Republic of the Philippines

Dr Paulino J. Garcia Memorial Research and Medical Center

Cabanatuan City

Department of Surgery

CASE REPORT

OBJECTIVES of this case report is to: 1. To present a rare case of malignant phylloides

cystosarcoma, review of current literatures, management, update,. 2. To discuss the correlation

between phylloides tumor and pregnancy 2. Discuss disease progression, prognosis, and prevent

fatal outcome, 3.Promote patients education

A case of P.H. 41 y/o female, single, roman catholic, presently residing in Lambakan,

Jaen, Nueva Ecija, born on August 28, 1971 who came in with a chief complaint of right breast

mass.

The present condition started at about 8 years PTA, when the patient was diagnosed as

Low Grade Phylloides Tumor and underwent Total Mastectomy right.

Since then no follow-up was done and went unremarkable. Until 1 year PTA, when the

patient became pregnant, G1P0, she noticed a mass on the previous incision site of her right

chest areat no consult was done. Until 10 months PTA, patient had a spontaneous abortion at 16

weeks AOG, the mass progressively enlarged into 5x7 cm with ulceration and draining

abscesses. She sought consult with an OB Gyne, completion curettage was done and was then

referred at this institution for further management of tumor recurrence. But due to financial

constraint, patient failed consult.

3 months PTA, patient breast mass size progressively enlarged to 12x15cm with

ulcerations and draining sinuses. Still no consult was done.

1 month PTA, the size of the breast mass increased to 25x40cm with associated weight

loss and body weakness. Patient sought consult at our institution. Incision biopsy of the mass

was done revealing ____________________. Patient was advised for consult to oncologist for

neoadjuvant therapy. But patient cannot afford for the therapy and patient was given an option of

tumor rebulking. Patient was then cp cleared and was admitted for operation.

Past Medical History

8 years PTA, patient underwent total mastectomy right secondary to low grade phylloides, right.

Patient was a diagnosed case of Diabetes mellitus 1 year prior to admission with maintenance

medication of metformin 500mg TID

8 months prior to admission, patient admitted due to incomplete abortion PU+- 14 wks AOG and

underwent completion curettage.

Obstetrics and Gynecologic History: revealed the following Data: LMP: April 14 2012,

Menstruation: at 10 years of age, with irregular interval, for 3to5 days, amount varies from

moderate-markedly soaked pad per period, no apparent symptoms of dysmenorrheal seen.

Patient is a G1P0 (0-0-1-0) Incomplete abortion PU+ 14 weeks AOG underwent completion

curettage (Npvember 2011). No history of oral contraceptive pill therapy. Family History: A

known family of Diabetics: the patient is the eldest of four siblings. No history of breast cancer.

No other heredofamilial disease extracted. Social Environmental History: Subject is a non

smoker and a non alcoholic beverage drinker graduate as an average student of high school at

16years old.

Review of Systems revealed: GENERAL: (-) wt. loss, (-) anorexia ; HEENT: (-) icteric

sclera (-) seizure, (-)changes in sensorium, (-) epistaxis, (-)ear discharge, deafness,

CARDIOVASCULAR: (-) chest pain, (-)chest heavines, (-) palpitation, CHEST AND LUNGS:

(-) orthopnea, (-)Dyspnea, (-)shortness of breath, GASTROINTESTINAL: (-) occasionally

skip meals, (-)constipation (-) loose stool, (-)black tarry stool, GENITOURINARY: (-)

frequency,urgency, (-) hypogastric, (-)dysuria, (-) Discharges, MUSCULOSKELETAL: (-) joint

and muscle pain, SKIN: (-) jaundice, HEMATOLOGIC:(-) bruise

Physical Examination: At the ER: patient was conscious, coherent, awake, oriented,

ambulatory not in cardio pulmonary distress, afebrile. Vital Signs: BP: 120/80 CR:84 RR: 18

T: 36.7’C; Spo2: 98% at 2lpm, Wt= 59.2kg.

SKIN : no pallor, no cyanosis, no jaundice, no active dermatoses,

HEENT: pinkish-white eyebrow, pale palpebral conjunctiva, anicteric sclerae, no nasoaural

discharges, moist buccal mucosa, no gingival hemorrhages, no tonsilopharyngeal wall

congestion, no cervical lymphadenopathy, no neck vein engorgement.

