Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 4, 2010, pp. 511-515

Journal of Cancer Research and Therapeutics, Vol. 6, No. 4, October-December, 2010, pp. 511-515

Original Article

Extent of surgery in the management of phyllodes tumor of the breast: A retrospective multicenter study from India

Satyajeet Verma¹, RK Singh¹, A Rai², CP Pandey³, Mahendra Singh⁴, N Mohan⁵

¹ Department of Surgery,G.S.V.M. Medical College, Kanpur, U.P, India
² Department of Surgery, Gandhi Medical College, Bhopal, M.P, India
³ Department of Surgery, Rohilkhand Medical College, Bareilly, U.P, India
⁴ Department of Pathology, G.S.V.M. Medical College, Kanpur, U.P, India
⁵ Department of Pathology, Rohilkhand Medical College, Bareilly, U.P, India

Correspondence Address: Satyajeet Verma, Associate Professor, Department of Surgery, G.S.V.M. Medical College, Kanpur, U.P., India - 208002, India, vsatyajeet@rediffmail.com

Code Number: cr10127

PMID: 21358091

DOI: 10.4103/0973-1482.77085

Abstract

Keywords: Mastectomy, phyllodes tumor, wide local excision

Introduction

Cystosarcoma phyllodes, now generally known as phyllodes tumor (PT) constitutes a rare form of breast neoplasia, which represents less than 1% of total breast neoplasms and only 2-3% of all fibro-epithelial breast tumor. ^{[1],[2],[3],[4]} It was first described by Muller in 1838, who also introduced the term "cystosarcoma phyllodes" because of the extensions of the tumor mimicking the shape of the leaves, intruding within the cystic cavities of the tumor. This neoplasm is manifested in women of all ages, including adolescent and the elderly, with the majority ranging between 35 and 54 years. ^[5],[6] In the recent years, multiple studies have been conducted concerning the comprehension of the biological behavior of PT. ^[7] The terminology ′′phyllodes tumor" given by the World Health Organization (WHO) classifies it into benign, borderline, and malignant tumors according to histopathological features. High-grade malignant phyllodes tumor (MPT) is a very rare but aggressive breast malignancy and forms approximately 25% of all PTs. ^[8]

There were few studies done in India for last many years and only few case reports have been seen.

The purpose of this retrospective multicentric study was to highlight the clinocopathological aspects of PT of the breast in the North-Central part of the India. We have also addressed various surgical options for the treatment of the PT of the breast.

Material and Methods

Twenty-four patients have been included in this retrospective study. Data were collected from the Department of Surgery of three tertiary institutes of North-Central part of India over a period of 8 years (2002-2009). We analyzed patients′ characteristics such as age, preoperative symptoms, menopausal status, preoperative investigations, and type of operation done and follow-up.

WHO pathological classification (1982) was followed in every case from the pathologists of concerned institutes. It includes the following: tumor margin (pushing or infiltrating), stromal cellularity (slight or severe), stromal overgrowth (absent, slight, or severe), tumor necrosis (present or absent), cellular atypia (absent, slight, or severe), number of mitoses per 10 high-power fields in the most mitotically active area of the slides.

Statistical analysis was done using Student′s t-test, the chi-square test, and analysis using SPSS version 10 (SPSS Inc., Chicago, IL, USA). A P value of less than 0.05 was considered significant for all the tests.

Results

The median age of presentation was 39.5 years (range 24-67 years). The presentation of the patients was breast lump in all cases, either as a primary or recurrent lump presentation [Figure - 1].

The mean duration of presentation of lump in the breast was 32.5±6 months. In seven patients, the duration of the presentation was less than 5 months. Two patients had a sudden increase of the previously presented breast lump in second term of the pregnancy. Both were undergone simple mastectomy after postpartum periods (Histopathological report came out to be malignant phyllodes).

In our study, right-sided lesion was present in 15/24 patients (62.5%) which is statistical significant in our study (P <0.05) [Table - 1]. Regarding menopausal status, 58.3% patients were in premenopausal category. Ten patients (71.4%) of premenopausal women were having benign PT as compared to 06/24 (60%) benign PTs of postmenopausal women (P >0.05).

The mean size of the lump was 9.5±5.5 cm (range was 4.0-23.0 cm). In 18.8% patients, the size was less than 5 cm. Fifty percent (12/24) of the cases were having size more than 10 cm [Table - 1]. Two patients had presented as breast lump with ipsilateral axillary lymphadenpathy. Preoperative fine needle aspiration cytology revealed inflammatory lymphadenitis in both without any metastasis. In these patients, modified radical mastectomy was done as per our records.

