Benign phyllodes tumours of the breast: (Over) treatment of margins – A literature review

Primary malignant phyllodes tumors of the breast: A retrospective analysis from a referral center

BACKGROUND

The treatment for primary malignant phyllodes tumors of the breast (B-MPT) consists of wide local excision with negative margins (≥1 cm). However, because of their rarity, prognostic factors, type of surgery and adjuvant treatments are still a matter of debate.

METHODS

We conducted a single-center retrospective study to describe outcomes and prognostic factors of patients with primary B-MPT, who underwent breast surgery from January 2000 to December 2021. The primary endpoint was the cumulative incidence of any recurrence. Secondary endpoints were the cumulative incidences of distant and local recurrences.

RESULTS

131 patients were included, of whom all received surgery, 5 adjuvant anthracycline-based chemotherapy and 15 radiation therapy. After a median follow-up of 6.4 years, the cumulative incidences at 5-years of any, local and distant recurrences were of 26% (95% Confidence Interval [CI], 4-34%), 16% (95%CI, 10-24%) and 10% (95%CI, 5.3-16%), respectively. Tumor size ≥ 5 cm was associated with higher distant recurrences (p = 0.05); instead, among small tumors (<5 cm), distant recurrences were higher in those with heterologous differentiation and/or multifocal disease (p = 0.06). Type of breast surgery (mastectomy vs. lumpectomy/excision) was not found to be significantly associated with distant (p = 0.32) or local (p = 0.17) recurrence, even after controlling local recurrence incidence for negative pathologic prognostic factors (p = 0.17).

CONCLUSIONS

The natural history of B-MPT is burdened by local and distant recurrences. Pathologic prognostic factors (i.e., tumor size, heterologous differentiation and multifocal disease) more than the type of wide breast surgery (mastectomy vs. lumpectomy) seem to represent the most significant prognostic factor for recurrences.

Multidisciplinary Management of Phyllodes Tumours and Breast Sarcoma: A Cross-sectional Survey of Clinical Practice across the UK and Ireland

AIMS

Phyllodes tumours and breast sarcomas are uncommon tumours and their rarity poses significant challenges in diagnosis and management. This cross-sectional study was conducted to evaluate the multidisciplinary clinical practice for these tumours across the UK and Ireland, with the aim of identifying gaps in knowledge and providing direction for establishing national guidelines.

MATERIALS AND METHODS

An international survey was adapted and circulated to breast and/or sarcoma surgeons and oncologists in the UK and Ireland through national organisations. Multidisciplinary team (MDT) responses were analysed anonymously.

RESULTS

Twenty-eight MDTs participated in this study, predominately from high-volume units (85.5%). Although only 43% of the surveyed units were part of a trust that holds a sarcoma MDT, 68% of units managed malignant phyllodes and angiosarcoma, whereas 64.5% managed soft-tissue sarcoma of the breast. Across all subtypes, axillary surgery was recommended by 14-21% of the MDTs and the most recommended resection margins for breast surgery were 'no tumour on ink' in benign phyllodes (39%) and 10 mm in the remaining subtypes (25-29%). Immediate breast reconstruction was supported by 11-18% of MDTs for breast sarcoma subtypes, whereas 36% and 32% advocated this approach in benign and borderline phyllodes tumours, respectively. Adjuvant radiotherapy and chemotherapy were recommended by up to 29% and 11% of the MDTs, respectively.

CONCLUSION

The results of this study demonstrate a wide variation in clinical practice across the surveyed MDTs. As only 28 MDTs participated in our study, with under-representation from low-volume units, our results might be an underestimation of the variability in practice across the UK and Ireland. This multi-institutional study sheds light on controversial aspects in the management of phyllodes tumours and breast sarcoma, identifies the need for national guidelines to inform best practice, and calls for the centralisation of the management of breast sarcoma within specialist centres.

Management of Benign Phyllodes Tumors: A Dutch Population-Based Retrospective Cohort Between 1989 and 2022

BACKGROUND

Phyllodes tumors (PTs) are rare tumors of the breast. The current National Comprehensive Cancer Network (NCCN) guidelines recommend excision of benign PTs, accepting close or positive margins. Controversy about the optimal treatment for benign PTs remains, especially regarding the preferred margin width after surgical excision and the need for follow-up evaluation.

METHODS

A nationwide retrospective study analyzed the Dutch population from 1989 to 2022. All patients with a diagnosis of benign PT were identified through a search in the Dutch nationwide pathology databank (Palga). Information on age, year of diagnosis, size of the primary tumor, surgical treatment, surgical margin status, and local recurrence was collected.

RESULTS

The study enrolled 1908 patients with benign PT. The median age at diagnosis was 43 years (interquartile range [IQR], 34-52 years), and the median tumor size was 30 mm (IQR, 19-40 mm). Most of the patients (95%) were treated with breast-conserving surgery (BCS). The overall local recurrence rate was 6.2%, and the median time to local recurrence was 31 months (IQR, 15-61 months). Local recurrence was associated with bilaterality of the tumor (odds ratio [OR], 4.91; 95% confidence interval [CI], 2.95-28.30) and positive margin status (OR, 2.51; 95% CI 1.36-4.63). The local recurrence rate was 8.9% for the patients with positive excision margins and 4.0% for the patients with negative excision margins. Notably, for 27 patients (22.6%) who experienced a local recurrence, histologic upgrading of the recurrent tumor was reported, 7 (5.9%) of whom had recurrence as malignant lesions.

CONCLUSIONS

This nationwide series of 1908 patients showed a low local recurrence rate of 6.2% for benign PT, with higher recurrence rates following positive margins.

