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Yang P, Zhang G, Zhang Y, Zhao W, Tang J, Zeng S, Lv X, Lv L. Effect of adjuvant radiotherapy on overall survival and breast cancer-specific survival of patients with malignant phyllodes tumor of the breast in different age groups: a retrospective observational study based on SEER. Radiat Oncol 2024; 19:59. [PMID: 38773616 PMCID: PMC11107058 DOI: 10.1186/s13014-024-02442-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/16/2024] [Indexed: 05/24/2024] Open
Abstract
PURPOSE Malignant phyllodes tumor of the breast (MPTB) is a rare type of breast cancer, with an incidence of less than 1%. The value of adjuvant radiotherapy (RT) for MPTB has been controversial. The aim of the study was to explore the effect of radiotherapy on the long-term survival of female patients with MPTB at different ages. METHODS Female MPTB patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2020. A Kaplan-Meier survival analysis was conducted to investigate the value of RT for the long-term survival of MPTB patients in different age groups. Additionally, univariate and multivariate Cox regression analyses were performed for overall survival (OS) and breast cancer-specific survival (BCSS) of MPTB patients. Furthermore, propensity score matching (PSM) was also performed to balance the differences in baseline characteristics. RESULTS 2261 MPTB patients were included in this study, including 455 patients (20.12%) with RT and 1806 patients (79.88%) without RT. These patients were divided into four cohorts based on their ages: 18-45, 46-55, 56-65, and 65-80. Before adjustment, there was a statistically significant difference in long-term survival between RT-treated and non-RT-treated patients in the younger age groups (age group of 18-45 years: OS P = 0.019, BCSS P = 0.016; age group of 46-55 years: OS P < 0.001, BCSS P < 0.001). After PSM, no difference was found in long-term survival of patients in both younger and older groups regardless of whether they received RT (age group of 18-45 years: OS P = 0.473, BCSS P = 0.750; age group of 46-55 years: OS P = 0.380, BCSS P = 0.816, age group of 56-65 years: OS P = 0.484, BCSS P = 0.290; age group of 66-80 years: OS P = 0.997, BCSS P = 0.763). In multivariate COX regression analysis, RT did not affect long-term survival in patients with MPTB. CONCLUSION There is no evidence that long-term survival of MPTB patients in specific age groups can benefit from RT.
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Affiliation(s)
- Ping Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Gongyin Zhang
- Department of Breast and Hernia Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Wanying Zhao
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jinhai Tang
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Siyuan Zeng
- Dalian Municipal Central Hospital, China Medical University, Shenyang, Liaoning, China
| | - Xiupeng Lv
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Li Lv
- Department of Pathology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
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Ma X, Zhang L, Xiao Q, Huang Y, Lin L, Peng W, Gong J, Gu Y. Predicting Prognosis of Phyllodes Tumors Using a Mammography- and Magnetic Resonance Imaging-Based Radiomics Model: A Preliminary Study. Clin Breast Cancer 2024:S1526-8209(24)00119-8. [PMID: 38839461 DOI: 10.1016/j.clbc.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/25/2024] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE To investigate whether a radiomics model based on mammography (MG) and magnetic resonance imaging (MRI) can be used to predict disease-free survival (DFS) after phyllodes tumor (PT) surgery. METHOD About 131 PT patients who underwent MG and MRI before surgery between January 2010 and December 2020 were retrospectively enrolled, including 15 patients with recurrence and metastasis and 116 without recurrence. 884 and 3138 radiomic features were extracted from MG and MR images, respectively. Then, multiple radiomics models were established to predict the recurrence risk of the patients by applying a support vector machine classifier. The area under the ROC curve (AUC) was calculated to evaluate model performance. After dividing the patients into high- and low-risk groups based on the predicted radiomics scores, survival analysis was conducted to compare differences between the groups. RESULTS In total, 3 MG-related and 5 MRI-related radiomic models were established; the prediction performance of the T1WI feature fusion model was the best, with an AUC value of 0.93. After combining the features of MG and MRI, the AUC increased to 0.95. Furthermore, the MG, MRI and all-image radiomic models had statistically significant differences in survival between the high- and low-risk groups (P < .001). All-image radiomics model showed higher survival performance than the MG and MRI radiomics models alone. CONCLUSIONS Radiomics features based on preoperative MG and MR images can predict DFS after PT surgery, and the prediction score of the image radiomics model can be used as a potential indicator of recurrence risk.
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Affiliation(s)
- Xiaowen Ma
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Zhang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qin Xiao
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Huang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Luyi Lin
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing Gong
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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Valenza C, De Pas TM, Gaeta A, Castellano G, Santoro C, Corona A, Chiappini G, Vivanet G, Trapani D, Coppola S, Conforti F, Mattar D, Gandini S, Veronesi P, Pennacchioli E, Curigliano G. Primary malignant phyllodes tumors of the breast: A retrospective analysis from a referral center. Eur J Cancer 2024; 196:113423. [PMID: 37977104 DOI: 10.1016/j.ejca.2023.113423] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The treatment for primary malignant phyllodes tumors of the breast (B-MPT) consists of wide local excision with negative margins (≥1 cm). However, because of their rarity, prognostic factors, type of surgery and adjuvant treatments are still a matter of debate. METHODS We conducted a single-center retrospective study to describe outcomes and prognostic factors of patients with primary B-MPT, who underwent breast surgery from January 2000 to December 2021. The primary endpoint was the cumulative incidence of any recurrence. Secondary endpoints were the cumulative incidences of distant and local recurrences. RESULTS 131 patients were included, of whom all received surgery, 5 adjuvant anthracycline-based chemotherapy and 15 radiation therapy. After a median follow-up of 6.4 years, the cumulative incidences at 5-years of any, local and distant recurrences were of 26% (95% Confidence Interval [CI], 4-34%), 16% (95%CI, 10-24%) and 10% (95%CI, 5.3-16%), respectively. Tumor size ≥ 5 cm was associated with higher distant recurrences (p = 0.05); instead, among small tumors (<5 cm), distant recurrences were higher in those with heterologous differentiation and/or multifocal disease (p = 0.06). Type of breast surgery (mastectomy vs. lumpectomy/excision) was not found to be significantly associated with distant (p = 0.32) or local (p = 0.17) recurrence, even after controlling local recurrence incidence for negative pathologic prognostic factors (p = 0.17). CONCLUSIONS The natural history of B-MPT is burdened by local and distant recurrences. Pathologic prognostic factors (i.e., tumor size, heterologous differentiation and multifocal disease) more than the type of wide breast surgery (mastectomy vs. lumpectomy) seem to represent the most significant prognostic factor for recurrences.
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Affiliation(s)
- Carmine Valenza
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Aurora Gaeta
- Department of Experimental Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Grazia Castellano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Celeste Santoro
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Amedeo Corona
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Chiappini
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Grazia Vivanet
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Dario Trapani
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Sara Coppola
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fabio Conforti
- Medical Oncology Division, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - Denise Mattar
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Sara Gandini
- Department of Experimental Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elisabetta Pennacchioli
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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Li C, Zhang C. A case report of a patient with ductal carcinoma and a malignant phyllodes tumor in situ in 2 separate breasts. Medicine (Baltimore) 2023; 102:e36405. [PMID: 38050272 PMCID: PMC10695601 DOI: 10.1097/md.0000000000036405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/10/2023] [Indexed: 12/06/2023] Open
Abstract
RATIONALE Breast malignant phyllodes tumors (MPT) are quite uncommon. It is rarely reported that they occur in conjunction with breast cancer. We detailed a case in which an MPT and ductal carcinoma in situ carcinoma occurred simultaneously in 2 different breasts. PATIENT CONCERNS A 79-year-old female patient was seen for a rapidly growing lump in the upper left quadrant of her breast. The lump was described as huge, hard, irregular, and palpable. MRI of the breasts revealed a big mass in the left breast and a smaller lump in the right. DIAGNOSIS Ductal carcinoma in situ with breast MPT. INTERVENTIONS We performed a double mastectomy. Post-operative endocrine treatment was suggested. OUTCOMES During the 18-month follow-up period, no signs of recurrence or metastasis were seen. The ultrasound examination of the chest wall showed no abnormality. Bilateral axillary and supraclavicular ultrasonography showed no lymphadenectasis and a CT scan of the lungs showed no suspicious cancer nodules. LESSONS It is possible for MPT and ductal carcinoma in situ to occur simultaneously in different breasts. Surgeons need to integrate clinical observations, imaging tools, and patient history to make an early diagnosis. Before undergoing surgery, a thorough examination of both breasts is required.
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Affiliation(s)
- Chen Li
- Department of Breast Surgery, Peking University International Hospital, Beijing, China
| | - Chun Zhang
- Department of Breast Surgery, Peking University International Hospital, Beijing, China
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Goodwin B, Oyinlola AF, Palhang M, Lehman D, Platoff R, Atabek U, Spitz F, Hong Y. Metastatic and Malignant Phyllodes Tumors of the Breast: An Update for Current Management. Am Surg 2023; 89:6190-6196. [PMID: 37611540 DOI: 10.1177/00031348231198114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Metastatic, malignant phyllodes tumor (PT) of the breast is a rare and aggressive neoplasm. Currently, there is no agreed upon consensus as to best management practices. A systematic review of literature was conducted investigating surgical, chemotherapeutic, and radiotherapeutic management for metastatic PT. Databases employed to identify articles included Embase, PubMed, and SAGE Journals. Diagnosis of metastatic PT has been of significant difficulty to radiologists as it is often confused with fibroadenomas. Surgically, metastatectomy has been correlated with increased overall survival (of 25.9 versus 9.9 months; P = .01). Radiotherapy has often been associated with palliation and pain control in metastatic, malignant neoplasia. However, one study showed that in malignant PT, radiation was associated with significantly lower rates of local recurrence (OR: 0.048 versus 0.209). Anthracycline containing chemotherapy regimens has been associated with improved overall survival (22.4 months versus 13.2 months; P = .040). Further research must be conducted into this rare malignancy to elucidate accurate diagnosis and care for patients with advanced metastatic or malignant phyllodes tumors.
