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Nizri E, Merimsky O, Lahat G. Optimal management of sarcomas of the breast: an update. Expert Rev Anticancer Ther 2014; 14:705-10. [PMID: 24611696 DOI: 10.1586/14737140.2014.895667] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Breast sarcomas are rare mesenchymal-derived breast tumors. The small number of patients, the different histological subtypes, and the variation in clinical practice impairs the ability to draw firm practice recommendations. Patient management is often extrapolated from other soft tissue sarcomas, mostly of the extremities in which more clinical data is available. Surgical resection with negative margins is the goal of treatment, irrespective of the surgical procedure; the implication of radiation and chemotherapy is variable. Further advances in treatment should follow the assembly of breast sarcoma patients in specific cancer networks in specialized sarcoma referral centers. The characterization of molecular pathways active in tumorogenesis of these tumors may pave the way for the application of novel therapeutic agents.
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Affiliation(s)
- Eran Nizri
- The Department of General Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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52
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Spitaleri G, Toesca A, Botteri E, Bottiglieri L, Rotmensz N, Boselli S, Sangalli C, Catania C, Toffalorio F, Noberasco C, Delmonte A, Luini A, Veronesi P, Colleoni M, Viale G, Zurrida S, Goldhirsch A, Veronesi U, De Pas T. Breast phyllodes tumor: A review of literature and a single center retrospective series analysis. Crit Rev Oncol Hematol 2013; 88:427-36. [DOI: 10.1016/j.critrevonc.2013.06.005] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/03/2013] [Accepted: 06/12/2013] [Indexed: 11/12/2022] Open
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Collin Y, Chagnon F, Mongeau CJ, Gonzalez-Amaya GL, Sideris L. Adrenal metastasis of a phyllodes tumor of the breast: Case report and review of the literature. Int J Surg Case Rep 2013; 4:687-9. [PMID: 23792482 DOI: 10.1016/j.ijscr.2013.04.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 03/22/2013] [Accepted: 04/05/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION A phyllodes tumor is a neoplasm of mixed mesenchymal and epithelial origin affecting the breast. It may pursue a benign or malignant evolution with distant metastases in the latter case. Sites most commonly affected by metastases are the lungs and bones. Simple mastectomy is the mainstay of treatment. This article presents the first described case of metastasis to the adrenal gland after sarcomatous transformation of a phyllodes tumor. A review of the literature is presented afterwards. PRESENTATION OF CASE A 57-year old female patient presented with a voluminous breast mass which was completely resected. Unfortunately she presented with malignant recurrence in the breast which was also resected. A later recurrence within the lung presented and was completely resected but showed aspects of sarcomatous changes. Finally a recurrence was pathologically documented within the adrenal gland. Unfortunately, disease later progressed and the patient refused further treatment at that point. DISCUSSION While malignant transformation of breast phyllodes tumors and metastasis is relatively common, the prognosis for initially benign lesion that are completely excised is usually good. This case represents the first documented metastasis to the adrenal gland of a breast phyllodes tumor. CONCLUSION We presented the first case of adrenal metastasis of a phyllodes tumor after sarcomatous degeneration. This is an unusual presentation of a relatively uncommon but well-recognized disease of variable malignant potential.
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Affiliation(s)
- Yves Collin
- Department of Surgery, Université de Sherbrooke, Sherbrooke, Canada.
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54
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Lahat G, Lev D, Gerstenhaber F, Madewell J, Le-Petross H, Pollock RE. Sarcomas of the breast. Expert Rev Anticancer Ther 2013; 12:1045-51. [PMID: 23030224 DOI: 10.1586/era.12.82] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sarcomas of the breast are a rare group of heterogeneous mesenchymal tumors accounting for less than 1% of all breast malignancies. Owing to the rarity of the disease, current knowledge is mostly based on numerous case reports and relatively small retrospective series; unlike epithelial breast cancer, there is no high level evidence to support a standard of care for primary and/or adjuvant therapy. To overcome this relative shortage of data, most therapeutic strategies for breast sarcoma are extrapolated from current treatment for soft tissue sarcoma in other locations, mainly of the extremities and thoracic wall. In general, the therapeutic approach to sarcoma of the breast should be based on a multidisciplinary strategy including surgery, radiation to improve local control and systemic chemotherapy in selected patients. This review discusses the results of the key larger retrospective studies including data on incidence, etiology, presentation, diagnosis, management and prognosis of this challenging rare disease entity.
