Recurrent Phyllodes Tumor of the Breast: Defining the Role for Skin-Sparing Mastectomy and Autologous Reconstruction

ABSTRACT

Phyllodes tumors (PTs) are uncommon fibroepithelial tumors of the breast, noteworthy for their difficult excisions and high recurrence rates. In the setting of recurrence, there is no consensus in the literature as to the extent of excision or the impact on reconstructive options. Breast-conserving surgery and simple mastectomy have each been described with mixed reports. Despite a shift toward the selective use of skin-sparing mastectomy and nipple-areola complex–sparing mastectomy in breast carcinoma, neither the role for these techniques nor the role for breast reconstruction in recurrent PT has been described. A case report is presented demonstrating the utility of skin-sparing mastectomy and autologous breast reconstruction for locally recurrent PT of the breast, with a literature review of management options in this setting presented. The case presented highlights an appropriate setting for autologous microsurgical reconstruction of the breast in recurrent PT. The literature review highlights a lack of any published management consensus, with only the role for mastectomy suggested for recurrent high-grade or malignant lesions. A potential management algorithm is thus presented. Skin-sparing mastectomy, particularly for intermediate-grade lesions, may allow wider resections while enabling aesthetically pleasing reconstructive options without affecting recurrence rates.

KEYWORDS

Phyllodes tumor - cystosarcoma - breast - skin sparing mastectomy - reconstruction