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Affiliation(s)
- Brandon Goodwin
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | - Meejan Palhang
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Danielle Lehman
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | - Umur Atabek
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Francis Spitz
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Young Hong
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
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Bogach J, Sriskandarajah A, Wright FC, Look Hong N. Phyllodes Tumors of the Breast: Canadian National Consensus Document Using Modified Delphi Methodology. Ann Surg Oncol 2023; 30:6386-6397. [PMID: 37556009 DOI: 10.1245/s10434-023-13912-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/14/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Phyllodes tumors are rare breast neoplasms with limited prospective data to guide treatment, leading to heterogeneous management of this disease. We developed National consensus statements using modified Delphi methodology including patients and practitioners across Canada. METHODS Statements were developed based on a literature review. Two iterations of surveys were distributed with a planned virtual consensus meeting. Panelists were invited from surgery, radiation oncology, medical oncology, pathology, radiology, and plastic surgery. RESULTS Twenty-three participants attended the virtual conference. One hundred statements regarding diagnostics, pathology, surgical planning, adjuvant therapies, recurrence, surveillance, and patient support were approved with an a priori defined consensus of ≥ 80%. Two tables on locoregional management were developed and approved. The management of borderline phyllodes tumors was a source of uncertainty, and recommendations reflect the lack of evidence in this rare presentation. CONCLUSION A consensus document containing all approved statements for the care and management of phyllodes tumors was developed to help guide practice and future research.
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Affiliation(s)
- Jessica Bogach
- Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | | | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicole Look Hong
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Liu N, Kang Y, Qu N, Kong C, Han Y. Clinical perspectives and outcomes of the giant breast phyllodes tumor and sarcoma: a real-world retrospective study. BMC Cancer 2023; 23:801. [PMID: 37635229 PMCID: PMC10463853 DOI: 10.1186/s12885-023-11279-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Giant breast malignant phyllodes tumor or sarcoma (GBPS) are rare entities with diameter larger than 10 cm and variously histological pleomorphisms. This disease poses a significant threat to the quality of life of individuals, and its prognosis remains unclear. This study aimed to explore the differential diagnosis, treatment, and prognosis of GBPS in a real-world retrospective cohort. METHODS We collected GBPS (diameter > 10 cm, n = 10) and BPS (diameter ≤ 10 cm, n = 126) from patients diagnosed with sarcoma or malignant phyllodes tumor between 2008 and 2022. We analyzed clinical characteristics, histological status, treatment, and local recurrence using the Fisher's exact test between GBPS (diameter > 10 cm) and BPS (diameter ≤ 10 cm) cohort. We described overall survival (OS) and disease-free survival (DFS) using Kaplan-Meier curves and identified risk factors for local recurrence using logistic regression. The tumor size, age at diagnosis, and differential immunohistochemistry markers of breast sarcoma or phyllodes tumor to determine the prognosis of GBPS. RESULTS In our retrospective analysis of breast malignancies, we identified 10 cases of GBPS and 126 cases of BPS, corresponding to a GBPS prevalence of 0.17% (10/6000). The median age was 38.5 years (inter-quartile range, IQR: 28.25-48.5 years). During the follow-up of period (median: 80.5 months, IQR: 36.75-122 months), the local recurrence (LR) rate was 40% and 20.6%, respectively. Clinical characteristics of young age (HR:2.799, 95%CI -00.09276-0.017, p < 0.05) and cytological characteristics of marked stromal atypia (HR:0.88, 95% CI 0.39-1.40, p < 0.05) were risk factors for the poor prognosis of GBPS by COX regression model analysis. The Kaplan-Meier curves of GBPS 5-year disease-free survival (DFS) and overall survival (OS) were 31.5 months and 40 months, respectively, and were not associated with adjuvant radiation or chemotherapy. CONCLUSION We recommend mastectomy with a clear surgical margin as the preferred treatment for GBPS. Age and stromal atypia are significantly associated with recurrence. Adjuvant radiation therapy is advised; however, there was no improvement in overall survival. There is no consensus on the effectiveness of adjuvant chemotherapy and genetic methods, highlighting the need for further research into this aggressive tumor. We recommend a multidisciplinary approach involving a dedicated team for the management of GBPS.
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Affiliation(s)
- Naiquan Liu
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ye Kang
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ningxin Qu
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Chenhui Kong
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ye Han
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, 110004, China.
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Li W, Fang K, Chen J, Deng J, Li D, Cao H. The application of clinical variable-based nomogram in predicting overall survival in malignant phyllodes tumors of the breast. Front Genet 2023; 14:1133495. [PMID: 37323673 PMCID: PMC10265739 DOI: 10.3389/fgene.2023.1133495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Background: We aimed to explore prognostic risk factors in patients with malignant phyllodes tumors (PTs) of the breast and construct a survival prediction model. Methods: The Surveillance, Epidemiology, and End Results database was used to collect information on patients with malignant breast PTs from 2004 to 2015. The patients were randomly divided into training and validation groups using R software. Univariate and multivariate Cox regression analyses were used to screen out independent risk factors. Then, a nomogram model was developed in the training group and validated in the validation group, and the prediction performance and concordance were evaluated. Results: The study included 508 patients with malignant PTs of the breast, including 356 in the training group and 152 in the validation group. Univariate and multivariate Cox proportional hazard regression analyses showed that age, tumor size, tumor stage, regional lymph node metastasis (N), distant metastasis (M) and tumor grade were independent risk factors for the 5-year survival rate of patients with breast PTs in the training group (p < 0.05). These factors were used to construct the nomogram prediction model. The results showed that the C-indices of the training and validation groups were 0.845 (95% confidence interval [CI] 0.802-0.888) and 0.784 (95% CI 0.688-0.880), respectively. The calibration curves of the two groups were close to the ideal 45° reference line and showed good performance and concordance. Receiver operating characteristic and decision curve analysis curves showed that the nomogram has better predictive accuracy than other clinical factors. Conclusion: The nomogram prediction model constructed in this study has good predictive value. It can effectively assess the survival rates of patients with malignant breast PTs, which will aid in the personalized management and treatment of clinical patients.
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Affiliation(s)
- Wei Li
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Kun Fang
- Department of Surgery, Yinchuan Maternal and Child Health Hospital, Yinchuan, China
| | - Jiaren Chen
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Jian Deng
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Dan Li
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Hong Cao
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
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Sain B, Gupta A, Ghose A, Halder S, Mukherjee V, Bhattacharya S, Mondal RR, Sen AN, Saha B, Roy S, Boussios S. Clinico-Pathological Factors Determining Recurrence of Phyllodes Tumors of the Breast: The 25-Year Experience at a Tertiary Cancer Centre. J Pers Med 2023; 13:jpm13050866. [PMID: 37241036 DOI: 10.3390/jpm13050866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/02/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Phyllodes tumors (PTs) of the breast are rare fibroepithelial tumors that are generally more prone to recurrence. AIMS AND OBJECTIVES This study aimed to assess the clinicopathological features, diagnostic modalities, and therapeutic interventions, along with their respective outcomes, to identify the factors associated with a recurrence of PTs of the breast. METHODOLOGY A retrospective cohort and observational study was conducted, which entailed analyzing the clinicopathological data of patients who were previously diagnosed or presented with PTs of the breast between 1996 and 2021. Data included the total number of patients diagnosed with PTs of the breast and their ages, tumor grade on initial biopsy, tumor location (left or right breast), tumor size, therapeutic interventions carried out (including surgery-either mastectomy or lumpectomy-and adjuvant radiotherapy), final tumor grade, recurrence status, type of recurrence, and time to recurrence. RESULTS We analyzed data on a total of 87 patients who were pathologically proven to have PTs, and 46 patients (52.87%) were found to have recurrences. All patients were female, with a mean age at diagnosis of 39 years (range 15-70). Patients aged <40 years had the highest incidence of recurrence, with a rate of 54.35% (n = 25/46), followed by patients aged >40 years, with a rate of recurrence of 45.65% (n = 21/46). A total of 55.4% of patients presented with primary PTs and 44.6% had recurrent PTs at presentation. The average time to local recurrence (LR) from the completion of treatment was 13.8 months, whereas for systemic recurrence (SR), it was 15.29 months. Surgery (mastectomy/lumpectomy) was the major determinant for local recurrence (p < 0.05). CONCLUSION Patients who received adjuvant radiotherapy (RT) had a minimal recurrence of PTs. Patients who were found to have a malignant biopsy on initial diagnosis (triple assessment) had a higher incidence of PTs and were more prone to SR than LR. Surgery was a determining factor in the increased rate of LR, with lumpectomy associated with a higher incidence of LR than mastectomy.
