Real-world data on malignant and borderline phyllodes tumors of the breast: A population-based study of all 921 cases in the Netherlands (1989 -2020)

AIM

The aim of our study is to analyze patterns in treatment and outcome in a population-based series of patients with borderline and malignant phyllodes tumors (PT).

MATERIAL AND METHODS

Data on all patients with a borderline or malignant PT (1989-2020) were extracted from the Netherlands Cancer Registry and the Dutch nationwide pathology databank (Palga) and retrospectively analyzed.

RESULTS

We included 921 patients (borderline PT n = 452 and malignant PT n = 469). Borderline PT patients more often had breast-conserving surgery (BCS) as final surgery (81 vs. 46%). BCS rates for borderline PT increased over time (OR 1.08 per year, 95%CI 1.04 - 1.13, P < 0.001). In malignant PT adjuvant radiotherapy was given in 14.7%; this rate increased over time (OR 1.07 per year, 95%CI 1.02 - 1.13, P = 0.012). Local recurrence rate (5-year estimate of cumulative incidence) was 8.7% (95%CI 6.0-11.4) for borderline PT and 11.7% (95%CI 8.6-14.8) for malignant PT (P = 0.187) and was related to tumor size ≥ 20 mm (HR 10.6 (95%CI 1.5-76.8) and positive margin (HR 3.0 (95%CI 1.6-5.6), p < 0.001), but not to negative margin width (HR 1.3 ( 95%CI 0.7-2.3), p = 0.350)). Distant metastasis occurred only in malignant PT with a 5-year cumulative incidence of 4.7% (95%CI 3.3 - 6.1).

CONCLUSION

This population-based series showed an increase in BCS in borderline PT and an increase in adjuvant radiotherapy in malignant PT over time. We identified malignant PT, BCS, larger tumor size and positive final margins as possible risk factors for local recurrence. Small but negative margins can be accepted.

Margin status impact on recurrence of phyllodes tumors in high-risk groups: a retrospective observational study

BACKGROUND

Phyllodes tumor (PT) is an fibroepithelial tumor with potential for local recurrence. The optimal margin for surgical resection of PT is still debated, particularly in cases of positive margins. This study aimed to identify the risk factors for phyllodes tumor recurrence and the effect of a free margin on tumor recurrence by considering these risk factors.

MATERIALS AND METHODS

This is a retrospective observational study of patients diagnosed with PT who had undergone surgical management. The data were collected from medical records from 2001 to 2020 in the breast clinic of Shahid Motahhari Clinic of Shiraz. Patients were followed up for at least 3 years after the operation to be checked for local recurrence or distant metastasis at regular intervals.

RESULTS

This retrospective study included 319 patients with PT who underwent surgical management. Of these patients, 83.9% (n = 267), 7.6% (n = 24), and 8.5% (n = 27) were classified as benign, borderline, and malignant, respectively. 8.8% of all patients and 7.6% of non-malignant cases experienced local recurrence, and risk factors for recurrence included oral contraceptive use, smoking, size > 4 cm, stromal overgrowth, and stromal cell atypia. A negative surgical margin decreased the prevalence of recurrence in tumors > 4 cm and with stromal overgrowth significantly.

CONCLUSION

The study found that a negative margin in all patients did not reduce the recurrence rate in benign and borderline phyllodes tumors, suggesting close follow up as a reasonable alternative. However, a negative margin may be effective in reducing recurrence in certain high-risk groups.

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.

Ki67 and P53 Expression in Relation to Clinicopathological Features in Phyllodes Tumour of the Breast

OBJECTIVE

Phyllodes tumour (PT) is a rare fibroepithelial neoplasm of the breast that carries a risk of malignancy. Histopathological examination remains a gold standard for diagnosis. The usage of the immunohistochemical markers of Ki67 and p53 acts as a supplement method, particularly for the malignant PT. We aim here to study the expression of these markers in PT and to see their relation to the tumour grading.

METHODOLOGY

We conducted a retrospective cross-sectional study on 57 archived formalin-fixed paraffin-embedded tissue blocks of PT from the years 2015 to 2018 from two hospitals in East Coast Malaysia. The histopathological examination and immunohistochemical stain for Ki67 and p53 were analysed.

RESULTS

There was an association between clinical descriptive data of skin changes, lump size of more than 3 cm, cytological atypia, stromal hypercellularity, mitosis and immunohistochemistry with the clinical diagnosis of PT. Both marked expression of Ki67 and p53 were seen in borderline and malignant PT. Our study showed that in the presence of high mitotic figures, marked expression of Ki67 was only seen in cases of malignant PT.

CONCLUSION

We found a significant association of Ki67 and p53 expressions, high mitosis and other descriptive histopathological features in malignant PT. Further study with larger sample size is recommended to predict tumour grade and prognosis as well as the disease-free survival of the tumour. 
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Postoperative follow-up practice of phyllodes tumour in the UK: Results from a national survey

BACKGROUND

Resected phyllodes tumours (PT) of the breast carry a small but significant risk of recurrence. Nevertheless, there are no national guidelines on the postoperative follow-up of these tumours potentially resulting in a wide variation in practice among breast surgeons in the UK.

