“°≈â“¡‡π◊ÈÕ pectoralis major ®–∑”„À≡ࠓ¡“√∂

‚¬°°âÕπ‰¥â (fixation)

√Ÿª∑’Ë 4 ºŸâªÉ«¬ phyllodes tumor ¢π“¥„À≠à æ∫¡’ superficial vein dilatation ¢Õߺ‘«Àπ—ß

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 103

√—ß ’«‘π‘®©—¬18,20

·¡â«à“°“√μ√«® mammogram ·≈– ultrasound ‡μâ“π¡®–‰¡à “¡“√∂·¬°

phyllodes tumor °—∫ fibroadenoma ‰¥â ·μà¡’¢âÕ —߇°μ‡°’ˬ«°—∫≈—°…≥–∑’Ë¡—°æ∫„π

phyllodes tumor ¥—ßπ’È26

Ultrasonography

- lobulated shape

- low level homogenous internal echoes

- echogenic rim

- fluid-filled clefts in a predominantly solid mass (highly sug-

gestive of phyllodes tumor)

≈—°…≥–°âÕπ®“° color-doppler ultrasound ∑’Ë ß —¬ malignant phyl-

lodes tumor §◊Õ

- marked hypoechogenicity

- posterior acoustic shadowing

- ill-definded tumor margins

- increased vascularity

√Ÿª∑’Ë 5 ¿“æ Breast ultrasound ¢Õß phyllodes tumor

Fibroadenoma and Phyllodes Tumor104

Mammography

- well circumscribed oval or lobulated mass with rounded bor-

ders

- radiolucent halo may be seen

- coarse calcification may be present (malignant microcalcification

is rare)