Phyllodes Tumor of the Breast Complicated With Mastitis

One of the rarest fibro-epithelial neoplasms of the breast during pregnancy is the phyllodes tumor (PT). It is typically a painless, bi-phasic, and rapidly growing neoplasm that resembles fibroadenomas. It is still unclear if the neoplasm is hormone-dependent during pregnancy. It is often challenging to diagnose and treat PT. Herein, we report a case of a 30-year-old female at 31 weeks gestation who was diagnosed with a benign phyllodes tumor of her breast with concurrent mastitis. She was first seen during her third trimester where the neoplasm was around 5 cm as reported by the ultrasound (US) examination. Her biopsy report was suggestive of a PT and she was advised surgery with excision of the tumor margin, but she refused. Ten days after her delivery she presented to the emergency department with a fever and a hard, engorged, erythematous, and tender left breast. She was diagnosed with mastitis of the left breast. She then underwent incision and drainage of the left breast that drained purulent milk; additionally, large necrotic grape-like tissues were removed and were confirmed by the histopathology report as a benign phyllodes tumor of the breast.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.

Clinico-Pathological Factors Determining Recurrence of Phyllodes Tumors of the Breast: The 25-Year Experience at a Tertiary Cancer Centre

BACKGROUND

Phyllodes tumors (PTs) of the breast are rare fibroepithelial tumors that are generally more prone to recurrence.

AIMS AND OBJECTIVES

This study aimed to assess the clinicopathological features, diagnostic modalities, and therapeutic interventions, along with their respective outcomes, to identify the factors associated with a recurrence of PTs of the breast.

METHODOLOGY

A retrospective cohort and observational study was conducted, which entailed analyzing the clinicopathological data of patients who were previously diagnosed or presented with PTs of the breast between 1996 and 2021. Data included the total number of patients diagnosed with PTs of the breast and their ages, tumor grade on initial biopsy, tumor location (left or right breast), tumor size, therapeutic interventions carried out (including surgery-either mastectomy or lumpectomy-and adjuvant radiotherapy), final tumor grade, recurrence status, type of recurrence, and time to recurrence.

RESULTS

We analyzed data on a total of 87 patients who were pathologically proven to have PTs, and 46 patients (52.87%) were found to have recurrences. All patients were female, with a mean age at diagnosis of 39 years (range 15-70). Patients aged <40 years had the highest incidence of recurrence, with a rate of 54.35% (n = 25/46), followed by patients aged >40 years, with a rate of recurrence of 45.65% (n = 21/46). A total of 55.4% of patients presented with primary PTs and 44.6% had recurrent PTs at presentation. The average time to local recurrence (LR) from the completion of treatment was 13.8 months, whereas for systemic recurrence (SR), it was 15.29 months. Surgery (mastectomy/lumpectomy) was the major determinant for local recurrence (p < 0.05).

CONCLUSION

Patients who received adjuvant radiotherapy (RT) had a minimal recurrence of PTs. Patients who were found to have a malignant biopsy on initial diagnosis (triple assessment) had a higher incidence of PTs and were more prone to SR than LR. Surgery was a determining factor in the increased rate of LR, with lumpectomy associated with a higher incidence of LR than mastectomy.

Recurrence is Not Associated with Margin Status in Phyllodes Tumor

BACKGROUND

Phyllodes tumor (PT) is a rare fibroepithelial neoplasm of the breast. The proper extent of resection is still under debate. This study aimed to investigate the optimal surgical margin to prevent recurrence after surgery for PT and to evaluate risk factors for local recurrence (LR).

METHODS

Retrospective analysis of a prospective cohort database was performed. Patients who underwent curative surgery for PT at Seoul National University Bundang Hospital between July 2003 and February 2022 were reviewed.

RESULTS

Of the 439 patients included, 285 were benign, 129 were borderline, and 25 were malignant. There was no statistically significant difference in 5-year disease-free survival (DFS) between margin-negative and margin-involved patients (87.3% vs. 85.1%, p = 0.081). When patients were classified into groups, according to margin status, as conventional (≥ 1 cm from tumor), close (< 1 cm from tumor), or involved, 5-year DFS rates were also similar (100% vs. 86.9% vs. 85.1%, p = 0.170). In subgroup analysis for different histologic grades, 5-year DFS was not affected by margin involvement. In univariate analysis, large tumor size (> 5 cm; hazard ratio [HR] 2.857, p = 0.028) and infiltrative tumor border (HR 3.096, p = 0.012) were independent risk factors for LR. Further multivariate analysis found both factors to be prognostic.

CONCLUSIONS

Recurrence was not significantly influenced by margin status in all histological grades. In benign and borderline tumors, local excision without wide surgical margins could be sufficient, and watchful waiting could be an option for patients with positive margins after initial surgery.

Margin Status and Local Recurrence in Phyllodes Tumours of the Breast: A Canadian Series

BACKGROUND

Phyllodes tumours of the breast are rare fibroepithelial neoplasms with a propensity for recurrence. While surgical excision remains the standard of care, the optimal margin width is an area of active investigation. Recent studies have questioned the necessity for wide, local excision.

METHODS

We conducted a retrospective, cohort study of patients with phyllodes tumours treated at our institution between 2003 and 2021. Demographic, histopathological, and recurrence data were captured; malignant phyllodes were excluded. Cox proportional hazard models were used to identify covariates associated with local recurrence.