METHODS

A web-based questionnaire was sent to breast surgeons across the UK to assess individual follow-up practices including availability of local guidelines, methods of follow-up and influence of risk factors.

RESULTS

Only 38% of 121 responses indicated the availability of local guidelines on PT follow-up. Modal follow-up duration for borderline and malignant disease was 5 years (53.7% and 79.3% of responses respectively), compared to 1 year for benign disease (43%) although 28% of respondents continue to review benign cases for 5 years. Immediate post-operative discharge and self-directed aftercare for benign and borderline cases remains uncommon practice in the UK. Within hospitals represented by more than one respondent in this survey, only around 30% demonstrated consistent practices pertaining to length and frequency of postoperative PT follow-up. Recurrent disease and margin status influenced the follow-up practice of 60% of respondents in our survey. More than 75% indicated that they combine clinical examination with radiological investigations (mammography and/or ultrasound) to follow up PT postoperatively.

CONCLUSION

This survey highlights the wide variation in follow-up practice for resected PT. This may affect the detection of disease relapse or, conversely, result in wasted clinical resources and unnecessary patient distress. Evidence-based national guidelines are necessary to resolve this issue and inform best follow-up practice.

Local Recurrent Phyllodes Tumors of the Breast: Clinical and Sonographic Features

OBJECTIVES

The purpose of this study was to investigate the clinical, pathologic, and sonographic features of local recurrent phyllodes tumors of the breast and provide evidence for diagnosing tumor recurrence.

METHODS

A total of 127 patients with phyllodes tumors who underwent surgery from 1993 to 2012 were followed. The clinical, pathologic, and sonographic features of local recurrent tumors were analyzed.

RESULTS

Of the 127 patients, pathologic diagnoses were benign, borderline, and malignant in 75 (59.1%), 41 (32.3%), and 11 (8.7%) patients, respectively. The patients were followed for a mean duration ± SD of 50.9 ± 42.1 months (range, 2-225 months). Twenty-one patients had local recurrence, for a recurrence rate of 16.5%. The benign, borderline, and malignant recurrence rates were 14.7%, 17.1%, and 27.3%. The local recurrence in the 21 patients occurred after a mean interval of 19.4 ± 13.4 months. The mean times to local recurrence were 20.2 ± 12.1, 16.9 ± 10.8, and 20.3 ± 19.0 months for benign, borderline, and malignant tumors. The histologic characteristics of the recurrent tumors were similar to those of the initial tumors in 14 patients (66.7%), whereas the characteristics changed in 7 (33.3%). The sonographic features of the recurrent tumors were as follows: 69.4% were lobulated; 88.9% appeared as well-defined lesions; 41.7% had posterior acoustic enhancement; 11.1% had intramural cystic areas; and 83.4% had moderate or marked blood flow.

CONCLUSIONS

The recurrence rate for phyllodes tumors is high. One to 2 years after surgery is the key time for follow-up. The sonographic features contribute to recurrence diagnosis.

Phyllodes tumors of the breast: ultrasonographic findings and diagnostic performance of ultrasound-guided core needle biopsy

We evaluated ultrasonography (US) findings between benign and malignant phyllodes tumors and analyzed diagnostic performance of US-guided core needle biopsy (CNB) for phyllodes tumors. Surgically removed phyllodes tumors of 168 women were divided into two groups according to the benign and malignant (including borderline tumor) groups and 116 were benign and 52 were malignant. On US, the complex cystic echogenicity (p = 0.021), presence of cleft (p = 0.005) and higher final US assessment (p = 0.008) were more frequent in the malignant group. The sensitivity of CNB including fibroepithelial tumors was 67.9% (114/168) and the concordant rate between CNB and surgical excision was 82.1% (32/39) and 5.8% (3/52) in the benign and malignant group. Our results suggested that the US findings of complex cystic echogenicity, cleft, higher final US assessment were more frequent in malignant phyllodes tumors. The sensitivity of CNB was 67.9% (114/168) and malignant phyllodes tumors were rarely diagnosed as malignant by US-guided CNB.

[Phyllodes tumor of the breast: clinicopathologic analysis of 22 cases]

INTRODUCTION

Phyllodes tumors of the breast are uncommon fibroepithelial neoplasms that have potential for recurrence. They are classified as benign, borderline, and malignant, based on a constellation of histologic characteristics that includes the degree of stromal hypercellularity, cytologic atypia and mitotic activity.

OBJECTIVE

To analyze the clinical and pathological features of 22 women treated at a referral center in Mexico City.

MATERIAL AND METHODS

We performed a retrospective analysis of women with phyllodes tumors of the breast treated at our institution between 1998 and 2011. Age, tumor size, surgical method, stromal cellular atypia, mitotic activity, stromal overgrowth, histological classification and surgical margin status were analyzed to determine their possible association with tumor recurrence.