°“√μ√«®«‘π‘®©—¬∑“ß欓∏‘«‘∑¬“

FNA : ‡π◊ËÕß®“°∑—Èß phyllodes tumor ·≈– fibroadenoma ‡ªìπ‡π◊ËÕßÕ°

„π°≈ÿà¡ fibroepithellial lesions μâÕßÕ“»—¬°“√¥Ÿ√“¬≈–‡Õ’¬¥¢Õß stromal cells

®÷ß®– “¡“√∂«‘π‘®©—¬·¬°‚√§‰¥â·¡à𬔠·μà FNA „Àâ¢âÕ¡Ÿ≈‡ªìπ cytology ®÷߉¡à

‡À¡“– ¡„π°“√„™â«‘π‘®©—¬·¬°‚√§√–À«à“ß phyllodes tumor °—∫ fibroadenoma

¡’°“√»÷°…“æ∫«à“ FNA ¡’§«“¡·¡à𬔄π°“√«‘π‘®©—¬ phyllodes tumor ‡æ’¬ß·§à

63%27

Core needle biopsy (CNB) : ¡’§«“¡πà“‡™◊ËÕ∂◊Õ¡“°°«à“ FNA ‡æ√“–‰¥â

™‘Èπ‡π◊ÈÕ‡ªìπ histology  “¡“√∂„Àâ√“¬≈–‡Õ’¬¥¢Õß stromal cells ‰¥â¥’°«à“FNA

¡’°“√»÷°…“æ∫«à“ CNB ¡’ sensitivity 99%, negative predictive value 93%

·≈– positive predictive value 83% „π°“√«‘π‘®©—¬ phyllodes tumor28

Phyllodes tumor ¡’≈—°…≥– histology ∑’Ë·μ°μà“ß®“° fibroadenoma ¥—ßπ’È

- increased stromal cellularity

- increased mitotic activity

- stromal cell atypia

Õ¬à“߉√°Áμ“¡∫“ߧ√—Èß CNB °Á‰¡à “¡“√∂·¬° phyllodes tumor °—∫fi-

broadenoma ‰¥â·¡à𬔇æ√“– „π benign phyllodes tumor Õ“®‰¡à¡’ cellular

atypia ·≈–‰¡àæ∫ mitotic activity ∑’ˇæ‘Ë¡º‘¥ª°μ‘‰¥â„π¢≥–‡¥’¬«°—π juvenile fi-

broadenoma °Á “¡“√∂¡’®”π«π stromal cells ‡æ‘Ë¡¢÷Èπ‰¥â ®÷ß®”‡ªìπμâÕß∑” ex-

cision ‡Õ“°âÕπÕÕ°¡“μ√«®∑—Èß°âÕπ‡æ◊ËÕ°“√«‘π‘®©—¬∑’Ë∂Ÿ°μâÕß

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 105

Excisional biopy : ¡’∫∑∫“∑ ”§—≠„π°√≥’∑’˺≈®“° CNB „À⧔μÕ∫

‰¡à™—¥‡®π ∑—È߬—߇ªìπ°“√√—°…“¥â«¬ ”À√—∫ fibroadenoma ¡’‡°≥±å∑’Ëπà“ —߇°μ

‡æ◊Ëՙ૬„π°“√μ—¥ ‘π„®«à“ºŸâªÉ«¬√“¬„¥¡’§«“¡‡ªìπ‰ª‰¥â Ÿß∑’Ë®–‡ªìπ phyllodes tu-

mor ´÷Ëߧ«√∑” CNB ‡æ◊ËÕ„À≥Ⱃ√«‘π‘®©—¬∑’Ë∂Ÿ°μâÕß°àÕπ«“ß·ºπºà“μ—¥∑’ˇÀ¡“–

 ¡∂â“æ∫≈—°…≥–‡¢â“‡°≥±å¥â“π≈à“ßπ’ÈÕ¬à“ßπâÕ¬ ÕߢâÕ ·π–π”„Àâ∑” CNB °àÕπ

excision

Paddington Clinicopathological Suspicious Score29

Clinical findings :

1) Sudden increase in size in a longstanding breast lesion

2) Apparent fibroadenoma > 3 cm diameter or in patient > 35

years

Imaging findings :

1) Rounded borders/ lobulated appearance at mammography

2) Attenuation or cystic areas within a solid mass on ultrasonog-

raphy

FNA findings :

1) Presence of hypercellularity stromal fragments

2) Indeterminate features

ANY 2 features mandate core biopsy

Tumor markers in phyllodes tumor

ªí®®ÿ∫—π∫∑∫“∑¢Õß tumor markers „π phyllodes tumor ¬—߉¡à™—¥‡®π

·≈–¬—߉¡à‰¥âπ”¡“„™âª√–‚¬™πå∑“ߧ≈‘π‘° μ—«Õ¬à“ß°“√»÷°…“‡°’ˬ«°—∫ tumor mark-

ers „π phyllodes tumor ‡™àπæ∫ p53 ·≈– CD117 ‰¥â∫àÕ¬„π malignant phyl-

lodes ‚¥¬¡—°®– —¡æ—π∏å°—∫ high histologic grade ·≈– tumor ∑’Ë¡’ CD117 pro-

tein expression ®–æ∫ recurrence ‰¥â∫àÕ¬30

°“√√—°…“ phyllodes tumor

Fibroadenoma and Phyllodes Tumor106

°“√ºà“μ—¥ (surgical management)