REFERENCES

• 1 Rowell M D, Perry R R, Hsiu J G, Barranco S C. Phyllodes tumors.  Am J Surg. 1993;  165 376-379
• 2 Barrio A V, Clark B D, Goldberg J I et al.. Clinicopathologic features and long-term outcomes of 293 phyllodes tumors of the breast.  Ann Surg Oncol. 2007;  14 2961-2970
• 3 WHO . Histological typing of breast tumors.  Tumor. 1982;  68 181-198
• 4 Palmer M L, De Risi D C, Pelikan A et al.. Treatment options and recurrence potential for cystosarcoma phyllodes.  Surg Gynecol Obstet. 1990;  170 193-196
• 5 Reinfuss M, Mituś J, Duda K, Stelmach A, Ryś J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases.  Cancer. 1996;  77 910-916
• 6 Lindquist K D, van Heerden J A, Weiland L H, Martin Jr J K. Recurrent and metastatic cystosarcoma phyllodes.  Am J Surg. 1982;  144 341-343
• 7 Chua C L, Thomas A, Ng B K. Cystosarcoma phyllodes: a review of surgical options.  Surgery. 1989;  105(2 Pt 1) 141-147
• 8 Barth Jr R J. Histologic features predict local recurrence after breast conserving therapy of phyllodes tumors.  Breast Cancer Res Treat. 1999;  57 291-295
• 9 de Roos W K, Kaye P, Dent D M. Factors leading to local recurrence or death after surgical resection of phyllodes tumours of the breast.  Br J Surg. 1999;  86 396-399
• 10 Azzopardi J G. Sarcoma in the breast. In: Azzopardi J G, ed. Problems in Breast Pathology. Philadelphia: W.B. Saunders; 1979: 346-65
• 11 Salvadori B, Cusumano F, Del Bo R et al.. Surgical treatment of phyllodes tumors of the breast.  Cancer. 1989;  63 2532-2536
• 12 Zissis Ch, Apostolikas N, Konstantinidou A, Griniatsos J, Vassilopoulos P P. The extent of surgery and prognosis of patients with phyllodes tumor of the breast.  Breast Cancer Res Treat. 1998;  48 205-210
• 13 Ciatto S, Bonardi R, Cataliotti L, Cardona G. Phyllodes tumor of the breast: a multicenter series of 59 cases.  Eur J Surg Oncol. 1992;  18 545-549
• 14 Kapiris I, Nasiri N, A'Hern R, Healy V, Gui G P. 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;  27 723-730
• 15 Norris H J, Taylor H B. Relationship of histologic features to behavior of cystosarcoma phyllodes. Analysis of ninety-four cases.  Cancer. 1967;  20 2090-2099
• 16 Halverson J D, Hori-Rubaina J M. Cystosarcoma phyllodes of the breast.  Am Surg. 1974;  40 295-301
• 17 Chaney A W, Pollack A, McNeese M D et al.. Primary treatment of cystosarcoma phyllodes of the breast.  Cancer. 2000;  89 1502-1511
• 18 Chen W H, Cheng S P, Tzen C Y et al.. Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases.  J Surg Oncol. 2005;  91 185-194
• 19 Hajdu S I, Espinosa M H, Robbins G F. Recurrent cystosarcoma phyllodes: a clinicopathologic study of 32 cases.  Cancer. 1976;  38 1402-1406
• 20 West T L, Weiland L H, Clagett O T. Cystosarcoma phyllodes.  Ann Surg. 1971;  173 520-528
• 21 Blichert-Toft M, Hansen J P, Hansen O H, Schiodt T. Clinical course of cystosarcoma phyllodes related to histologic appearance.  Surg Gynecol Obstet. 1975;  140 929-932
• 22 Ben Hassouna J, Damak T, Gamoudi A et al.. Phyllodes tumors of the breast: a case series of 106 patients.  Am J Surg. 2006;  192 141-147
• 23 Contarini O, Urdaneta L F, Hagan W, Stephenson Jr S E. Cystosarcoma phylloides of the breast: a new therapeutic proposal.  Am Surg. 1982;  48 157-166
• 24 Mangi A A, Smith B L, Gadd M A, Tanabe K K, Ott M J, Souba W W. Surgical management of phyllodes tumors.  Arch Surg. 1999;  134 487-492 discussion 492-493
• 25 Kario K, Maeda S, Mizuno Y, Makino Y, Tankawa H, Kitazawa S. Phyllodes tumor of the breast: a clinicopathologic study of 34 cases.  J Surg Oncol. 1990;  45 46-51
• 26 Buchanan E B. Cystosarcoma phyllodes and its surgical management.  Am Surg. 1995;  61 350-355
• 27 Pezner R D, Schultheiss T E, Paz I B. Malignant phyllodes tumor of the breast: local control rates with surgery alone.  Int J Radiat Oncol Biol Phys. 2008;  71 710-713
• 28 Pezner R D, Schultheiss T E, Paz I B. Malignant phyllodes tumor of the breast: local control rates with surgery alone.  Int J Radiat Oncol Biol Phys. 2008;  71 710-713
• 29 Hawkins R E, Schofield J B, Fisher C, Wiltshaw E, McKinna J A. The clinical and histologic criteria that predict metastases from cystosarcoma phyllodes.  Cancer. 1992;  69 141-147
• 30 Morales-Vásquez F, Gonzalez-Angulo A M, Broglio K et al.. Adjuvant chemotherapy with doxorubicin and dacarbazine has no effect in recurrence-free survival of malignant phyllodes tumors of the breast.  Breast J. 2007;  13 551-556
• 31 McGregor G I, Knowling M A, Este F A. Sarcoma and cystosarcoma phyllodes tumors of the breast—a retrospective review of 58 cases.  Am J Surg. 1994;  167 477-480
• 32 Reinfuss M, Mituś J, Duda K, Stelmach A, Ryś J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast: an analysis of 170 cases.  Cancer. 1996;  77 910-916
• 33 Tavassoli F A, Devilee P. Pathology and genetics of tumors of the breast and female genital organs. In: World Health Organization Classification of Tumors. Lyons: IARC Press; 2003: 99-103
• 34 Birch J M, Alston R D, McNally R J et al.. Relative frequency and morphology of cancers in carriers of germline TP53 mutations.  Oncogene. 2001;  20 4621-4628
• 35 Mulero F, Roca V, Nicolás F et al.. Usefulness of quantification and visual analysis of the uptake of (99m)Tc-MIBI in the diagnosis of mammary lesions.  Rev Esp Med Nucl. 2000;  19 192-198
• 36 Dillon M F, Quinn C M, McDermott E W, O'Doherty A, O'Higgins N, Hill A D. Needle core biopsy in the diagnosis of phyllodes neoplasm.  Surgery. 2006;  140 779-784
• 37 Tan E Y, Tan P H, Yong W S et al.. Recurrent phyllodes tumours of the breast: pathological features and clinical implications.  ANZ J Surg. 2006;  76 476-480
• 38 Lindquist K D, van Heerden J A, Weiland L H, Martin Jr J K. Recurrent and metastatic cystosarcoma phyllodes.  Am J Surg. 1982;  144 341-343
• 39 Macdonald O K, Lee C M, Tward J D, Chappel C D, Gaffney D K. 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 2127-2133
• 40 Lai Y L, Weng C J, Noordhoff M S. Breast reconstruction following excision of phylloides tumor.  Ann Plast Surg. 1999;  43 132-136
• 41 Sufi P A, Gittos M, Collier D S. Envelope mastectomy with immediate reconstruction (EMIR).  Eur J Surg Oncol. 2000;  26 367-370
• 42 Carlson G W, Losken A, Moore B et al.. Results of immediate breast reconstruction after skin-sparing mastectomy.  Ann Plast Surg. 2001;  46 222-228
• 43 Liang M I, Ramaswamy B, Patterson C C et al.. Giant breast tumors: surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature.  World J Surg Oncol. 2008;  6 117-119