RESULTS

Of 187 patients with phyllodes tumours, 82.9% (n = 155) were classified as benign while 17.1% (n = 32) were borderline. Initial surgical margins were positive in 26.2% (n = 49), < 2 mm in 50.8% (n = 95), and ≥ 2 mm in 23% (n = 43) patients. Among patients with positive margins, 61.2% (n = 30) underwent margin revision. At a median follow-up of 2.9 years, the recurrence rate was 3.7%. On univariate analysis, only a positive margin at the time of initial surgery and not margin width was significantly associated with a higher rate of disease recurrence (hazard ratio [HR] 9.52, 95% confidence interval [CI] 1.85-49.2), as was a size greater than 4 cm on preoperative imaging (HR 10.78, 95% CI 0.97-120.1). Revision of an initially positive margin was not significantly associated with decreased local recurrence (p = 1).

CONCLUSIONS

In this large cohort of benign and borderline phyllodes tumours, positive resection margins and not margin width at the initial surgery were associated with a increased recurrence. Individualization of decisions regarding margin reexcision is important.

Fibroepithelial Lesions of the Breast: Update on Molecular Profile With Focus on Pediatric Population

CONTEXT.—

This review article derives from the breast pathology lecture at the Eighth Princeton Integrated Pathology Symposium (PIPS VIII).

OBJECTIVE.—

To provide a literature review and update on fibroepithelial lesions of the breast with molecular findings and findings regarding the pediatric population.

DATA SOURCES.—

The sources include extensive literature review, personal research, and experience.

CONCLUSIONS.—

Given significant differences in prognosis and management of fibroepithelial lesions, we aim to provide readers with pertinent definitions, pathomorphology, molecular findings, and management for each diagnosis, with insights on the pediatric population.

Incidence and Outcome of Breast Sarcomas in England (2013-2018): An analysis from the National Cancer Registration and Analysis Service

BACKGROUND

Breast sarcomas (BS) are rare cancers originating from mesenchymal breast tissue with a paucity of national population level data detailing their incidence and outcomes.

METHODS

We performed an analysis of data collected by National Cancer Registration and Analysis Service (NCRAS) for patients diagnosed with BS between 2013 and 2018. Chi-square test was used to compare groups. Overall survival (OS) was calculated by Kaplan-Meier. Specialist sarcoma centres (SSC) were defined as centres with a sarcoma multidisciplinary team (MDT).

RESULTS

There were 684 patients with BS (357 malignant phyllodes tumours [PTs], 238 vascular tumours, 93 other morphology) with a median age of 64 (range 14-96); 187 (27%) had received breast radiotherapy for a prior malignancy; 633 (92%) had resection of the tumour within 12 months of diagnosis. Five-year OS was 82%, 54% and 48% in patients with PT, vascular tumours and other sarcomas, respectively, and 55% for those with radiation-induced BS. Patients managed within SSC more frequently had a biopsy prior to surgery 83% versus 72%, p < 0.05) and were less likely to require multiple operations (26% versus 41%, p < 0.05). Tumour stage and grade data were not available.

CONCLUSION

This is the first population series evaluating incidence and outcomes for BS. Patients treated at non-specialist sarcoma centres (NSSCs) are less likely to have a biopsy prior to surgery and more likely to require multiple operations. Based on these observational data, we would recommend all BS are discussed at a sarcoma MDT meeting early in their pathway and surgery to be considered at SSC where possible.

Morphological features of 52 cases of breast phyllodes tumours with local recurrence

Typical phyllodes tumours (PTs) of the breast are fibroepithelial neoplasms characterised histologically by stromal hypercellularity and leaf-like structures. However, morphological changes may be atypical in some cases, increasing the difficulty of diagnosis and the likelihood of misdiagnosis. To provide more morphological clues for pathological diagnosis of PTs, we retrospectively analysed 52 PT cases with typical morphological features after recurrence, and summarized the clinicopathological characteristics of the paired primary tumours. We found five special histological features in the primary tumours distinct from classic PTs, namely (1) PTs with epithelioid feature (three cases); (2) PTs with gland-rich feature (eight cases); (3) PTs with fibroadenoma-like feature (20 cases); (4) PTs with myxoid fibroadenoma-like feature (five cases); and (5) PTs with pseudohemangiomatoid stromal hyperplasia–like feature (four cases). All the features can exist independently, and a few cases displayed more than two distinctive features at the same time. In this cohort of recurrent PTs, all the primary tumours were absent of recognisable stromal hypercellularity and leaf-like structures that are the critical diagnostic criteria of PTs; however, they showed some other non-classic characteristics which may provide significant clues for the diagnosis of PTs. Particularly, tumours with epithelioid feature displayed high grade at earlier stages, tumours with fibroadenoma-like feature were most likely to be confused with classical fibroadenomas, and tumours with myxoid feature were prone to be neglected because of their hypocellularity.

Surgical management and prognosis of phyllodes tumors of the breast

BACKGROUND

Regardless of histological grade, phyllodes tumors (PTs) exhibit the potential of local recurrence. The National Comprehensive Cancer Network (NCCN) recommends wide local excision (WLE) with a 1 cm margin or more for borderline/malignant PTs but excisional biopsy for benign PTs. However, the treatment of benign PTs remains controversial and the clinicopathologic risk factors for the local recurrence is still unclear.

METHODS

We retrospectively analyzed 238 patients with PTs who underwent surgery at the Chinese PLA General Hospital from January 1, 2006 and April 30, 2020. We stratified our analysis according to histologic grade and explored the clinicopathologic factors to influence local recurrence (LR), including age, histologic grade, history of fibroadenoma, type of surgery [vacuum-assisted biopsy system (VABS), local excision (LE), wide local excision (WLE) and mastectomy].