°“√ºà“μ—¥‡ªìπ°“√√—°…“À≈—°¢Õß phyllodes tumor ¡ÿàßÀ¡“¬‡æ◊ËÕ‡Õ“°âÕπ

ÕÕ°„ÀâÀ¡¥ ·≈– ≈¥‚Õ°“ °≈—∫‡ªìπ´È” ·π–π”„Àâ«“ß·ºπ°“√√—°…“·¬°μ“¡

·μà≈– ∂“π°“√≥套ßπ’È

● °√≥’∑√“∫°àÕπºà“μ—¥«à“‡ªìπ phyllodes tumor

·π–π”„Àâ∑” wide excision ‚¥¬æ¬“¬“¡μ—¥„Àâ°«â“ßÕ¬à“ßπâÕ¬ 1 cm

‚¥¬√Õ∫°âÕπ ‚¥¬‡©æ–Õ¬à“߬‘ËߺŸâªÉ«¬°≈ÿà¡ borderline ·≈– malignant phyllodes

tumors ´÷Ëß¡’‚Õ°“ °≈—∫‡ªìπ´È” Ÿß°“√æ‘®“√≥“‡≈◊Õ°√–À«à“ß°“√∑” wide exci-

sion À√◊Õ mastectomy π—Èπ¢÷ÈπÕ¬Ÿà°—∫¢π“¥¢Õß°âÕπ‡∑’¬∫°—∫¢π“¥‡μâ“π¡¢Õß

ºŸâªÉ«¬°“√‡∫’¬¥∫—߇π◊ÈÕ‡μâ“π¡·≈–°“√≈ÿ°≈“¡ Ÿà‡π◊ÈÕ‡¬◊ËÕ¢â“߇§’¬ß °√≥’∑’Ë°âÕπ¡’

¢π“¥„À≠àÀ≈—ß∑” wide excision ·≈â«¡—°®–¡’‡μâ“π¡º‘¥√Ÿª ®÷ß®”‡ªìπμâÕߺà“μ—¥

μ°·μà߇ √‘¡‡μâ“π¡ (breast reconstruction) ¥â«¬„π§√“«‡¥’¬«°—π‡æ◊ËÕ§«“¡

 «¬ß“¡‚¥¬‡©æ“–°√≥’ Giant phyllodes tumor (phyllodes tumor ∑’Ë¡’¢π“¥

>10 cm æ∫‰¥â 20% ¢Õß phyllodes tumor ∑—ÈßÀ¡¥25 ºŸâªÉ«¬°≈ÿà¡π’È¡—°®–μâÕß

∑” mastectomy ‚¥¬®–‡≈◊Õ° total mastectomy À√◊Õ subcutaneous mastec-

tomy π—Èπ¢÷Èπ°—∫°“√≈ÿ°≈“¡¢Õß°âÕπ«à“®– “¡“√∂√—°…“º‘«Àπ—ßÀ√◊ÕÀ—«π¡‰«â

‰¥âÀ√◊Õ‰¡à

● °√≥’‰¡à∑√“∫°àÕπºà“μ—¥«à“‡ªìπ phyllodes tumors ·≈–‰¥â√—∫°“√ºà“μ—¥

excision ¡“·≈â«

ºŸâªÉ«¬∑’ˉ¥â√—∫°“√ºà“μ—¥°âÕπ‡π◊ÈÕ·∫∫ local excision ·≈⫺≈™‘Èπ‡π◊ÈÕ

ÕÕ°¡“‡ªìπ phyllodes tumor §«√æ‘®“√≥“·π«∑“ß°“√√—°…“®“°º≈™‘Èπ‡π◊ÈÕ∑’Ë

‰¥â¥—ßπ’È

1. °√≥’ benign phyllodes tumor

- ∂⓺≈™‘Èπ‡π◊ÈÕæ∫«à“‰¥â negative margin ·π–π”„Àâ‡ΩÑ“μ‘¥μ“¡

Õ“°“√ºŸâªÉ«¬‰¥â (wait and watch policy) ‰¡à®”‡ªìπμâÕߺà“μ—¥ È” ¡’√“¬ß“πæ∫

«à“‡¡◊ËÕμ‘¥μ“¡ºŸâªÉ«¬°≈ÿà¡π’ȉª 5 ªï®–æ∫°“√‡°‘¥‡ªìπ´È”ª√–¡“≥ 4% ·≈–¡’