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Affiliation(s)
- Baijaeek Sain
- Department of Trauma & Orthopaedics, Imperial College London Healthcare NHS Trust, London W2 1NY, UK
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Arnab Gupta
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Aruni Ghose
- Department of Medical Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, London SG1 4AB, UK
- Department of Medical Oncology, Barts Cancer Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London E1 1BB, UK
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
| | - Sudip Halder
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Vishal Mukherjee
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Samir Bhattacharya
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Radha Raman Mondal
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Aditya Narayan Sen
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Bijan Saha
- Department of Surgical Oncology, Saroj Gupta Cancer Center and Research Institute, Kolkata 700063, India
| | - Shravasti Roy
- Department of Pathology, Saroj Gupta Cancer Centre and Research Institute, Kolkata 700001, India
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King's College London, London SE1 9RT, UK
- Kent Medway Medical School, University of Kent, Canterbury CT2 7LX, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
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10
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Chen C, Huang X, Xu Y, Sun Q. Rethinking on the management strategy of malignant phyllodes tumor of the breast: An analysis based on the SEER database. Medicine (Baltimore) 2023; 102:e33326. [PMID: 36961178 PMCID: PMC10036047 DOI: 10.1097/md.0000000000033326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 02/28/2023] [Indexed: 03/25/2023] Open
Abstract
Malignant phyllodes tumor of the breast (MPTB) is a rare breast neoplasm that has a high recurrence rate and its optimal treatment strategies remain controversial. Our study used the most up-to-date database to determine prognostic factors that predict cancer-specific survival (CSS) and to evaluate the effects of different treatment strategies for MPTB. We performed a retrospective cohort study using the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Women who were diagnosed with MPTB from 2000 to 2019 were included. Kaplan-Meier method and Cox proportional hazards regressions were used to evaluate the prognostic power of variables on CSS. A total of 1902 women with MPTB were included in the study, with a median follow-up duration of 87.5 months. Age was found not to independently predict CSS in patients with tumors larger than 10 cm (P = .235). Mastectomy was performed on a total of 898 (47.2%) patients including 210 women (23.4%) undergoing radiotherapy after surgery. Mastectomy showed worse CSS when compared with breast-conserving surgery in patients with tumors smaller than 10 cm. Patients undergoing radiotherapy were not inferior to non-radiotherapy patients on CSS when patients were stratified by tumor size. Breast-conserving surgery showed survival benefits for patients with small tumors (T1 and T2). Patients with radiotherapy were not inferior to non-radiotherapy patients on CSS. Treatment of patients with MPTB should be carefully selected based on different tumor sizes.
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Affiliation(s)
- Chang Chen
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Huang
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Xu
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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A Rare Case of the Malignant Phyllodes Breast Tumor - Case Report. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
The phyllodes tumor (cystosarcoma phyllodes) is a rare fibroepithelial neoplasm presenting less than 1% of all breast tumors. Based on histologic features World Health Organization (WHO) classifies into benign, border line and malignant tumors (the rarest). Only around 5-15% of all malignant form cases metastasize hematogeneosly in the lung, bone and brain. Clinically are mostly presented the phyllodes tumor mostly presents as a rapid growth, palpabile, painless, elastic, oval or lobulated masses over 5 cm among women between 40 to 50 years old. On ultrasound and mammography these tumors usually resembles other round or oval benign lesions, mostly like fibroadenomas. These tumors on ultrasound and mammography usually resembles other round or oval benign tumors, mostly like fibroadenomas. Ultrasound guided core needle biopsiy (CNB) performed under ultrasound is a gold standard for palpabile breast masses. Surgical resection remains the gold standard of treatment. To date, there is no consensus regarding the recommendations for radiotherapy, hormonal therapy and systemic chemotherapy. We present the case of 30 years old woman, who noted a painless mass in her left breast, which was gradually increasing in size. Clinical, ultrasound and magnetic resonance examination confirmed the existence of tumor formation without the possibility of making an accurate diagnosis. Malignant phyllodes tumor was initially diagnosed by core biopsy. The patient underwent a radical modified mastectomy and postoperative radiotherapy. During the follow-up for the first 11 months, our patient has been feeling well without signs of local recurrence and metastasis. The aim of our case is to emphasize the importance of early diagnosis and treatment of this rare breast tumor.
Treatment is based on the size and the extent of the mass with surgical resection and adequate margins extremely important in successful outcome. We present the case of 30 old woman, who noted a painless mass in her left breast, which was gradually increasing in size. She was diagnosed with ultrasound and magnetic resonance imaging and the diagnosis of the malignant phyllodes tumor was confirmed by patohistological verification.
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12
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Yu CY, Huang TW, Tam KW. Management of phyllodes tumor: A systematic review and meta-analysis of real-world evidence. Int J Surg 2022; 107:106969. [PMID: 36328344 DOI: 10.1016/j.ijsu.2022.106969] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/01/2022] [Accepted: 10/22/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Phyllodes tumor is rare but has a high recurrence rate. Treatment modalities and clinicopathological prognostic factors for recurrence remain unclear. The synthesis of real-world data can enable the integration of sufficient evidence on optimal treatment for this population. METHODS We searched PubMed, Embase, and Cochrane Library databases for studies focusing on the management of phyllodes tumor including the surgical margin, different clinicopathological prognostic factors, and postoperative adjuvant radiotherapy versus no radiotherapy. RESULTS Fifty-two studies were retrieved. The pooled estimated recurrence rates of benign, borderline, and malignant tumors were 7.1%, 16.7%, and 25.1%, respectively. Surgical margins of 1 mm (odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.27-0.61) and 1 cm (OR: 0.45, 95% CI: 0.15-0.85) resulted in significantly higher recurrence rates. Postoperative adjuvant radiotherapy significantly reduced the recurrence rate of malignant tumors relative to no radiotherapy (P = 0.034) but did not significantly reduce the recurrence rates of overall and borderline tumors. Regarding clinicopathological features, moderate or severe stromal atypia and hypercellularity, stromal overgrowth, mitotic number of 5, tumor necrosis, tumor border, and margin status were determined as independent prognostic factors for recurrence, except a tumor size of 5 cm. CONCLUSION The ideal surgical margin for phyllodes tumor incision should be at least 1 cm in width. Adjuvant radiotherapy reduced the recurrence of malignant tumor. By identifying patients with poor clinicopathological risk factors, surgeons may reduce the recurrence rate of phyllodes tumor.
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Affiliation(s)
- Chia-Yun Yu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
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13
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Ji Y, Zhong Y, Zheng Y, Hu H, Min N, Wei Y, Geng R, Hong C, Guan Q, Li J, Wang Z, Zhang Y, Li X. Surgical management and prognosis of phyllodes tumors of the breast. Gland Surg 2022; 11:981-991. [PMID: 35800748 PMCID: PMC9253188 DOI: 10.21037/gs-21-877] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/15/2022] [Indexed: 02/28/2024]
Abstract
BACKGROUND Regardless of histological grade, phyllodes tumors (PTs) exhibit the potential of local recurrence. The National Comprehensive Cancer Network (NCCN) recommends wide local excision (WLE) with a 1 cm margin or more for borderline/malignant PTs but excisional biopsy for benign PTs. However, the treatment of benign PTs remains controversial and the clinicopathologic risk factors for the local recurrence is still unclear. METHODS We retrospectively analyzed 238 patients with PTs who underwent surgery at the Chinese PLA General Hospital from January 1, 2006 and April 30, 2020. We stratified our analysis according to histologic grade and explored the clinicopathologic factors to influence local recurrence (LR), including age, histologic grade, history of fibroadenoma, type of surgery [vacuum-assisted biopsy system (VABS), local excision (LE), wide local excision (WLE) and mastectomy]. RESULTS All 238 cases were categorized as benign (171, 71.8%), borderline (38, 16.0%), or malignant (29, 12.2%). The median follow-up was 50.2 months. In multivariate analysis, histologic grade (P<0.01) and history of fibroadenoma (P<0.01) were independent prognostic factors for LR. No difference existed in the recurrence rate of BPT treated with different surgical procedures (P=0.397), whereas a higher recurrence rate was found in VABS and LE subgroups than in WLE and mastectomy subgroups for borderline/malignant tumors (P<0.01). CONCLUSIONS No association found between surgical modalities and LR rate for BPT. We suggested a "wait-and-watch" policy for patients with unexpected benign subtypes, instead of unnecessary re-excision. In addition, VABS or LE can be treated for BPT with small mass, whereas WLE or even mastectomy should be conducted for borderline/malignant PTs with large mass.
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Affiliation(s)
- Yashuang Ji
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Yuting Zhong
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yiqiong Zheng
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Huayu Hu
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ningning Min
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Yufan Wei
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Geng
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Chenyan Hong
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Qingyu Guan
- School of Medicine, Nankai University, Tianjin, China
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jie Li
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Zhili Wang
- Department of Ultrasound, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Yanjun Zhang
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xiru Li
- Department of General Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
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14
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Gutnik L, Ren Y, Thomas SM, Plichta JK, Greenup RA, Fayanju OM, Hwang ES, Rosenberger LH. Malignant phyllodes tumor and primary breast sarcoma; distinct rare tumors of the breast. J Surg Oncol 2022; 125:947-957. [PMID: 35179788 PMCID: PMC8995353 DOI: 10.1002/jso.26820] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Malignant phyllodes (MP) and primary breast sarcomas (PBS) are rare neoplasms with overlapping histopathologic features. We compared overall survival (OS) and estimated the association of surgery and therapies with OS. METHODS We utilized the National Cancer Database (2004-2016). Patients without surgery, unknown surgery, or margins, or Stage IV disease were excluded. Kaplan-Meier curves and Cox proportional hazards models were used to estimate unadjusted and adjusted OS, respectively. RESULTS A total of 3209 (59.5%) MP, and 2185 (40.5%) PBS were identified. Despite a larger median tumor size in MP (46 vs. 40 mm PBS, p < 0.001), lumpectomy rate was higher for MP (52.9% vs. 27.0% PBS, p < 0.001). Compared to MP, PBS patients more frequently received radiation (28.9% vs. 24%), and chemotherapy (28.1% vs. 4%), both p < 0.001. Unadjusted OS was lower for PBS (57% vs. 85% MP, log-rank p < 0.001). PBS (vs. MP) had persistently worse survival (hazard ratio [HR]: 1.98, 95% confidence interval [CI]: 1.69-2.31) after adjustment. Receipt of adjuvant therapies was not associated with OS (either neoplasm); however, lumpectomy was associated with improved OS (vs. mastectomy) for both PBS (HR: 0.59, 95% CI: 0.50-0.75) and MP (HR: 0.65, 95% CI: 0.53-0.81). Positive margins had no association with OS for MP (HR: 1.09, 95% CI: 0.75-1.60), but was associated with worse survival for PBS (HR: 2.35, 95% CI: 1.82-3.02). DISCUSSION We found significant survival differences between MP and PBS, with PBS having a consistently worse OS. Our findings support surgery as the mainstay of treatment for both tumor types and suggest that lumpectomy may be a reasonable option for select patients without compromising outcomes.