BREAST: Right: 30x40cm movable, non tender, ulcerating with yellowish discharge breast mass

with palpable axillary lymph nodes

Left: no palpable mass, no axillary lymph node

CHEST: Symmetrical wall expansion, infection, no intercostals retraction, clear breath sounds,

no crackles and wheezes noted

HEART: Adynamic precordium, Normal rate regular rhythm, no murmur, PMI 5th ICS (L) MCL

ABDOMEN: flabby, no previous surgical scar, normoactive bowel sounds NABS, soft, no

tenderness elicited, no hepatosplenomegaly noted,

DRE: good sphincter tone, no pararectal tenderness, no palpable mass, full rectal vault, no blood,

no black tarry stool, positive stool on examining finger

EXTREMITIES: full and equal pulses, No bipedal edema, all are gross normal

Neurologic Examination revealed the following

Cerebral: conscious, awake, coherent, in an appropriate mood, oriented to 3spheres

cerebellar: no dysmetria, no dysdiadochokinesia, no intentional tremors, negative Romberg’s

sign

Cranial Nerve test: CRANIAL NERVE I can smell; CRANIAL NERVE II: photophobia,

3to4mm OU, ERTLA; CRANIAL NERVE Ill. IV. Vl: intact EOM’s; CRANIAL NERVE V : (+)

corneal reflex; CRANIAL NERVE VII: no facial asymmetry; CRANIAL NERVE VIII: can

hear; VESTIBULAR DIVISION; CRANIAL NERVE IX ,X good swallow reflex; CRANIAL

NERVE XI: shrugs shoulder full range; CRANIAL NERVE XII: no tongue deviation; no

weakness noted;

Motor: 5/5, full ROM, against gravity and resistance in all extrimities ; Sensory: 100% sensation;

Reflexes: ++/normoreflex; (-)babinski, (-)kernigs, (-)clonus.

Given the case presented: Salient points include:

Our initial impression: Malignant Phylloides Right s/p total mastectomy, right (2004;

PJGMRMC) secondary to low grade Phylloides tumor right

Differential Diagnosis:

Conditions to consider in the differential diagnosis of phyllodes tumors include the following:

Angiosarcoma Breast cancer Juvenile fibroadenoma Giant fibroadenoma Inflammatory carcinoma Sclerosing adenosis Radial scar Fat necrosis Fibrocystic change Breast abscess Adenocarcinoma Mastitis

Figure 1. Diagnostic Algorithm

Course in the ward:

Initial plan: For correction of anemia

For nutritional work up

For possible Subtotal gastrectomy with billroth II reconstruction after Cardiopulmonary

clearance

Patient was admitted and managed as table below:

Diagnostics Therapeutics

Cbc, blood typing, APC

Ctbt

PT, PTT

CXR-pa

12lead ECG

LIPID Profile

FBS, BUN, CREA

Serum Na/K

Pnss at KVO

Celecoxib 200mg BID

Coamoxiclav 625 mg BID

Aminoblend OD

Humulin R

Glimeperide 20mg OD PO

Diltiazem 30mg OD PO

Phytomenadione 10mg q 6 hrs

Ranitidine 50mg q 8 hrs

RESULTS:

1. Complete Blood Count Result: revealed anemia with,

5-09-12 5-12-12

Hgb 97 102

Hct 0.30 0.31

RBC ct

WBC ct 7.27 10

Neutro .68 0.74

Lympho .32 0.26

Plt ct 260 447

BT ‘O+’

2. A. Protime : 15.3 secs (10-15 secs)

%activity: 50% ( 70-130%)

B. APTT : 28.3 secs ( 27-38secs)

3. Clotting time: 6 mins ( 3-5minutes)

Bleeding time: 4mins, 45 secs ( 2-6 minutes)

4. Lipid Profile

cholesterol : 166.4 mg/dl (<200mg/dl)

triglycerides: 120.3 mg/dl (60-150mg/dl)

HDL cholesterol:29 mg/dl (40-70mg/dl)

LDL cholesterol: 113.34 mg/dl (<150mg/dl)

5. Blood Chemistry:

Fasting blood sugar: 107.9 mg/dl ( 70-105mg/dl)

Creatinine: 1 mg/dl ( 0.5-1.7 mg/dl)

6. Serum electrolytes

Sodium: 150.3 mmol/L (135-155mmol/L)

Potassium: 3.14 mmol/L ( 3.4-5.3mmol/L)--------corrected to 3. 59mmol/L

Chloride: 114. 9 mmo/L ( 96-106mmol/L)

Calcium: 1.06mmol/L (1 -1.3 mmol/L)

7. Urinalysis:

Glucose: negative Protein: positive 1 Pus cells : 10-15/hpf Red blood cells : 2-4/hpf

8. Chest Xray:

Dome shaped soft tissue density noted at the lower 2/3 of right chest area obliterating the

right cardiac border, right hemidiaphragm and costophrenic sinus.