RESULTS

All 238 cases were categorized as benign (171, 71.8%), borderline (38, 16.0%), or malignant (29, 12.2%). The median follow-up was 50.2 months. In multivariate analysis, histologic grade (P<0.01) and history of fibroadenoma (P<0.01) were independent prognostic factors for LR. No difference existed in the recurrence rate of BPT treated with different surgical procedures (P=0.397), whereas a higher recurrence rate was found in VABS and LE subgroups than in WLE and mastectomy subgroups for borderline/malignant tumors (P<0.01).

CONCLUSIONS

No association found between surgical modalities and LR rate for BPT. We suggested a "wait-and-watch" policy for patients with unexpected benign subtypes, instead of unnecessary re-excision. In addition, VABS or LE can be treated for BPT with small mass, whereas WLE or even mastectomy should be conducted for borderline/malignant PTs with large mass.

Factors effective on recurrence and metastasis in phyllodes tumors

Background and Aim

Phyllodes tumors (PT) are rare biphasic breast tumors containing stromal mesenchyme and epithelial components. It was classified as benign, borderline, and malignant by the World Health Organization (WHO). Although there is no certainty about the size of the desired margin in the surgery to be applied, a tumor-free area of 1 cm is often targeted. Our study aimed to determine the subtype rates in patients with PT and evaluate the surgical margin, recurrence, and survival times obtained after the surgery.

Patients and Methods

This study was conducted at Seyhan Goverment Hospital and involved the PT patients treated between January 2010 and June 2020. We analyzed PT patients retrospectively. Sixty-one patients with PT were analyzed. In the patient, demographic characteristics, body mass index (BMI), surgical procedures, tumor type, size, mitosis rate, and distance of tumor to surgical margin were evaluated. During follow-up, reoperation, recurrence, metastasis, survival times, and mortality rates were evaluated.

Results

Sixty-one phyllodes breast tumor patients whose histopathology was reported as malignant, borderline, and benign were evaluated and presented in our study. The mean age was 37.84 (15-100), and the BMI was 25.78 (±5.35) mm. Of the 61 patients, 41 (67.2%) were diagnosed with benign phyllodes tumor (BPT), 10 (16.4%) as borderline phyllodes tumor (BLPT), and 10 (16.4%) as malignant phyllodes tumor (MPT).

Conclusions

Preoperative diagnosis of PT can reduce the rate of secondary surgical procedures and the loss of extra breast tissue. A large diameter needle and sufficient number of tissue samples for preoperative core biopsy may increase the rate of accurate diagnosis.

Surgical management in phyllodes tumors of the breast: a systematic review and meta-analysis

BACKGROUND

Information is still controversial in the studies regarding the current optimal surgical management of phyllodes tumors (PTs) of the breast. Local recurrence (LR) may occur with an upgraded in the pathological grade, influencing the prognosis of patients with PT. This systematic review and meta-analysis aimed to investigate the association of LR risk with margin status and margin width which could have significant implications on the surgical management of PT.

METHODS

Independent and comprehensive searches were performed by two authors through five databases including PubMed, Medline, Embase, ScienceDirect and Cochrane Library from January 1990 to October 2021. Studies investigating the association between margin width, margin status and LR rates were considered for inclusion. Study quality was evaluated using the Newcastle-Ottawa Scale (NOS). Meta-analysis was performed using RevMan5.3 software, and statistical heterogeneity was assessed using the Chi-square test and quantified using the I2 statistic. Visual inspection of funnel plots was used to judge publication bias.

RESULTS

A total of 34 articles were included in this article, all of which with NOS scores above 5. Regardless of the PT grade, positive margin significantly increased the risk of LR [odds ratio (OR) 3.64, 95% confidence interval (CI): 2.60-5.12]. No significant difference was found in the risk of LR between the margins <1 and ≥1 cm (OR 1.39, 95% CI: 0.67-2.92). For benign and borderline PTs, there were no significant differences of the LR risk between breast-conserving surgery (BCS) and mastectomy (benign OR 0.68, 95% CI: 0.12-3.78; borderline OR 1.14, 95% CI: 0.29-4.51). While the LR risk was significantly increased by BCS for malignant PT (OR 2.77, 95% CI: 1.33-5.74).

DISCUSSION

Different surgical management strategies should be considered for different PT grades. BCS was a feasible option and margins <1 cm was not significantly associated with LR risk for all grade of PT. After BCS, benign PT with positive margin could adopt the "wait and watch" strategy with regular follow-up, while borderline and malignant PTs were expected to underwent re-excision to ensure negative margins. More studies are still needed to clarify and update the existing conclusions and improve the prognosis of PT patients.

Diagnosis and management of phyllodes tumours for the surgeon: An algorithm

A Phyllodes Tumour (PT) is an uncommon fibroepithelial lesion, with three histological grades - benign, borderline and malignant. PTs cause significant challenges in diagnosis, management and prognostication. Recent publications have clarified the definitions and prognostication of PTs. Contemporary data currently challenge international guidelines on PT management. We performed an in-depth literature review to develop a best-practice management algorithm for PTs. Diagnostic recommendations are that neither current imaging techniques, nor fine-needle biopsies, can reliably diagnose a PT. Core needle biopsy is the optimal diagnostic technique. Indeterminate or suspicious lesions are recommended to undergo an excisional biopsy due to the inherently heterogeneous nature of PTs. Management guidelines are that benign PTs should be completely excised, although an involved margin is acceptable in select situations. Borderline PTs should have a clear margin on excision due to their higher risk of recurrence, as well as the potential for a recurrence to progress to a malignant PT. In malignant PTs, a margin of 3 mm is acceptable as there is no reduction in recurrence risk if margins are >3 mm. Routine axillary surgery is not indicated in PTs, with axillary surgery only indicated in a histologically-confirmed positive axilla. Adjuvant treatment recommendations are that borderline and malignant PTs should be discussed at MDT, with radiotherapy considered in both. Chemotherapy should be discussed in malignant PT patients. In summary, we have developed an up-to-date simple algorithm to guide the surgeon's management of patients diagnosed with PTs and reduce excessive surgery.

