Phyllodes breast tumor

Joint Hospital Surgical Grand Round26 April 2014

Ng Yuen Shan, Sandy(Tuen Mun Hospital)

Phyllodes tumor Rare fibroepithelial breast tumor (1% of all

breast tumors, 2.5% of all fibroepithelial tumors)

A spectrum of disease Epithelial and cellular stromal component Histological classification:

Benign (60%) Borderline (20%) Malignant (20%) distant metastasis

Median age of presentation at 40-50 years Palpable mass with rapid growth, large size

(>2cm) Poor pre-operative diagnostic accuracy

Case scenario

F/40 2.5cm L12H breast mass, interval growth. MMG/US: well-circumscribed lobulated mass FNAC: benign. Excisional pathology:

Benign phyllodes tumor Margin POSITIVE

Pok Oi Hospital A review of 28 consecutive patients with phyllodes

tumour excision in 2009-2012 in Pok Oi Hospital 11 operations performed for recurrent phyllodes tumour

(6 patients) have been excluded.

Operation type Indication Total no.

Margin +ve

Simple enucleation

Benign breast mass 5 3 (60%)

Wide local excision

Clinical/ pathological diagnosis of phyllodes tumour

20 2 (10%)

Mastectomy Large tumor-breast ratio, or suspicious malignant

4 1 (25%)

Margin status and histological grade

Involved Touch/ close <1 cm >/= 1 cm

Malignant 2 0 4 2

Borderline 1 2 3 3

Benign 3 3 3 3

Close follow-up

Margin-involved outcomes Age Grade Tumour

size (cm)Primary Operation

FU duration (months)

Lost to FU

Reoperation

Patient A 63 Malignant 3.2 WLE 48 No No

Patient B 48 Malignant 11 Mastectomy 18 No No

Patient C 42 Borderline 6 WLE 14 No Mastectomy for co-existing DCIS

Patient D 50 Benign 7.5 Enucleation 57 No Wide local excision for recurrent phyllodes

Patient E 21 Benign 3.5 Enucleation 35 Yes No

Patient F 40 Benign 2.2 Enucleation 47 No No

Mean FU period: 36 months

POH case series

Results:Local recurrence rate in margin-involved = 16.7%No recurrence was detected in close or clear margin.

Conclusion: Margin status of the primary resection is probably the most important factor in determining risk of recurrence.

Margin-involved phyllodes tumor

Why does it matter? What to do next? How to “prevent”?

Local recurrence

Spitaleri G, Toesca A, Botteri E, et al. Breast phyllodes tumor: a review of literature and a single center retrospective series analysis. Crit Rev Oncol Hematol. 2013 Nov;88(2):427-36.

Local recurrence

Study Stromal atypia Positive margin Necrosis Fibroproliferation

Asoglu, 2004 - + - -Chen, 2005 - + - -Barrio, 2007 - + + +Lenhard, 2007 - + - -Telli, 2007 + + - -Belkacemi, 2008

+ + + -

Associated factors:

Calhoun KE, Lawton TJ, Kim JN, Lehman CD, Anderson BO. Phyllodes tumors. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2010:781-792.

Disease-free survival curves of 42 patients treated with breast-conservative surgery for phyllodes tumor.

Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736

Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736

Margin-involved phyllodes tumor

Why does it matter? Predictor of local recurrence

What to do next? How to “prevent”?

Stromal growth as a predictive factor of local recurrence in positive margin cases One of the malignant features

Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736

If margin positive…

If margin positive…

Some authors had suggested “wait-and-see” policy for benign phyllodes tumor

Chua, 1989 (106 patients)

Zurrida, 1992 (216 patients): recurrence 8%

Chua CL, Thomas A, Ng BK. Cystosarcoma phyllodes: a review of surgical options. Surgery 1989;105(2 Pt 1):141-147Zurrida S, Bartoli C, Galimberti V, et al. Which therapy for unexpected phyllodes tumour of the breast? Eur J Cancer 1992;28(2-3):654-657

Management strategy ofMargin-involved phyllodes tumor

Benign “wait-and-see” Malignant Re-excision Follow-up every 6 months for initial 2-3 years

(highest chance of recurrence) Then yearly Self breast examination Clinical suspicion on follow-up: triple assessment

Margin-involved phyllodes tumor

Why does it matter? What to do next? How to “prevent”?

Phyllodes tumor

Difficult preoperative diagnosis…..

Phyllodes tumor – Initial workup

Clinical suspicious of phyllodes tumor- Palpable mass- Rapid growth- USG suggestive of fibroadenoma except for size (>2cm) / rapid growth

- History and P/E- USG- MMG for >30yo

Core needle biopsy

Fibroadenoma or indeterminate

Phyllodes tumor (benign, borderline, malignant)

Observe

Fibroadenoma

Excisional biopsy Wide excision (>=1cm) without axillary staging

Patient presentation Triple assessment

M D Anderson Cancer Center 2012

Margin-involved phyllodes tumor

Why does it matter What to do next How to “prevent”

?

Thank you

WHO classification

To improve preoperative diagnosisPaddington Clinicopathological Suspicion ScoreClinical findings

Sudden increase in size in a longstanding breast lesion Apparent fibroadenoma >3cm diameter or in patient >35

yearsImaging findings

MMG: Rounded borders/ lobulated appearance USG: Attenuation or cystic areas within a solid mass

FNAC findings Presence of hypercellular stromal fragments Indeterminate features

ANY 2 features mandate core biopsyR K Jacklin, P F Ridgway, P Ziprin, et al. Optimising preoperative diagnosis in phyllodes tumour ofthe breast. J Clin Pathol 2006;59:454–459.

Phyllodes tumor - Recurrence

Local recurrent breast mass after excision of phyllodes tumor

- History and P/E- MMG, USG- Core needle biopsy- Consider chest imaging

No metastatic disease Metastatic disease

Re-excision with wide margins without axillary staging

Consider post-op RT

As soft tissue sarcoma

Patient presentation Workup

M D Anderson Cancer Center 2012