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Phyllodes Tumor: Borderline and Malignant
Whitney S. Boyce, MD; Jessica W. T. Leung, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Abbreviations

                • Phyllodes tumor (PT)
              • Synonyms

                • Cystosarcoma phyllodes (older term, out of favor)
              • Definitions

                • PT: Hypercellular fibroepithelial neoplasm with characteristic leaf-like architecture
                  • Biphasic tumor composed of stromal and epithelial elements
                  • Characterized by leaf-like stromal projections into epithelium-lined clefts
                    • Phyllodes: "Leaf-like" in Greek
                    • Clefts between projections form distinctive "cystic" spaces
                • Phyllodes tumors can be benign, borderline, or malignant
                  • Cannot reliably distinguish with imaging
                  • Graded at histopathology based on: Mitoses, stromal cellularity, stromal overgrowth and borders
                • Benign PT
                  • < 5 mitoses per 10 HPF
                  • Low stromal cellularity, no stromal overgrowth, circumscribed margins
                  • Recurrence rate: 5-17%; distant metastasis < 1%
                • Borderline PT (low-grade malignant)
                  • 5-9 mitoses per 10 HPF
                  • Stromal overgrowth present, may be focal
                  • Recurrence rate: 14-25%; distant metastasis 2%
                • Malignant PT (high-grade)
                  • ≥ 10 mitoses per 10 HPF (WHO criteria)
                  • Marked stromal cellularity, extensive stromal overgrowth, invasive margins
                  • Recurrence rate: 23-30%; distant metastasis 17%