An integrative ultrasound-pathology approach to improve preoperative phyllodes tumor classification: A pilot study

OBJECTIVE

Preoperative diagnosis of phyllodes tumor (PT) is challenging, core-needle biopsy (CNB) has a significant rate of understaging, resulting in suboptimal surgical planification. We hypothesized that the association of imaging data to CNB would improve preoperative diagnostic accuracy compared to biopsy alone.

METHODS

In this retrospective pilot study, we included 59 phyllodes tumor with available preoperative imaging, CNB and surgical specimen pathology.

RESULTS

Two ultrasound features: tumor heterogeneity and tumor shape were associated with tumor grade, independently of CNB results. Using a machine learning classifier, the association of ultrasound features with CNB results improved accuracy of preoperative tumor classification up to 84%.

CONCLUSION

An integrative approach of preoperative diagnosis, associating ultrasound features and CNB, improves preoperative diagnosis and could thus optimize surgical planification.

Diagnostic challenges of benign breast phyllodes tumour: A rapid-growing tumour during pregnancy caused breast loss. A case report

•

Phyllodes tumours are rare breast neoplasms.

•

Inadequate treatment of phyllodes tumour can result to tumour recurrence, growth or metastatic spread, when tumour has malignant potential.

•

In suitable cases, skin-sparing mastectomy with immediate silicone implant reconstruction might be a treatment option.

•

The patients with microscopically radical removed benign phyllodes tumours can be followed up with annual surveillance.

Introduction

Phyllodes tumours are rare breast neoplasms. It is especially rare in pregnancy.

Presentation of case

We report a case of a 37-year-old woman with left breast benign phyllodes tumour, which started to grow very fast during pregnancy. The tumour was too big for breast-conserving surgery and it was necessary to remove the whole left breast. Patient underwent successful nipple-skin-sparing mastectomy with immediate silicone implant reconstruction.

Conclusion

Breast phyllodes are classified as benign, borderline, and malignant. Standard treatment of breast phyllodes is surgery. The choice of surgery type depends on the tumour factors and breast size.

We highlight that, inadequate treatment of phyllodes tumour can result to recurrence, growth, or even metastatic spread, when tumour has malignant potential.

Malignant Phyllodes of Breast

Phyllodes tumors of breast (PTB) have been known to an uncommon and particular disease to handle owing to diagnostic ambiguity and unpredictable clinical outcome. Malignant phyllodes tumors (MPT) are diagnosed when there are marked stromal hypercellularity, atypia, increased mitoses of ≥10/10 HPFs, permeative tumor borders, and stromal overgrowth. The presence of a malignant heterologous element (MHE) places the tumor into the malignant category regardless of other histological features. Excision with negative margins should be achieved for recurrent and malignant phyllodes tumor. An ideal margin width remains to be determined, and may need to be considered in relation to factors such as tumor size and cosmesis. Without the convincing evidence of survival benefit, adjuvant RT has revealed more favorable local control rate compared with observation group. Stromal expression of Twist and Foxc2, epithelial-mesenchymal transition marker, was associated with high tumor grade and poor prognosis. Tumor-associated macrophage drives myoblast differentiation and malignant progression of PTB through a CCL18-driven signaling cascade amenable to antibody disruption. Recent targeted sequencing on PTBs provided insights into the molecular pathogenesis and genetic characterization with potential clinical implications.

Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines

PURPOSE

Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary.

METHODS

We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR).

RESULTS

Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96).

CONCLUSION

In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.

Width of margins in phyllodes tumors of the breast: the controversy drags on?-a systematic review and meta-analysis

PURPOSE

Phyllodes tumors (PT) of the breast are rare fibroepithelial neoplasms. Information is controversial in the literature regarding to the optimal surgical management. Most studies suggested margins of at least 10 mm while some recent studies suggested narrower margins without an increased risk of local recurrences (LR) and distant metastases (DM). The objective of this systematic review was to identify and compare studies that assessed these different practices.

METHODS

A systematic review was performed through five databases up to April 2019. Studies exploring the association between the width of margins, subtypes of PT, and the LR and DM rates were considered for inclusion. A statistical model for analyzing sparse data and rare events was used.

RESULTS

Thirteen studies met eligibility criteria and were selected. Considering a threshold of 10 mm (margins < 10 vs margins ≥ 10 mm), the 5-year incidence rate of LR was estimated to be 5.22 vs. 3.63 (diff. -1.59) per 100 person-years for benign PT, 9.60 vs. 7.33 (diff. -2.27) for borderline PT, and 28.58 vs. 21.84 (diff. -6.74) for malignant PT. For DM, it was estimated to be 0.88 vs. 0.86 (diff. -0.02) for benign PT, 1.61 vs. 1.74 (diff. 0.13) for borderline PT, and 4.80 vs 5.18 (diff. 0.38) for malignant PT. The data for a threshold of 1 mm were not sufficient to draw any conclusions.