9. 12Lead ECG

normal sinus rhythm

10. Mammography of left breast: small breast nodule left lateral aspect; axillary

lymphadenopathies

Intraoperative

FINAL DIAGNOSIS

______________________________________________________________________________

Case Discussion:

Introduction:

The cysto-sarcoma phylloides (CP) tumors of the breast are fibroepithelial tumors which are

rarely seen and have potential recurrence [1-4]. Its name is derived from the Greek words

sarcoma, meaning fleshy tumor, and phyllo, meaning leaf. CP tumors about which a great deal

of studies have been done, was clinically identified first by Muller in 1838. Less than 1 % of all

the breast tumors consist of CP tumors [4]. Phyllodes tumors can appear in any age group of

women, although it is seldom seen in girls [5,6,]. CP tumors are the ones which are not considered

initially in clinical diagnosis, show slow or rapid growth pattern, and are diagnosed after biopsy.

These rarely encountered tumors are typically seen as mobile masses in the diameter of 5

centimeters and more. Nevertheless, CP’s with diameter of 40centimeters are reported in the

literature [7]. CP tumors which are clinically similar to fibroadenomas are distinguished

histopathologically by their cellular pattern, having increased cellular atypical changes and

excessive stromal growth. CP tumors typically have more frequent local recurrence and higher

malignancy compared with fibroadenomas. Grossly, the tumor displays characteristics of a

large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial,

cystlike spaces when viewed histologically. The malignant variety of the phylloides tumor is rare

with <1% occurrence. Metastasis is usually hematogenous, and axillary lymph node dissection is

not routinely performed. [8]

Phyllodes tumor during pregnancy grows fast and its size is relatively big. Malignant phylloides

tumors are exceedingly rare with few cases being reported in pregnancy. Blaker et al describe the

first case ever reported of a malignant phylloides tumor presenting in the first trimester of

pregnancy and provide insight into the complexities of management as well as a review of the

known literature. Six other cases of phylloides tumor presenting in pregnancy have been reported

in the literature, one of which had bilateral disease. Of these, the average patient age was 32

years (range, 28 to 35 years). The majority of these patients presented in their third trimester

(mean, 29 weeks; range, 20 to 36 weeks) and often had large tumors (mean, 15 cm; range, 5 to

21 cm). Four of the seven tumors (57%) required a mastectomy. Previous cases have shown

phylloides tumors to present in the third trimester as large masses that require mastectomy. With

early detection, malignant phylloides tumors can present in the first trimester of pregnancy at

smaller sizes; in these patients, breast-conserving surgery is possible. [9]

DIAGNOSTIC CRITERIA Usually large and grossly circumscribed

Fibroepithelial proliferation with broad "leaf-like" papillae inserting into slit-lilke or cleft-like spaces

- Exaggerated intracanalicular pattern

Cellular stroma- Periductal stromal condensation may seen

Frankly sarcomatous stroma may be seen in malignant phyllodes tumor- Heterologous differentiation may occur in malignant phyllodes tumor

A. Liposarcoma B. Osteosarcoma

C. Chondrosarcoma D. Rhabdomyosarcoma

Grading determined by presence or absence of atypical stromal features

Benign Versus Malignant Phyllodes Tumors

Because of limited data, the percentage of benign versus malignant phyllodes tumors is not well

defined. Reports suggest, however, that about 85-90% of phyllodes tumors are benign and that

approximately 10-15% are malignant.[4-10]

Although the benign tumors do not metastasize, they have a tendency to grow aggressively and

can recur locally.[2-11] Similar to other sarcomas, the malignant tumors metastasize

hematogenously. Unfortunately, the pathologic appearance of a phyllodes tumor does not always

predict the neoplasm's clinical behavior; in some cases, therefore, there is a degree of uncertainty

about the lesion's classification.