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Affiliation(s)
- Lily Gutnik
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yi Ren
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Jennifer K Plichta
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Rachel A Greenup
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E Shelley Hwang
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura H Rosenberger
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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15
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Zhang H, Tang S, Biskup E, Zhang Y, Yong L, Chen L, Cai F. Long-term Survival After Diverse Therapeutic Modalities in Malignant Phyllodes Tumors of the Breast. Technol Cancer Res Treat 2022; 21:15330338221121086. [PMID: 36000314 PMCID: PMC9425899 DOI: 10.1177/15330338221121086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and Objects: Malignant phyllodes tumor of the breast (MPTB) is a rare tumor for which surgery or surgery combined with radiotherapy (RT) is the primary treatment method. However, recently, the therapeutic effect of RT on MPTB has been controversial. We aimed to explore the role of RT, chemotherapy (CT), and surgical modalities in patients with MPTB. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to select patients with MPTB who met the criteria between 2010 and 2018. Kaplan–Meier curves and Cox proportional risk regression models were used to analyze the effects of RT on MPTB patients. Based on this, we compared the effects of breast-conserving surgery (BSC) and mastectomy on the postoperative survival of MPTB. Results: A total of 298 patients with MPTB were included in this study. RT was received by 22.1% (n = 66) of the patients while 77.9% (n = 232) did not receive RT. CT was received by 4.7% (n = 14) patients while 95.3% (n = 284) did not receive CT. According to Kaplan–Meier curves, RT and CT combined resulted in a decrease in breast cancer-specific survival (BCSS) and overall survival (OS) compared to patients who did not receive RT. Mastectomy improved the OS and BCSS of the patients more than BCS). The findings of univariate and multivariate Cox regression analyses suggested that “distant metastasis”, “tumor grade” and “number of positive lymph node biopsies” affected OS of breast cancer, while “distant metastasis”, “tumor grade”, “surgery combined with radiotherapy/surgery”, and “radiotherapy/chemotherapy or not”, had a significant effect on BCSS. Conclusion: RT and CT did not significantly improve the long-term survival of MPTB patients. Mastectomy improved OS and BCSS of the patient more than BCS. RT in an early stage improved early prognosis moderately in MPTB patients with tumor diameter less than 50 mm.
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Affiliation(s)
- Hongyi Zhang
- Department of Breast Surgery, School of Medicine, Yangpu Hospital, 481875Tongji University, Shanghai, China
| | - Shasha Tang
- Department of Breast Surgery, School of Medicine, Yangpu Hospital, 481875Tongji University, Shanghai, China
| | - Ewelina Biskup
- 191610Shanghai University of Medicine and Health Sciences, Shanghai, PR China
| | - Yi Zhang
- Department of Breast Surgery, School of Medicine, Yangpu Hospital, 481875Tongji University, Shanghai, China
| | - Liyun Yong
- Department of Breast Surgery, School of Medicine, Yangpu Hospital, 481875Tongji University, Shanghai, China
| | - Lijun Chen
- Department of Oncology, 58305Shanghai Medical College, Fudan University, Shanghai, China
| | - Fengfeng Cai
- Department of Breast Surgery, School of Medicine, Yangpu Hospital, 481875Tongji University, Shanghai, China
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16
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Kalra A, Dehr L, Malouff TD, May BC, Vallow LA. Brisk Erythematous Reaction Outside of the Radiation Field in a Patient Treated With Adjuvant Radiation for Phyllodes Tumor. Adv Radiat Oncol 2021; 6:100752. [PMID: 34458649 PMCID: PMC8377432 DOI: 10.1016/j.adro.2021.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Aarushi Kalra
- Philadelphia College of Osteopathic Medicine-Georgia Campus, Suwannee, Georgia
| | - Lindsay Dehr
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Byron C May
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
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17
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Bogach J, Shakeel S, Wright FC, Hong NJL. Phyllodes Tumors: A Scoping Review of the Literature. Ann Surg Oncol 2021; 29:446-459. [PMID: 34296360 DOI: 10.1245/s10434-021-10468-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Phyllodes tumors are rare tumors of the breast, with most literature being retrospective with limited guidelines on the management of these patients. Scoping review was performed to highlight themes and gaps in the available literature. METHODS A scoping review of the literature was performed as per PRISMA-ScR guidelines with titles, abstracts, and full texts reviewed in duplicate. Data were abstracted and summarized in categories of diagnostics, surgical management, adjuvant therapies, treatment of recurrence, and surveillance. Quality assessment was performed for each paper. RESULTS The search identified 4498 references, 434 full-text papers were reviewed, and 183 papers were included. Ultrasound, magnetic resonance imaging, and core needle biopsy are valuable preoperative diagnostics tools. Pathology reporting should include stromal overgrowth, stromal cellularity, nuclear atypia, mitotic rate, borders, and presence of heterologous elements. Ki67 may have a role in grading and prognosticating. Breast conservation is safe in all grades of phyllodes but may be associated with increased local recurrence in malignant phyllodes. Surgical margins should depend on grade. Axillary node positivity rate is very low, even with clinically enlarged lymph nodes. Adjuvant radiation is a useful tool to decrease local recurrence in malignant phyllodes tumors, tumors > 5 cm, age < 45 years, close margins, and breast conservation. There is no evidence supporting adjuvant chemotherapy. Recurrence can be managed with repeat wide excision; however, mastectomy is associated with lower re-recurrence. Surveillance protocols are variable in the literature. CONCLUSIONS There is heterogeneity in the literature on phyllodes tumors. Consensus guidelines based on the literature will help provide evidence-based care.
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Affiliation(s)
- Jessica Bogach
- Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | - Saad Shakeel
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicole J Look Hong
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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18
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Li Y, Song Y, Lang R, Shi L, Gao S, Liu H, Wang P. Retrospective study of malignant phyllodes tumors of the breast: Younger age, prior fibroadenoma surgery, malignant heterologous elements and surgical margins may predict recurrence. Breast 2021; 57:62-70. [PMID: 33774460 PMCID: PMC8027899 DOI: 10.1016/j.breast.2021.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose The potential recurrence rate of malignant phyllodes tumors (MPTs) of the breast is high, and the prognostic factors are still unclear. We therefore aim to study the factors affecting the outcome of MPTs. Methods A retrospective review of MPT patients treated from 2006 to 2020 at our institution was conducted. Univariate and multivariate Cox proportional hazard models were used to examine the influence of different variables on RFS. Moreover, significant prognostic factors were combined to construct the nomogram to predict the probability of relapse occurring in MPT patients. The 5-year and 10-year RFS rates were estimated using the Kaplan–Meier method. Results During the study period, 188 MPT patients were identified. The presence of malignant heterologous elements was observed in 23 (12.2%) patients with MPT, and the patients with malignant heterologous elements who received chemotherapy had longer RFS, which could reduce the risk of recurrence (p = 0.022). Recurrence occurred in 56/188 (29.8%) patients, of whom 47 experienced local recurrence and 11 experienced distant metastases. The 5-year and 10-year cumulative RFS rates were 77.5% and 70.1%, respectively. Age (p = 0.041), fibroadenoma surgery history (p = 0.004), surgical margins (p = 0.001) and malignant heterologous elements (p < 0.001) were independent risk factors for postoperative RFS. Subsequently, a nomogram was built, with a C-index of 0.64 (95% CI: 0.629–0.661), to predict the risk of recurrence. Conclusion The results of this study showed that younger age, fibroadenoma surgery history, malignant heterologous elements and surgical margins <1 cm predict a higher incidence of recurrence in MPT patients. Patients with malignant heterologous elements treated with chemotherapy could have a reduced risk of recurrence. This is the largest cohort of malignant phyllodes tumors in China. Age, fibroadenoma surgery history, surgical margins and malignant heterologous elements predict the risk of recurrence. Patients with malignant heterologous elements treated with chemotherapy could reduce the risk of recurrence.
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Affiliation(s)
- Yang Li
- The Second Surgical Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China; Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Yixuan Song
- The Second Surgical Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Ronggang Lang
- Department of Breast Cancer Pathology and Research Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, State Key Laboratory of Breast Cancer Research, Tianjin, China
| | - Lu Shi
- College of Computer Science and Technology, Harbin Institute of Technology (Shenzhen), China
| | - Shuang Gao
- The Second Surgical Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Hong Liu
- The Second Surgical Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China.
| | - Ping Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China.
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Malignant Phyllodes of Breast. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1187:601-612. [PMID: 33983602 DOI: 10.1007/978-981-32-9620-6_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Phyllodes tumors of breast (PTB) have been known to an uncommon and particular disease to handle owing to diagnostic ambiguity and unpredictable clinical outcome. Malignant phyllodes tumors (MPT) are diagnosed when there are marked stromal hypercellularity, atypia, increased mitoses of ≥10/10 HPFs, permeative tumor borders, and stromal overgrowth. The presence of a malignant heterologous element (MHE) places the tumor into the malignant category regardless of other histological features. Excision with negative margins should be achieved for recurrent and malignant phyllodes tumor. An ideal margin width remains to be determined, and may need to be considered in relation to factors such as tumor size and cosmesis. Without the convincing evidence of survival benefit, adjuvant RT has revealed more favorable local control rate compared with observation group. Stromal expression of Twist and Foxc2, epithelial-mesenchymal transition marker, was associated with high tumor grade and poor prognosis. Tumor-associated macrophage drives myoblast differentiation and malignant progression of PTB through a CCL18-driven signaling cascade amenable to antibody disruption. Recent targeted sequencing on PTBs provided insights into the molecular pathogenesis and genetic characterization with potential clinical implications.