RESULTS

Mean patient age at presentation was 42 years. Ten of them (43.5%) had late menarche. Six patients (27.27%) used hormones. Twenty patients (91%) had tumor detected by self-examination. Mean size of the lesion was 7.4 cm. Most lesions were located in the upper outer quadrant (77.3%) and in the left breast (59.1%). Fourteen patients (63.6%) were treated with conservative surgery. Three patients (13.6%) presented local recurrence, two as benign tumors and one patient with two recurrences, first as benign tumor thereafter as malignant phyllodes tumor at 72 and 108 months respectively.

CONCLUSIONS

. In our study, surgical positive margin status is the main prognostic factor for recurrence.

Malignant phyllodes tumour of the breast

BACKGROUND

Malignant Phyllodes Tumour (MPT) is considered to be a rare disease of the breast. The most frequent clinical presentation of a MPT is a rapidly growing breast lump.

METHODS

Consecutive cases of MPT registered between Jan 1, 1995 and Dec 31, 2012 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, were reviewed, to obtain information on age, tumour size, treatment given, disease-free survival, and overall survival. Disease-free survival was computed between the dates of surgery and recurrence, whereas, the overall survival time between the dates of diagnosis and last contact, both in months.

RESULTS

A total of 101 cases of Phyllodes tumour were recorded. These included: malignant tumours (42) benign (27), and borderline (32). Malignant Phyllodes tumours (42 cases) were studied further and 41 included for additional analysis. The mean age of the women in the study was 40.3 +/- 12.5 (22-72 years). Of the 33 patients who were disease-free after surgery, 15 had a recurrence, whereas, 18 did not have a recurrence. In those who had surgery alone versus those who received radiation treatment in addition to surgery, the median disease-free survival was 117 and 44.2 months, respectively. The mean overall survival time was 33.7 months.

CONCLUSION

In this study, patients presented at a younger age than in other studies. Further exploration into molecular, biologic, geographic, and socioeconomic factors is needed to clearly understand the epidemiology of this disease in our population.

Benign breast lesions in Eastern Nigeria

OBJECTIVE

To characterize benign breast diseases in Eastern Nigeria and to highlight the age variations of these lesions as base line data.

METHODS

The Department of Morbid Anatomy, University of Nigeria Teaching Hospital, Enugu caters for over 30 million African blacks and receives 2000 surgical pathology specimens yearly. Seven hundred and twenty-two benign breast specimens were analyzed over 5 years from 1st January 2000 to 31st December 2004, out of 1050 breast samples received.

RESULTS

Of 1050 breast specimens received, 722 (68.8%) were benign. Fibroadenoma was the most common lesion with 318 cases (44%), occurring at a mean age of 16-32 years. Next was fibrocystic changes with 165 cases (22.9%) at a mean age of 23-45 years. Normal breast in the axillary tail region was seen in 32 cases (4.4%), represented as no pathology, with a mean presentation age of 20-46 years. Low grade Phyllodes tumor had 28 cases (3.9%), presenting at an average mean age of 17-32 years. Lactating adenoma had 19 (2.6%) cases. Other lesions made up less than 3% each. Benign breast lesions peaked at the 20-24 age range and then declined. Most were females.

CONCLUSION

Benign breast lesions occur more frequently than malignant breast lesions with a ratio of 2.3:1 and were presented 20 years earlier than their malignant counterparts. Fibroadenoma was the most common benign lesion followed by fibrocystic disease, similar to the findings in Western Nigeria. In Northern Nigeria, fibrocystic breast disease was more common.

Phylloides tumors in adolescent girls and young women in Pakistan

The objective of this study was to determine the frequency of phylloides tumor (PT) in adolescent girls and young women (less than and equal to 25 years of age) and to define the clinico-pathological features of PT in this unusual clinical setting. This descriptive study was carried out at the Aga Khan University Hospital (AKUH) pathology department. All consecutive cases of PT diagnosed during the last sixteen years in the section of histopathology from 1st January 1990 to 31st June 2005 were included. Selection of cases was restricted to patients up to 25 years of age. A total of 42 cases of PT in up to 25 years of age were diagnosed. This comprised 11% of the total PT cases (total n=363). The number of benign (BPT), borderline (BLPT) and malignant (MPT) was identical i.e. 14 (33.3%) each. Clinically all cases presented with a solid, mobile, palpable mass. The mean age was 19.1 years (95% CI, 16.7-21.6), 21.9 years (95% CI, 20.7-21.9) and 19.7 years (95% CI, 17.2-22.3) in BPT, BLPT and MPT respectively. In majority of cases the surgical procedure performed was lumpectomy (50% of BPT, 78% of BLPT and 64% of MPT). High grade PT (BLPT and MPT) is an uncommon mammary tumor in adolescent girls and young women but seems to be occurring with increased frequency in the study population. This observation may indicate the biological behavior of PT in a high risk population, though chances of referral bias are also present. In view of the rarity of the disease, larger population studies are suggested to confirm our findings.

Phyllodes tumors of the breast: a case series of 106 patients

BACKGROUND

Phyllodes tumors (PTs) of the breast are rare, and their prognosis and treatment are still subject of discussion. The purpose of this study is to clarify therapeutic aspects and prognostic factors of this disease.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 106 patients who had histologically confirmed PTs collected over a period of 10 years.