The characteristics of a malignant phyllodes tumor include the following[5-12] :

Recurrent malignant tumors seem to be more aggressive than the original tumor

The lungs are the most common metastatic site, followed by the skeleton, heart, and liver

Symptoms of metastatic involvement can arise from as early as a few months to as late as

12 years after the initial therapy

Most patients with metastases die within 3 years of the initial treatment[6-13]

No cures for systemic metastases exist

Roughly 30% of patients with malignant phyllodes tumors die from the disease

Frequency

Phyllodes tumors account for less than 1 percent of all breast tumors. The malignant variety of

the phylloides tumor is rare with <1% occurrence.

Race

As far as is known, phyllodes tumors occur with the same frequency in women of all races and in

all parts of the world.

Sex- and age-related demographics

Phyllodes tumors occur almost exclusively in females, although rare case reports have been

described in males. The tumors can develop in people of any age; however, the median age is the

fifth decade of life.

History

Phyllodes tumors generally manifest as larger masses and display rapid growth. A small mass

may rapidly increase in size in the few weeks before the patient seeks medical

attention.Phyllodes tumor include the rapid but painless growth of a smooth, bulky mass within

the affected breast. The patient may notice that her entire breast is enlarged and its shape

distorted. The skin over-lying the tumor may feel warm to the touch and develop a shiny

appearance; it may also become translucent. Tumors rarely involve the nipple-areola complex or

ulcerate to the skin. Patients with metastases may present with such symptoms as dyspnea,

fatigue, and bone pain.

Physical examination

A firm, mobile, well-circumscribed, nontender breast mass is appreciated. Curiously,

cystosarcoma phyllodes tends to involve the left breast more commonly than the right one.

Overlying skin may display a shiny appearance and be translucent enough to reveal underlying

breast veins. Physical findings (ie, the occurrence of mobile masses with distinct borders) are

similar to those of fibroadenoma.[3-14]

The median size of phyllodes tumors is around 4 cm [1]. Twenty percent of tumors grow larger

than 10 cm, the arbitrary cut off point for the designation as a giant tumor. These tumors can

reach sizes up to 40 cm in diameter [2].

Journal of Surgical Oncology 2008, 6:117 doi:10.1186/1477-7819-6-117 Giant breast tumors: Surgical management of phyllodes tumors,potential for reconstructive surgery and a review of literatureMargaret I Liang1, Bhuvaneswari Ramaswamy2, Cynthia C Patterson1,Michael T McKelvey3, Gayle Gordillo4, Gerard J Nuovo5 andWilliam E Carson III*6Address: 1The Ohio State College of Medicine, Columbus, Ohio, USA, 2The Ohio State University Department of Haematology-Oncology, ArthurG. James Cancer Hospital and Richard J. Solove Research Institute, Division of Internal Medicine, Columbus, Ohio, USA, 3The Ohio StateUniversity Division of Dermatology, Columbus, Ohio, USA, 4The Ohio State University Division of Plastic Surgery, Columbus, Ohio, USA, 5TheOhio State University Department of Pathology, Columbus, Ohio, USA and 6The Ohio State University Department of Surgery, Arthur G. JamesCancer Hospital and Richard J. Solove Research Institute, Division of Surgical Oncology, Columbus, Ohio, USA

Differential Diagnosis

Conditions to consider in the differential diagnosis of phyllodes tumors include the following:

Angiosarcoma Breast cancer Juvenile fibroadenoma Giant fibroadenoma Inflammatory carcinoma Sclerosing adenosis Radial scar Fat necrosis Fibrocystic change Breast abscess Adenocarcinoma Mastitis

Juvenile Fibroadenoma Low Grade Phyllodes Tumor

No leaf-like architecture Prominent leaf-like architectureNo condensation around ducts Stromal condensation around ductsDoes not infiltrate May infiltrate surrounding breast***The histologic border between these two is not always sharp

Juvenile Fibroadenoma High Grade Phyllodes TumorNo stromal atypia Atypical stromaStromal mitotic rate < 3/hpf Elevated stroma mitotic rateNo stromal overgrowth Stromal overgrowthDoes not infiltrate May infiltrate surrounding breast ***Stromal overgrowth defined as at least one low power field (40x total magnification) composed entirely of stroma

Fibroadenoma Low Grade Phyllodes TumorLacks significant stromal hypercellularity Hypercellular stroma is prominentNo stromal overgrowth May have stromal overgrowthNo leaf-like architecture Prominent leaf-like architectureNo condensation around ducts Stromal condensation around ductsDoes not infiltrate May infiltrate surrounding breast***The histologic border between these two is not always sharp

