Phyllodes tumours of the breast: radiological presentation, management and follow-up

Abstract

Results: 53 patients with 54 lesions were diagnosed as having a PT. The median age was 27.5, 35.0 and 38.5 years for benign, borderline and malignant PT, respectively. Borderline and malignant PTs were larger than benign PTs, with mean sizes of 33 and 42 mm compared with 29 mm. 38% of PTs were labelled by the reporting radiologist as fibroadenomas, including two borderline PTs and one malignant PT. In 24% of cases, the radiologist raised the possibility of PT in the report. 17 patients (40%) developed a new fibroepithelial breast lesion during follow-up of which 4 were recurrent PTs. Conclusion: Despite adequate surgical management, the development of further fibroepithelial lesions in the ipsilateral breast is common. 3-year clinical surveillance, with the addition of 6-monthly ultrasound is advised for females with initial borderline or malignant PT histology. Advances in knowledge:We propose a follow-up protocol with ultrasound based on the grade of the PT diagnosed for 3 years to detect recurrence.Phyllodes tumours (PTs) are rare biphasic fibroepithelial neoplasms accounting for ,1% of all breast lesions. 1 In the literature, they have been described as occurring in females aged 35-55 years, typically 15-20 years older than females with fibroadenomas (FAs) and with a higher incidence in Asian females.2,3 Imaging findings of PT and FA overlap and as such lesions may be misdiagnosed. 4 Histologically, PTs can be identified by their distinctive leaf-like architecture and increased stromal cellularity. 5 Typically, PTs present as a palpable breast lump and were traditionally differentiated from FAs based on their larger size at presentation.6 However, with increased breast awareness and screening programmes, smaller and incidental lesions are being found on imaging. 6 In symptomatic breast clinics, including this institution, "triple assessment" consisting an initial physical examination, followed by radiological imaging (ultrasound and/or mammography) and histological sampling either by fine-needle aspiration cytology (FNAC) or core biopsy is the standard diagnostic pathway for palpable breast lesions. The purpose of triple assessment is to provide a more accurate pre-operative diagnosis to ensure proper surgical planning and avoiding re-excision or tumour recurrence. 7According to the World Health Organization criteria, there are two grading systems for PTs; a two-tiered system or a three-tiered system. 8 Our institution employs the threetiered system, the subgroups being benign, borderline and malignant. Grading is based on semi-quantitative assessment of stromal cellularity, cellular pleomorphism, mitotic activity, margin appearance and stromal distribution. The standard procedure for treatment, no matter what the grade of the PT, is surgical wide local excision, preferably with clear margins of at least 1 cm. However, owing to the fact that most PTs are not fully diagnosed pre-operatively, initial surgery does not always provide adequate margins necessitating frequent post-operative re-excision of the margi...

Phyllodes Tumor of the Breast: Analysis of 48 Patients

“…However, no specific color Doppler US finding was found to help differentiate PT from FA, or benign PTs from malignant (14). MG also has limited diagnostic value in differentiating PT and other benign breast lesions (12). In our study, US was used as the first-step imaging method in all patients, and MG was only performed in patients aged more than 35 years.…”

“…With US, the majority of PTs are described as well-defined hypoechoeic oval lesions surrounded by a capsule or pseudocapsule. Contrary to FAs, several sonographic findings including heterogeneous internal structure with irregular margins, septae, lobulation, and the absence of microcalcifications were reported to be associated with PT (11)(12)(13). In addition, increased intralesional vascularity with Doppler US is a frequent feature of these tumors.…”

Expression of biomarkers in the AKT pathway correlates with malignancy and recurrence in phyllodes tumours of the breast

“…Recurrence of PT has been attributed to many factors, including histological grade and surgical margins . However, despite the many attempts to investigate parameters that predict PT recurrence, no consistent results have been obtained, and the current opinions on postoperative surveillance and management vary . In addition, the precise mechanism of the malignant progression of PT remains unclear.…”

“…6 However, despite the many attempts to investigate parameters that predict PT recurrence, no consistent results have been obtained, and the current opinions on postoperative surveillance and management vary. 19,20 In addition, the precise mechanism of the malignant progression of PT remains unclear. In this study, we examined the expression of AKT pathway components in a series of PTs in relation to tumour grade and recurrence.…”

Borderline Phyllodes Tumour

“…[8] Early and periodic follow-up with 6 monthly sonographic examinations up to 2 years are recommended after surgery. [9][10][11]…”