RESULTS

The mean age was 39.5 years (14-71 years). The mean tumoral size was 83 mm (15-250). According to criteria of Azzopardi and Salvadori, tumors were classified into 3 groups: benign (62 cases, 58.4%), borderline (16 cases, 15%), and malignant (28 cases, 26.4%). Eighty-two patients (77.4%) were treated conservatively (62 benign, 11 borderline, and 9 malignant) and 24 (22.6%) by radical surgery (5 borderline and 19 malignant). For malignant PTs treated by enucleation or local excision with or without reexcision of the tumor bed, the 5-year overall and disease-free survivals were 28.5% and 15.6% versus 72.7% and 73.6% when the surgery was radical (mastectomy with or without axillary dissection) (P = .12 and P = .0022). For the other histotypes, this difference disappeared. The rate of recurrence was 12.2% (13) after a mean follow-up of 39 months (5 benign, 2 borderline, and 5 malignant). The treatment of recurrences consisted of radical mastectomy (8 cases), simple mastectomy (2 cases), and local excision in 3 cases. Eight patients developed metastases, 2 of whom after recurrences. The 5-year overall and disease-free survivals were 86.54% and 78%, respectively. In univariate analysis, age and recurrences are not of prognostic value for survival, whereas tumor size, histotype, necrosis, cytonuclear atypia, tumor margins, and number of mitosis were significant prognostic factors for survival. In a multivariate study, only cytonuclear atypia remained an independent predictor for survival.

CONCLUSION

According to our results, we recommend for malignant PT a simple mastectomy, whereas for borderline and benign PT, treatment is based rather on wide excision passing in healthy tissue.

Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases

BACKGROUND AND OBJECTIVES

Phyllodes tumors (PTs) are uncommon biphasic breast tumors that usually occur in adult females. They are composed of a benign epithelial component and a cellular, spindle cell stroma forming a leaf-like structure. No one morphologic finding is reliable in predicting the clinical behavior of the tumor. The purpose of this study was to explore the clinicopathologic factors associated with outcome and metastasis.

METHODS

We retrospectively reviewed the records of 172 patients seen at Mackay Memorial Hospital from January 1985 to December 2003. Clinical data analyzed included age, presenting symptoms and signs, tumor size, location, type of surgery, time to recurrence, and metastasis. The clinicopathologic factors associated with outcome and metastasis were analyzed statistically using the chi-square test with Yate correction.

RESULTS

The mean follow-up was 71 months (range 7-237). The mean age was 37 years (range 11-73). The majority of tumors were found in the upper outer quadrant (46.0%), with an equal propensity to occur in either breast (48.8% vs. 50.0%). The pathologic diagnoses included 131 benign, 12 borderline, and 29 malignant lesions. Nineteen patients (11%) had a recurrence and three (1.7%) had metastases. The initial diagnosis of all 19 recurrent tumors were benign. Age, surgical approach, mitotic activity, and surgical margin were significantly correlated with recurrence (P = 0.029, 0.020, 0.048, and 0.00018, respectively). Stromal cellularity, stromal overgrowth, stromal atypia, mitotic activity, tumor margin, and heterologous stromal elements were significantly correlated with metastases (P = 0.032, 0.00008, 0.000002, 0.004, 0.005, and 0.046, respectively). Mammography and breast echo were not reliable for differentiating PTs from fibroadenomas (6.9% vs. 37.9% and 3.3% vs. 45%, respectively). Frozen section was of limited value (41.6%). The role of adjuvant radiotherapy and chemotherapy remains to be defined. Local excision, wide excision, or mastectomy with negative surgical margins yielded high local control rates (88.7%, 88.2%, and 100%, respectively), but local excision was associated with a relatively high percentage of positive surgical margins (18.3%). A total of 42 modified radical mastectomies were performed. The reasons for these procedures included a diagnosis of malignancy on frozen section or because the tumors were so large, they were assumed to be carcinomas. No axillary lymph node metastases were found. Fifteen patients in our series had tumors with infiltrating tumor margin, severe stromal overgrowth, atypia, and cellularity. All three patients with metastases (3/15) were in this group. Presence of metastases was significantly correlated with this group (P = 0.0000038).

CONCLUSIONS

Wide excision with a clear margin may be the preferable initial therapy, even for malignant PTs. Routine axillary lymph node dissection is not recommended. Patients have tumors with infiltrating tumor margin, severe stromal overgrowth, atypia, and cellularity are at high risk for metastases.

Retrospective analysis of 25 women with malignant cystosarcoma phyllodes--treatment results

PURPOSE

Mastectomy without axillary dissection should be the standard treatment in patients with malignant form of cystosarcoma phyllodes. The role of postoperative radiotherapy and chemotherapy remains to be fully established. We evaluate treatment results in a group of patients with cystosarcoma phyllodes (CP) treated at our Institute.

PATIENTS AND METHODS

In this report we analyze treatment outcome in 25 patients with malignant cystosarcoma phyllodes treated at Masaryk Memorial Cancer Institute between 1970 and 1995. Mean tumor size was 10 cm in diameter. All patients underwent surgery. Subsequently, 17 patients (68%) received radiotherapy on the breast or chest wall.

