Management of Benign Phyllodes Tumor With Close Margins: A Case Presented in Multidisciplinary Session With Clinical Discussion and Decision Making

Main Article Content

Adel Yazdankhah
Hamid Ahmadi

Keywords

Phyllodes tumor, Breast tumor, Close margin, Multidisciplinary team decision

Abstract

Background: Phyllodes tumors (PTs) are a small group of fibroepithelial breast lesions, which are classified as benign, borderline, or malignant. Traditionally, a margin of 1 cm has been suggested as the standard of care for all groups of PTs. According to new studies and recent updates, the recurrence rate of benign PT is low and not associated with the surgical margin status. There is still a controversy for PT surgical margin.
Case Presentation: A woman with the primary diagnosis of fibroadenoma in core needle biopsy underwent surgery. The pathology report showed benign PT and margins about 1 mm in some areas. This case was presented in the weekly breast multidisciplinary team session of the Department of Breast Surgery, Tehran University of Medical Sciences.
Question: The question was whether re-excision was necessary to achieve the safe surgical margin.
Conclusion: In accordance with the latest published evidence, the members of the panel decided to accept the margin, informed the patient about the risk of recurrence, and recommended close follow-up.

References

1. Moutte A, Chopin N, Faure C, Beurrier F, Ho Quoc C, Guinaudeau F, et al. Surgical Management of Benign and Borderline Phyllodes Tumors of the Breast. The Breast Journal. 2016;22(5):547-52.
2. FA T, P D. Pathology and Genetics of Tumours of the Breast and Female Genital Organs. in: World Health Organization Classification of Tumors. Lyon: IARC Press; 2003.
3. Rosen PP. Rosen's breast pathology: Lippincott Williams & Wilkins; 2001.
4. Zhou Z-R, Wang C-C, Sun X-J, Yang Z-Z, Yu X-L, Guo X-M. Diagnostic performance of core needle biopsy in identifying breast phyllodes tumors. Journal of Thoracic Disease. 2016;8(11):3139-51.
5. Contarini O, Urdaneta LF, Hagan W, Stephenson SE, Jr. Cystosarcoma phylloides of the breast: a new therapeutic proposal. The American surgeon. 1982;48(4):157-66.
6. Poynter GN, Monica R, S. JPA. National Surgical Patterns of Care for Primary Surgery and Axillary Staging of Phyllodes Tumors. The Breast Journal. 2009;15(1):41-4.
7. Network NCC. Breast Cancer 2017 [Available from: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
8. MD CA, MD FA, MD DA, MD EA, MD BA, MD GB, et al. phyllodes tumor The University of Texas MD Anderson Cancer Center: MD Anderson Cancer Center
[updated 2015. Available from: https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/cancer-treatment/ca-treatment-phyllodes-web-algorithm.pdf.
9. Reinfuss M, Mitus J, Duda K, Stelmach A, Rys J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases. Cancer. 1996;77(5):910-6.
10. Parker S, Harries S. Phyllodes tumours. Postgraduate Medical Journal. 2001;77(909):428-35.
11. Hawkins RE, Schofield JB, Fisher C, Wiltshaw E, McKinna JA. The clinical and histologic criteria that predict metastases from cystosarcoma phyllodes. Cancer. 1992;69(1):141-7.
12. Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast. 5th ed. china: Wolters Kluwer Health; 2014.
13. Surgeons ASoB. Consensus Guideline on Concordance Assessment of Image-Guided Breast Biopsies and Management of Borderline or High-Risk Lesions 2016 [Available from: https://www.breastsurgeons.org/about/statements/PDF_Statements/Concordance_and_High%20RiskLesions.pdf.
14. MD AMG, MD FBC, MD FC. Phyllodes tumors of the breast. In: MD LJP, MD DFH, editors. uptodate. Waltham, MA: uptodate; 2018.
15. Chaney AW, Pollack A, McNeese MD, Zagars GK, Pisters PW, Pollock RE, et al. Primary treatment of cystosarcoma phyllodes of the breast. Cancer. 2000;89(7):1502-11.
16. Macdonald OK, Lee CM, Tward JD, Chappel CD, Gaffney DK. Malignant phyllodes tumor of the female breast: association of primary therapy with cause-specific survival from the Surveillance, Epidemiology, and End Results (SEER) program. Cancer. 2006;107(9):2127-33.