Õ—μ√“°“√Õ¬Ÿà√Õ¥ 96%25

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 107

- ∂⓺≈™‘Èπ‡π◊ÈÕæ∫«à“‰¥â positive margin ¬—ß¡’¢âÕ∂°‡∂’¬ß°—π‡°’Ë¬«°—∫

·π«∑“ߪؑ∫—μ‘«à“§«√®–°≈—∫‰ªºà“μ—¥Õ’°§√—Èß∑—π∑’‡æ◊ËÕ‡Õ“°âÕπ‡π◊ÈÕÕÕ°„ÀâÀ¡¥

‡æ◊ËÕ≈¥°“√‡°‘¥‡ªìπ´È” À√◊Õ®–‡ΩÑ“μ‘¥μ“¡ºŸâªÉ«¬Õ¬à“ß„°≈♑¥∂â“æ∫«à“¡’°“√°≈—∫

‡ªìπ´È”§àÕ¬¡“ºà“μ—¥°≈ÿà¡»—≈¬·æ∑¬å∑’ˬա√—∫«à“°“√‡ΩÑ“μ‘¥μ“¡ºŸâªÉ«¬‡ªìπ∑“ß

‡≈◊Õ°Àπ÷Ëß∑’ˬա√—∫‰¥â‚¥¬Õâ“ßÕ‘ß°“√»÷°…“∑’Ëæ∫«à“¡’·§à 8% ¢ÕߺŸâªÉ«¬benign

phyllodes tumor ∑’Ë®–‡°‘¥‚√§ È”´÷ËßμË”°«à“ºŸâªÉ«¬°≈ÿà¡ borderline °—∫malignant

phyllodes tumor ∑’Ë¡’‚Õ°“ °≈—∫‡ªìπ´È” 20-23%31

2. °√≥’ borderline À√◊Õ malignant phyllodes tumor

·π–π”„Àâ∑”ºà“μ—¥Õ’°§√—È߇æ◊ËÕ„À≥â¢Õ∫‡¢μ∑’Ë°«â“ߢ÷Èπ (re-excision)

‡æ√“–ºŸâªÉ«¬°≈ÿà¡π’È¡’‚Õ°“ °≈—∫‡ªìπ´È” Ÿß

Breast reconstruction

°√≥’∑’˺ŸâªÉ«¬‰¥â√—∫°“√ºà“μ—¥ wide excision ‡μâ“π¡¡’‚Õ°“ º‘¥√Ÿª À√◊Õ

‰¥â√—∫°“√ºà“μ—¥ mastectomy »—≈¬·æ∑¬å “¡“√∂∑”ºà“μ—¥μ°·μà߇ √‘¡‡μâ“π¡

„À⺟âªÉ«¬‰¥â„π§√“«‡¥’¬«°—π (immediate breast reconstruction) ‡æ◊ËÕ§«“¡

 «¬ß“¡´÷Ëß¡’º≈μàÕ§ÿ≥¿“æ™’«‘μ¢ÕߺŸâªÉ«¬ ‚¥¬∑’Ë°“√ºà“μ—¥ breast reconstruc-

tion π’ȉ¡à¡’º≈‡ ’¬μàÕ°“√‡ΩÑ“μ‘¥μ“¡°“√°≈—∫‡ªìπ È”¢Õß‚√§ ¥—ßπ—Èπ®÷߉¡à¡’¢âÕ

Àâ“¡„π°“√ºà“μ—¥ immediate breast reconstruction À≈—ß mastectomy „πºŸâªÉ«¬

giant phyllodes tumor32

Axillary lymph node management

°“√ºà“μ—¥μàÕ¡πÈ”‡À≈◊Õß∑’Ë√—°·√â„πºŸâªÉ«¬ phyllodes tumor π—Èπ‰¡à·π–π”

„Àâ∑”∑ÿ°√“¬ ‰¡à«à“®–‡ªìπ sentinel lymph node biopsy À√◊Õ axillary lymph

node dissection ‡æ√“– malignant phyllodes tumor ¡—°·æ√à°√–®“¬∑“ß

À≈Õ¥‡≈◊Õ¥ (hematogenous spread) ·≈–¡’√“¬ß“πæ∫°“√°√–®“¬¡“μàÕ¡πÈ”