RESULTS

Median follow-up was 139.5 months. Local recurrence was observed in 16% of all patients and all patients with local recurrence died. Time to local relapse after surgery was 4-11 months. Distant metastases occurred in 5 patients. All patients with local recurrence had distant metastases. Dissemination occurred 3-19 months after local recurrence. Five-year survival of all patients was 80%.

CONCLUSION

A specific protocol for the treatment of cystosarcoma phyllodes is missing, probably due to rarity of the disease. The treatment of local recurrent disease remains unsuccessful in most CP patients. We recommend postoperative irradiation on the chest wall in patients with malignant form of CP, because adjuvant radiotherapy decreased the incidence of local relapse in our group of patients.

Phyllodes tumor of the breast: case series of 40 patients

Cystosarcoma phyllodes is a rare, uncommon fibroepithelial tumor of the breast. We analyzed the clinical situation in relation to the histopathologic findings. Forty types of surgery, recurrences, histopathologic diagnosis and follow-up of patients were studied retrospectively. Histopathologic examination results were evaluated by logistic regression analysis. Surgery was performed on all patients as the initial treatment. At the first examination 38 cases were evaluated as benign and the remaining two as malignant. Recurrent tumors were seen in nine (22.5%) cases during follow-up with a mean recurrence time of 30.1 months. Five of the recurrent cases were evaluated as malign. The total number of malignant cases reached seven (17.5%). In statistical analysis evidence of tumor necrosis, stromal atypism, stromal cellularity, number of mitoses and stromal overgrowth were found to be significantly correlated with malignancy (p < 0.05). Recurrences were also significantly correlated with stromal cellularity, stromal overgrowth, necrosis and malignancy (p < 0.05). Cystosarcoma phyllodes recur with a high incidence and may transform to malignant disease. The patients should be followed strictly in order to detect recurrence earlier.

Malignant phyllodes tumor of the breast: review of the literature and case report of stromal overgrowth

Cystosarcoma phyllodes constitutes only 0.3-0.9% of all breast tumors. The term "sarcoma" was initially used because of its fleshy appearance, a more modern term is Phyllodes tumor (PT). The behavior of PT constitutes a spectrum from benign and locally recurrent to malignant and metastatic. In a general surgical series, 6.2% of the tumors were malignant. The microscopic appearance of PT is that of epithelial elements and connective tissue stroma. Malignancy is determined by characteristics of the stroma. The metastatic spread of malignant PT is mainly hematogenous to lung, with infrequent lymphatic involvement. Wide local excision with 2 cm margins is the treatment of choice. In 20% of both benign and malignant cases, PT will locally recur. There is no proven benefit of radiation or chemotherapy, although radiotherapy may be useful in selected cases. We present a case of a sarcomatous overgrowth in a malignant phyllodes tumor involving multiple histologic types.

Effectiveness of fine-needle aspiration cytology of breast: analysis of 2,375 cases from northern Thailand

At the Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand, 2,375 cases of breast lesions were sampled by fine-needle aspiration (FNA) from 1994-1999. Cytologic diagnoses were: benign (48%), suspicious for malignancy (5%), malignant (15%), and unsatisfactory (32%). Comparison with histology was possible in 721 cases. The diagnoses obtained by FNA showed a sensitivity of 84.4%, specificity of 99.5%, positive predictive value of 99.8%, negative predictive value of 84.3%, false-negative rate of 16.7%, false-positive rate of 0.5%, and overall diagnostic accuracy of 91.3%. We conclude that, in experienced hands, FNA of breast masses is reliable for diagnosis. Assessment of samples at the time of aspiration can reduce the number of inadequate specimens to near zero. Correlation of FNA results with clinical and radiologic findings can identify false-negatives and false-positives, ensuring optimal patient management. Many centers now recommend needle core biopsy instead of FNA. For regions such as ours, the added cost of this test would make it unavailable to many patients, which could delay a diagnosis of breast cancer. We advocate keeping FNA as a first-line diagnostic procedure, at least in areas under economic restrictions, in order to maximize the availability of health care to women with breast disease.

Morphological types of breast cancer in family members and multiple primary tumours: is morphology genetically determined?

BACKGROUND

We conducted the present study to determine whether breast cancer morphology is genetically determined.

METHODS

Using the nationwide Swedish Family Cancer Database, which includes data on 10.2 million individuals and over 25,000 morphology-specific breast cancers, we followed morphological types in familial cancers between mothers and daughters and between sisters. Additionally, we recorded morphological data in women who presented with two primary breast cancers and in those who presented with an invasive and in situ breast cancer. We used kappa statistics to examine the association between genetics and morphology. A kappa value of 0 indicates that the process is random and a value of 1 indicates that it is completely determined (i.e. genetic); values between 0.40 and 0.60 are considered to indicate a moderately determined process.