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Affiliation(s)
- Guy Lahat
- Department of Surgery, Sourasky Medical Center, Tel-Aviv, Israel.
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55
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Singer A, Tresley J, Velazquez-Vega J, Yepes M. Unusual aggressive breast cancer: metastatic malignant phyllodes tumor. J Radiol Case Rep 2013; 7:24-37. [PMID: 23705037 DOI: 10.3941/jrcr.v7i2.1430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
For the year of 2012, it has been estimated that breast cancer will account for the greatest number of newly diagnosed cancers and the second highest proportion of cancer related deaths among women. Breast cancer, while often lumped together as one disease, represents a diverse group of malignancies with different imaging findings, histological appearances and behavior. While most invasive primary breast cancers are epithelial derived adenocarcinomas, rare neoplasms such as the phyllodes tumor may arise from mesenchymal tissue. Compared to the breast adenocarcinoma, the phyllodes tumor tends to affect a younger population, follows a different clinical course, is associated with different imaging and histological findings and is managed distinctively. There may be difficulty in differentiating the phyllodes tumor from a large fibroadenoma, but the mammographer plays a key role in reviewing the clinical and imaging data in order to arrive at the correct diagnosis. Early diagnosis with proper surgical management can often cure non-metastatic phyllodes tumors. However, in rare cases where metastasis occurs, prognosis tends to be poor. This report describes the presentation, imaging findings and management of a metastatic malignant phyllodes tumor.
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Affiliation(s)
- Adam Singer
- Department of Radiology, Jackson Memorial Hospital, Miami, FL 33136, USA.
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56
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Sarcoma of the Breast: Outcome and Reconstructive Options. Clin Breast Cancer 2012; 12:438-44. [DOI: 10.1016/j.clbc.2012.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 08/31/2012] [Accepted: 09/13/2012] [Indexed: 11/19/2022]
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Schechet SA, Askenasy EP, Dhamne S, Scott BG. Anemia and jejunal intussusception: An unusual presentation for a metastatic phyllodes breast tumor. Int J Surg Case Rep 2012; 3:62-4. [PMID: 22288047 DOI: 10.1016/j.ijscr.2011.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 10/10/2011] [Indexed: 10/15/2022] Open
Abstract
INTRODUCTION Phyllodes tumor of the breast is a rare cause of breast cancer, accounting for less than 0.5% of breast cancers. These tumors are classified as benign, borderline, or malignant, with malignant tumors compromising nearly 25% of cases. Metastases occur in 20% of malignant tumors, lungs, bones, liver and brain being the frequent sites of metastases. PRESENTATION OF CASE We present a case of a metastatic phyllodes tumor to the small bowel causing jejunal intussusception, symptomatic anemia, and small bowel obstruction. DISCUSSION Patients with phyllodes tumor of the breast can develop disease recurrence even years after initial treatment. Phyllodes tumor metastasizing to the small bowel is extremely rare, with only three known previously described case reports in the literature. CONCLUSION High risk patients, with a past medical history of phyllodes breast cancer, should be monitored closely. Even years after breast cancer treatment, these patients may present with gastrointestinal complaints such as obstruction or bleeding, and therefore metastatic disease to the small bowel should be considered on the differential with subsequent abdominal imaging obtained.
