Saudi Journal of Laparoscopy

REVIEW ARTICLE
Year
: 2019  |  Volume : 4  |  Issue : 1  |  Page : 1--3

Malignant breast phyllodes: Literature review of management and case report


Amal Abdullah Abdulkareem 
 Department of General Surgery, Breast and Endocrine Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Correspondence Address:
Dr. Amal Abdullah Abdulkareem
Department of General Surgery, Breast and Endocrine Unit, College of Medicine, King Saud University, Riyadh
Saudi Arabia

Abstract

The rarity of malignant phyllodes leads to variability in diagnosis and management. Most of the reported cases in the literature are large malignant phyllodes tumor. Malignant phyllodes tumor was seen in the age group between 35 and 55 years. The youngest age reported was an 11-year-old girl. The eldest reported was an 89-year-old woman. Phyllodes tumors are characterized by a typical rapid growth. Phyllodes tumor are composed of epithelial element and connective tissue stroma with stromal increased cellularity, cellular atypia, and pleomorphism with increased mitosis. The most common path of spread is hematological mostly to the lung, pleura, bone, heart, liver, metastasis to the brain and adrenal have been reported. Palpable axillary lymph node is found in 10%–15% cases; only <1% of them is pathologically positive for malignancy. Surgery in the form of breast conservative or mastectomy remains the primary treatment of malignant breast phyllodes. No literature support axillary lymph node dissection. For breast conservative surgery (BCS), 1 cm free margin is recommended less than that will be associated with higher recurrence rate. Mastectomy is indicated only if tumor-free margin cannot be obtained by BCS. In multivariate analysis, patient with more adverse prognostic factors underwent postoperative radiation therapy (RT). The RT groups were not inferior to non-RT groups on cancer-specific survivor regardless of surgery (mastectomy or BCS). But post-operative radiation therapy for BCS will significantly reduce local recurrence. Post-operative chemotherapy is seeing increased in palliation of metastatic cases.



How to cite this article:
Abdulkareem AA. Malignant breast phyllodes: Literature review of management and case report.Saudi J Laparosc 2019;4:1-3


How to cite this URL:
Abdulkareem AA. Malignant breast phyllodes: Literature review of management and case report. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 21 ];4:1-3
Available from: http://www.saudijl.org/text.asp?2019/4/1/1/257341


Full Text

 Introduction



Chelius in 1827 first described the tumor.[1] Johannes Muller was the first to use the term cystosarcoma phyllodes. It was believed to be benign until 1943 when Cooper and Ackerman reported on the malignant potential. WHO adopted the phyllodes in 1981.[1] Phyllodes tumor is uncommon fibroepithelial neoplasms of the breast that account for only 0.3%–0.5% of primary breast tumors.[1] Phyllodes tumor are classified into benign, borderline, and malignant grade on the basis of histological parameters, the degree of stromal cellularity, atypia mitotic count, stromal overgrowth, and tumor borders.[2] The majority are benign (35%–64%); the rest are divided between the borderline and malignant. Phyllodes are true biphasic neoplasms within which interaction between the epithelium and the stroma critical for tumor development.[3] Tumor recurrence and progression is likely to reflect the presence of underrecognized subclones. P (16INK4a) (CDKN2A) inactivation also appears to be important in phyllodes tumor pathogenesis.[3] P53 expiration is one of the most significant parameters for the differentiation of benign and malignant phyllodes tumor of the breast.[3] Malignant phyllodes are occurring between the age of 35 and 55 years.[1],[4],[5] But case reported the age of 89 years[5] and rarely in adolescents[1] age of 11 years has been reported.[6] It is characterized by a typical rapid growth[5] like fibroadenoma. Phyllodes tumors are composed of epithelial elements and connective tissue stroma. But phyllodes tumor has higher stromal cellularity.[5]