RESULTS

The study sample included a total of 25,730 first and 3394 second invasive breast cancers, and 2990 in situ breast cancers. Ductal, lobular, tubuloductal and comedo were the most common invasive types. We identified 164 mother-daughter pairs with breast cancer of a defined morphology, yielding a low kappa value of 0.08. Among 100 sister pairs the kappa value was 0.002. In individuals with two primary breast cancers the kappa values were 0.22 and 0.01 for two invasive and in situ-invasive pairs, respectively. However, for a tumour with a subsequent tumour detected in the contralateral breast less than 1 year later the kappa value was 0.47.

CONCLUSION

The data suggest that breast cancer morphology is not genetically determined. However, because of mixed morphologies and the overwhelming prevalence of ductal morphology, the results for rare morphologies should be interpreted with caution.

Phyllodes tumors of the breast: a review of 32 cases

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18-91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2-17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.

Cystosarcoma phyllodes: the Western Australian experience

BACKGROUND

Cystosarcoma phyllodes is a rare breast tumour whose behaviour is not well understood by many clinicians.

METHODS

In 1998 a retrospective study was undertaken of women diagnosed with phyllodes tumour of the breast who had their initial surgery between 1983 and 1994 in Western Australian public hospitals.

RESULTS

Forty women were diagnosed and treated over this period; however, only 28 received ongoing follow-up (70%). Follow-up was obtained on 26 of these. The median age at diagnosis in this group was 46 years. Cases were predominantly Caucasian (85.5%). Postmenopausal women were affected in 26.9% of cases. Four patients had recurrences after surgery (one malignant and three benign). No patient had a recurrence with primary tumours with a diameter of < or = 2 cm. Mean time to recurrence was 35.8 months.

CONCLUSIONS

Breast-conserving surgery was used in almost all cases (96.2% of first operations).

[Malignant phyllodes tumor with liposarcomatous differentiation. Description of a clinical case]

Sarcoma of the breast are a rare group of neoplasms representing less than 5% of Soft Tissue Sarcomas (STS). Between 1980 and 1995 in the National Institute foe Cancer Research (IST) of Genoa, 2188 patients were submitted to surgery for breast cancer. Seven of them were found to be affected by sarcoma, confirmed by histologic diagnosis. All the patients were between 39 and 87 years-old. Surgical treatments were: wide excision (1 case), total mastectomy (2 cases), radical mastectomy following Halsted (4 cases). A case of a 53 year-old woman with a phyllodes tumor initially transforming in to liposarcoma is reported. The patient was submitted to surgery (total mastectomy) and nowadays is alive and free of disease after 29 months. All authors agree that the treatment for sarcoma of the breast is early and complete surgical excision of the mass. The role of chemotherapy and radiotherapy is still uncertain. Outcome is based on histologic type, degree of differentiation and tumor size.

Metastatic tumors of the thyroid gland: a study of 79 cases in Chinese patients

OBJECTIVE

To evaluate the clinical and pathologic impact of metastases to the thyroid gland.

CASE MATERIAL

We studied the clinical/autopsy records and pathologic features of 79 Chinese patients (38 men, 41 women) with secondary tumors of the thyroid over a 26-year period.

RESULTS

The incidence of thyroid secondaries at autopsy was 0.5% and at thyroidectomies for malignancy was 1.2%. Eighteen (23%) of the 79 patients presented with an enlarged mass in the thyroid. The diagnosis of metastasis in the thyroid gland was suspected clinically in six cases. Fine-needle aspiration cytology detected an 80% malignancy rate, but in only half of such cases was the diagnosis specific for secondary malignancy. Many of the metastatic lesions in the thyroid gland occurred shortly after the detection of primaries (mean latency period, 9 months). The time from diagnosis of the primary tumor to metastasis to the thyroid gland was greater than or equal to 3 years in only eight patients. The majority (81%) of the secondary tumors were carcinomas. Of these, the lung was the most common primary tumor site (43%), followed by the breast (9%) and stomach (8%). Rare sources of primary tumors, such as nasopharyngeal carcinoma, choriocarcinoma, malignant phylloides, and osteosarcoma, were also found. The metastatic lesions in the thyroid gland could be identified macroscopically in 43 patients (54%). Lesions were often solitary (n = 24) rather than diffuse (n = 8) or multiple (n = 11). Microscopic examination revealed that secondary thyroid tumors were often moderate or poorly differentiated adenocarcinomas (n = 42). All the patients died shortly after the appearance of metastatic lesions in the thyroid gland.

CONCLUSIONS

Metastasis in the thyroid gland is uncommon and may be a diagnostic problem. Its presence often indicates a poor prognosis.

[Cystosarcoma phyllodes of the breast: clinical cases]

The authors report their experience in the management of 8 cases of cystosarcoma phylloides of the breast observed between January 1979 and December 1986 in the Surgical Department of the University of Bari. This uncommon breast pathology, which stands halfway between benign (adenofibromas) and malignant (carcinomas) tumors presents considerable difficulties in terms of diagnosis particularly problematic for the small-sized lesions. The authors stress the need of a surgical treatment which takes into account women aesthetic desire assuring at the same time a complete exeresis. The latter includes the sacrifice of at least 1 cm thick normal breast tissue to prevent the frequent local relapses.