CONCLUSION

Irrespective of tumor grade, we found that DM was a rarer event than LR. Malignant PT had the highest incidence rate of LR and DM. This meta-analysis found a clear association between width of margins and LR rates. Whatever the tumor grade, surgical margins ≥ 10 mm guaranteed a lower risk of LR than margins < 10 mm. On the other hand, the width of margin did not influence the apparition of DM.

En Bloc Excision of Phyllodes Tumor of the Breast: Radical Approach Heralds Better Outcome

INTRODUCTION

Surgery is the primary treatment of phyllodes tumor of the breast, and margins are the most important risk factor associated with local recurrence. We conducted a retrospective audit of 433 patients treated at our center.

PATIENTS AND METHODS

Women who presented with phyllodes tumors between 1999 and 2017 were included in the analysis. Data was collected from the hospital medical records, telephonic interviews, and electronic mail.

RESULTS

Of the 433 women included in this study, 177 (40.9%) had benign phyllodes tumors, 84 (19.4%) were borderline, 131 (30.3%) were malignant, and 41 (9.5%) had sarcoma. A history of previous excision was noted in 154 (35.6%) patients, of which 104 presented with local recurrence. Of the total patients, 209 (48.3%) underwent breast conservation surgery; the median pT was 6 cm. At a median follow-up of 37.9 months, the 5-year disease-free survival (DFS) was 82.9%. On multivariate analysis, the factors that impacted DFS were histology (hazard ratio, 4.1; 95% confidence interval [CI], 1.5-10.9; P = .005) and history of previous excision biopsy (hazard ratio, 3.39; 95% CI, 1.76-6.52; P < .001). We analyzed 231 women who presented without any prior excision separately, wherein at a median follow-up of 44.1 months, the DFS was 92.1% (95% CI, 92.05%-92.15%). In addition, less recurrences were noted in this cohort (5.6% [13/231] in no-excision biopsy vs. 12.5% with surgery done prior to presentation to our institute).

CONCLUSION

A previous history of excision and the histologic subtype of phyllodes tumor are factors that have an impact on DFS, thus emphasizing the need for appropriate surgical planning and en bloc excision of the phyllodes at presentation.

Core needle biopsy diagnosis of fibroepithelial lesions of the breast: a diagnostic challenge

Fibroepithelial lesions (FEL) of the breast are biphasic neoplasms consisting of proliferative epithelial and stromal components and include fibroadenoma, phyllodes tumour and periductal stromal tumour. Core needle biopsy (CNB) is a commonly used diagnostic modality for investigation of breast lesions. As the accurate diagnosis of FEL requires integrated assessment of both epithelial and stromal components, this may create problems in small biopsies with limited sampling. In this review, common problems encountered in CNB of FEL are discussed, including establishing a diagnosis of borderline/malignant phyllodes tumour in a biopsy consisting of malignant spindle cells, differentiating phyllodes tumour from fibroadenoma on CNB, grading of phyllodes tumour of intermediate histological grade and assessment of periductal stromal tumours. The approaches are detailed systematically based on histology, immunohistochemistry and molecular characterisation. This comprehensive approach may aid in dealing with the overlapping histological appearance of FEL and sampling limitations of CNB.

Benign Phyllodes Tumor in Children: A Study of 8 Cases and Review of the Literature

Phyllodes tumor (PT) occurs predominantly in middle-aged women, and although its occurrence in young women, adolescents, and even children is documented, presentation in the pediatric population has been the least well studied because of its rarity. Incompletely defined in children with PT are recurrence rates and optimal surgical management. We retrospectively studied the pathology database of Hartford Hospital from 2010 to 2017 to find all cases of PT in patients 18 years of age or younger. A series of 8 children/adolescents with breast masses diagnosed as benign PT were identified. Patients were 14 to 16 years of age (mean 15.2 y) and tumor size ranged from 2.2 to 7.2 cm (mean 4.4 cm). Both breasts were equally affected. All patients were treated with excision, tantamount to simple enucleation in most cases, and positive or "tumor-abutting" margins were universal. Mean follow-up after surgery was 27.5 months, during which time a single recurrence (at 9 mo) became manifest, which was re-excised and again showed benign PT. There were no pathologic features (including marginal status) that could have predicted the sole recurrence. Despite positive margins, the local recurrence rate for pediatric benign PT appears acceptably low (1 in 8 cases) such that reflex re-excision is probably unnecessary.

Phyllodes tumours of the breast: Outcomes and recurrence after excision

INTRODUCTION

Wide excision margins are traditionally recommended for phyllodes tumours of the breast to reduce recurrence. Recent studies suggest margin status and histopathological features, excluding margin width, influence recurrence. This study evaluated treatment outcomes for phyllodes tumours and examined predictors of recurrence.

METHODS

Clinical and follow-up information for phyllodes tumours patients treated between 2008 and 2017 were obtained from chart review. Tumour subtype and histopathological features were determined from pathology reports. Primary endpoints were recurrence rate and time to recurrence or mortality.

RESULTS

Among 96 patients, there were 6 local and 1 distant recurrences. Overall recurrence rate was 7.3% and average time-to-recurrence was 13.7 months. Tumour size, margin status, necrosis, and mitoses were associated with recurrence; margin width was not. Two deaths (2.1%) from malignant phyllodes occurred.

CONCLUSIONS

Multiple histopathological features influence phyllodes recurrence. Wide excision and re-excising positive margins for benign tumours was not beneficial.

Phyllodes Tumors-The Predictors and Detection of Recurrence

BACKGROUND

Phyllodes tumors are rare breast neoplasms and the histopathological grade and surgical margins help guide treatment and follow-up. The traditional surgical teaching is resection with ≥10 mm margins, but are narrower surgical margins acceptable? The purpose of our study was to identify predictors of local recurrence.