17. Onkendi EO, Jimenez RE, Spears GM, Harmsen WS, Ballman KV, Hieken TJ. Surgical treatment of borderline and malignant phyllodes tumors: the effect of the extent of resection and tumor characteristics on patient outcome. Annals of surgical oncology. 2014;21(10):3304-9.
18. Soumarova R, Seneklova Z, Horova H, Vojkovska H, Horova I, Budikova M, et al. Retrospective analysis of 25 women with malignant cystosarcoma phyllodes--treatment results. Archives of gynecology and obstetrics. 2004;269(4):278-81.
19. Pezner RD, Schultheiss TE, Paz IB. Malignant phyllodes tumor of the breast: local control rates with surgery alone. International journal of radiation oncology, biology, physics. 2008;71(3):710-3.
20. Parker SJ, Harries SA. Phyllodes tumours. Postgrad Med J. 2001;77(909):428-35.
21. Belkacemi Y, Bousquet G, Marsiglia H, Ray-Coquard I, Magne N, Malard Y, et al. Phyllodes tumor of the breast. International journal of radiation oncology, biology, physics. 2008;70(2):492-500.
22. Burton GV, Hart LL, Leight GS, Jr., Iglehart JD, McCarty KS, Jr., Cox EB. Cystosarcoma phyllodes. Effective therapy with cisplatin and etoposide chemotherapy. Cancer. 1989;63(11):2088-92.
23. Telli ML, Horst KC, Guardino AE, Dirbas FM, Carlson RW. Phyllodes tumors of the breast: natural history, diagnosis, and treatment. Journal of the National Comprehensive Cancer Network : JNCCN. 2007;5(3):324-30.
24. J. Barth R J. Margin negative, breast conserving resection: adequate for benign phyllodes tumors, but inadequate therapy for borderline and malignant phyllodes tumors. Breast cancer research and treatment. 2013;142(2):463-4.
25. Ben Hassouna J, Damak T, Gamoudi A, Chargui R, Khomsi F, Mahjoub S, et al. Phyllodes tumors of the breast: a case series of 106 patients. American journal of surgery. 2006;192(2):141-7.
26. Chen WH, Cheng SP, Tzen CY, Yang TL, Jeng KS, Liu CL, et al. Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases. Journal of surgical oncology. 2005;91(3):185-94.
27. Barth RJ, Jr. Histologic features predict local recurrence after breast conserving therapy of phyllodes tumors. Breast cancer research and treatment. 1999;57(3):291-5.
28. Barth RJ, Jr., Wells WA, Mitchell SE, Cole BF. A prospective, multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumors. Annals of surgical oncology. 2009;16(8):2288-94.
29. Shaaban M, Barthelmes L. Benign phyllodes tumours of the breast: (Over) treatment of margins - A literature review. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2017;43(7):1186-90.
30. Asoglu O, Ugurlu MM, Blanchard K, Grant CS, Reynolds C, Cha SS, et al. Risk factors for recurrence and death after primary surgical treatment of malignant phyllodes tumors. Annals of surgical oncology. 2004;11(11):1011-7.
31. Jang JH, Choi MY, Lee SK, Kim S, Kim J, Lee J, et al. Clinicopathologic risk factors for the local recurrence of phyllodes tumors of the breast. Annals of surgical oncology. 2012;19(8):2612-7.
32. Tan EY, Tan PH, Yong WS, Wong HB, Ho GH, Yeo AW, et al. Recurrent phyllodes tumours of the breast: pathological features and clinical implications. ANZ journal of surgery. 2006;76(6):476-80.
33. Wei J, Tan Y-T, Cai Y-C, Yuan Z-Y, Yang D, Wang S-S, et al. Predictive factors for the local recurrence and distant metastasis of phyllodes tumors of the breast: a retrospective analysis of 192 cases at a single center. Chinese Journal of Cancer. 2014;33(10):492-500.
34. Abdalla HM, Sakr MA. Predictive factors of local recurrence and survival following primary surgical treatment of phyllodes tumors of the breast. Journal of the Egyptian National Cancer Institute. 2006;18(2):125-33.
35. Co M, Chen C, Tsang JY, Tse G, Kwong A. Mammary phyllodes tumour: a 15-year multicentre clinical review. Journal of clinical pathology. 2018;71(6):493-7.
36. Rodrigues MF, Truong PT, McKevitt EC, Weir LM, Knowling MA, Wai ES. Phyllodes tumors of the breast: The British Columbia Cancer Agency experience. Cancer radiotherapie : journal de la Societe francaise de radiotherapie oncologique. 2018;22(2):112-9.
37. Kim S, Kim JY, Kim DH, Jung WH, Koo JS. Analysis of phyllodes tumor recurrence according to the histologic grade. Breast cancer research and treatment. 2013;141(3):353-63.
