we report an unusual case of a massive malignant phyllodes tumour that had almost replaced the entire breast presenting with severe chronic blood loss , extensive deep venous thrombosis ( dvt ) and a silent pulmonary embolus . this patient presented with a long - standing neglected phyllodes tumour that had grown to a massive fungating ulcerative mass larger than her left haemothorax . a previously healthy woman in her 40s presented to the emergency department with a massive exophytic left breast tumour ( fig . however , an incidental right lower lobe pulmonary embolus and extensive thrombus were seen within the right common femoral vein extending to the iliac vein . due to the ooze from the fungating breast tumour she was unable ultrasound ( ge logic e9 system , ge healthcare , uk ) was performed as mammogram was not possible due to the size and nature of the tumour . the internal architecture exhibited a macro - foliated echo - pattern intermixed with disorganised echogenic curvilinear foci on a heterogenous hypoechoic background . the deep margin was not assessable due to marked beam attenuation and depth of lesion . coronal ct image showed a massive left breast mass with superficial chest wall muscle invasion but no bony involvement . parasitic vascular supply was predominately via large vessels arising from the left axillary and left internal thoracic arteries ( fig . 2c ) . mri was performed to further aid characterisation , delineate the deep margin and assess chest wall involvement . multiplanar pre and post contrast acquisitions ( siemens magnetom aera 1.5 t magnet , siemens healthcare , malvern , pa ) , showed the mass had replaced the entire breast , with a maximal cranio - caudal length of 300  mm ( fig . the mass showed a massively exophytic growth pattern in an antero- lateral direction with a crenellated macro - foliated bright t2 ( fig . fat suppressed t1 study , the tumour exhibited encapsulated hypointensity posteriorly with a peripheral frill of hyperintense crenellated flanges extending anteriorly . superficially the tumour exhibited a disorganised lobulated contour , at the deep margin there was superficial chest wall muscle invasion and parasitic vascular supply was noted . 2c ) of the chest , abdomen and pelvis , as well as pre and post - contrast cranial ct ( 64 slice ge lightspeed vct , ge healthcare , little chalfont , uk ) did not reveal any distant metastatic focus . however , it did detect an incidental right pulmonary embolism and extensive right deep vein thrombosis . macroscopic examination revealed the tumour to involve the majority of the breast tissue measuring 395  mm in maximal extent including a large exophytic ulcerated component . the nipple was preserved in the skin inferior to the tumour . on the cut surface , the tumour had an intracanalicular growth pattern with cleft - like spaces and the epithelial component did not show atypia . focal areas of hypercellular stroma with moderate nuclear atypia and up to 12 mitoses per 10 high power fields were identified amounting to a malignant phyllodes tumour . in addition , a 10  mm focus of sarcomatous change with pleomorphic bizarre spindled cells and frequent mitoses was identified . ultrasound ( ge logic e9 system , ge healthcare , uk ) was performed as mammogram was not possible due to the size and nature of the tumour . the internal architecture exhibited a macro - foliated echo - pattern intermixed with disorganised echogenic curvilinear foci on a heterogenous hypoechoic background . the deep margin was not assessable due to marked beam attenuation and depth of lesion . coronal ct image showed a massive left breast mass with superficial chest wall muscle invasion but no bony involvement . parasitic vascular supply was predominately via large vessels arising from the left axillary and left internal thoracic arteries ( fig . 2c ) . mri was performed to further aid characterisation , delineate the deep margin and assess chest wall involvement . multiplanar pre and post contrast acquisitions ( siemens magnetom aera 1.5 t magnet , siemens healthcare , malvern , pa ) , showed the mass had replaced the entire breast , with a maximal cranio - caudal length of 300  mm ( fig . the mass showed a massively exophytic growth pattern in an antero- lateral direction with a crenellated macro - foliated bright t2 ( fig . fat suppressed t1 study , the tumour exhibited encapsulated hypointensity posteriorly with a peripheral frill of hyperintense crenellated flanges extending anteriorly . superficially the tumour exhibited a disorganised lobulated contour , at the deep margin there was superficial chest wall muscle invasion and parasitic vascular supply was noted . 2c ) of the chest , abdomen and pelvis , as well as pre and post - contrast cranial ct ( 64 slice ge lightspeed vct , ge healthcare , little chalfont , uk ) did not reveal any distant metastatic focus . however , it did detect an incidental right pulmonary embolism and extensive right deep vein thrombosis . macroscopic examination revealed the tumour to involve the majority of the breast tissue measuring 395  mm in maximal extent including a large exophytic ulcerated component . the nipple was preserved in the skin inferior to the tumour . on the cut surface , the tumour had an intracanalicular growth pattern with cleft - like spaces and the epithelial component did not show atypia . focal areas of hypercellular stroma with moderate nuclear atypia and up to 12 mitoses per 10 high power fields were identified amounting to a malignant phyllodes tumour . in addition , a 10  mm focus of sarcomatous change with pleomorphic bizarre spindled cells and frequent mitoses was identified . the patient was given 3 units blood transfusion and had an ivc filter inserted prior to breast surgery . left total mastectomy follow - up , the wound was granulating well with no skin grafting required for closure . however , subsequent surveillance imaging and biopsy of her contralateral breast showed widespread ductal carcinoma in - situ for which she still refuses surgery . phyllodes tumours are rare fibroepithelial breast lesions that have the propensity to grow rapidly to a large size if neglected . they are classified histologically as benign , borderline or malignant with larger lesions more likely to be malignant , this is suggested by a single institution study of 65 cases which found that the mean volume of tumour was higher in the malignant group . the world health organisation reports an overall metastatic rate of 10% with most arising from the malignant category . staging investigations in our patient detected an incidental pulmonary embolus arising from lower limb deep vein thrombosis . due to the large oozing ulcerative surface of the tumour , she went on to have an ivc filter preoperatively and subsequent postoperative anticoagulation . while the incidence of venous thromboembolism in breast cancer patients is reported to be 1.2% , the incidence in patients with malignant phyllodes is unknown . it may be prudent to consider the diagnosis and if necessary exclude this in patients with massive phyllodes tumours that undergo preoperative staging given their higher chance of malignancy . a recurrence rate of 1520% is reported for tumours with margins of < 1  cm . however , in the absence of an adequate surgical margin , localised radiotherapy may be considered . a recent prospective study reported no local recurrence at a mean 56 month follow - up in 46 patients treated with this strategy . all authors declare that they have no financial and personal relationships with any other people or organisations that could inappropriately influence ( bias ) this work including by employment , consultancies , stock ownership , honoraria , paid expert testimony , patent applications / registrations , and grants or other funding . approval has been obtained from hrec scgh ( ethics committee ) . reference  =  qia # 4133 . this manuscript has six contributing authors who have all contributed to the case report , literature search and write up of the case . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . i , anita geraldine bourke , the corresponding author , has the right to assign on behalf of all authors and does assign on behalf of all authors , a full assignment of all intellectual property rights for all content within the submitted case report in any media known now or created in the future , and permits this case report ( if accepted ) to be published in the international journal of surgery case reports .
highlightsmassive phyllodes tumour has a higher chance of being malignant.staging imaging is undertaken to confirm and define local chest wall invasion.an associated silent dvt / pulmonary embolism should be considered.pre-operative diagnosis of dvt / pulmonary embolism changes peri - operative planning.peri-operative morbidity / mortality is reduced by recognising dvt / pulmonary embolism .