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20
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Zhang WX, Kong XY, Zhai J, Fang Y, Song Y, Wang J. Fatal outcome of malignant phyllodes tumor of the breast in pregnancy: a case and literature review. Gland Surg 2021; 10:371-377. [PMID: 33633994 DOI: 10.21037/gs-20-538] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Phyllodes tumor of the breast (PTB) is a rare fibroepithelial breast neoplasm that accounts for less than 1% of breast tumors. Only a few cases related to pregnancy have been reported. It is not known how pregnancy affects the diagnosis, treatment and prognosis of breast tumors. Here we report a case of a 38-year-old female patient with a small, mobile palpable lump in the left breast for about 15 years. it was considered a benign lesion and no surgical treatment was performed at the beginning. The left breast mass became larger suddenly during pregnancy, However, she did not see the doctor and receive any treatment in time. The lump was resected one year after labor and confirmed to be malignant phyllodes of the breast by histopathology and immunohistochemistry. Unfortunately, local recurrence occurred within six months after the first operation, and lung metastasis occurred eight months later. And this patient finally died 13 months after the operation due to tumor progression. This is the first report of pregnancy-related malignant PTB, with local recurrence and distant metastasis in a short period. This case report highlights a situation: the patient should be diagnosed early and treated in time when she has a previous breast fibroadenoma, but suddenly increased during pregnancy.
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Affiliation(s)
- Wen-Xiang Zhang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiang-Yi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhai
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Song
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Wang Y, Kang P, He W, Li R. MR-guided 125I seed implantation treatment for maxillofacial malignant tumor. J Appl Clin Med Phys 2021; 22:92-99. [PMID: 33295143 PMCID: PMC7856506 DOI: 10.1002/acm2.13112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/26/2020] [Accepted: 11/08/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study assessed the therapeutic efficacy of postoperative magnetic resonance (MR)-guided interstitial 125 I seed implantation for treatment of oral and maxillofacial malignant tumors. METHODS AND MATERIALS A total of 127 patients with oral or maxillofacial malignant tumors were included in this study who received interstitial 125 I treatment after the surgery resection. Before implantation, all the patients received MR scans to assess the lesion scope, extent, and nature. 125 I implantation target regions were based on the pre-operative imaging. 125 I seeds were delivered to target regions via puncture needles under the real-time guidance of MR. Computed tomography (CT)or MR was performed immediately after implantation and again every 3 months later. RESULTS After successful 125 I implantation, all patients were also examined regularly to detect tumor recurrence, lymphatic, and distant metastases. To date, CT or MR verification showed that 13/127 patients experienced tumor recurrence or lymphatic metastasis or distant metastasis. No seeds migration was observed, no serious treatment-related complications affected patient quality of life, and no important organ (such as major cervical vessels, spinal cord, etc.) injuries were observed. CONCLUSION Our results show that MR-guided 125 I implantation is an effective approach to site-specific treatment for oral and maxillofacial tumor, which could potentially reduce postoperative complications and tumor recurrence rates, increase patient survival, and improve quality of life.
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Affiliation(s)
- Ying Wang
- Department of StomatologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Peng Kang
- Department of StomatologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Wei He
- Department of StomatologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Rui Li
- Department of StomatologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
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22
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Rosenberger LH, Thomas SM, Nimbkar SN, Hieken TJ, Ludwig KK, Jacobs LK, Miller ME, Gallagher KK, Wong J, Neuman HB, Tseng J, Hassinger TE, King TA, Jakub JW. Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines. J Clin Oncol 2020; 39:178-189. [PMID: 33301374 DOI: 10.1200/jco.20.02647] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary. METHODS We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR). RESULTS Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96). CONCLUSION In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.
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Affiliation(s)
- Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, NC.,Duke Cancer Institute, Duke University, Durham, NC
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, NC.,Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Suniti N Nimbkar
- Brigham & Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
| | | | - Kandice K Ludwig
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lisa K Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Megan E Miller
- Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Jasmine Wong
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Taryn E Hassinger
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Tari A King
- Brigham & Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
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23
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Rosenberger LH, Thomas SM, Nimbkar SN, Hieken TJ, Ludwig KK, Jacobs LK, Miller ME, Gallagher KK, Wong J, Neuman HB, Tseng J, Hassinger TE, Jakub JW. Germline Genetic Mutations in a Multi-center Contemporary Cohort of 550 Phyllodes Tumors: An Opportunity for Expanded Multi-gene Panel Testing. Ann Surg Oncol 2020; 27:3633-3640. [PMID: 32504368 PMCID: PMC9945652 DOI: 10.1245/s10434-020-08480-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND A paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT. METHODS We performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing. RESULTS Of 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing. CONCLUSIONS Very few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients.
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Affiliation(s)
- Laura H. Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, North Carolina,Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Samantha M. Thomas
- Duke Cancer Institute, Duke University, Durham, North Carolina,Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Suniti N. Nimbkar
- Brigham & Women’s Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tina J. Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kandice K. Ludwig
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lisa K. Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Megan E. Miller
- Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Jasmine Wong
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | | | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Taryn E. Hassinger
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James W. Jakub
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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24
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Obeng-Gyasi S, Bhattacharyya O, Li Y, Eskander M, Tsung A, Oppong B. The implications of neighborhood socioeconomic status on surgical management and mortality in malignant phyllodes patients in the Surveillance, Epidemiology, and End Results program. Surgery 2020; 168:1122-1127. [PMID: 32847674 DOI: 10.1016/j.surg.2020.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neighborhood socioeconomic status has been implicated in breast cancer incidence and mortality. However, there are no studies on the impact of neighborhood socioeconomic status on clinical outcomes or surgical management among patients with phyllodes tumors. The objective of this study is to understand the relationship between neighborhood socioeconomic status, surgical management and disease specific mortality in malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program. METHODS Surveillance, Epidemiology, and End Results program was queried for malignant phyllodes tumor patients diagnosed between 2000 and 2016. Using the National Cancer Institute census tract-level index for neighborhood socioeconomic status the data were stratified into low neighborhood socioeconomic status, middle neighborhood socioeconomic status, and high neighborhood socioeconomic status. Bivariate intergroup analysis was conducted. Disease specific mortality was evaluated using a Cox proportional hazards model. RESULTS Of the 651 patients with malignant phyllodes tumor in the sample, the disease specific mortality was 7.6% and 7.9% at 5 and 10 years, respectively. On bivariate analysis, there were no differences between the neighborhood socioeconomic status groups and surgery type (P = .794). On multivariable analysis, older age (≥71 years; hazard ratio 9.9; 95% confidence interval, 2.84-34.57; P < .001) and larger tumor size (≥40 mm; hazard ratio 2.20; 95% confidence interval, 1.09-4.44; P = .027) were associated with a higher disease specific mortality compared with younger age (≤ 40 years) and smaller tumor size (<40 mm). There was no association between neighborhood socioeconomic status and disease specific mortality (low neighborhood socioeconomic status-ref, middle neighborhood socioeconomic status hazard ratio 0.87 (95% confidence interval, 0.71-1.78; P = .71), high hazard ratio 0.91 (95% confidence interval, 0.44-1.90, P = .81). CONCLUSION Among malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program, disease specific mortality and surgical management are mostly driven by tumor characteristics and not social determinants of health.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH.
| | | | - Yaming Li
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Mariam Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Bridget Oppong
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
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25
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The role of adjuvant radiotherapy in patients with malignant phyllodes tumor of the breast: a propensity-score matching analysis. Breast Cancer 2020; 28:110-118. [PMID: 32748225 PMCID: PMC7796876 DOI: 10.1007/s12282-020-01135-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 07/16/2020] [Indexed: 11/05/2022]
Abstract
Background and objectives Malignant phyllodes tumor of the breast (MPTB) is a kind of rare tumor. Our objective was to investigate the role of adjuvant radiotherapy (RT) in MPTB patients. Methods MPTB patients were identified in the Surveillance, Epidemiology and End Results (SEER) database. Kaplan–Meier curves and multivariable Cox proportional hazards analyses were conducted to determine the effect of adjuvant RT on MPTB patients. Propensity-score matching (PSM) method was used to balance the clinicopathological characteristics. Results A total of 1353 MPTB patients were included in our study and the median follow-up time was 99 months (range: 0–331 months). 16.7% (226) MPTB patients received adjuvant RT, of which 49.1% (111) received mastectomy and 50.9% (115) underwent breast conservation surgery (BCS). Patients receiving adjuvant RT were more likely to be white, with better differentiation and larger tumors (p < 0.05). Multivariate analysis showed that poorer tumor differentiation grade, larger tumor size, and lymph node metastasis were associated with reduced survival while BCS was a protective factor of disease-specific survival (DSS) (HR 0.297; 95% CI 0.184–0.480) and overall survival (OS) (HR 0.445; 95% CI 0.321–0.616). After PSM, survival curves showed patients did not achieve an improved OS or DSS from adjuvant RT (p > 0.05). In subgroup analysis, no subgroup benefited from adjuvant RT. Exploratory analysis showed a survival benefit trend from adjuvant RT in patients with tumor larger than 50 mm and undergoing BCS. Conclusions Among MPTB patients, adjuvant RT did not improve OS or DSS. In patients with tumor larger than 50 mm and receiving BCS, a survival benefit trend from adjuvant RT existed. Electronic supplementary material The online version of this article (10.1007/s12282-020-01135-7) contains supplementary material, which is available to authorized users.