‡À≈◊Õß∑’Ë√—°·√âπâÕ¬¡“°§◊Õ < 1% ·π–π”„Àâºà“μ—¥‡≈“–μàÕ¡πÈ”‡À≈◊Õß∑’Ë√—°·√⇩擖

°√≥’∑’Ë°àÕπºà“μ—¥æ∫«à“¡’μàÕ¡πÈ”‡À≈◊Õß‚μ·≈–‰¥âæ‘ Ÿ®πå·≈â««à“¡’¡–‡√Áß°√–®“¬

¡“®√‘ß (histologically positive for malignant cells)33,34 °√≥’°àÕπºà“μ—¥æ∫

«à“¡’μàÕ¡πÈ”‡À≈◊Õß√—°·√â‚μ ∑—Èß®“° clinical À√◊Õ imaging ·π–π”„À⇮“–μ√«®

Fibroadenoma and Phyllodes Tumor108

‚¥¬„™â ultrasound guided core needle biopsy

Chest wall invasion25

°“√≈ÿ°≈“¡∂÷ß chest wall ¢Õß phyllodes tumor π—Èπæ∫‰¥â‰¡à∫àÕ¬ ‚¥¬

¡—°®–æ∫„π√“¬∑’Ë°âÕπ„À≠à¡“°Ê·≈–‡ªìπ™π‘¥ malignant phyllodes ‡¡◊ËÕ ß —¬

«à“¡’ chest wall invasion ®“°ª√–«—μ‘·≈–μ√«®√à“ß°“¬§«√ àßμ√«® CT chest

‡æ◊ËÕª√–‡¡‘π°“√≈ÿ°≈“¡¢Õß°âÕπ°àÕπ«“ß·ºπºà“μ—¥‡æ◊ËÕ„À≥â¢Õ∫‡¢μ∑’Ë°«â“ßæÕ

Õ“®μâÕßμ—¥°≈â“¡‡π◊ÈÕ pectoralis major ÕÕ°‰ª°—∫‡μâ“π¡·≈–∫“ß√“¬®”‡ªìπ

μâÕßμ—¥°√–¥Ÿ°´’Ë‚§√ßÕÕ°‰ª¥â«¬ ÷ËßμâÕß«“ß·ºπ°“√ àÕ¡ºπ—ßÀπâ“Õ°∑’Ë∂Ÿ°μ—¥

ÕÕ°‰ª (chest wall reconstruction) ‚¥¬¡’À≈“¬«‘∏’·≈â«·μà°√≥’‡™àπ „™â latissi-

·ºπ¿Ÿ¡‘∑’Ë 1 ¿“æ √ÿª surgical management  ”À√—∫ phyllodes tumor (NCCN 2014)

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 109

mus dorsi myocutaneous flap ·≈– marlex mesh ‡ªìπμâπ À≈—ߺà“μ—¥§«√

æ‘®“√≥“„Àâ√—ß ’√—°…“‡æ◊Ëՙ૬≈¥‚Õ°“ °“√°≈—∫‡ªìπ È” ‡æ√“–°“√ºà“μ—¥§√—Èß

μàÕ‰ª®–¡’§«“¡¬ÿà߬“°·≈–‡ ’ˬߡ“° À√◊ÕÕ“®®–‰¡à “¡“√∂ºà“μ—¥‰¥âÕ’°

°“√√—°…“‡ √‘¡À≈—ߺà“μ—¥ (Adjuvant treatment)