Metaplastic Carcinoma Phyllodes TumorSpindled component may be positive for high molecular weight keratin or p63

Stromal component negative for high molecular weight keratin and p63

Epithelial component is malignant Epithelial component is benignSquamous differentiation may be present No squamous differentiation

Pure Sarcoma of the Breast Very rare The presence of an epithelial component defines phyllodes tumor

 Fibromatosis

Bland spindle cells Stellate configuration Absence of intrinsic epithelial component

May entrap normal breast lobules Myofibroblastoma

Resembles solitary fibrous tumor

Lacks intrinsic epithelial component

Biopsy and Histology

Open excisional breast biopsy for smaller lesions and incisional biopsy for large lesions are the

definitive methods for diagnosing phyllodes tumors.

Fine-needle aspiration for cytologic examination usually is inadequate for the diagnosis of

phyllodes tumors. Core biopsy is more reliable, but there still can be sampling errors and

difficulty in distinguishing the lesion from a fibroadenoma.

All phyllodes tumors contain a stromal component that can vary significantly in histologic

appearance from one lesion to another.[7] In general, benign phyllodes tumors demonstrate a

markedly increased number of regular fusiform fibroblasts in the stroma. Occasionally, highly

anaplastic cells with myxoid changes are observed. A high degree of cellular atypia, with

increased stromal cellularity and an increased mitotic count, is almost always observed in the

malignant form of cystosarcoma phyllodes.

Micrograph of a phyllodes tumor (right of image) with the characteristic long clefts and myxoid cellular stroma. Normal breast andfibrocystic change are also seen (left of image). H&E stain

Fig.1. Panoramic view of the tumor showing tubular and malignant adipose components (H&E, x 40)Fig.2.

Fig.2. Stromal component with liposarcomatous differentiation (H&E, x 100)

Fig.3. Leaf-like projections characteristic of phyllodes tumor (H&E, x 40)

Fig.4. Tubular component with juxtaposed regular mammary lobules (H&E, x 40)

Ultrastructurally, in the benign and malignant forms of phyllodes tumors, nucleoli may reveal a coarsely meshed nucleolonema and abundant cisternae in the endoplasmic reticulum.

Laboratory and Imaging Studies

Laboratory studies

No specific hematologic tumor markers or other blood tests can be used to diagnose

cystosarcoma phyllodes.[7]

Imaging studies

Although mammography and ultrasonography generally are important in the diagnosis of breast

lesions, they are notoriously unreliable in differentiating benign cystosarcoma phyllodes from the

malignant form of the condition or from fibroadenomas. (The phyllodes tumor’s mammographic

appearance, as a round density with smooth borders, is similar to that of fibroadenoma.) Thus,

findings on imaging studies are not definitively diagnostic of phyllodes tumors.[8]

Clinical Staging, Treatments, and Prognosis

Staging

Phyllodes tumors are not staged in the usual sense; they are classified on the basis of their

appearance under the microscope as benign, borderline (or indeterminate), or malignant. The

pathologist makes the decision on the basis of the cells' rate of division (mitosis) and the number

of irregularly shaped cells in the biopsy sample. In one series of 101 patients with phyllodes

tumors, 58 percent were identified as benign, 12 percent as borderline, and 30 percent as

malignant.

GradingAdverse features

Stromal overgrowth (> one 40x field without epithelium) High mitotic index (>10 /10 hpf) Sarcomatous stroma (stromal nuclear pleomorphism and atypia) Infiltrative margin

Benign

No adverse features 20% recurrence rate after local excision 10% recurrence rate after wide excision (at least 1 cm margin) No reported metastases

Borderline One or more adverse features but short of definition for malignant (see below) 45% recurrence rate after local excision 30% recurrence rate after wide excision (at least 1 cm margin) No reported metastases

Malignant High mitotic index and sarcomatous stroma OR Stroma overgrowth and either high mitotic index or sarcomatous stroma 65% recurrence rate after local excision 35% recurrence rate after wide excision (at least 1 cm margin) 30% metastatic rate

Staging Not applicable

Report Grade Size Margin status Presence and type of heterologous differentiation

Treatments

Multidisciplinary approach

The treatment team for a patient with a phyllodes tumor will usually include a diagnostic

radiologist, a gynecologist, a general surgeon, oncologist and a pathologist

Surgical excision is the usual treatment for phyllodes tumors, whether benign or malignant. In

the case of benign tumors, the surgeon will usually try to spare as much breast tissue as possible,

generally removing about 1 in (2 cm) of normal breast tissue from the area around the tumor as

well as the tumor itself. If the tumor is very large, however, the doctor may remove the entire

breast.