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26
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Neron M, Firmin N. ASO Author Reflections: How Far Should We Go in Local Management for a Localized Malignant Phyllodes Tumor of the Breast? Ann Surg Oncol 2020; 27:1828-1829. [DOI: 10.1245/s10434-020-08390-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 11/18/2022]
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27
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Wong RX, Koh YS, Wong FY, Kusumawidjaja G, Ng WL, Yeo RMC, Farid M, Sheng Chan JY, Yan Z, Gudi MA, Tan PH. The Impact of Radiotherapy and Histological Risk Factors on Outcomes in Malignant Phyllodes Tumors. Clin Breast Cancer 2020; 20:e695-e700. [PMID: 32636151 DOI: 10.1016/j.clbc.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Breast phyllodes tumors (PT) are classified into benign, borderline, and malignant grades based on histopathologic characteristics. Specific to malignant PT (MPT), surgery is the mainstay yet relapse rates are high and knowledge gaps in the literature exist regarding adjuvant radiotherapy (RT). We aimed to investigate the outcomes of patients with MPT treated in a tertiary Asian institution. METHODS AND MATERIALS Patients with nonmetastatic MPT treated from February 1992 to June 2019 were analyzed retrospectively. RT details and relapse fields were studied. Outcomes of patients with and without RT were compared and hazard ratios were calculated using Cox proportional hazard test. Multivariable analysis was performed. RESULTS Twenty-two of 89 patients received adjuvant RT and the median dose was 60 Gy. In the no-RT group, 4 patients received RT on relapse and had no further recurrences; a further 2 received RT for fungating relapses with good symptomatic relief. RT was only increasingly prescribed after 2004. Median follow-up in the RT group was 3.31 years, compared with 6.17 years in the no-RT group. In the RT group, 15 patients (68.2%) underwent mastectomy, versus 39 (58.2%) in the no-RT group. One patient in the RT group developed an infield local relapse, compared with 21 of 67 patients in the no-RT group. Multivariate model showed that RT decreased risk of locoregional failure (hazard ratio 0.12, 95% confidence interval [CI] 0.02-0.92, P = .04). Three-year locoregional recurrence-free survival was higher in the RT group, 92.3% (95% CI, 78.9-100) versus 73.3% (95% CI, 63.1-85.1) in the no-RT group (P = .03). There were no differences in 3-year survival. CONCLUSIONS We recommend that adjuvant radiotherapy be discussed for malignant PT for local control, even after mastectomy.
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Affiliation(s)
- Ru Xin Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.
| | - Yen Sin Koh
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Fuh Yong Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Wee Loon Ng
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Richard M C Yeo
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Mohamad Farid
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Zhiyan Yan
- Department of Surgery, Kandang Kerbau Women & Children Hospital, Singapore
| | - Mihir A Gudi
- Department of Pathology and Laboratory Medicine, Kandang Kerbau Women and Children Hospital, Singapore
| | - Puay Hoon Tan
- Division of Pathology, Singapore General Hospital, Singapore
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28
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Neron M, Sajous C, Thezenas S, Piperno-Neumann S, Reyal F, Laé M, Chakiba C, Michot A, Penel N, Honoré C, Owen C, Bertucci F, Salas S, Saada-Bouzid E, Valentin T, Bompas E, Brahmi M, Ray-Coquard I, Blay JY, Firmin N. Surgical Margins and Adjuvant Therapies in Malignant Phyllodes Tumors of the Breast: A Multicenter Retrospective Study. Ann Surg Oncol 2020; 27:1818-1827. [PMID: 31989361 DOI: 10.1245/s10434-020-08217-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal threshold of surgical margins for breast malignant phyllodes tumors (MPTs) and the impact of adjuvant chemotherapy and radiotherapy were investigated. PATIENTS AND METHODS We conducted a multicenter nationwide retrospective study of all MPT cases with central pathological review within the French Sarcoma Group. Endpoints were local recurrence-free survival (LRFS), metastasis-free survival (MFS), and overall survival (OS) rates. RESULTS Overall, 212 patients were included in the study. All non-metastatic patients underwent primary surgical treatment, including 58.6% of conservative surgeries. An R0 resection was achieved in 117 patients (59.4%: 26.9% of patients with 1-2 mm margins, 12.2% of patients with 3-7 mm margins, 20.3% of patients with ≥ 8 mm margins). Ninety-four patients (45%) underwent a second surgery (SS) to obtain R0 margins, with a final mastectomy rate of 72.6%. Radiotherapy and chemotherapy were performed in 91 (43.1%) and 23 patients (10.9%), respectively, but were not associated with better outcomes. Mastectomy was significantly associated with better LRFS (p < 0.001). Margins of 0, 1, or 2 mm with SS were associated with better MFS (hazard ratio [HR] 0.3, p = 0.005) and OS (HR 0.32, p = 0.005) compared with margins of 0-1-2 mm without SS. Wider margins (> 8 mm) were not superior to margins of 3-7 mm (3-7 mm vs. > 8 mm; HR 0.81, p = 0.69). Age (HR 2.14, p = 0.038) and tumor necrosis (HR 1.96, p = 0.047) were found to be poor prognostic factors and were associated with MFS. CONCLUSIONS This study suggests that 3 mm margins are necessary and sufficient for surgical management of MPTs, and emphasizes the importance of SS to obtain clear margins in case of 0-1-2 mm margins. No impact of adjuvant chemotherapy or radiotherapy was detected in this study.
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Affiliation(s)
- Mathias Neron
- Department of Surgical Oncology, Institut du Cancer Montpellier (ICM), Univ Montpellier, Montpellier, France.
| | - Christophe Sajous
- Department of Medical Oncology, Centre Léon Bérard, Université Claude Bernard Lyon I, Lyon, France
| | - Simon Thezenas
- Department of Biostatistics, Institut du Cancer Montpellier, Univ Montpellier, Montpellier, France
| | | | - Fabien Reyal
- Department of Surgical Oncology, Institut Curie, Paris, France
| | - Marick Laé
- Department of Pathology, Institut Curie, Paris, France
| | - Camille Chakiba
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Audrey Michot
- Department of Surgical Oncology, Institut Bergonié, Bordeaux, France
| | - Nicolas Penel
- Department of Medical Oncology, Institut Oscar Lambret, Lille, France
| | - Charles Honoré
- Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, France
| | - Clémentine Owen
- Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, France
| | - François Bertucci
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Sébastien Salas
- Department of Medical Oncology, CHU La Timone, Marseille, France
| | - Esma Saada-Bouzid
- Department of Medical Oncology, Centre Antoine Lacassagne, Nice, France
| | | | - Emmanuelle Bompas
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Nantes, France
| | - Mehdi Brahmi
- Department of Medical Oncology, Centre Léon Bérard, Université Claude Bernard Lyon I, Lyon, France
| | - Isabelle Ray-Coquard
- Department of Medical Oncology, Centre Léon Bérard, Université Claude Bernard Lyon I, Lyon, France
| | - Jean-Yves Blay
- Department of Medical Oncology, Centre Léon Bérard, Université Claude Bernard Lyon I, Lyon, France
| | - Nelly Firmin
- Department of Medical Oncology, Institut du Cancer Montpellier, Univ Montpellier, Montpellier, France
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Xiao Y, Jiang Y, Xiong Y, Ruan S, Huang T. Pediatric Malignant Phyllodes Tumors of the Breast: Characteristics and Outcomes Based on the Surveillance Epidemiology and End Results Database. J Surg Res 2020; 249:205-215. [PMID: 31991330 DOI: 10.1016/j.jss.2019.12.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Malignant phyllodes tumors of the breast are uncommon in women and rare in children. This study aimed to assess the differences in survival among five specific pathologic groups of breast malignancies and the differences between pediatric and adult breast phyllodes malignancy. MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results database, we collected data on 270 pediatric (aged ≤21 y) female breast malignant tumor patients and 2773 female malignant phyllodes tumor patients between 1976 and 2015. We evaluated survival differences among younger patients with breast malignancy and compared the pediatric and adult groups based on characteristics, treatment patterns, and survival months. Finally, we identified the risk and protective factors for breast phyllodes cases using a multivariable Cox analysis. RESULTS We collected and analyzed 270 malignant breast cancer patients aged ≤21 y and 2773 malignant phyllodes tumor patients. Pediatric patients with malignant phyllodes tumors (22.2%, n = 60) exhibited better overall survival (OS; log-rank, P = 0.012) and cancer-specific survival (CSS; log-rank, P = 0.005) among the younger patients with malignant breast tumors. Furthermore, pediatric patients with malignant phyllodes tumors showed better OS (log-rank, P = 0.004), and similar CSS (log-rank, P = 0.105), compared with older patients. After adjustments for potential confounding factors, age >21 y, Black race, tumor size of >100 mm, high grade, wider invasion, positive nodal status, larger scope surgery, and no surgery were found to be associated with worse OS. All these factors, except for race, were found to be independent risk factors for CSS. CONCLUSIONS The prognosis of malignant phyllodes tumors in children is better than that of adults. Appropriate surgical scope and risk of overtreatment should be considered when treating pediatric malignant phyllodes tumor patients.
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Affiliation(s)
- Yunxiao Xiao
- Department of Thyroid and Breast Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yujia Jiang
- Department of Thyroid and Breast Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yiquan Xiong
- Department of Thyroid and Breast Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shengnan Ruan
- Department of Thyroid and Breast Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tao Huang
- Department of Thyroid and Breast Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Wu H, Li L, Yang J, Guo C, Zhang W, Wang H. Radiotherapy with apatinib for recurrence of malignant phyllodes tumor of the breast: A case report. Medicine (Baltimore) 2020; 99:e18808. [PMID: 32011486 PMCID: PMC7220223 DOI: 10.1097/md.0000000000018808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Malignant phyllodes tumors of the breast are rare, and there are currently no guidelines and a large number of clinical trials to guide the treatment of recurrence tumor. Here we reported a case of radiotherapy with apatinib for the treatment of recurrent malignant phyllodes tumor of the breast. PATIENT CONCERNS A 58-year-old patient with massive breast mass was admitted to our hospital. Two months after surgical treatment, the tumor recurred in the chest wall scar. DIAGNOSES The histopathologic diagnoses was right breast malignant phyllodes tumor with chondrosarcomas and osteosarcomas in some areas. INTERVENTIONS The patient was first treated with surgery. Malignant phyllodes tumor recurred in the chest wall two months after surgery and was treated with radiotherapy and apatinib. OUTCOMES With surgery, radiotherapy and apatinib treatment, the patient still died within several months. LESSONS Apatinib and radiotherapy failed to obtain good therapeutic effect in the recurrence of breast malignant phyllodes tumor in this case.