Mammographic record was available only in five patients. Three in mammography revealed well-defined mass lesion and two had an ill-defined mass lesion.

Ultrasound high frequency was done in eight patients. Six out of 11 patients in USG revealed hypo echoic, and 3 were described as "heterogeneous" echoic. In 11/24 patients there were no data regarding imaging studies were present.

Preoperatively fine aspiration needle cytology was done in all cases but on the basis of FNAC, proper diagnosis of PT was made in 6/24 patients (25%). FNAC showed giant fibroadenoma in 11/24 (45.5%) patients. A trucut biopsy was done in only 5/24 patients and an incisional biopsy was done in 8/24 patients after suspicion of PT and in three patients, excisional biopsy was done as the size was less than 5 cm.

Histopathologically, 62.4% (15/24) patients were diagnosed as benign phyllodes (P<0.05). 16.8% (4/24) were included in malignant PT category and 20.8% were having borderline phyllodes.

Overall, 31 surgical procedures have been done including 24 as primary surgical procedures and 7 in recurrent disease. All included primary as well as recurrent PT were primarily managed with concerned institute.

Simple lumpectomy was done in 10 patients with inadequate preoperative diagnosis. Two of them were converted to wide local excision taking 1 cm peripheral normal breast tissue and two were converted to simple mastectomy after final histopathological report [Table - 2], [Figure - 2]. Conversion could not be done in six patients of Lumpectomy. So, simple lumpectomy was done in 25% cases of primary cases of PT.

Wide local excision was done in seven patients as primary procedures, i.e. in 27.4% of primary cases and in two cases of recurrent cases of PT (where simple lump excision was done previously and preoperative histopathology was benign PT).

Simple mastectomy was done in 27.4% seven patients in which two cases were of conversion from lumpectomy. In two cases of recurrent PT, simple mastectomy was also done (one was previously managed with simple lumpectomy and one with wide local excision). Modified radical mastectomy (simple mastectomy with axillary clearance) was performed in three patients of primary (non-recurrent) PT as per our records. One had presentation with axillary lymphadenopathy although preoperative it was negative for malignant cells. One case of recurrent malignant PT was managed with modified radical mastectomy i.e. simple mastectomy with axillary clearance.

In one younger patient (age 21 years) with benign PT, reconstruction with LD flap was done. As far as adjuvant therapy is concerned, only one case of malignant PT was given external irradiation but no systemic chemotherapy was given in any case as adjuvant therapy.

Follow up of all cases done for up to 5.1 years (range 3 months to 7.4 years). Seven lost in follow up and two patients died due to pulmonary metastasis at 4-7 months following surgery. Others were all alive without recurrence in their last follow-up.

Recurrence was seen in 7 (29.2%) patients, who later on presented as recurrent swellings after their primary surgery. Six cases of lumpectomy and one case of WLE done for malignant PT were presented as recurrent. Two of them died after 4-7 months of second surgery because of lung metastases. The median time for the recurrence was 6 months (range 5.0-36.0 months).

Discussion

In this retrospective study, we have included patients′ details from three tertiary institutes of the North-Central part of India. This gives a better understanding of this disease prevalence in this zone of India.

In our series of the 24 patients, benign lesions were more common among younger patients (median age 34 years) than borderline and malignant cases, which occurs more in slightly older age group (median age = 51 years). Joshi et al. also described same in the study from the north India. ^[9] Right-sided lesions were more common than left-sided PT. This has also shown in various other studies. ^{[9],[10],[-11]}

In this series, clinically the presentation of PT was as a round, mobile and painless breast mass primary or recurrent swelling. In most patients, axillary lymph nodes are not palpable at presentation, because metastatic spread of these tumors is primarily hematogenous (lungs, pleura, and bone have been the most common sites of metastasis). Metastasis to axillary lymph nodes occurred in only 2%. ^[12] We did not have found any metastasis to axillary lymph nodes.

There is no any clinical parameter to differentiate the three categories of PT, except the size of the lump. Tumor size has been repeatedly confirmed as a valuable predictor of malignancy. ^[13],[14] In our series, 50% patients had size of lump more than 10 cm and 25% of these were malignant PT.

Regarding histological aspects, the PT consists of epithelial cells and connective tissue with more stromal proliferation than that of fibroadenoma, often accompanied by cellular atypia. For malignant PT, they are further divided into borderline, low grade, and high-grade on the basis of the following histological criteria: tumor borders, mitotic activity, stromal atypical, and stromal overgrowth. Only the stromal cells have the potential to metastasize. The malignant character of the PT is therefore confirmed by the microscopic appearance of the stroma. ^[14],[15]

Most of the time, Both mammographic ally, and high frequency ultrasonographically, PTs are difficult to be differentiated from fibroadenomas on ultrasound the tumors were lobulated in most of the cases. Heterogeneous internal echoes and intramural cysts are also said to be suggestive of PTs. ^[5] PT on mammography is described as a sharply defined round or oval mass with lobulation. ^[5] We had three patients who had heterogeneous echos on ultrasonography. As we had mammographic records of five patients, all these had well-defined mass lesions.