Tumor Excision and Mastectomy

Complete excision, with accurate histologic examination and continued follow-up care, is the

best way to treat phyllodes tumors. In most cases of cystosarcoma phyllodes, perform wide local

excision, with a rim of normal tissue included.[9, 10, 11] No absolute rules on margin size exist.

However, a 2cm margin for small (< 5cm) tumors and a 5cm margin for large (>5cm) tumors

have been advocated.

The lesion should not be "shelled out," as might be done with a fibroadenoma, or the recurrence

rate will be unacceptably high.[6]

If the tumor-to-breast ratio is sufficiently high to preclude a satisfactory cosmetic result by

segmental excision, total mastectomy, with or without reconstruction, is an alternative. More

radical procedures are generally not warranted.[10]

Perform axillary lymph node dissection only for clinically suspicious nodes. However, virtually

all of these nodes are reactive and do not contain malignant cells.[12]

Postoperative complications

As with most breast surgery, postoperative complications from the surgical treatment of

phyllodes tumors include the following:

Infection

Seroma formation

Local and/or distant recurrence

Adjuvant therapy

There is no proven role for adjuvant chemotherapy or radiation therapy in the treatment of

phyllodes tumors. Response to chemotherapy and radiotherapy for recurrences and metastases

has been poor, and no success with hormonal manipulation has been documented.

Alternative and Complementary Therapies

Women who have had surgery for removal of a phyllodes tumor appear to use CAM therapies as

often and for the same reasons as women treated for breast cancer. According to the Behavioral

Research Center of the American Cancer Society, breast cancer survivors are highly likely to use

some form of alternative or complementary therapy during cancer treatment or within a year or

two of completing conventional treatment. A survey of 608 longer-term (8 years or longer)

breast cancer survivors reported in early 2005 that the majority were still using CAM therapies.

The survey respondents gave four reasons for using alternative treatments:

To maintain an active role in recovery from cancer.

To reduce their stress level.

To reduce the risk of recurrence.

To maintain hope.

Specific CAM therapies mentioned by the women in the ACS survey included exercise, humor,

self-help books (bibliotherapy), prayer or spiritual practice, vitamin treatments, relaxation

exercises, and support groups. Dr. Kenneth Pelletier, the former director of the program

in complementary and alternative medicine at Stanford University School of Medicine,

lists hypnosis, visualization, naturopathy, and journaling as other alternative approaches that

breast cancer patients find helpful. Acupuncture is frequently mentioned as a useful method of

pain control.

Coping With Treatment

Coping with the aftereffects of surgery for a phyllodes tumor is similar to coping with the effects

of surgery for breast cancer. Patients who have had a complete mastectomy may experience pain,

limited range of motion or weakness in the affected arm, scarring, or swelling.

Exercises, outpatient physical therapy, and massage help to relieve these side effects of breast

surgery. In terms of follow-up, most patients treated for phyllodes tumors are scheduled for

a postoperative visit with the surgeon 1–2 weeks after surgery, with periodic checkups thereafter.

Clinical Trials

The National Cancer Institute (NCI) is not conducting any clinical trials involving phyllodes

tumors as of 2005. There is, however, an ongoing study at the Dartmouth-Hitchcock Medical

Center in New Hampshire of the effectiveness of radiation therapy in preventing recurrences of

borderline or malignant phyllodes tumors in patients who have been treated with local excision

of the tumor. Women who have had a borderline or malignant phyllodes tumor removed within

the past three months may wish to consider participating in this study.

Prognosis

The prognosis for benign phyllodes tumors is good following surgical removal, although there is

a 20–35 percent chance of recurrence, particularly in patients over the age of 45. Recurrence is

usually treated with further surgery, either another local excision or a complete mastectomy.

The prognosis for patients diagnosed with borderline or malignant phyllodes tumors is more

guarded. About 4 percent of borderline tumors will eventually metastasize. A Mayo Clinic study

of 50 patients with malignant tumors found that 32 percent had a recurrence within two years

after surgery; 26 percent developed metastases, and 32 percent of the group died from

their malignancy. The most common sites for metastases from malignant phyllodes tumors are

the lungs, bones, liver, and chest wall, although metastases to the lymph nodes have also been

reported. Most patients with metastases from a malignant phyllodes tumor die within three years

of their first treatment.