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Affiliation(s)
- Sidney A Schechet
- Baylor College of Medicine, Ben Taub General Hospital, Michael E. DeBakey Department of Surgery, 1504 Taub Loop, Houston, TX 77030, United States
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58
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Mojallal A, La Marca S, Shipkov C, Sinna R, Braye F. Poland syndrome and breast tumor: a case report and review of the literature. Aesthet Surg J 2012; 32:77-83. [PMID: 22231415 DOI: 10.1177/1090820x11430499] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Poland syndrome is a rare congenital malformation. Hypoplasia of the sternocostal portion of the pectoralis major muscle is the most significant feature and is most frequently associated with homolateral breast hypoplasia. In this article, the authors present a case of bilateral phyllodes tumors in a 28-year-old woman with Poland syndrome and discuss (1) the relationship between the condition and breast cancer, (2) the modes of surveillance in patients with Poland syndrome, and (3) its impact on breast reconstruction.
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Affiliation(s)
- Ali Mojallal
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Edouard Herriot Hospital, Lyon, France
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59
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Treatment for breast sarcoma: A large, single-centre series. Eur J Surg Oncol 2011; 37:703-8. [DOI: 10.1016/j.ejso.2011.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/11/2011] [Accepted: 04/19/2011] [Indexed: 11/18/2022] Open
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60
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Sueta A, Yamamoto Y, Inoue K, Kuriwaki K, Iwase H. Stromal sarcoma of the breast with lung metastases showing a clinical complete response to doxorubicin plus ifosfamide treatment: report of a case. Surg Today 2011; 41:1145-9. [PMID: 21773909 DOI: 10.1007/s00595-010-4406-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Accepted: 08/29/2010] [Indexed: 11/28/2022]
Abstract
A 29-year-old woman presented with a painful right breast tumor, measuring 15 cm in diameter, which had progressed rapidly over 3 months. Core needle biopsy of the tumor revealed a malignant mesenchymal tumor. A mastectomy was performed, and pathological examination of the tumor showed stromal sarcoma. Solitary pleural dissemination in the right lung was suspected, based on the computed tomography image taken before the operation. Two months after surgery, bilateral multiple lung nodules were demonstrated. Systemic chemotherapy with doxorubicin plus ifosfamide was performed, and 3 months later the lung metastases had disappeared. Moreover, there is still no sign of recurrence at 5 months after the initiation of the chemotherapy. Breast stromal sarcoma is very rare, accounting for less than 1% of mammary neoplasms, and the treatment strategy is not well established, especially regarding chemotherapy. This case demonstrates the effectiveness of chemotherapy with doxorubicin plus ifosfamide for lung metastases from breast stromal sarcoma.
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Affiliation(s)
- Aiko Sueta
- Department of General Surgery, Kumamoto Rousai Hospital, Kumamoto, Japan
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61
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Middela S, Jones M, Maxwell W. Primary osteosarcoma of the breast- a case report and review of literature. Indian J Surg 2011; 73:363-5. [PMID: 23024543 DOI: 10.1007/s12262-011-0260-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Accepted: 03/18/2009] [Indexed: 10/18/2022] Open
Abstract
Primary Osteosarcoma of the breast is an aggressive and relatively rare tumour whose prognosis is very poor.It is often a diagnostic dilemma to the pathologists and the surgeons are perplexed due to its aggressive behaviour as its pathology and prognostic factors are unclear. Due to its rarity we suggest pooling of tissue samples from various centres in biobanks for future studies (including molecular biological studies) so that its behaviour can be better understood.
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62
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Voutsadakis IA, Zaman K, Leyvraz S. Breast sarcomas: current and future perspectives. Breast 2011; 20:199-204. [PMID: 21398126 DOI: 10.1016/j.breast.2011.02.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/04/2011] [Accepted: 02/14/2011] [Indexed: 12/16/2022] Open
Abstract
Breast sarcomas are rare neoplasms of the breast that need to be clearly distinguished from the very common breast carcinomas and treated in a multidisciplinary manner modelled after treatment paradigms in other sarcoma locations. An increasing need to differentiate sarcoma sub-types based on molecular characteristics that will also be depicted in differential treatment sensitivities and development of specifically targeted therapies are equally valid in sarcomas in general and in breast sarcomas in particular. Of special interest in breast are sarcomas developing after breast irradiation for a previous breast carcinoma, a scenario that is increasingly common, given the increasing trends of breast conservation in the surgical treatment of breast carcinoma that necessitates the adjuvant use of radiotherapy.