ª√–‚¬™πå·≈–∫∑∫“∑¢Õß√—ß ’√—°…“°—∫‡§¡’∫”∫—¥„π°“√√—°…“ phyllodes

tumor π—Èπ¬—߉¡à™—¥‡®π ¡’μ—«Õ¬à“ß·π«∑“ߪؑ∫—μ‘¥—ßπ’È

MD Anderson Cancer Center giudeline 2012

·π–𔇰’ˬ«°—∫°“√„Àâ√—ß ’√—°…“‡ √‘¡ ‚¥¬æ‘®“√≥“„À⇩擖malignant

phyllodes tumor ¥—ßπ’È

- ∂â“∑” mastectomy ·≈⫉¥â negative margins ‰¡à®”‡ªìπμâÕß„Àâ

√—ß ’√—°…“À≈—ߺà“μ—¥

- ∂â“∑” mastectomy ·≈⫉¥â positive/ close/ concerning mar-

gins À√◊Õ‡π◊ÈÕßÕ°¡’°“√≈ÿ°≈“¡∂÷ß fascia, chest wall À√◊Õ °âÕπ phyllodes tumor

¡’¢π“¥„À≠à > 5 cm

- ∂â“∑” partial mastectomy ·≈â«„Àâæ‘®“√≥“„Àâ√—ß ’√—°…“À≈—ߺà“μ—¥

Chaney ·≈–§≥–35 æ∫«à“°“√„Àâ√—ß ’√—°…“‡ √‘¡Õ“®¡’ª√–‚¬™πå„πºŸâªÉ«¬

¥—ßμàÕ‰ªπ’È

- Bulky mass - High mitotic rate

- Close or positive margins - Presence of necrosis

- Hypercellular stroma - Increased vascularity within the tumor

- High nuclear pleomorphism - Tumor recurrence

NCCN guideline 2014

·π–π”„Àâ√—ß ’√—°…“‡ √‘¡„π°√≥’∑’ˇ°‘¥ local recurrent ¢Õß phyllodes

tumor ´÷Ë߇¡◊ËÕºà“μ—¥·≈â«„πÕπ“§μ∂â“°“√°≈—∫‡ªìπ´È”Õ’°®–∑”„Àâ°“√ºà“μ—¥

∑”‰¥â¬“° ¡’ morbodity  Ÿß‡™àπ chest wall recurrence À≈—ß salvage mastec-

Fibroadenoma and Phyllodes Tumor110

tomy ®÷ß·π–π”„Àâ√—ß ’√—°…“À≈—ߺà“μ—¥‡æ◊ËÕÀ«—ß≈¥‚Õ°“ °“√°≈—∫‡ªìπ´È”„Àâ

‡°‘¥πâÕ¬∑’Ë ÿ¥

欓°√≥å‚√§

Local recurrence : ·¡â«à“®– “¡“√∂ºà“μ—¥°âÕπ phyllodes tumor ÕÕ°

¡“‰¥â∑—ÈßÀ¡¥°Á¡’√“¬ß“πæ∫ local recurrence ‰¥â¡“°∂÷ß 30%‚¥¬°≈ÿà¡ benign

phyllodes tumor ‡°‘¥ local recurrence ‰¥â 5-15%  à«π°≈ÿà¡ borderline °—∫

malignant phyllodes tumors æ∫local recurrence ‰¥â20-30%36

Distant metastases : ºŸâªÉ«¬ phyllodes tumors ∑—ÈßÀ¡¥æ∫¡’ 10% ∑’Ë

‡°‘¥°“√·æ√à°√–®“¬‰ª¬—ßÕ«—¬«–Õ◊Ëπ (distant metastases) „π∫“ß√“¬ß“πÕ“®

 Ÿß∂÷ß 22% ÷Ë߇ªìπºŸâªÉ«¬ borderline °—∫ malignant phyllodes tumors ‚¥¬

μ”·Àπàß∑’Ëæ∫¡’°“√°√–®“¬‰ª‰¥â∫àÕ¬§◊Õ lungs, soft tissue, bone ·≈– pleura37

ªí®®—¬∑’˙૬∑”π“¬‚Õ°“ °“√‡°‘¥ local recurrence ·≈– distant me-

tastases ¡’¥—ßμ“√“ß∑’Ë 218

ªí®®—¬ ”§—≠∑’Ë ÿ¥ ∑’Ë —¡æ—π∏å°—∫°“√‡°‘¥ local recurrence §◊Õ inadequate

μ“√“ß∑’Ë 2

Factors associated with local Factors associated with distant

recurrence metastases

- Positive resection margin or resection - Stromal overgrowthwithin 1 cm - Stromal cellularity

- Increased mitotic index - Stromal atypia- Tumor necrosis - Positive resection margin or resection margin- Large tumor size within 1cm