The descriptive epidemiology of malignant cystosarcoma phyllodes tumors of the breast

BACKGROUND

Malignant cystosarcoma phyllodes tumors of the breast are rare fibroepithelial tumors. The epidemiologic features of these malignancies in a defined population have not previously been described.

METHODS

Incidence data were collected from 1972-1989 by the Cancer Surveillance Program, the population-based cancer registry for Los Angeles County.

RESULTS

The average annual age-adjusted incidence rate of malignant cystosarcoma phyllodes is 2.1 per 1 million women. Latina whites have a higher risk of this cancer than other racial-ethnic groups. The age-incidence curve shows that risk of cystosarcoma phyllodes peaks in the 45-49-year-old age group, but the age patterns vary by race-ethnicity, with Asian and Latina patients significantly younger, on average, than non-Latina white patients. The incidence rates of malignant cystosarcoma phyllodes were substantially higher in the 1980s than in the 1970s, particularly among Latina whites and Asians. For Latina whites, birthplace is a significant predictor of risk. Women born in Mexico and Central and South America are at threefold to fourfold greater risk of malignant cystosarcoma phyllodes tumors than Latina whites born in the United States.

CONCLUSIONS

The epidemiology of malignant cystosarcoma phyllodes tumors of the breast is strikingly different from that of the more common histologic types of breast cancer. The high risk in Latina immigrants may offer an important clue as to the cause of this rare tumor.

Prostatic cystic epithelial-stromal tumors: a report of 2 new cases

The case records of 2 patients recently treated at our medical centers with prostatic cystic epithelial-stromal tumor (ages 22 and 62 years), as well as 14 cases previously reported in the literature were reviewed to obtain a consensus as to the therapy for this uncommon malignancy. Patients with prostatic cystic epithelial-stromal tumor often present with obstructive voiding symptoms and a palpable suprapubic mass. Computerized tomography typically reveals a huge, complex retrovesical mass with displacement of surrounding pelvic and abdominal structures, which may invade locally into the bladder, ureters or rectal wall. Our experience with immunohistochemical staining of these tumors suggests an epithelial component that is positive for prostate specific antigen, prostatic acid phosphatase, epithelial membrane antigen, chorioembryonic antigen and cytokeratin, and a stromal component that is positive for vimentin, desmin, cytokeratin and myosin. Rapid recurrences are the rule in patients in whom the tumor is incompletely resected. Histological evidence of malignant transformation and distant metastases has been reported in these neoplasms. An aggressive surgical approach aimed at total removal of this pelvic tumor will be discussed.

Metastatic cystosarcoma phyllodes associated with paraplegia: an uncommon complication of an uncommon tumor

Cystosarcoma phyllodes is a rare form of breast cancer that rarely metastasizes. This case represents the first reported case of a pathological spine fracture and neurologic injury as a result of metastatic cystosarcoma phyllodes. Physicians should be aware of a recently identified histological subtype of cystosarcoma that exhibits an increased incidence of hematogenous metastasis.

[Giant juvenile fibroadenoma in an adolescent. A case report]

Fibroadenomas occupy the first place, in terms of prevalence, among benign breast disorders in adolescent girls. Juvenile giant fibroadenoma is a special though rare form, which must be recognised in terms of differential diagnosis from virginal hyperplasia in its asymmetrical early form and phylloid tumours, the prognosis of which is different. The authors describe the clinical and pathological features necessary for diagnosis and report the results of breast reconstruction after excision via a lateral radial approach in a 14-year-old adolescent girl.

Phyllodes tumours: a clinicopathological review of 30 cases

Thirty cases of phyllodes tumour (cystosarcoma phyllodes) of the breast that presented to the Clinical Oncology Unit at Guy's Hospital were reviewed. Tumours were classified as benign, malignant or borderline according to the following histological criteria: mitotic rate, nuclear pleomorphism, stromal overgrowth and tumour margins. In 14 (46.5%) cases the tumours were considered histologically benign, in 11 (36.5%) malignant, and in five (17%) borderline. Recurrence was seen in a similar proportion of patients with tumours classified as benign (21%) and malignant (18%) according to histological criteria. Malignant lesions tended to recur earlier. Infiltrating tumour margins were noted in all patients and stromal overgrowth in all but one in whom recurrence was observed. Risk of recurrence also appeared to be related to tumour size. Only one patient developed distant metastases and died of her disease. Because of treatment variation no conclusion can be made regarding optimal therapy but the importance of adequate clearance, either through wide excision or mastectomy, is emphasized for all phyllodes tumours irrespective of histological features.

Phyllode tumor of the breast: mammographic experience in 99 cases

The clinically variable course of phyllode tumor with its complex histological picture--ranging from benign to malignant--poses problems for the preoperative diagnosis and, in particular, the therapeutic approach. Mammograms of 99 patients with this disease, observed and treated from 1975 to 1989, were reviewed to determine mammographic/histologic correlations useful for early diagnosis. Opacity, size, shape, margin characteristics, the presence of calcifications and radiolucent halo were determined from the mammograms. The most useful characteristics were opacity and the character of the tumor's margins. However, mammographic features alone could not distinguish phyllode tumor from fibroadenoma.