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Affiliation(s)
- Ioannis A Voutsadakis
- Centre Pluridisciplinaire d'Oncologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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63
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Breast angiosarcoma that is not related to radiation exposure: a comprehensive review of the literature. Surg Today 2011; 41:163-8. [PMID: 21264749 DOI: 10.1007/s00595-010-4341-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 03/04/2010] [Indexed: 12/24/2022]
Abstract
Breast angiosarcomas that are not related to previous radiotherapy are very rare. Surgical resection is the primary treatment for these tumors, but there is no general agreement on the extent of surgery. The role of multimodality adjuvant treatment also remains controversial. The aim of this study was to summarize the available data from the largest published series of patients in terms of management and outcome. We also sought to identify prognostic factors influencing patient survival. We have included studies presenting detailed data on multimodality therapy and survival of patients with breast angiosarcoma. Ten studies presenting data on 280 patients were included in the review. Seventy-five percent of patients underwent a total mastectomy and 25% had breast-conserving treatment (BCT). In 42% of patients, an axillary node dissection was combined with mastectomy or BCT. Thirty-six percent of patients received chemotherapy and 35% were treated with radiotherapy in an adjuvant or neoadjuvant setting. Survival varied significantly according to tumor size and grade. Adjuvant multimodality therapy may improve the outcome in selected patients with breast angiosarcoma. Tumor size, grade, and margin status are the most important prognostic factors for survival.
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64
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Fakhir B, Louba A, Bouchikhi C, Bouguern H, Chaara H, Melhouf M, Banani A. Les sarcomes phyllodes: à propos de cinq patientes et revue de la littérature. ONCOLOGIE 2010. [DOI: 10.1007/s10269-010-1883-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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65
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Brown-Glaberman U, Graham A, Stopeck A. A Case of Metaplastic Carcinoma of the Breast Responsive to Chemotherapy with Ifosfamide and Etoposide: Improved Antitumor Response by Targeting Sarcomatous Features. Breast J 2010; 16:663-5. [PMID: 21070449 DOI: 10.1111/j.1524-4741.2010.00975.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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66
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Vieira SC, Tavares MBAC, Da Cruz Filho AJG, Sousa RB, Dos Santos LG. Metastatic osteosarcoma to the breast: A rare case. J Obstet Gynaecol Res 2010; 36:891-3. [DOI: 10.1111/j.1447-0756.2010.01239.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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67
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Al-Benna S, Poggemann K, Steinau HU, Steinstraesser L. Diagnosis and management of primary breast sarcoma. Breast Cancer Res Treat 2010; 122:619-26. [DOI: 10.1007/s10549-010-0915-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 04/21/2010] [Indexed: 11/28/2022]
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68
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Dillman JR, Pernicano PG, McHugh JB, Attili AK, Mourany B, Pinsky RW, Strouse PJ, Kazerooni EA. Cross-Sectional Imaging of Primary Thoracic Sarcomas with Histopathologic Correlation: A Review for the Radiologist. Curr Probl Diagn Radiol 2010; 39:17-29. [DOI: 10.1067/j.cpradiol.2009.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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69
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Prise en charge des tumeurs phyllodes malignes du sein : l’expérience de l’institut Curie. Cancer Radiother 2009; 13:305-12. [DOI: 10.1016/j.canrad.2009.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 04/25/2009] [Accepted: 05/03/2009] [Indexed: 11/22/2022]
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70
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Karim R, Gerega S, Yang Y, Spillane A, Carmalt H, Scolyer R, Lee C. Phyllodes tumours of the breast: A clinicopathological analysis of 65 cases from a single institution. Breast 2009; 18:165-70. [DOI: 10.1016/j.breast.2009.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 03/08/2009] [Accepted: 03/09/2009] [Indexed: 10/21/2022] Open
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71
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72
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Breast sarcoma--a review of diagnosis and management. Int J Surg 2008; 7:20-3. [PMID: 19114317 DOI: 10.1016/j.ijsu.2008.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 12/04/2008] [Indexed: 11/20/2022]
Abstract
Sarcoma of the breast is a rare condition. The biological differences from other primary breast tumours necessitate a corresponding difference in approach to diagnostic and management strategies. The rarity of the condition has made clinicopathological study difficult, with most series limited to less than 50 patients. We review the current literature on the diagnosis and management of breast sarcoma, and highlight areas of likely future development.
