LETTER TO THE EDITOR

Giant Recurrent Phyllodes Tumors of the Breast:Treatment Dilemmas and Literature Review

To the Editor:

Phyllodes tumor represents 0.3–0.5% of all breast

neoplasms. It has an incidence of 2.1 million and can

occur at any age from 10 to 90 peaking in women

45–49 years (1,2). Histologically, they are fibroepithe-

lial neoplasms, consisting of epithelial and stromal

components. Only stromal cells have the potential to

metastasize. The malignant character of the phyllodes

tumor is therefore confirmed by the microscopic

appearance of stroma (3).

Clinical and imaging presentation of phyllodes

tumors is similar to fibroadenomas. Therefore, phyll-

odes tumors can become extremely difficult to differ-

entiate from fibroadenomas, often leading to delay in

diagnosis and mismanagement.

In 1983, Cole-Beuglet et al. described the radio-

graphic characteristics of phyllodes. It was suggested

sonographic findings of cystic spaces with low-level

internal echoes, smooth walls, and good through

transmission within a large, lobulated, solid breast

mass should indicate the diagnosis of phyllodes tumor

(4). In a recent review, Chao et al. identified three

sonographic features that are characteristic of these

tumors: well-circumscribed, lobulated masses, hetero-

geneous internal echo patterns, and a lack of micro-

calcifications (5).

Magnetic resonance imaging (MRI) is also investi-

gated in phyllodes tumor imaging. Kinoshita et al. ret-

rospectively reviewed MRI findings in eight patients.

They concluded that a benign tumor includes a lobu-

lated or polygonal shape with smooth borders, cystic

or septated features, and a gradual or rapid pattern of

time-signal intensity curve. It was difficult to differen-

tiate a small phyllodes tumor from a small fibroade-

noma (6,7).

Along with multiple imaging modalities, fine needle

aspiration has been used to improve preoperative

diagnosis. However, reports are not promising (1,2,6).

The fact that phyllodes tumor shares multiple cyto-

logic features with fibroadenoma, and it makes the

differentiation very difficult based on cellular morpho-

logical bases (5,6). Core needle biopsy not only pro-

vides cytologic features, but also delineates the

structural characteristics of tumors.

The WHO grading criteria classifies phyllodes

tumors as benign, borderline, or malignant, depending

on the morphology of the stromal component (8).

Fifteen to 30% of phyllodes tumors are malignant.

Malignant tumors have distinct cellular and nuclear

polymorphisms and increased mitoses in the stromal

component. Tumors classified as malignant and bor-

derline have metastatic potential.

Reinfuss et al. used histotype criteria developed by

Salvadori et al. to determine the correlation between his-

topathologic type and prognosis. They reported 5-year

survival was 95.7% for benign tumors, 73.7% for bor-

derline tumors, and 66.1% for malignant tumors (1).

Histopathologic criteria suggesting poor clinical

prognosis include necrosis, severe atypia, three or

more mitotic figures per high-power field, and tumor

infiltration through margins. Stromal overgrowth and

morphology other than fibromyxoid are also poor

prognostic factors. Duration of symptoms, growth

rate of the tumor, and age of the patient have not

been shown to affect prognosis (9).

While 20% of patients with phyllodes tumors have

axillary lymphadenopathy on initial presentation, a

mere 5% of these patients have histologically con-

firmed metastatic disease (1,9). A retrospective study

by Kessinger et al. did not find any epithelial compo-

nents in these lesions. Rather, all metastases exhibited

only stromal morphology. Indicating, malignant

tumors may behave similarly to sarcomas and there-

fore metastasize primarily hematogenously. As true

lymphatic metastases are rare, most authors agree that

axillary lymph node dissection is not necessary unless

there are clinically suspicious, palpable nodes (1,9).

Address correspondence and reprint requests to: Amir Fathi, MD,

Department of Surgery, University Hospitals Case Medical Center, 11100

Euclid Avenue, Cleveland, OH 44106, USA, or e-mail: AHF59@yahoo.com

DOI: 10.1111/tbj.12239

© 2014 Wiley Periodicals, Inc., 1075-122X/14The Breast Journal, Volume 20 Number 2, 2014 210–212

Surgical resection is the treatment of choice for

phyllodes tumor. The extent of surgical resection has

been a controversial issue for years. The risk of local

recurrence is the most important factor in influencing

the extent of surgery and formulating a treatment

plan. All histologic subtypes have potential for recur-

rence, with low rates for benign tumors (4.7–30%)

and higher rates for malignant and borderline neo-

plasms (30–45%) (1–3).Phyllodes tumors contain a pseudo-capsule formed

by the compression of adjacent breast parenchyma.