38. Borhani-Khomani K, Talman ML, Kroman N, Tvedskov TF. Risk of Local Recurrence of Benign and Borderline Phyllodes Tumors: A Danish Population-Based Retrospective Study. Annals of surgical oncology. 2016;23(5):1543-8.
39. Cowan ML, Argani P, Cimino-Mathews A. Benign and low-grade fibroepithelial neoplasms of the breast have low recurrence rate after positive surgical margins. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2016;29(3):259-65.
40. Kim GR, Kim EK, Yoon JH, Kim MJ, Moon HJ. Recurrence Rates of Benign Phyllodes Tumors After Surgical Excision and Ultrasonography-Guided Vacuum-Assisted Excision. Ultrasound quarterly. 2016;32(2):151-6.
41. Ouyang Q, Li S, Tan C, Zeng Y, Zhu L, Song E, et al. Benign Phyllodes Tumor of the Breast Diagnosed After Ultrasound-Guided Vacuum-Assisted Biopsy: Surgical Excision or Wait-and-Watch? Annals of surgical oncology. 2016;23(4):1129-34.
42. Dixon JM. breast surgery 5th ed. china: Elsevier; 2013.
43. Kim G-E, Kim J-H, Lee KH, Choi YD, Lee JS, Lee JH, et al. Stromal Matrix Metalloproteinase-14 Expression Correlates With the Grade and Biological Behavior of Mammary Phyllodes Tumors. Applied Immunohistochemistry & Molecular Morphology. 2012;20(3):298-303.
44. Sawalhi S, Al-Shatti M. Phyllodes tumor of the breast: a retrospective study of the impact of histopathological factors in local recurrence and distant metastasis. Annals of Saudi medicine. 2013;33(2):162-8.
45. Zurrida S, Bartoli C, Galimberti V, Squicciarini P, Delledonne V, Veronesi P, et al. Which therapy for unexpected phyllode tumour of the breast? European journal of cancer (Oxford, England : 1990). 1992;28(2-3):654-7.
46. Mishra SP, Tiwary SK, Mishra M, Khanna AK. Phyllodes tumor of breast: a review article. ISRN surgery. 2013;2013:361469.
47. S T, M D. Breast surgery. Edinburgh: Saunders Elsevier; 2014. p. 272.
48. Wei J, Tan YT, Cai YC, Yuan ZY, Yang D, Wang SS, et al. Predictive factors for the local recurrence and distant metastasis of phyllodes tumors of the breast: a retrospective analysis of 192 cases at a single center. Chin J Cancer. 2014;33(10):492-500.
49. Tremblay-LeMay R, Hogue JC, Provencher L, Poirier B, Poirier E, Laberge S, et al. How Wide Should Margins Be for Phyllodes Tumors of the Breast? Breast J. 2017;23(3):315-22.
50. Sevinc AI, Aksoy SO, Guray Durak M, Balci P. Is the extent of surgical resection important in patient outcome in benign and borderline phyllodes tumors of the breast? Turkish journal of medical sciences. 2018;48(1):28-33.
51. Karim RZ, Gerega SK, Yang YH, Spillane A, Carmalt H, Scolyer RA, et al. Phyllodes tumours of the breast: a clinicopathological analysis of 65 cases from a single institution. Breast (Edinburgh, Scotland). 2009;18(3):165-70.
52. Bhargav PR, Mishra A, Agarwal G, Agarwal A, Verma AK, Mishra SK. Phyllodes tumour of the breast: clinicopathological analysis of recurrent vs. non-recurrent cases. Asian journal of surgery. 2009;32(4):224-8.
53. Guillot E, Couturaud B, Reyal F, Curnier A, Ravinet J, Lae M, et al. Management of phyllodes breast tumors. Breast J. 2011;17(2):129-37.
54. Lin CC, Chang HW, Lin CY, Chiu CF, Yeh SP. The clinical features and prognosis of phyllodes tumors: a single institution experience in Taiwan. International journal of clinical oncology. 2013;18(4):614-20.
55. Kim GE, Kim JH, Lee KH, Choi YD, Lee JS, Lee JH, et al. Stromal matrix metalloproteinase-14 expression correlates with the grade and biological behavior of mammary phyllodes tumors. Applied immunohistochemistry & molecular morphology : AIMM. 2012;20(3):298-303.
56. Tan PH, Thike AA, Tan WJ, Thu MM, Busmanis I, Li H, et al. Predicting clinical behaviour of breast phyllodes tumours: a nomogram based on histological criteria and surgical margins. Journal of clinical pathology. 2012;65(1):69-76.
57. Tsang JY, Mendoza P, Putti TC, Karim RZ, Scolyer RA, Lee CS, et al. E-cadherin expression in the epithelial components of mammary phyllodes tumors. Human pathology. 2012;43(12):2117-23.
58. Nishimura R, Tan PH, Thike AA, Tan MH, Taira N, Li HH, et al. Utility of the Singapore nomogram for predicting recurrence-free survival in Japanese women with breast phyllodes tumours. Journal of clinical pathology. 2014;67(8):748-50.