METHODS

A retrospective analysis was performed to identify patients with phyllodes tumors who underwent surgery between 2002 and 2014 using a regional pathology database. Electronic medical records were used to identify surgical management, pathological characteristics, and follow-up encounters.

RESULTS

A total of 150 phyllodes tumors were included: 110 of 150 (73%) benign, 21 of 150 (14%) borderline, and 19 of 150 (13%) malignant. At initial surgery, 29 specimens had a positive margin and 15 (56%) underwent re-excision. Seventy tumors had a surgical margin of ≤1 mm, 40 had a margin of 2 to 9 mm, and 11 had a margin of ≥10 mm. There were 11 of 150 (7.3%) locally recurrent tumors: 5 of 11 (45%) benign, 3 of 11 (27%) borderline, and 3 of 11 (27%) malignant. In total, 10 of 11 locally recurrent tumors had a positive margin or ≤1 mm margin at initial surgery.

CONCLUSIONS

Phyllodes tumors can have a personalized treatment approach based on histopathological grade and surgical margins. Borderline and malignant phyllodes tumors with a positive or ≤1 mm surgical margin have an increased risk of recurrence. In benign phyllodes tumors, an optimal narrow negative margin may exist but the traditional ≥10 mm excisional margin is not necessary. Local recurrence rates may be sufficiently low in benign phyllodes tumors that imaging can be performed on the presence of clinical symptoms.

Accuracy of p53 and ki-67 in the graduation of phyllodes tumor, a model for practical application

Background

The accurate graduation of a phyllodes tumor (PT) is critical for effective treatment as it allows correct surgical management, and avoids inadequate excision for malignant or borderline PT, or surgical overtreatment in benign PT. PTs of the breast are notoriously difficult to classify, and reliable differentiation of a benign PT from a borderline or malignant PT can be problematic, especially among relatively inexperienced pathologists. Although several authors acknowledge a strong relationship between the immunohistochemical expression of p53 and Ki-67 and the histopathological grade of PT—with potential impact on diagnostic accuracy—the literature lacks consensus about which cutoff defines a positive index test. The objective of this study is to establish a practical application score that increases the graduation accuracy of PT through the appropriate use of these auxiliary methods.

Methods

A retrospective study cohort of 146 pathology reviewed PTs surgically removed between January 2000 and December 2015. The Ki-67 test was considered positive if > 10% of neoplastic cells showed nuclear staining. The p53 test was considered positive if > 10% of neoplastic nuclear cells showed nuclear staining in a moderate or strong intensity.

Results

Of the 146 PT cases reviewed, 110 were classified as benign, 16 as borderline, and 20 as malignant. The correlation between age and size with benign, borderline, and malignant subgroups was statistically significant (p < 0.001). Significance was observed in the expression of both Ki-67 and p53 in the comparison of benign, borderline, and malignant PT with p < 0.001 and a 95% confidence interval (CI). When correlating the presence of positivity in either of the two index tests with the diagnosis of borderline or malignant PT, we reached a sensitivity of 100% and a specificity of 91.8 (p < 0.001; 95% CI).

Conclusion

We propose a practical methodology to achieve an accurate grade of PT, based on clearly defined and easy to apply cutoffs of a simple immunohistochemical panel of Ki-67 and p53. A PT positive for either of the index tests should be graded as borderline or malignant, so pathologists can use this test to improve accuracy. We hope this new approach might provide the basis for the development of standardization in using p53 and Ki-67 for grading PT.

Surgical margins for borderline and malignant phyllodes tumours

BACKGROUND

Phyllodes tumours represent less than 1% of all UK breast neoplasms. Histological features allow classification into benign, borderline or malignant, which has a significant impact on prognosis and recurrence. Currently, there is no consensus for the optimal surgical excision margin. This systematic review aims to provide a comparative summary of outcomes (local recurrence, metastasis and survival) for borderline and malignant phyllodes tumours resected with either ≥1cm or <1cm margins.

METHODS

MEDLINE and Embase were systematically searched (1990 to July 2019), in line with PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Ten retrospective studies were included (Newcastle-Ottawa scale mean score: 5.6, range: 8-4). Nine reported local recurrence rates, four reported distant metastasis and four reported survival. Meta-analysis pooling demonstrated no statistically significant difference between <1cm and ≥1cm margins in terms of local recurrence rates (relative risk [RR] 1.43, 95% confidence interval [95% CI] 0.70 - 2.93; p=0.33, n=456), distant metastasis (RR 1.93, 95% CI 0.35 - 10.63; p=0.45, n=72) or mortality (RR 1.93, 95% CI 0.42 - 8.77; p=0.40, n=58) for borderline and malignant tumours. Additionally, two studies demonstrated no significant difference in local recurrence for borderline tumours excised with <0.1cm margins compared to ≥1cm.

CONCLUSION

Current evidence suggests that margins <1cm may provide adequate tumour excision. This could enable breast conservation in patients with smaller breast-to-tumour volume ratios, with improved cosmetic outcomes and patient satisfaction. A prospective, multi-institutional trial would be appropriate to further elucidate the safety of smaller margins.

Phyllodes tumour of the breast and margins: How much is enough

Summary

Phyllodes breast tumours are fairly uncommon, and they can be benign, borderline or malignant. General surgeons usually encounter them following the surgical excision of a breast lump that had the appearance of a fibroepithelial lesion. The surgeon is then faced with the question of what to do to establish an acceptable treatment margin. In this discussion, we recommend a plan for the management of Phyllodes tumours based on a review of the recent literature, confirmed by a retrospective review of the results from our centre. A negative margin is acceptable treatment following a lumpectomy for Phyllodes tumours. Only patients with a positive margin should undergo a revision.

Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

Purpose

The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations.

Methods

This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy.

Results

In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)].

Conclusions

Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.

Phyllodes tumors of the breast. The treatment results for 340 patients from a single cancer centre

PURPOSE

The primary treatment of choice for patients with phyllodes tumor of the breast (PTB) is surgery. Two major problems regarding the treatment of such patients remain unclear: what is the appropriate surgical margin and what role is played by adjuvant radiotherapy (ART).

METHODS

The study provides a retrospective review of all patients with PTB treated between 1952 and 2013 at a single institute. The histology slides were re-examined based on WHO criteria. The clinical characteristics and therapy outcomes were obtained. The five-year survival with no evidence of disease (NED) was used as the end point.

RESULTS

The study population comprised 340 women with PTB. Fifty-five percent of the patients were diagnosed with the benign, 11.8% with borderline and 33.2% with malignant PTB. All the patients received primary treatment with surgery (mastectomy-27.1%, and BCS- 72.9%). Local recurrence (LR) was found in 28 (9.1%) of these patients. Four patients with borderline and 8 with malignant PTB who were treated with BCS and had tumor-free margins < 1 cm received ART. None of these patients had LR and all survived 5 years NED. Of the 340 patients from our group, 294 (86.4%) survived five-years NED.

CONCLUSION

The prognosis for benign PTB is excellent and can be cured with surgery alone. A sufficient margin would be 0.1 cm (data from the literature) or 0.2-0.4 cm (our study). We recommend application of ART for such patients but the role of ART in patients with borderline and malignant PTB treated with BCS and with surgical margin < 1 cm remains uncertain.

Fibroepithelial lesions of the breast: a comprehensive morphological and outcome analysis of a large series

Mammary fibroepithelial lesions encompass a wide spectrum of tumors ranging from an indolent fibroadenoma to potentially fatal malignant phyllodes tumor. The criteria used for their classification based on morphological assessment are often challenging to apply and there is no consensus as to what constitutes an adequate resection margin. We studied a retrospective cohort of 213 fibroepithelial lesions in 178 patients (80 fibroadenomas with unusual features and 133 phyllodes tumors: 63 benign, 41 borderline, and 29 malignant) in order to describe the spectrum of changes within each group, with special emphasis on margin evaluation. Outcome data were available for 153 fibroepithelial lesions in 139 patients (median 56 months, range 3-249 months). Positive final margin (tumor transected), age < 50 years and a predominantly myxoid stroma were statistically significant predictors of local recurrence, while age > 50, stromal overgrowth, diffuse marked atypia, necrosis and mitotic index of ≥ 10 per 10 HPF were predictive of distant metastases. Tumors with satellite/bulging nodules were at a significantly higher risk to have a final positive resection margin. Our findings highlight important aspects of the interpretation and reporting of fibroepithelial lesions: the amount of myxoid stroma and the presence of satellite nodules are clinically relevant and should be routinely assessed and reported; infiltrative border might not be a prerequisite for the diagnosis of malignant phyllodes tumor, while the presence of tumor necrosis, massive stromal overgrowth or mitotic index of ≥ 25 per 10 HPF is diagnostic of malignant phyllodes tumor. On the other hand, increased mitotic index outside of the range of the World Health Organization guidelines in the absence of other worrisome features should be treated with caution, as it can be found in benign tumors.

Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment

BACKGROUND

Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults.

METHODS

We queried the NCDB (2004-2014) for female patients with phyllodes tumor histology, excluding patients with missing age or survival data. Patients were stratified by age (pediatric <21, adult ≥21), and compared based on patient characteristics, treatment patterns, and survival.

RESULTS

We identified 2787 cases of phyllodes tumor (2725 adult, 62 pediatric). Median age was 17years in children and 52years in adults. Margin positivity rates and median tumor size were similar between adults and children. Treatment was discordant with NCCN guidelines in 28.6% of adults and 14.5% of children through use of axillary staging, chemotherapy, adjuvant endocrine therapy, and radiotherapy. Five-year and ten-year survival were comparable between both groups.

CONCLUSION

Children and adults present with similarly sized phyllodes tumors. Trends reveal high margin positivity rates, and overtreatment with regional axillary staging and systemic adjuvant therapies. Particularly in children, treatment decisions must consider risks of adjuvant therapy including radiation-related second primary cancers, given uncertain benefit.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

BILATERAL BREAST SARCOMA IN WOMEN WITH MACROMASTIA

Bilateral breast sarcomas are rare malignancies of unknown etiology. Most common histological subtypes of breast sarcoma are angiosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Phyllodes tumors have a predisposition to transform into sarcoma. The present clinical case describes bilateral breast fibrosarcomas in a 39 years-old female with macromastia. This peculiarity gave possibilities to do wide local excision of both tumors within 3.0 cmresection margins and preserve both breasts. Histological and immunohistochemical (ERG, CK-AE1/AE3) examination confirmed fibrosarcomas in both breast (in right – stage IIB, in left – stage IIA). Patient carried on postoperative treatment with radiation therapy (36.1 Gy for both breasts) and four cycles of adjuvant chemotherapy (doxorubicin, cisplatin, cyclophosphamide). For the first year patient had clinical and ultrasound examination every three months, then every 6 months. CT scan of chest and abdomen was every year. In seven post-op years there was no evidence of disease recurrence. Thus, macromastia gives an exceptional chance to carry out organ-sparing radical surgery in women with advanced breast malignancies.