Difficulties with diagnosis of PT by FNAC have been reported. The cytologist reported PT in only 23% of cases where FNAC was done at the time of diagnosis. In cases where a core biopsy was done at the visit where the diagnosis was made, the core biopsy correctly diagnosed 65% of PTs. ^[16] In our study, 25% PT diagnosis was made preoperatively on the basis of FNAC only which is consistent with other studies.

Mangi et al. observed an 18% incidence of fibroadenomas in their study, suggesting a possible overlap and misdiagnosis between benign PT and fibroadenoma. ^[17] Although in our series, we did not have any patients of PT associated with fibroadenoma in histopathological examination.

Surgical treatment is generally accepted as the most important and primary therapy for PTs, regardless of its histological type.

There were controversies regarding extent of the surgery performed for this disease. However, relatively rarity of the tumor and heterogeneity of procedures applied for managing these by various centers, no definite conclusion regarding the appropriate surgical procedure can be drawn. Since PTs are rarely multifocal, wide local excision is currently being suggested to be an appropriate primary surgical procedure for all histological types of PT. ^{[18],[19],[20]} A mastectomy should be performed in the case of bigger >10 cm, malignant or recurrent disease. An axillary lymphadenectomy should only be performed in clinically conspicuous cases, as PT has predominantly hematogenous metastases and axillary metastases occur in less than 10% of cases. ^[15],[17] Reconstruction of the breast can be done as an additional procedure along with WLE or simple mastectomy especially in younger ladies with PT. ^[20]

Nowadays, radical mastectomy is not applied, and because the tumor is hematogenously disseminated, resection of auxillary lymph nodes is not justified. ^[21],[22] The preferred procedure is local resection of the tumor within healthy borders (1-2 cm) in order to prevent local recurrence. ^[23] For PT which have already manifest metastases, there is no sufficient treatment available for a successful control of the disease. ^[23]

The role of radiotherapy is still unclear from published reports because of small patient numbers and a lack of controlled data. August and Kearney recommended that adjuvant radiotherapy be considered for high-risk PT, including those >5 cm, with stromal overgrowth, with >10 mitoses/high-power field, or with infiltrating margins. ^[4]

Different chemotherapy regimens have been applied in malignant PTs. Doxorubicin and ifosfamide-based chemotherapies have shown some efficacy in women with metastatic spread of PTs. In one study of 101 patients, 4 patients were treated with chemotherapy and a role for adjuvant chemotherapy in patients with stromal overgrowth was considered. This recommendation has so far not been confirmed in the literature. Altogether, there is no clear indication for adjuvant chemotherapy for patients with PTs. ^[17]

Today, however, the studies upon estrogen and progesterone receptors in these tumors to provide hopeful results, useful for the hormonal management of PT. ^[6],[17]

Local recurrences (LR) are a common complication of high-grade lesions with a reported frequency of approximately 26% (12-65%). ^[1] The local recurrence rate was 29.2% in this present study, which corresponds to the reported rate in the literatures. ^[1],[22] Stromal overgrowth, larger tumor size, and involved margin were all significantly correlated with LR. Stromal overgrowth increased the probability of LR seven-fold, whereas if the margin was <1cm, the risk of LR increased five-fold, and if tumor size was >10 cm, then the prevalence of LR was four times greater than for smaller tumors. ^[12]

The 5- and 10-year survival rates for malignant PT range from 54% to 82% and from 23% to 42%, respectively. ^[12],[17]

It has been concluded, in the cases of large breast lumps, one has to include it as clinical differential diagnosis. For preoperative pathological diagnosis, a trucut biopsy should be done in giant lump cases of the breast. Wide local excision is optimal treatment of benign and borderline PT and simple mastectomy for the malignant PT. Above all, long follow-up is needed in every case of PT of the breast.

