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Phyllodes breast tumor

Phyllodes breast tumor. Joint Hospital Surgical Grand Round 26 April 2014 Ng Yuen Shan, Sandy (Tuen Mun Hospital). Phyllodes tumor. Rare fibroepithelial breast tumor (1% of all breast tumors, 2.5% of all fibroepithelial tumors) A spectrum of disease

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Phyllodes breast tumor

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  1. Phyllodes breast tumor Joint Hospital Surgical Grand Round 26 April 2014 Ng Yuen Shan, Sandy (Tuen Mun Hospital)

  2. Phyllodes tumor • Rare fibroepithelial breast tumor (1% of all breast tumors, 2.5% of all fibroepithelial tumors) • A spectrum of disease • Epithelial and cellular stromal component • Histological classification: • Benign (60%) • Borderline (20%) • Malignant (20%)  distant metastasis

  3. Median age of presentation at 40-50 years Palpable mass with rapid growth, large size (>2cm) Poor pre-operative diagnostic accuracy

  4. Case scenario • Excisional pathology: • Benign phyllodes tumor • MarginPOSITIVE F/40 2.5cm L12H breast mass, interval growth. MMG/US: well-circumscribed lobulated mass FNAC: benign.

  5. Pok Oi Hospital • A review of 28 consecutive patients with phyllodes tumour excision in 2009-2012 in Pok Oi Hospital • 11 operations performed for recurrent phyllodes tumour (6 patients) have been excluded.

  6. Margin status and histological grade Close follow-up

  7. Margin-involved outcomes Mean FU period: 36 months

  8. POH case series Results: Local recurrence rate in margin-involved = 16.7% No recurrence was detected in close or clear margin. Conclusion: Margin status of the primary resection is probably the most important factor in determining risk of recurrence.

  9. Margin-involved phyllodes tumor Why does it matter? What to do next? How to “prevent”?

  10. Local recurrence Spitaleri G, Toesca A, Botteri E, et al. Breast phyllodes tumor: a review of literature and a single center retrospective series analysis. Crit Rev Oncol Hematol. 2013 Nov;88(2):427-36.

  11. Local recurrence Associated factors: Calhoun KE, Lawton TJ, Kim JN, Lehman CD, Anderson BO. Phyllodes tumors. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2010:781-792.

  12. Disease-free survival curves of 42 patients treated with breast-conservative surgery for phyllodes tumor. Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736

  13. Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736

  14. Margin-involved phyllodes tumor • Why does it matter? • Predictor of local recurrence • What to do next? • How to “prevent”?

  15. If margin positive… Taira N, Takabatake D, Aogi K, et al. Phyllodes Tumor of the Breast: Stromal Overgrowth and Histological Classification are Useful Prognosis-predictive Factors for Local Recurrence in Patients with a Positive Surgical Margin. Jpn J Clin Oncol 2007;37(10)730–736 • Stromal growth as a predictive factor of local recurrence in positive margin cases • One of the malignant features

  16. If margin positive… Chua CL, Thomas A, Ng BK. Cystosarcoma phyllodes: a review of surgical options. Surgery 1989;105(2 Pt 1):141-147 Zurrida S, Bartoli C, Galimberti V, et al. Which therapy for unexpected phyllodes tumour of the breast? Eur J Cancer 1992;28(2-3):654-657 • Some authors had suggested “wait-and-see” policy for benign phyllodes tumor • Chua, 1989 (106 patients) • Zurrida, 1992 (216 patients): recurrence 8%

  17. Management strategy ofMargin-involved phyllodes tumor Benign “wait-and-see” Malignant  Re-excision Follow-up every 6 months for initial 2-3 years (highest chance of recurrence) Then yearly Self breast examination Clinical suspicion on follow-up: triple assessment

  18. Margin-involved phyllodes tumor Why does it matter? What to do next? How to “prevent”?

  19. Phyllodes tumor Difficult preoperative diagnosis…..

  20. Phyllodes tumor – Initial workup Triple assessment Patient presentation Clinical suspicious of phyllodes tumor - Palpable mass - Rapid growth - USG suggestive of fibroadenoma except for size (>2cm) / rapid growth - History and P/E - USG - MMG for >30yo Core needle biopsy Fibroadenoma Phyllodes tumor (benign, borderline, malignant) Fibroadenoma or indeterminate Observe Excisional biopsy Wide excision (>=1cm) without axillary staging M D Anderson Cancer Center 2012

  21. Margin-involved phyllodes tumor ? Why does it matter What to do next How to “prevent”

  22. Thank you

  23. WHO classification

  24. To improve preoperative diagnosis R K Jacklin, P F Ridgway, P Ziprin, et al. Optimising preoperative diagnosis in phyllodes tumour of the breast. J Clin Pathol 2006;59:454–459. Paddington Clinicopathological Suspicion Score • Clinical findings • Sudden increase in size in a longstanding breast lesion • Apparent fibroadenoma >3cm diameter or in patient >35 years • Imaging findings • MMG: Rounded borders/ lobulated appearance • USG: Attenuation or cystic areas within a solid mass • FNAC findings • Presence of hypercellular stromal fragments • Indeterminate features ANY 2 features mandate core biopsy

  25. Phyllodes tumor - Recurrence Patient presentation Workup - History and P/E - MMG, USG - Core needle biopsy - Consider chest imaging Local recurrent breast mass after excision of phyllodes tumor No metastatic disease Metastatic disease As soft tissue sarcoma Re-excision with wide margins without axillary staging Consider post-op RT M D Anderson Cancer Center 2012

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