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Affiliation(s)
| | | | | | | | | | - Hui Wang
- Department of Orthopedic trauma, Affiliated Hospital of Binzhou Medical University, Binzhou, China
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31
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Cervoni GE, Quintana L, Erlinger AL, Neo DT, Recht A, Schnitt SJ, Hacker MR, Sharma R. Local recurrence after breast-conserving therapy for phyllodes tumors: A 15-year retrospective review. Breast J 2019; 26:988-990. [PMID: 31814215 DOI: 10.1111/tbj.13707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/30/2022]
Abstract
There are few data on the long-term outcomes of patients with phyllodes tumors following breast-conserving surgery with or without radiation therapy (RT). We reviewed 69 patients diagnosed from 2000 to 2015 with surgical specimens available for central pathology assessment for outcome in relation to histopathologic subtype, margin width, and utilization of RT. Median follow-up was 63 months (interquartile range, 35-131 months). Forty-eight patients had benign, 13 borderline, and eight malignant phyllodes tumors, with local recurrence rates of 4%, 0%, and 38%, respectively (P ≤ .04 comparing malignant lesions to both benign and borderline lesions). None of the eight patients who received RT suffered a local recurrence. Two of the 26 (8%) patients with benign phyllodes tumors who did not receive RT with margins that were positive or <1 mm had local recurrence, compared to none of 18 patients with margins 1 mm or wider who did not receive RT. The one patient with a malignant phyllodes tumor who did not receive RT with margins that were positive or <1 mm did not locally recur, while both patients with margins 10 mm or wider who did not receive RT had local recurrence. One patient with a malignant phyllodes tumor developed distant recurrence following local recurrence. Phyllodes histologic type and margin width were both associated with the risk of local recurrence following breast-conserving surgery without RT, though the number of events and patients was too small to show these trends were statistically significant.
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Affiliation(s)
- Gabrielle E Cervoni
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Liza Quintana
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Adrienne L Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dayna T Neo
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Abram Recht
- Departments of Radiation Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Stuart J Schnitt
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham & Women's Hospital, Boston, MA, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Ranjna Sharma
- Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
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Malignant Phyllodes Tumor Recurrence in the Pleural Cavity via the Deep Inferior Epigastric Perforator Flap and Internal Mammary Vessel Bundle. Ann Plast Surg 2019; 82:618-621. [DOI: 10.1097/sap.0000000000001795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Spanheimer PM, Barrio AV. ASO Author Reflections: Malignant/Borderline Phyllodes Tumors Without Uniformly Poor Histologic Features Have an Excellent Prognosis. Ann Surg Oncol 2019; 26:619-620. [PMID: 31111350 DOI: 10.1245/s10434-019-07459-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Philip M Spanheimer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Choi N, Kim K, Shin KH, Kim Y, Moon HG, Park W, Choi DH, Kim SS, Ahn SD, Kim TH, Chun M, Kim YB, Kim S, Choi BO, Kim JH. The Characteristics of Local Recurrence After Breast-Conserving Surgery Alone for Malignant and Borderline Phyllodes Tumors of the Breast (KROG 16-08). Clin Breast Cancer 2019; 19:345-353.e2. [PMID: 31103280 DOI: 10.1016/j.clbc.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/22/2019] [Accepted: 04/01/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite margin-negative breast-conserving surgery (BCS), phyllodes tumors (PT) of the breast show high local recurrence (LR) rates. In this study we aimed to assess the site and grade of LR to identify high-risk patients after initial treatment of malignant and borderline PT using BCS alone. PATIENTS AND METHODS From 1981 to 2014, 312 patients with malignant (n = 164) and borderline (n = 148) PT were treated using BCS alone at 10 centers. LR was defined as true recurrence (TR) if < 2 cm from the primary tumor bed and as elsewhere failure (EF) if otherwise. RESULTS At a median of 21 months, LR occurred in 17.6% (55 of 312), 18.9% (31 of 164) among malignant and 16.2% (24 of 148) among borderline PT (P = .636). Only 1.9% (6 of 312) had EF. Five-year cumulative LR rates were 14.7% and 35.9% after margin-negative and -positive BCS, respectively (P < .001). Positive margin was an independent risk factor for TR (P = .002) and EF (P = .002). In multivariable competing risk regression of patients with negative margins < 1 cm (n = 115), age < 35 years (P = .001), and tumor size ≥ 5 cm (P = .008) independently increased LR risk. Of patients who experienced a LR, 30.9% (17 of 55) had a second or third repeated event. Borderline-to-malignant transformation rates increased at each LR event: 4.1% (6 of 148), 12.5% (3 of 24), and 77.8% (7 of 9) at first, second, and third LR, respectively (P = .006). CONCLUSION LRs almost always develop near the primary tumor bed. Many patients experience multiple events, with heightened risk of borderline-to-malignant transformation at each subsequent event. For patients with negative margins < 1 cm, younger age and larger tumor size are independent risk factors for increased LR.
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Affiliation(s)
- Noorie Choi
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea; Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.
| | - Yumi Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong-Gon Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Tae Hyun Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Mison Chun
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Suzy Kim
- Department of Radiation Oncology, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Ock Choi
- Department of Radiation Oncology, Seoul St Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Park HJ, Ryu HS, Kim K, Shin KH, Han W, Noh DY. Risk Factors for Recurrence of Malignant Phyllodes Tumors of the Breast. In Vivo 2019; 33:263-269. [PMID: 30587634 DOI: 10.21873/invivo.11470] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM In this study, the treatment outcome and risk factors for recurrence in patients undergoing surgery with or without adjuvant radiotherapy (RT) for malignant phyllodes tumors of the breast (MPTB) were analyzed. PATIENTS AND METHODS Forty-three patients (61.4%) underwent breast-conserving surgery (BCS) and 27 (38.6%) underwent mastectomy. Fifteen patients (21.4%) received adjuvant RT. RESULTS With a median follow-up of 76 months, the 7-year local control (LC), distant metastasis-free survival (DMFS), disease-free survival (DFS), and cause-specific survival (CSS) rates were 90.7%, 85.2%, 80.3%, and 87.1%, respectively. Either the extent of surgery or treatment with adjuvant RT did not affect the outcomes. On multivariate analysis, the presence of tumor necrosis was associated with inferior DFS (p=0.017), while infiltrative tumor border showed a marginal significance (p=0.078). When stratified using these two adverse pathological features, the 7-year DFS rates were 100%, 54.9%, and 55.6% in patients with 0, 1, and 2 risk factors, respectively (p=0.002). CONCLUSION MPTB patients undergoing surgery with or without adjuvant RT had a favorable outcome. Although there was no local recurrence in patients treated with adjuvant RT, the effect of adjuvant RT failed to reach a statistical significance. Risk-grouping based on pathological features might help design a clinical trial for MPTB.
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Affiliation(s)
- Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Han Suk Ryu
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong-Young Noh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Moten AS, Goldberg AJ. Malignant Phyllodes Tumors of the Breast: Association Between Race, Clinical Features, and Outcomes. J Surg Res 2019; 239:278-283. [PMID: 30897515 DOI: 10.1016/j.jss.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/05/2018] [Accepted: 01/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to investigate associations between race, clinical characteristics, and outcomes among patients with malignant phyllodes of the breast. METHODS Malignant phyllodes cases were identified using Surveillance Epidemiology and End Results database. We used chi-square tests to compare characteristics between racial groups and multinomial logistic regression to calculate relative risk ratios (RRR) and 95% confidence intervals (CI) comparing the likelihood of having particular characteristics by race. Survival analyses included Cox regression and Kaplan-Meier functions. RESULTS Among 1202 patients included, mean age was 51.7 y and 55.2% were white. Compared to whites, blacks were younger (mean age 45.7 versus 55.1 y; P < 0.001), and more likely to have tumors 51-100 mm (RRR = 1.91; 95% CI: 1.20-3.05) and tumors > 100 mm (RRR = 2.52; 95% CI: 1.56-4.05) than tumors ≤ 50 mm in size. Compared to whites, Hispanics were younger (mean age 46.7 versus 55.1 y; P < 0.001), and more likely to have tumors 51-100 mm (RRR = 1.46; 95% CI: 1.01-2.11) than tumors ≤ 50 mm in size. Asians were more likely to have tumors 51-100 mm (RRR = 1.52; 95% CI: 1.01-2.30) and tumors > 100 mm (RRR = 1.61; 95% CI: 1.03-2.52) than tumors ≤ 50 mm in size, and more likely to have tumors that extended beyond the breast tissue (RRR = 1.87; 95% CI: 1.05-3.31), compared to whites. Survival was similar for blacks (HR = 1.48; 95% CI: 0.80-2.76), Hispanics (HR = 1.02; 95% CI: 0.54-1.93), and Asians (HR = 1.13; 95% CI: 0.63-2.01) compared to whites. CONCLUSIONS Further research into factors contributing to extensive disease at presentation among minorities is warranted.