- Increased mitotic index- Tumor necrosis- Large tumor size

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 111

surgery ‚¥¬æ∫«à“°“√ºà“μ—¥°âÕπÕÕ°¡“‰¥â¢Õ∫‡¢μ‚¥¬√Õ∫πâÕ¬°«à“ 1 cm

‡ªìπªí®®—¬‡ ’ˬߠŸß∑’Ë ÿ¥∑’Ë®–‡°‘¥ local recurrence  à«πªí®®—¬‡ ’ˬß∑’Ë¡’º≈¡“°

∑’Ë ÿ¥μàÕ°“√‡°‘¥ distant metastases §◊Õ stromal overgrowth

Õ—μ√“°“√Õ¬Ÿà√Õ¥∑—ÈßÀ¡¥ (overall survival) ¢ÕߺŸâªÉ«¬ phyllodes tu-

mor ∑’Ë 15 ªï§◊Õ 62% ‚¥¬°≈ÿà¡ nonmalignant (benign ·≈– borderline) phyl-

lodes tumor ®–¡’Õ—μ√“°“√Õ¬Ÿà√Õ¥∑’Ë¥’°«à“§◊Õ 79% ∑’Ë 10 ªï „π¢≥–∑’Ë°≈ÿà¡ ma-

lignant phyllodes tumor ®–¡’Õ—μ√“°“√Õ¬Ÿà√Õ¥·¬à°«à“§◊Õ 42% ∑’Ë 10 ªï38 ∂â“¡’