Prevention

There is no way to prevent phyllodes tumors as of the early 2000s because their cause is not yet

known.

Outpatient Care

Although specific guidelines regarding follow-up care for phyllodes tumors are limited because

of the rarity of these lesions, regular, long-term follow-up care should be performed to detect

possible local recurrences.

An initial visit 1-2 weeks after surgery to detect any initial complications should be followed by

periodic visits as determined by the patient's surgeon. A reasonable schedule might be physical

examinations every 6 months and mammograms yearly for at least 5 years. Carefully observe

patients for any possible recurrence.

References

1. Carter BA, Page DL. Phylloides tumor of the breast: Local recurrence versus metastatic capacity. Hum Pathol. 2004; 35: 1051-1052

2. Korula A, Varghese J, Thomas M, Vyas F, Korula A. Malignant phyllodes tumour with intraductal and invasive carcinoma and lymph node metastasis. Singapore Med Journal 2008; 49(11); e318

3. Moffat CJC, Pinder SE, Dixon AR, Elaston CW, Blarney RW, Elis IO. Phyllodes tumors of the breast: a clinicopathological review of thirty-two cases. Histopathology. 1995;27:205-218.

4. Reinfuss M, Mitus J, Duda K, Stelmach A, Rys J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast – analysis of 170 cases. Cancer 1996;77: 910-16.

5. Carter BA, Page DL. Phylloides tumor of the breast: Local recurrence versus metastatic capacity. Hum Pathol. 2004; 35: 1051-1052

6. Korula A, Varghese J, Thomas M, Vyas F, Korula A. Malignant phyllodes tumour with intraductal and invasive carcinoma and lymph node metastasis. Singapore Med Journal 2008; 49(11); e318

7. Moffat CJC, Pinder SE, Dixon AR, Elaston CW, Blarney RW, Elis IO. Phyllodes tumors of the breast: a clinicopathological review of thirty-two cases. Histopathology. 1995;27:205-218.

8. Reinfuss M, Mitus J, Duda K, Stelmach A, Rys J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast – analysis of 170 cases. Cancer 1996;77: 910-16.

9. Blaker KM, Sahoo S, Schweichler MR, Chagpar AB. Malignant phylloides tumor in pregnancy Department of Surgery, University of Louisville, Louisville, Kentucky, USA.

10. Jones AM, Mitter R, Poulsom R, et al. mRNA expression profiling of phyllodes tumours of the breast: identification of genes important in the development of borderline and malignant phyllodes tumours. J Pathol. Dec 2008;216(4):408-17. [Medline]

11. Parker SJ, Harries SA. Phyllodes tumours. Postgrad Med J. Jul 2001;77(909):428-35. [Medline]. [Full Text].

12. Abe M, Miyata S, Nishimura S, Iijima K, Makita M, Akiyama F, et al. Malignant transformation of breast fibroadenoma to malignant phyllodes tumor: long-term outcome of 36 malignant phyllodes tumors. Breast Cancer. Oct 2011;18(4):268-72. [Medline].

13. Brooks HL, Priolo S, Waxman. Cystosarcoma phylloides: a case report of an 11-year survival and review of surgical experience. Contemp Surg. 1998;53:169-72.

14. Yohe S, Yeh IT. "Missed" diagnoses of phyllodes tumor on breast biopsy: pathologic clues to its recognition. Int J Surg Pathol. Apr 2008;16(2):137-42. [Medline].

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1. Hoover HC. Cystosarcomas of the breast. In: Raaf JH, ed. Soft Tissue Sarcomas: Diagnosis and Treatment. St Louis, Mo: Mosby; 1993:113-21.

2. Parker SJ, Harries SA. Phyllodes tumours. Postgrad Med J. Jul 2001;77(909):428-35. [Medline]. [Full Text].

3. Yohe S, Yeh IT. "Missed" diagnoses of phyllodes tumor on breast biopsy: pathologic clues to its recognition. Int J Surg Pathol. Apr 2008;16(2):137-42. [Medline].

4. Jones AM, Mitter R, Poulsom R, et al. mRNA expression profiling of phyllodes tumours of the breast: identification of genes important in the development of borderline and malignant phyllodes tumours. J Pathol. Dec 2008;216(4):408-17. [Medline].

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