              IMAGING

              • General Features

                • Mammographic Findings

                  • Ultrasonographic Findings

                    • MR Findings

                      • CT Findings

                        • Image-Guided Biopsy

                          • Imaging Recommendations

                            DIFFERENTIAL DIAGNOSIS

                              PATHOLOGY

                              • General Features

                                • Staging, Grading, & Classification

                                  • Gross Pathologic & Surgical Features

                                    • Microscopic Features

                                      CLINICAL ISSUES

                                      • Presentation

                                        • Demographics

                                          • Natural History & Prognosis

                                            • Treatment

                                              DIAGNOSTIC CHECKLIST

                                              • Consider

                                                • Image Interpretation Pearls

                                                  Selected References

                                                  1. Choi N et al: Malignant and borderline phyllodes tumors of the breast: a multicenter study of 362 patients (KROG 16-08). Breast Cancer Res Treat. 171(2):335-344, 2018
                                                  2. Kalambo M et al: Phyllodes Tumor of the Breast: Ultrasound-Pathology Correlation. AJR Am J Roentgenol. 210(4):W173-W179, 2018
                                                  3. Li J et al: Expression of biomarkers in AKT pathway correlated with malignancy and recurrence in phyllodes tumors of the breast. Histopathology. ePub, 2018
                                                  4. Tan BY et al: A Diagnostic Approach to Fibroepithelial Breast Lesions. Surg Pathol Clin. 11(1):17-42, 2018
                                                  5. Krings G et al: Fibroepithelial lesions; The WHO spectrum. Semin Diagn Pathol. ePub, 2017
                                                  6. Strode M et al: Update on the diagnosis and management of malignant phyllodes tumors of the breast. Breast. 33:91-96, 2017
                                                  7. Adesoye T et al: Current Trends in the Management of Phyllodes Tumors of the Breast. Ann Surg Oncol. 23(10):3199-205, 2016
                                                  8. Liu SY et al: Genomic profiling of malignant phyllodes tumors reveals aberrations in FGFR1 and PI-3 kinase/RAS signaling pathways and provides insights into intratumoral heterogeneity. Mod Pathol. 29(9):1012-27, 2016
                                                  9. Tan BY et al: Phyllodes tumours of the breast: a consensus review. Histopathology. 68(1):5-21, 2016
                                                  10. Roberts N et al: Aggressive malignant phyllodes tumor. Int J Surg Case Rep. 8C:161-5, 2015
                                                  11. Yom CK et al: Reappraisal of conventional risk stratification for local recurrence based on clinical outcomes in 285 resected phyllodes tumors of the breast. Ann Surg Oncol. 22(9):2912-8, 2015
                                                  12. Cimino-Mathews A et al: A Subset of Malignant Phyllodes Tumors Express p63 and p40: A Diagnostic Pitfall in Breast Core Needle Biopsies. Am J Surg Pathol. 38(12):1689-96, 2014
                                                  13. McCarthy E et al: Phyllodes tumours of the breast: radiological presentation, management and follow-up. Br J Radiol. 87(1044):20140239, 2014
                                                  14. Tan H et al: Imaging findings in phyllodes tumors of the breast. Eur J Radiol. 81(1):e62-9, 2012
                                                  15. Tse GM et al: Phyllodes tumor of the breast: an update. Breast Cancer. 17(1):29-34, 2010
                                                  16. Yoo JL et al: Can MR Imaging contribute in characterizing well-circumscribed breast carcinomas? Radiographics. 30(6):1689-702, 2010
                                                  17. Chung EM et al: From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation. Radiographics. 29(3):907-31, 2009
                                                  18. Pezner RD et al: Malignant phyllodes tumor of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Phys. 71(3):710-3, 2008
                                                  19. Bode MK et al: Ultrasonography and core needle biopsy in the differential diagnosis of fibroadenoma and tumor phyllodes. Acta Radiol. 48(7):708-13, 2007
                                                  20. Morales-Vásquez F et al: Adjuvant chemotherapy with doxorubicin and dacarbazine has no effect in recurrence-free survival of malignant phyllodes tumors of the breast. Breast J. 13(6):551-6, 2007
                                                  21. Kersting C et al: Amplifications of the epidermal growth factor receptor gene (egfr) are common in phyllodes tumors of the breast and are associated with tumor progression. Lab Invest. 86(1):54-61, 2006
                                                  22. Yabuuchi H et al: Phyllodes tumor of the breast: correlation between MR findings and histologic grade. Radiology. 241(3):702-9, 2006
                                                  23. Chen WH et al: Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases. J Surg Oncol. 91(3):185-94, 2005
                                                  24. Franceschini G et al: Phyllodes tumor of the breast: magnetic resonance imaging findings and surgical treatment. Breast J. 11(2):144-5, 2005
                                                  25. Franceschini G et al: Surgical treatment and MRI in phyllodes tumors of the breast: our experience and review of the literature. Ann Ital Chir. 76(2):127-40, 2005
                                                  26. Goel NB et al: Fibrous lesions of the breast: imaging-pathologic correlation. Radiographics. 25(6):1547-59, 2005
                                                  27. Tan PH et al: p53 and c-kit (CD117) protein expression as prognostic indicators in breast phyllodes tumors: a tissue microarray study. Mod Pathol. 18(12):1527-34, 2005
                                                  28. Tse GM et al: Stromal nitric oxide synthase (NOS) expression correlates with the grade of mammary phyllodes tumour. J Clin Pathol. 58(6):600-4, 2005
                                                  29. Kinoshita T et al: Magnetic resonance imaging of benign phyllodes tumors of the breast. Breast J. 10(3):232-6, 2004
                                                  30. Tse GM et al: Stromal expression of vascular endothelial growth factor correlates with tumor grade and microvessel density in mammary phyllodes tumors: a multicenter study of 185 cases. Hum Pathol. 35(9):1053-7, 2004
                                                  31. Gordon PB et al: Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology. 229(1):233-8, 2003
                                                  32. Komenaka IK et al: Core needle biopsy as a diagnostic tool to differentiate phyllodes tumor from fibroadenoma. Arch Surg. 138(9):987-90, 2003
                                                  33. Tse GM et al: Tumour angiogenesis and p53 protein expression in mammary phyllodes tumors. Mod Pathol. 16(10):1007-13, 2003
                                                  34. Liberman L et al: Benign and malignant phyllodes tumors: mammographic and sonographic findings. Radiology. 198(1):121-4, 1996
                                                  Related Anatomy
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                                                  Related Differential Diagnoses
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                                                  References
                                                  Tables

                                                  Tables

                                                  KEY FACTS

                                                  • Terminology

                                                    • Imaging

                                                      • Top Differential Diagnoses

                                                        • Pathology

                                                          • Clinical Issues

                                                            • Diagnostic Checklist

                                                              TERMINOLOGY

                                                              • Abbreviations

                                                                • Phyllodes tumor (PT)
                                                              • Synonyms