 Presentation of Case



A 37-year-old patient notices a painless mass in her right breast during the 3rd month of her pregnancy which is increasing in size but she did not seek medical advice. After 18 months of her symptom, she reported it to our hospital. She was seen in the clinic, her right breast enlarged with big lobulated mass occupying the upper and inner parts of her breast with no axillary lymph node breast ultrasound [Figure 1] and [Figure 2]. And mammogram [Figure 3] and [Figure 4] was done as well core biopsy. The biopsy result was (epithelial and stromal components. The epithelial is benign the mesenchymal part showed spindle cell with increased cellularity, mitotic rate reaching up to 5/10 HPF, no atypia or necrosis). The patient underwent lumpectomy. The histopathological report was tissue weight of 834.5 g mass with central hemorrhage and necrosis, the size 13 cm × 11 cm × 7 cm malignant phyllodes tumor with hypercellularity, increased mitotic rate (18/10 HPF) in addition to irregular tumor margin. All resection margin are free of tumor but < 1mm. She was booked for re-excision of margin. The final histopathological report was as follows: All resection margins are 2 cm free of tumor, Ki67 >30%–40% of tumor cell, P53 showed focal mild to moderate positive nuclear staining, and the CD117 stain was positive in the capillary. The case was discussed in the tumor board and booked for radiation therapy. Having tumor >10 cm and mitotic rate >10/10 HPF indicates aggressive tumor. Her (computed tomography [CT] scan cap) and bone scan all negative for metastasis.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



Surgical resection remains the gold stander of treatment; most studies recommend more than 1–2 cm resection margin, local recurrence is more frequent with narrow margin <1–2 cm,[5] and low-grade tumor may recur if inadequately excised.[4] The most common path of spared is hematological. Large phyllodes tumor >10 cm have higher cancer rate (42.5%) and recurrent rate (41%) than smaller tumor (21% malignant and 29% recurrence rate),[5] radiation therapy has been used with good result for local control of the disease,[5] and chemotherapy is somewhat controversial.[5] Phyllodes tumor appears clinically as a rounded, mobile, and painless mass[1],[7] or can present as big fix mass with skin tethering or ulceration. The largest reported phyllodes is 50 cm × 50 cm.[1],[8] Position emission tomography/CT scan can show pathological accumulation of trace F-fludeoxyglucose[7] once the patient developed metastasis. Their prognosis is extremely poor;[9] the mean overall survival is 30 months; approximately, 22% of cases of malignant phyllodes tumor may give rise to hematogenous metastases.[9] The frequency of metastases in each site: lungs (66%), bones (28%), heart (9%), and liver (6%).[9] Furthermore, metastases to brain and adrenal have been reported[8] in 10%–15% of cases; axillary lymph nodes are palpable but only <1% of them had pathological-positive nodes.[1] Belkace'mi et al.[10] reported that radiotherapy significantly decreased local recurrence rate (P = 0.02);[9] none of their patients who underwent breast–conservative surgery with adjuvant radiotherapy developed a local recurrence with median follow-up of 56 months.[4],[9] The use of radiotherapy has increased recently due to high risk of local recurrence. The use of chemotherapy is controversial in margin-negative resection.[8] Chemotherapy is seen increased in palliation in metastatic cases.[8] Surgical management includes either breast-conserving surgery obtaining at least 1 cm free margin[1] or mastectomy for larger tumor[1] or tumor-free margins cannot be obtained by breast conservative surgery[11],[12] when the margin <1 cm; there is a higher recurrence rate ranging from 16.6% to 40%[13] since phyllodes tumor is more considered as soft tissue sarcoma; adjuvant chemotherapy with doxorubicin plus dacarbazine could provide some benefit to the patient with large (>5 cm) high-risk aggressive tumor.[13] In malignant and borderline, radiation therapy significantly decreases local recurrence (P = 0.02).[10] Surgery in the form of breast conservative or mastectomy remains the primary treatment of malignant breast phyllodes, the extent of the disease, the pathological grading. The margin of the tumor and the presence or absence of metastases will define the use of radiation or chemotherapy post-operatively. The recent literature advocates the use of post-operative RT for BCS;[14] still, we need to have an answer whether chemotherapy is recommended in nonmetastatic malignant phyllodes tumor or not.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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