distant metastases ·≈⫺ŸâªÉ«¬®–¡’欓°“√≥å‚√§·¬à¡“° ¡’√“¬ß“π«à“ºŸâ

ªÉ«¬°≈ÿà¡π’È®–¡’Õ—μ√“Õ¬Ÿà√Õ¥‡©≈’ˬ 30 ‡¥◊Õππ—∫®“°«—π∑’Ë«‘π‘®©—¬‰¥â«à“¡’°“√·æ√à

°√–®“¬39

°“√μ√«®μ‘¥μ“¡ºŸâªÉ«¬ phyllodes tumors À≈—ߺà“μ—¥

®”‡ªìπμâÕßπ—¥μ√«®μ‘¥μ“¡Õ“°“√ºŸâªÉ«¬À≈—ߺà“μ—¥Õ¬à“ß„°≈♑¥‡æ√“–

phyllodes tumor ¡’‚Õ°“ ‡°‘¥‡ªìπ´È”‡©æ“–∑’ˉ¥â  “¡“√∂·æ√à°√–®“¬‰ª

Õ«—¬«–Õ◊Ëπ‰¥â‚¥¬‡©æ“–Õ¬à“߬‘Ëß°≈ÿà¡ malignant phyllodes

·π«∑“ߪؑ∫—μ‘„π°“√μ√«®μ‘¥μ“¡ºŸâªÉ«¬¡’¥—ßπ’È

- π—¥μ√«®μ‘¥μ“¡Õ“°“√∑ÿ° 6 ‡¥◊Õπ„π™à«ß 2 ªï·√°À≈—ߺà“μ—¥

‡æ√“–‚Õ°“ °≈—∫‡ªìπ´È”®–‡°‘¥ Ÿß ÿ¥„π™à«ß 2 ªï·√°

- À≈—ß®“° 2 ªï‰ª·≈â«„Àâπ—¥μ√«®∑ÿ° 1ªï

- ·π–π”„À⺟âªÉ«¬μ√«®§≈”‡μâ“π¡¥â«¬μπ‡Õß ¡Ë”‡ ¡Õ ∂ⓧ≈”æ∫

 ‘Ëߺ‘¥ª°μ‘„Àâ¡“ª√÷°…“·æ∑¬å

·π«∑“ß°“√√—°…“ recurrent phyllodes tumor

‡¡◊ËÕμ√«®æ∫§«“¡º‘¥ª°μ‘ ß —¬«à“‡°‘¥°“√°≈—∫‡ªìπ´È”¢Õß phyllodes

tumor §«√ àßμ√«®‡æ‘Ë¡‡μ‘¡§◊Õ breastultrasound, mammogram ·≈–‡®“–

μ√«®™‘Èπ‡π◊ÈÕ∑’Ë ”§—≠μâÕßÀ“«à“¡’°“√·æ√à°√–®“¬‡°‘¥¢÷Èπ·≈â«À√◊Õ‰¡à‡æ√“–¡’º≈

μàÕ欓°√≥å‚√§·≈–·ºπ°“√√—°…“μàÕ‰ª

Fibroadenoma and Phyllodes Tumor112

 √ÿª

Phyllodes tumor ‡ªìπ‚√§¢Õ߇μâ“π¡∑’Ëæ∫‰¥â‰¡à∫àÕ¬·μ৫√§‘¥∂÷ß‚√§π’È

¥â«¬‡ ¡Õ„πºŸâªÉ«¬∑’Ë¡“¥â«¬°âÕπ∫√‘‡«≥‡μâ“π¡‚¥¬‡©æ“–°âÕπ¢Õ∫‡¢μ™—¥‡®π∑’Ë

‚μ‡√Á« „πºŸâªÉ«¬™à«ßÕ“¬ÿ 35-55 ªï ´÷ËßÕ“¬ÿ¡“°°«à“°≈ÿà¡ fibroadenoma

 ‘Ëß ”§—≠§◊Õ°“√«‘π‘®©—¬„À≥â°àÕπºà“μ—¥«à“‡ªìπ phyllodes tumor À√◊Õ

fibroadenoma ‡æ◊ËÕ«“ß·ºπ°“√ºà“μ—¥∑’ˇÀ¡“– ¡ ‚¥¬·π–π”„À⇮“–™‘Èπ‡π◊ÈÕ‚¥¬«‘∏’

CNB ‡¡◊ËÕº≈‡ªìπ phyllodes tumor ·π–π”„Àâ∑” wide excision ®–™à«¬≈¥

‚Õ°“ °“√°≈—∫‡ªìπ´È”°“√√—°…“‡ √‘¡Õ◊ËπÊ ‡™àπ √—ß ’√—°…“ À√◊Õ‡§¡’∫”∫—¥π—Èπ

ªí®®ÿ∫—π∫∑∫“∑¬—߉¡à™—¥‡®π‚¥¬∑—Ë«‰ª·π–π”„Àâ √—ß ’√—°…“À≈—ߺà“μ—¥°√≥’∑’Ë∂â“

¡’°“√‡°‘¥‡ªìπ´È”·≈â«®–‰¡à “¡“√∂ºà“μ—¥ÕÕ°‰¥âÀ√◊Õ°“√ºà“μ—¥®–¡’§«“¡‡ ’ˬß

 Ÿß‡™àπ chest wall invasion  à«π‡§¡’∫”∫—¥¡—°„Àâ„π°√≥’∑’ˇªìπ palliative treat-

ment  ”À√—∫ºŸâªÉ«¬∑’Ë¡’°“√·æ√à°√–®“¬·≈â«

·ºπ¿Ÿ¡‘∑’Ë 2 ·π«∑“ß°“√ªØ‘∫—쑇¡◊ËÕæ∫ local recurrence ¢Õß phyllodes tumor (NCCN2014)

Õ“®“√¬å·æ∑¬åÀ≠‘ß «‘‰≈√—μπå ª√–‡ √‘∞ 113

¢Õ¢Õ∫§ÿ≥ ¿“æ∂à“¬æ¬“∏‘ ¿“æ fibroadenoma ·≈– phyllodes tumor

®“°

Õ“®“√¬å·æ∑¬åÀ≠‘ß«—π«‘ “¢å À‘¡–§ÿ≥ Õ“®“√¬åª√–®”¿“§«‘™“欓∏‘«‘∑¬“

§≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

‡Õ° “√Õâ“ßÕ‘ß

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