                                                                • Cystosarcoma phyllodes (older term, out of favor)
                                                              • Definitions

                                                                • PT: Hypercellular fibroepithelial neoplasm with characteristic leaf-like architecture
                                                                  • Biphasic tumor composed of stromal and epithelial elements
                                                                  • Characterized by leaf-like stromal projections into epithelium-lined clefts
                                                                    • Phyllodes: "Leaf-like" in Greek
                                                                    • Clefts between projections form distinctive "cystic" spaces
                                                                • Phyllodes tumors can be benign, borderline, or malignant
                                                                  • Cannot reliably distinguish with imaging
                                                                  • Graded at histopathology based on: Mitoses, stromal cellularity, stromal overgrowth and borders
                                                                • Benign PT
                                                                  • < 5 mitoses per 10 HPF
                                                                  • Low stromal cellularity, no stromal overgrowth, circumscribed margins
                                                                  • Recurrence rate: 5-17%; distant metastasis < 1%
                                                                • Borderline PT (low-grade malignant)
                                                                  • 5-9 mitoses per 10 HPF
                                                                  • Stromal overgrowth present, may be focal
                                                                  • Recurrence rate: 14-25%; distant metastasis 2%
                                                                • Malignant PT (high-grade)
                                                                  • ≥ 10 mitoses per 10 HPF (WHO criteria)
                                                                  • Marked stromal cellularity, extensive stromal overgrowth, invasive margins
                                                                  • Recurrence rate: 23-30%; distant metastasis 17%