References

1.	Gogas JG. Cystosarcoma Phylloides: A clinicopathological analysis of 14 cases. Int Surg 1979;64:77-80.  Back to cited text no. 1  [PUBMED]
2.	Kessinger A, Foley JF, Lemon HM, Miller DM. Metastatic cystosarcoma phyllodes: A case report and review of the literature. J Surg Oncol 1972;4:131-47.  Back to cited text no. 2  [PUBMED]
3.	Vorherr H, Vorherr UF, Kutvirt DM, Key CR. Cystosarcoma phyllodes: Epidemiology, pathophysiology, pathology, diagnosis, therapy and survival. Arch Gynaecol 1985;236:171-81.  Back to cited text no. 3
4.	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 J Surg 2006;76:476-80.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.	Parker SJ, Hrries SA. Phyllodes tumours. Postgrad Med J 2001;77:428-35.  Back to cited text no. 5
6.	Cheng SP, Chang YC, Liu TP, Lee JJ, Tzen CY, Liu CL. Phyllodes tumor of the breast: The challenges persists. World J Surg 2006;30:1414-21.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.	Pietruszka M, Barnes L. Cystosarcoma phyllodes. A clinicopathologic analysis of 42 cases. Cancer 1978;41:1947.  Back to cited text no. 7
8.	Kapiris I, Nasiri N, Hern R, Healy V, Gui GP. Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phyllodes tumours of the breast. Eur J Surg Oncol 2001;27:723-30.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.	Joshi SC, Sharma DN, Bahadur AK, Maurya R, Kumar S, Khurana N. Cystosarcoma Phylloides - Our institutional experience. Australas Radiol 2003;47:434-7.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.	Kok KY, Telesinge PU, Yapp SK. Treatment and outcome of cystosarcoma phyllodes in Brunei: A 13-years experience. J R Coll Surg Edin 2001;46:198-201.  Back to cited text no. 10
11.	Sabban F, Collinet P, Lucot JP, Boman F, Leory JL, Vinatier D. Phyllodes tumour of the breast: Analysis of patients. Gynecol Obstet Biop Reprod 2005;34:252-6.  Back to cited text no. 11
12.	Asoglu O, Ugurlu M, Blanchard K, Grant CS, Reynolds C, Cha SS, Donohue JH. Risk factors for recurrence and death after primary surgical treatment of malignant phylloedes tumors. Ann Surg Oncol 2004;11:1011-7.  Back to cited text no. 12
13.	Zissis Ch, Apotolikas N, Konstantindou A. The extent of surgery and prognosis of patients with phyllodes tumor of the breast. Breast Cancer Res Treat 1998;48:205-10.  Back to cited text no. 13
14.	Kapali AS, Singh M, Deo SV, Shukla NK, Muduly DK. Aggressive palliative surgery in metastatic phyllodes tumor: Impact on quality of life. Indian J Palliat Care 2010;16:101-6.  Back to cited text no. 14
15.	Kraemer B, Hoffmann J, Roehm C, Gall C, Wallwiener D, Krainick-Strobel U. Cystosarcoma phyllodes of the breast: A rare diagnosis: Case studies and review of literature. Arch Gynecol Obstet 2007;276:649-53.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.	Foxcroft LM, Evans EB, Porter AJ. Difficulties in the pre-operative diagnosis of phyllodes tumours of the breast: A study of 84 cases. Breast 2007;16:27-37.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.	Lenhard MS, Kahlert S, Himsl I, Ditsch N, Untch M, Bauerfeind I. Phyllodes tumour of the breast: Clinical follow-up of 33 cases of this rare disease. Eur J Obstet Gynecol Reprod Biol 2008;138:217-21.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.	Reinfuss M, Mitus J, Duda K. The treatment and prognosis of patients with phyllodes tumour of the breast: An analysis of 170 cases. Cancer1996;77:910-6.  Back to cited text no. 18
19.	Bennett IC, Khan A, De Freitas R. Phyllodes tumours: A clinicopathological review of 30 cases. Aust N Z J Surg 1992;62:628-33.  Back to cited text no. 19
20.	Bhargav PV, Mishra A, Agrawal G, Agrawal A, Verma AK, Mishra SK. Phyllodes tumour of the breast: Clinicopathological analysis of reccurrent vs. nonrecurrent cases. Asian J Surg 2010;32:224-8.  Back to cited text no. 20
21.	Norris HJ, Taylor HB. Relationship of Histologic features to behavior of Cystosarcoma phylloides-Analysis of 94 cases. Cancer 1967;20:2090-1.  Back to cited text no. 21  [PUBMED]
22.	Dacic S, Kounelis S, Kaouri E, Jones M. Immunohstochemical profile od cystosarcoma phylloides of the breast: A study of 23 cases. Breast J 2002;8:376-81.  Back to cited text no. 22
23.	Haagensen CD. Cystosarcoma phyllodes in disease of the breast. 2nd ed. Philadelphia: W.B. Saunders Co; 1971. p. 227.  Back to cited text no. 23

Copyright 2010 - Journal of Cancer Research and Therapeutics

The following images related to this document are available:

Photo images