Recent Management of Phyllodes Tumour of the Breast

Abstract

Phyllodes tumours are uncommon fibro-epithelial lesions, arise outside of the ducts and lobules, in the breast’s connective tissue, called the stroma which includes the fatty tissue and ligaments that surround the ducts, lobules, and blood and lymph vessels in the breast. In addition to stromal cells, phyllodes tumours can also contain cells from the ducts and lobules. they account for a range of 0.3 to 0.5% of whole female breast tumours having peak incidence of about 2.1 per million among women aged 45 to 49 years uncommonly to be present in elderly and adolescents, they varies in size ranging from 1 cm to 15 cm. It was thought that median age for the phyllodes tumour is 45 years unlike fibroadenoma which is found in younger age average 20 years. The tumour accounts for less than 1 % of malignant tumours and less than 5 % of sarcomas. Phyllodes were described in 1774, as a giant type of fibroadenoma as misleading but in 1827 Johannes Muller described this tumour for the first time in 1838 using the term “cystosarcoma phyllodes”. It was thought to be benign till 1943, when Cooper and Ackerman reported the malignant potential of this tumour. In 1981 the “World Health Organization” adopted the term “phyllodes tumour” and Rosen subclassified them histologically as benign, borderline, or malignant according to some features as cellular atypia, stromal overgrowth, tumour necrosis, and the number of mitosis per high power field. Most “phyllodes” was adopted as benign (35% to 64%), with having a manner between the borderline and malignant subtypes. No doubt that accurate preoperative pathological diagnosis leads the correct surgical planning and avoidance of recurrence and possibility of re-operation. Regarding malignant phyllodes tumours, if not well excised, may recur with rapid growth and metastatic spread may occur, on the other hand benign phyllodes tumours clinically, radiologically, and by cytological examination are difficult to distinguish from fibroadenomas and can be treated by local excision surgery. The main target of phyllodes tumours today lies to differentiate them from other benign breast lesions. Treatment can be either wide local excision or mastectomy according to the size with histologically clear specimen margins. Macroscopically, Phyllodes tumours vary in size with reporting lesions up to 20 cm in diameter. Like fibroadenoma, most small tumours have a uniform white consistency mixed with a lobulated surface. They are seldom cystic in nature. Large tumours often have a red or grey meaty or fleshy consistency with, haemorrhagic, fibrogelatinous and necrotic appearance. Microscopically, phyllodes tumours are characterised by epithelial lined cystic spaces into which projects a hypercellular stroma. The presence of both epithelial and stromal elements are mandatory to confirm the diagnosis. The stroma is the neoplastic component and determines the pathological behavior having the potentiality to metastasize. Its presentation usually presents as a rapidly growing but a benign breast lump clinically. In some patients a lesion may be apparent for several years, with clinical presentation of sudden increase in size.