                                                              IMAGING

                                                              • General Features

                                                                • Mammographic Findings

                                                                  • Ultrasonographic Findings

                                                                    • MR Findings

                                                                      • CT Findings

                                                                        • Image-Guided Biopsy

                                                                          • Imaging Recommendations

                                                                            DIFFERENTIAL DIAGNOSIS

                                                                              PATHOLOGY

                                                                              • General Features

                                                                                • Staging, Grading, & Classification

                                                                                  • Gross Pathologic & Surgical Features

                                                                                    • Microscopic Features

                                                                                      CLINICAL ISSUES

                                                                                      • Presentation

                                                                                        • Demographics

                                                                                          • Natural History & Prognosis

                                                                                            • Treatment

                                                                                              DIAGNOSTIC CHECKLIST

                                                                                              • Consider

                                                                                                • Image Interpretation Pearls

                                                                                                  Selected References

                                                                                                  1. Choi N et al: Malignant and borderline phyllodes tumors of the breast: a multicenter study of 362 patients (KROG 16-08). Breast Cancer Res Treat. 171(2):335-344, 2018
                                                                                                  2. Kalambo M et al: Phyllodes Tumor of the Breast: Ultrasound-Pathology Correlation. AJR Am J Roentgenol. 210(4):W173-W179, 2018
                                                                                                  3. Li J et al: Expression of biomarkers in AKT pathway correlated with malignancy and recurrence in phyllodes tumors of the breast. Histopathology. ePub, 2018
                                                                                                  4. Tan BY et al: A Diagnostic Approach to Fibroepithelial Breast Lesions. Surg Pathol Clin. 11(1):17-42, 2018
                                                                                                  5. Krings G et al: Fibroepithelial lesions; The WHO spectrum. Semin Diagn Pathol. ePub, 2017
                                                                                                  6. Strode M et al: Update on the diagnosis and management of malignant phyllodes tumors of the breast. Breast. 33:91-96, 2017
                                                                                                  7. Adesoye T et al: Current Trends in the Management of Phyllodes Tumors of the Breast. Ann Surg Oncol. 23(10):3199-205, 2016
                                                                                                  8. Liu SY et al: Genomic profiling of malignant phyllodes tumors reveals aberrations in FGFR1 and PI-3 kinase/RAS signaling pathways and provides insights into intratumoral heterogeneity. Mod Pathol. 29(9):1012-27, 2016
                                                                                                  9. Tan BY et al: Phyllodes tumours of the breast: a consensus review. Histopathology. 68(1):5-21, 2016
                                                                                                  10. Roberts N et al: Aggressive malignant phyllodes tumor. Int J Surg Case Rep. 8C:161-5, 2015
                                                                                                  11. Yom CK et al: Reappraisal of conventional risk stratification for local recurrence based on clinical outcomes in 285 resected phyllodes tumors of the breast. Ann Surg Oncol. 22(9):2912-8, 2015
                                                                                                  12. Cimino-Mathews A et al: A Subset of Malignant Phyllodes Tumors Express p63 and p40: A Diagnostic Pitfall in Breast Core Needle Biopsies. Am J Surg Pathol. 38(12):1689-96, 2014
                                                                                                  13. McCarthy E et al: Phyllodes tumours of the breast: radiological presentation, management and follow-up. Br J Radiol. 87(1044):20140239, 2014
                                                                                                  14. Tan H et al: Imaging findings in phyllodes tumors of the breast. Eur J Radiol. 81(1):e62-9, 2012
                                                                                                  15. Tse GM et al: Phyllodes tumor of the breast: an update. Breast Cancer. 17(1):29-34, 2010
                                                                                                  16. Yoo JL et al: Can MR Imaging contribute in characterizing well-circumscribed breast carcinomas? Radiographics. 30(6):1689-702, 2010
                                                                                                  17. Chung EM et al: From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation. Radiographics. 29(3):907-31, 2009
                                                                                                  18. Pezner RD et al: Malignant phyllodes tumor of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Phys. 71(3):710-3, 2008
                                                                                                  19. Bode MK et al: Ultrasonography and core needle biopsy in the differential diagnosis of fibroadenoma and tumor phyllodes. Acta Radiol. 48(7):708-13, 2007
                                                                                                  20. Morales-Vásquez F et al: Adjuvant chemotherapy with doxorubicin and dacarbazine has no effect in recurrence-free survival of malignant phyllodes tumors of the breast. Breast J. 13(6):551-6, 2007
                                                                                                  21. Kersting C et al: Amplifications of the epidermal growth factor receptor gene (egfr) are common in phyllodes tumors of the breast and are associated with tumor progression. Lab Invest. 86(1):54-61, 2006
                                                                                                  22. Yabuuchi H et al: Phyllodes tumor of the breast: correlation between MR findings and histologic grade. Radiology. 241(3):702-9, 2006
                                                                                                  23. Chen WH et al: Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases. J Surg Oncol. 91(3):185-94, 2005
                                                                                                  24. Franceschini G et al: Phyllodes tumor of the breast: magnetic resonance imaging findings and surgical treatment. Breast J. 11(2):144-5, 2005
                                                                                                  25. Franceschini G et al: Surgical treatment and MRI in phyllodes tumors of the breast: our experience and review of the literature. Ann Ital Chir. 76(2):127-40, 2005
                                                                                                  26. Goel NB et al: Fibrous lesions of the breast: imaging-pathologic correlation. Radiographics. 25(6):1547-59, 2005
                                                                                                  27. Tan PH et al: p53 and c-kit (CD117) protein expression as prognostic indicators in breast phyllodes tumors: a tissue microarray study. Mod Pathol. 18(12):1527-34, 2005
                                                                                                  28. Tse GM et al: Stromal nitric oxide synthase (NOS) expression correlates with the grade of mammary phyllodes tumour. J Clin Pathol. 58(6):600-4, 2005
                                                                                                  29. Kinoshita T et al: Magnetic resonance imaging of benign phyllodes tumors of the breast. Breast J. 10(3):232-6, 2004
                                                                                                  30. Tse GM et al: Stromal expression of vascular endothelial growth factor correlates with tumor grade and microvessel density in mammary phyllodes tumors: a multicenter study of 185 cases. Hum Pathol. 35(9):1053-7, 2004
                                                                                                  31. Gordon PB et al: Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology. 229(1):233-8, 2003
                                                                                                  32. Komenaka IK et al: Core needle biopsy as a diagnostic tool to differentiate phyllodes tumor from fibroadenoma. Arch Surg. 138(9):987-90, 2003
                                                                                                  33. Tse GM et al: Tumour angiogenesis and p53 protein expression in mammary phyllodes tumors. Mod Pathol. 16(10):1007-13, 2003
                                                                                                  34. Liberman L et al: Benign and malignant phyllodes tumors: mammographic and sonographic findings. Radiology. 198(1):121-4, 1996