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73
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Pezner RD, Schultheiss TE, Paz IB. Malignant phyllodes tumor of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Phys 2008; 71:710-3. [PMID: 18234448 DOI: 10.1016/j.ijrobp.2007.10.051] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 10/23/2007] [Accepted: 10/24/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Patients with malignant phyllodes tumors of the breast (MPTB) are routinely treated with surgery alone. We performed a retrospective study to determine local control rates based on tumor size and type of surgery performed. METHODS AND MATERIALS We reviewed records of 478 patients with MPTB treated between March 1964, and August 2005. The data were extracted from the IMPAC National Oncology Database consisting of merged tumor registries from 130 hospitals. RESULTS Median follow-up was 64 months (range, 0-410 months). Actuarial 5-year local control rates were 79.4% for 169 lumpectomy patients and 91.2% for 207 mastectomy patients treated by surgery alone. Five-year local control rates for lumpectomy based on tumor size were 91% for 0-2 cm tumors, 85% for 2-5 cm tumors, and 59% for 5-10 cm tumors. For mastectomy patients, 5-year local control rates were 100% for 0-2 cm tumors, 95% for 2-5 cm tumors, 88% for 5-10 cm tumors, and 85% for 10-20 cm tumors. Multivariate analysis of overall survival found several factors to be significant including advancing age with each decade after 50 years of age, appearance of distant metastases, larger primary tumor size, and local control vs. local recurrence (Hazard Ratio [HR] 2.5, p < 0.05). CONCLUSIONS Malignant phyllodes tumors of the breast local recurrence rates are 15% or greater for patients with tumors >2 cm treated by lumpectomy alone and tumors >10 cm treated by mastectomy alone. Adjuvant radiation therapy should be evaluated for these patients. This may be especially important because our study showed that local recurrence impacted on survival rates.
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Affiliation(s)
- Richard D Pezner
- Division of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA.
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74
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Chromosomal aberrations and genetic relations in benign, borderline and malignant phyllodes tumors of the breast: a comparative genomic hybridization study. Breast Cancer Res Treat 2008; 112:411-8. [DOI: 10.1007/s10549-007-9876-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Accepted: 12/17/2007] [Indexed: 12/13/2022]
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75
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Jerbi M, Hidar S, Hattab N, Tebra S, Yacoubi T, Korbi S, Bouaouina N, Khairi H. [Radiation induced breast sarcoma: a case report]. ACTA ACUST UNITED AC 2007; 35:997-1000. [PMID: 17920327 DOI: 10.1016/j.gyobfe.2007.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 05/16/2007] [Indexed: 11/19/2022]
Abstract
Radiation-induced breast sarcoma is a late complication of radiation treatment. We report a case of an undifferentiated sarcoma occurring 8 years after breast conserving treatment, which required mastectomy taking pectoralis major.
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Affiliation(s)
- M Jerbi
- Service de gynécologie-obstétrique, CHU Farhat-Hached, 40002 Sousse, Tunisie.
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76
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