The tumor mass is also comprised of stromal tongues,

protruding radially into normal tissue. Multiple case

series have demonstrated that the enucleation proce-

dure is associated with higher local recurrence rates

regardless of histology (1–3). Most authors reviewed

in our literature search agree that wide local excision

with 1–2 cm margins is a satisfactory procedure for

the resection of benign phyllodes tumors, providing

the tumor to breast size will permits (1–3,10).Barth et al. in showed recurrence rates as high as

46% for borderline and 65% for malignant subtypes

after local excision. After wide local excision, recur-

rence rates remained high (29% and 36%, respec-

tively) (3). They concluded that local excision is not a

sufficient treatment for borderline or malignant sub-

types. This finding was reinforced by data from Has-

souna et al. (2).

Contrarily, Asoglu et al. showed no relationship

between the type of surgical procedure and local

recurrence rates (10).

Given the findings of these studies, simple mastec-

tomy is the best surgical option for breasts invaded by

large borderline or malignant phyllodes tumors. Breast

conservation procedures should be reserved for larger

volume breasts, allowing generous clear margins in all

directions (1–3,10). It should be emphasized that evo-

lution of a giant phyllodes tumor substantially

increases the risk of microinfiltration of the remaining

breast tissue with cancer cells.

Considering all subtypes, local recurrence occurs in

0% and 60% of patients, according to various series

in literature. Hassouna et al. showed 65% of these

recurrences take place during the first 2 years after ini-

tial treatment (2). Local recurrence correlates with

positive surgical margins, nuclear atypia, and stromal

overgrowth (1,2).

In general, there is not a contraindication for imme-

diate reconstruction. As long as chest wall or skin

envelope involvement is not the case.

In summary, recurrent malignant phyllodes

tumors of the breast impose a challenging treatment

dilemma for surgeons. The pathologic subtype and

the extent of local invasion of the phyllodes tumor

should dictate the extent of surgical resection. While

surgery remains the mainstay of treatment, addi-

tional investigation should address adjuvant chemo-

therapy and radiation with the goal of reducing

recurrence and improving long-term morbidity and

mortality.

DISCLOSURE

This work did not receive any support or funding

from any organization and the authors declare no

competing or conflict of interests.

Amir H. Fathi, MD*

M. Julieta Zutel, MD†

Natalie E. Joseph, MD‡

*Department of Surgery

Metrohealth Medical Center

Case Medical Center

Case Western Reserve University

Cleveland, Ohio;†Metrohealth Medical Center

Case Western Reserve University

Cleveland, Ohio;

and ‡Department of Surgery

Division of Surgical Oncology

Metrohealth Medical Center

Case Western Reserve University

Cleveland, Ohio

REFERENCES

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tumors of the breast: a case series of 106 patients. Am J Surg2006;192:141–7.

3. Barth RJ Jr. Histologic features predict local recurrence after

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4. Cole-Beuglet C, Soriano R, Kurtz AB, et al. Ultrasound, x-raymammography, and histopathology of cystosarcomaphylloides.

Radiology 1983;146:481–6.5. Chao TC, Lo YF, Chen SC, et al. Sonographic features of

phyllodes tumors of the breast. Ultrasound ObstetGynecol2002;20:64–71.

6. Buchberger W, Strasser K, Heim K, et al. Phylloides tumor:findings on mammography, sonography, and aspiration cytology in

10 cases. AJR Am J Roentgenol 1991;157:715–9.

letter to the editor • 211

7. Kinoshita T, Fukutomi T, Kubochi K. Magnetic resonance ima-

ging of benign phyllodes tumors of the breast. Breast J 2004;10:232–6.8. Bocker W. [WHO classification of breast tumors and tumors

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9. Hines JR, Murad TM, Beal JM. Prognostic indicators in

cystosarcomaphylloides. Am J Surg 1987;153:276–80.10. Asoglu O, Ugurlu MM, Blanchard K, et al. Risk factors for

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212 • letter to the editor