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      Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature

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          Abstract

          Background

          Phyllodes tumors are biphasic fibroepithelial neoplasms of the breast. While the surgical management of these relatively uncommon tumors has been addressed in the literature, few reports have commented on the surgical approach to tumors greater than ten centimeters in diameter – the giant phyllodes tumor.

          Case presentation

          We report two cases of giant breast tumors and discuss the techniques utilized for pre-operative diagnosis, tumor removal, and breast reconstruction. A review of the literature on the surgical management of phyllodes tumors was performed.

          Conclusion

          Management of the giant phyllodes tumor presents the surgeon with unique challenges. The majority of these tumors can be managed by simple mastectomy. Axillary lymph node metastasis is rare, and dissection should be limited to patients with pathologic evidence of tumor in the lymph nodes.

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          Most cited references38

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          The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases.

          B A Stelmach, J. W. Mituś, K Smolak … (1996)
          The study addresses the controversial prognostic and therapeutic aspects of phyllodes tumor of the breast. Records of 170 women with phyllodes tumor of the breast were reviewed. On the basis of the criteria proposed by Azzopardi and Salvadori et al., including estimation of tumor margin, growth of the connective tissue component, mitoses, and cellular atypia, the entire series was divided into three histotypes of phyllodes tumor, i.e., benign (92 cases, 54.1%), borderline (19 cases, 11.2%), and malignant (59 cases, 34.7%). Ninety-eight patients (57.6%) were treated by wide local excision (79 benign, 15 borderline, and 4 malignant), 43 (25.3%) by simple mastectomy (13 benign, 4 borderline, and 26 malignant), and 29 (17.1%) by radical mastectomy (all malignant). Of the 170 treated patients, 141 (82.9%) survived 5 years without evidence of disease. In the Cox multivariate analysis the histotype of the tumor was the only independent prognostic factor: 5-year NED survival was observed in 95.7% of the patients with benign phyllodes tumor, 73.7% with borderline phyllodes tumor, and 66.1% with malignant phyllodes tumor. After a wide local excision 98.7% of the patients with benign tumor, and 80% with borderline tumor, were cured. Local recurrence was found in 14 patients (8.2%) (4 benign, 3 borderline, and 7 malignant); 10 of these underwent reoperation (7 wide local excision, 3 radical mastectomy) and survived 5 years NED. The histotype of phyllodes tumor (benign, borderline, and malignant), assessed on the basis of the criteria proposed by Azzopardi and Salvadori et al., was the only prognostic factor in our group of patients. Based on the data from literature and our own observations, we observed that a wide local excision, with an adequate margin of normal breast tissue, is the preferred initial therapy for phyllodes tumor of the breast.
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            Primary treatment of cystosarcoma phyllodes of the breast.

            Kelly Hunt, A Chaney, P Pisters … (2000)
            Cystosarcoma phyllodes is a rare sarcoma of the breast. Although surgical removal is the mainstay of treatment, the extent of surgery required (excision vs. mastectomy) and the need for additional local therapy, such as radiotherapy, are unclear. The current study evaluated the rate of local and distant failure, as well as potential prognostic factors, to better define appropriate treatment strategies. One hundred one patients treated primarily for cystosarcoma phyllodes of the breast were evaluated. These tumors were classified histologically into benign (58%), indeterminate (12%), and malignant (30%) based on well defined criteria. Stromal overgrowth (29%) was considered separately. Surgery was comprised of local excision with breast conservation (47%) or mastectomy (53%). Microscopic surgical margins were negative in 99% of cases. Six patients received adjuvant radiotherapy. Overall survival for the 101 patients was 88%, 79%, and 62% at 5, 10, and 15 years, respectively. For patients with nonmalignant (benign or indeterminate) and malignant cystosarcoma phyllodes, the overall survival was 91% and 82%, respectively, at 5 years, and 79% and 42%, respectively, at 10 years. Similar rates were observed based on the presence or absence of stromal overgrowth. Local recurrence occurred in 4 patients, with an actuarial 10-year rate of 8%. Eight patients developed distant metastases, with an actuarial 10-year rate of 13%. Multivariate analysis using Cox proportional hazards regression revealed stromal overgrowth to be the only independent predictor of distant failure. Local failure in this group of largely margin negative patients with cystosarcoma phyllodes of the breast was low, showing that breast-conserving surgery with appropriate margins is the preferred primary therapy. The current study data do not support the use of adjuvant radiotherapy for patients with adequately resected disease. Patients with stromal overgrowth, particularly when the tumor size was > 5 cm, were found to have a high rate of distant failure; such patients merit consideration of a trial that examines the efficacy of systemic therapy.
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              The descriptive epidemiology of malignant cystosarcoma phyllodes tumors of the breast.

              D Deapen, Diana L Bernstein, R. Paul Ross (1993)
              Malignant cystosarcoma phyllodes tumors of the breast are rare fibroepithelial tumors. The epidemiologic features of these malignancies in a defined population have not previously been described. Incidence data were collected from 1972-1989 by the Cancer Surveillance Program, the population-based cancer registry for Los Angeles County. The average annual age-adjusted incidence rate of malignant cystosarcoma phyllodes is 2.1 per 1 million women. Latina whites have a higher risk of this cancer than other racial-ethnic groups. The age-incidence curve shows that risk of cystosarcoma phyllodes peaks in the 45-49-year-old age group, but the age patterns vary by race-ethnicity, with Asian and Latina patients significantly younger, on average, than non-Latina white patients. The incidence rates of malignant cystosarcoma phyllodes were substantially higher in the 1980s than in the 1970s, particularly among Latina whites and Asians. For Latina whites, birthplace is a significant predictor of risk. Women born in Mexico and Central and South America are at threefold to fourfold greater risk of malignant cystosarcoma phyllodes tumors than Latina whites born in the United States. The epidemiology of malignant cystosarcoma phyllodes tumors of the breast is strikingly different from that of the more common histologic types of breast cancer. The high risk in Latina immigrants may offer an important clue as to the cause of this rare tumor.
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                Author and article information

                Journal
                Journal ID (nlm-ta): World J Surg Oncol
                Title: World Journal of Surgical Oncology
                Publisher: BioMed Central
                ISSN (Electronic): 1477-7819
                Publication date Collection: 2008
                Publication date (Electronic): 11 November 2008
                Volume: 6
                Page: 117
                Affiliations
                [1 ]The Ohio State College of Medicine, Columbus, Ohio, USA
                [2 ]The Ohio State University Department of Haematology-Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Division of Internal Medicine, Columbus, Ohio, USA
                [3 ]The Ohio State University Division of Dermatology, Columbus, Ohio, USA
                [4 ]The Ohio State University Division of Plastic Surgery, Columbus, Ohio, USA
                [5 ]The Ohio State University Department of Pathology, Columbus, Ohio, USA
                [6 ]The Ohio State University Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Division of Surgical Oncology, Columbus, Ohio, USA
                Article
                Publisher ID: 1477-7819-6-117
                DOI: 10.1186/1477-7819-6-117
                PMC ID: 2648962
                PubMed ID: 19014438
                SO-VID: e44a8aff-3621-47e3-9832-47d8edfcece2
                Copyright © Copyright © 2008 Liang et al; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 10 March 2008
                Date accepted : 11 November 2008
                Categories
                Subject: Review

                ScienceOpen disciplines: Surgery
                Data availability:
                ScienceOpen disciplines: Surgery

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