Fibrosarcoma of the breast: mammographic findings in five cases

The mammographic features of fibrosarcoma of the breast, a rare malignant tumor, have not been described. Accordingly, we reviewed the mammograms, pathology reports, and medical records of five women with this tumor. All cases had surgical biopsies and a diagnosis made by histologic evaluation. The age of the patients ranged from 48 to 79 years. Histologically, three of the five fibrosarcomas were thought to have arisen from phyllodes tumor, and four were palpable. On mammograms, the tumors were dense masses with largely indistinct margins, ranging from 1.5 to 7.0 cm in diameter. One contained calcified osseous elements suggesting osseous trabeculae. Although the osseous trabeculae in that tumor strongly suggested sarcoma, most of the tumors had a nonspecific appearance on mammograms. Fibrosarcomas of the breast have a nonspecific mammographic appearance. Surgical biopsy and histologic evaluation are necessary for definitive diagnosis.

[The mammographic and sonographic clinical picture of cystosarcoma phyllodes]

Cystosarcoma phylloides is characterized by frequent local recurrences, by questionable tumour status and by the often large size or extension. This very rare tumour is mentioned in the literature mostly as a case report. During 1974-1989 a group of 15 cases could be collected. Starting with the different pathological and anatomical features, the typical mammographic and sonographic criteria are described. The outline of the tumour is smooth and often lobulated. The solid component has echo levels lower than the surrounding breast tissue and is mostly homogeneous. Some parts may be cystic. Endotumoral calcifications are very rare. In all cases a zone of dorsal acoustic enhancement was seen. Differential diagnosis is discussed. In large breast tumours with slow and episodic growth, the tentative diagnosis cystosarcoma phylloides should be considered more often.

Malignant Cystosarcoma phyllodes: report of two cases

Two cases of malignant Cystosarcoma phyllodes seen in Jos University Teaching Hospital over a 9-year period are being reported. One occurred in a 16-year girl now dead and the other in a 52-year old woman probably dead. Both cases showed metastases, the axillary nodes being involved in the deceased, cervical nodes in the elderly patient, and both had pulmonary and presumably hepatic metastasis. These were the 2 cases seen out of a total of 696 surgical breast specimens reviewed thus constituting 0.3 percent. It is not certain if chemotherapy has been beneficial but one might need more cases well organised trials to arrive at definitive conclusions.

Cystosarcoma phyllodes--Asian variations

Cystosarcoma phyllodes afflicting 106 female patients in a multiracial Asian society is reviewed and some interesting variations are noted when compared with Western patients. The incidence of phyllodes tumour is 3.83% of surgically removed breast tumours compared with 0.5-2.5% in Western series. This lends weight to the belief that non-Caucasians are more prone to this enigmatic breast disease than the Caucasian population. The profile of the Asian phyllodes patient is that of a young female, aged 25-30 years, whereas her Western counterpart is in her 40s. As a result, she is liable to be mistaken clinically as having fibro-adenoma. The disease is notably rare among the females below 20 years of age but in the Asian context, as much as one-quarter-one-third may be in the adolescent group. There were only three malignant and six borderline phyllodes tumours out of 106 cases, and this incidence is far below that of many other studies in which the malignant cases are believed to constitute 23-27%. However, this may not be a racial variation but explicable by the fact that the present study is an unselected cohort from a general surgical unit. The presence of associated benign breast disease in 25.5% cases helps to reinforce the widely held belief that fibro-adenoma and phyllodes tumour are related to some degree.

Cystosarcoma phyllodes in young women

A total of eight cases of cystosarcoma phyllodes in women under 25 years of age were reported to the Swedish Cancer Registry during a ten-year period (1960 to 1969). Only one of these tumors was malignant. It was successfully treated with simple mastectomy and postoperative radiation therapy. Of the remaining seven cases, six were treated with local excision of the lesion and one with simple mastectomy. In no case, did the tumor recur during a follow-up of an average of ten years. Local excision seems to be sufficient for the benign form of the tumor, whereas simple mastectomy is indicated for the malignant form. Radical mastectomy is indicated only of the tumor has invaded the pectoral fascia. The tumor rarely metastasizes to the axillary lymph nodes.

Metastatic cystosarcoma phylloides in an adolescent girl: an unusually malignant tumor

The first case of metastatic cystosarcoma phylloides in an adolescent is reported. This case also represents the first reported response of this tumor to chemotherapy and irradiation. This tumor showed an unusually rapid rate of cell division probably making it more susceptible to these agents. The importance of an early diagnosis and definitive excision is stressed.

Giant fibro-adenoma (cystosarcoma phyllodes) in adolescent females--a clinicopathological study

1. An analysis of the findings in a series of 25 cases of giant fibro-adenoma of the breast in adolescent females is presented together with a review of the relevant literature. The clinical features, histology, prognosis and treatment of these tumours are discussed.

2. Follow-up of from 2 to 8 years after total excision of the tumours has shown that normal breast development occurred in all the cases. There was no recurrence or distant metastasis.

3. Despite clinical features and histological characteristics suggestive of malignancy the tumour has been found in our experience to be strictly benign in patients under the age of 20 years.