Phyllodes Tumors — History, Examination & Surgery

Background

History Taking

Demographics & Timing

• Peak age: 5th–6th decade (40s–60s); occurs ~10–20 years later than the fibroadenoma peak
• Ask about prior benign breast disease, especially history of fibroadenoma
• Li-Fraumeni syndrome is the only recognised risk factor — take a family history of sarcomas, early-onset breast cancer, brain tumours, adrenocortical carcinoma

Presenting Complaint

• Painless breast lump — usually smooth, firm, mobile, well-demarcated, multinodular
• Rapid growth — a key distinguishing feature from fibroadenoma; ask how quickly the lump has grown
• Large size — average 4–7 cm at presentation (vs. fibroadenoma typically ≤3 cm)
• Skin changes — in large tumors, stretched, shiny skin or pressure necrosis over the lump (not true invasion)
• Ask about nipple discharge, skin tethering, nipple retraction (less typical but important to exclude malignancy)
• Ask about axillary swelling (lymphadenopathy is palpable in up to 20% but true nodal involvement is very rare)

Systemic Symptoms (for malignant disease)

• Cough, haemoptysis, dyspnoea — lung is the most common site of haematogenous metastasis
• Weight loss, anorexia

Obstetric/Menstrual History

• Phyllodes tumors may enlarge during pregnancy
• Menopausal status (post-menopausal women rarely develop new phyllodes)

Clinical Examination

Inspection

• Asymmetry — large phyllodes tumors cause visible breast enlargement
• Skin changes — stretched, shiny, bluish-tinged skin over large masses due to pressure necrosis (not tumour invasion — a key differentiating point)
• No peau d'orange or skin dimpling (which would suggest carcinoma)
• Nipple position — distortion possible with large tumours

Palpation of the Breast

• Firm, smooth, multinodular, well-demarcated mass
• Mobile — not fixed to skin or chest wall
• Painless on palpation
• Large average size (4–7 cm); may fill the entire breast in extreme cases

Axillary Examination

• Palpable axillary lymph nodes may be found in up to 20% of patients — but pathological nodal involvement is very rare (in the SEER database, only 8/498 patients had involved nodes)

Systemic Examination

• Chest — if malignant phyllodes suspected, examine for signs of pleural effusion or lung metastases

Investigations

• Core needle biopsy (CNB): Recommended for diagnosis; however, has a false-negative rate of 25–30% because limited sampling cannot always classify phyllodes vs. fibroadenoma (reported as "cellular fibroepithelial lesion")
• Excisional biopsy: Performed when CNB is equivocal or when there is a rapidly enlarging mass
• Imaging: Smooth multi-lobulated mass resembling fibroadenoma on both mammography and ultrasound — imaging alone cannot reliably distinguish from fibroadenoma
• Chest X-ray: For surveillance of malignant phyllodes (every 6 months × 2 years, then annually) due to pulmonary metastasis risk

Surgical Management

Principles

• All phyllodes tumors require surgical excision — unlike fibroadenomas, even benign phyllodes are not managed conservatively
• The fundamental goal is excision to negative histological margins

By Grade

Axillary Management

• No axillary staging (SLNB/ALND) is indicated — lymph node spread is exceedingly rare; axillary lymph node dissection is contraindicated

Adjuvant Therapy

• Radiotherapy: Controversial; considered for borderline or malignant phyllodes after breast-conserving surgery to reduce local recurrence
• Chemotherapy: For metastatic malignant phyllodes, managed as per sarcoma guidelines (limited benefit); once metastases develop, mean overall survival is ~30 months

Recurrence

• Local recurrence occurs most often within the first 2 years after excision
• Close follow-up with clinical examination and imaging is essential
• Metastases (malignant phyllodes) occur via haematogenous spread, predominantly to the lungs

Key Differentiating Features from Fibroadenoma

• Sabiston Textbook of Surgery, p.1391
• Mulholland and Greenfield's Surgery (7e), p.3977–3978
• Current Surgical Therapy (14e), p.898–900
• Robbins, Cotran & Kumar Pathologic Basis of Disease, p.351–363