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Affiliation(s)
- Ambria S Moten
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Amy J Goldberg
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
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Lu Y, Chen Y, Zhu L, Cartwright P, Song E, Jacobs L, Chen K. Local Recurrence of Benign, Borderline, and Malignant Phyllodes Tumors of the Breast: A Systematic Review and Meta-analysis. Ann Surg Oncol 2019; 26:1263-1275. [PMID: 30617873 DOI: 10.1245/s10434-018-07134-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to investigate local recurrence (LR) rates among the three grades (benign, borderline, and malignant) of phyllodes tumors (PTs). The study also assessed various risk factors for LR. METHODS Electronic articles published between 1 January 1995 and 31 May 2018, were searched and critically appraised. The authors independently reviewed the abstracts and extracted data for LR rates and LR risk factors. RESULTS The review incorporated 54 studies with 9234 individual cases. The pooled LR rates were 8% for benign, 13% for borderline, and 18% for malignant PTs. The risk of LR was significantly increased by borderline versus benign PTs (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.68-2.38) and malignant versus borderline PTs (OR 1.28; 95% CI 1.05-1.55). The significant risk factors for LR were mitoses, tumor border (infiltrating vs. pushing), stromal cellularity (moderate/severe vs. mild), stromal atypia (severe vs. mild/absent), stromal overgrowth (severe vs. mild/absent), and tumor necrosis (positive vs. negative). Age and tumor size were not associated with LR risk. The subgroup analysis showed that breast-conserving surgery versus mastectomy and positive versus negative surgical margins were significantly associated with an increased LR risk only in malignant PTs. CONCLUSIONS The risk of LR was significantly increased from benign to borderline to malignant PTs. Mitoses, tumor border, stromal cellularity, stromal atypia, stromal overgrowth, tumor necrosis, type of surgery, and surgical margin status may be risk factors for LR. Different management strategies could be considered for different PT grades.
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Affiliation(s)
- Yiwen Lu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yanbo Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Liling Zhu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Paul Cartwright
- Departments of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Erwei Song
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China. .,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Lisa Jacobs
- Departments of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Kai Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China. .,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
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Mitus JW, Blecharz P, Jakubowicz J, Reinfuss M, Walasek T, Wysocki W. Phyllodes tumors of the breast. The treatment results for 340 patients from a single cancer centre. Breast 2018; 43:85-90. [PMID: 30521986 DOI: 10.1016/j.breast.2018.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/13/2018] [Accepted: 11/25/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The primary treatment of choice for patients with phyllodes tumor of the breast (PTB) is surgery. Two major problems regarding the treatment of such patients remain unclear: what is the appropriate surgical margin and what role is played by adjuvant radiotherapy (ART). METHODS The study provides a retrospective review of all patients with PTB treated between 1952 and 2013 at a single institute. The histology slides were re-examined based on WHO criteria. The clinical characteristics and therapy outcomes were obtained. The five-year survival with no evidence of disease (NED) was used as the end point. RESULTS The study population comprised 340 women with PTB. Fifty-five percent of the patients were diagnosed with the benign, 11.8% with borderline and 33.2% with malignant PTB. All the patients received primary treatment with surgery (mastectomy-27.1%, and BCS- 72.9%). Local recurrence (LR) was found in 28 (9.1%) of these patients. Four patients with borderline and 8 with malignant PTB who were treated with BCS and had tumor-free margins < 1 cm received ART. None of these patients had LR and all survived 5 years NED. Of the 340 patients from our group, 294 (86.4%) survived five-years NED. CONCLUSION The prognosis for benign PTB is excellent and can be cured with surgery alone. A sufficient margin would be 0.1 cm (data from the literature) or 0.2-0.4 cm (our study). We recommend application of ART for such patients but the role of ART in patients with borderline and malignant PTB treated with BCS and with surgical margin < 1 cm remains uncertain.
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Affiliation(s)
- J W Mitus
- Department of Surgical Oncology, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland; Department of Anatomy, Collegium Medicum, Jagiellonian University, ul. Kopernika 12, 31-034 Cracow, Poland.
| | - P Blecharz
- Department of Gynecological Oncology, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland
| | - J Jakubowicz
- Department of Gynecological Oncology, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland
| | - M Reinfuss
- Department of Radiotherapy, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland
| | - T Walasek
- Department of Radiotherapy, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland
| | - W Wysocki
- Department of Surgical Oncology, Centre of Oncology, Maria Sklodowska-Curie Memorial Institute, Cracow Branch, ul. Garncarska 11, 31-115 Cracow, Poland
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Assi H, Salem R, Sukhon F, Abbas J, Boulos F, Saghir NE. Phyllodes tumors of the breast treated in a tertiary health care center: case series and literature review. J Int Med Res 2018; 48:300060518803530. [PMID: 30318976 PMCID: PMC7113489 DOI: 10.1177/0300060518803530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective This study was performed to determine the subtypes of phyllodes tumor (PT) in
patients at a single tertiary healthcare center in Lebanon and to describe
their characteristics along with a review of the literature. Methods This single-institution retrospective cohort study included all cases of PT
of the breast treated at the American University of Beirut Medical Center
from 1 January 2010 to 31 December 2014. The patients’ demographic data,
tumor characteristics, treatment data, and pathology reports were
analyzed. Results Thirty patients were enrolled. Their median age was 42 years. In total, 66.7%
had benign disease and 22.3% had malignant disease. Twenty-seven patients
underwent surgery, four received radiotherapy, and one received systemic
chemotherapy after PT progression. Twenty-seven patients had no recurrence
at the last follow-up, two had local recurrence, and one had metastatic
disease. All three patients with recurrence had an adequate negative
surgical margin at the first excision. Conclusion This is the first cohort of patients with PT described in Lebanon and one of
few in the Middle East. Our findings provide insight into the epidemiology,
treatment modalities, and prognosis of PT in this geographical region.
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Affiliation(s)
- Hazem Assi
- Hematology and Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Salem
- Hematology and Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fares Sukhon
- Hematology and Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jaber Abbas
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fouad Boulos
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nagi El Saghir
- Hematology and Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment. J Pediatr Surg 2018; 53:1123-1128. [PMID: 29605260 DOI: 10.1016/j.jpedsurg.2018.02.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults. METHODS We queried the NCDB (2004-2014) for female patients with phyllodes tumor histology, excluding patients with missing age or survival data. Patients were stratified by age (pediatric <21, adult ≥21), and compared based on patient characteristics, treatment patterns, and survival. RESULTS We identified 2787 cases of phyllodes tumor (2725 adult, 62 pediatric). Median age was 17years in children and 52years in adults. Margin positivity rates and median tumor size were similar between adults and children. Treatment was discordant with NCCN guidelines in 28.6% of adults and 14.5% of children through use of axillary staging, chemotherapy, adjuvant endocrine therapy, and radiotherapy. Five-year and ten-year survival were comparable between both groups. CONCLUSION Children and adults present with similarly sized phyllodes tumors. Trends reveal high margin positivity rates, and overtreatment with regional axillary staging and systemic adjuvant therapies. Particularly in children, treatment decisions must consider risks of adjuvant therapy including radiation-related second primary cancers, given uncertain benefit. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Choi N, Kim K, Shin KH, Kim Y, Moon HG, Park W, Choi DH, Kim SS, Ahn SD, Kim TH, Chun M, Kim YB, Kim S, Choi BO, Kim JH. Malignant and borderline phyllodes tumors of the breast: a multicenter study of 362 patients (KROG 16-08). Breast Cancer Res Treat 2018; 171:335-344. [DOI: 10.1007/s10549-018-4838-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/25/2018] [Indexed: 12/25/2022]
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42
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Kim JY, Yu JH, Nam SJ, Kim SW, Lee SK, Park WY, Noh DY, Nam DH, Park YH, Han W, Lee JE. Genetic and Clinical Characteristics of Phyllodes Tumors of the Breast. Transl Oncol 2017; 11:18-23. [PMID: 29145046 PMCID: PMC5684533 DOI: 10.1016/j.tranon.2017.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/12/2017] [Accepted: 10/23/2017] [Indexed: 12/11/2022] Open
Abstract
PURPOSE: Phyllodes tumors (PTs) of the breast are rare, accounting for less than 1% of all breast tumors. Among PTs, malignant PTs (MPTs) have malignant characteristics and distant metastases occur in about 20% to 30% of MPTs. However, there is no effective treatment for MPTs with distant metastasis, resulting in an abject prognosis. We performed targeted deep sequencing on PTs to identify the associations between genetic alterations and clinical prognosis. METHODS: We performed targeted deep sequencing to evaluate the genetic characteristics of PTs and analyzed the relationships between clinical and genetic characteristics. RESULTS: A total of 17 PTs were collected between 2001 and 2012. Histologic review was performed by pathologists. The samples included three benign PTs, one borderline PT, and 13 MPTs. The most frequently detected genetic alteration occurred in the TERT promoter region (70.6%), followed by MED12 (64.7%). EGFR amplification and TP53 alteration were detected in four MPTs without genetic alterations in MED12 and TERT promoter regions. Genetic alterations of RARA and ZNF703 were repeatedly found in PTs with local recurrence, and genetic alterations of SETD2, BRCA2, and TSC1 were detected in PTs with distant metastasis. Especially, MPT harboring PTEN and RB1 copy number deletion showed rapid disease progression. CONCLUSIONS: In this study, we provide genetic characterization and potential therapeutic target for this rare, potentially lethal disease. Further large-scale comprehensive genetic study and functional validation are warranted.
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Affiliation(s)
- Ji-Yeon Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,06351, Korea
| | - Jong Han Yu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Seok Won Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Se Kyung Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Woong-Yang Park
- Samsung Genome Institute, Samsung Medical Center, Seoul, 06351, Korea; Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul 06351, Korea
| | - Dong-Young Noh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Do-Hyun Nam
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul 06351, Korea; Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea; Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Korea
| | - Yeon Hee Park
- Division of Hematology-Oncology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,06351, Korea; Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul 06351, Korea; Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea; Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul 06351, Korea; Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Korea.
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Strode M, Khoury T, Mangieri C, Takabe K. Update on the diagnosis and management of malignant phyllodes tumors of the breast. Breast 2017; 33:91-96. [DOI: 10.1016/j.breast.2017.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 01/31/2023] Open
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