Ann Surg Oncol (2018) 25:3088–3095
https://doi.org/10.1245/s10434-018-6622-3
ORIGINAL ARTICLE – BREAST ONCOLOGY
Trends in the Diagnosis of Phyllodes Tumors and Fibroadenomas
Before and After Release of WHO Classification Standards
Jenny Chang, BA1, Laura Denham, MD2, Eun Kyu Dong, BS1, Kirollos Malek, MD1, and Sharon S. Lum, MD1
1
Department of Surgery, Division of Surgical Oncology, Loma Linda University School of Medicine, Loma Linda, CA;
2
Department of Pathology, Loma Linda University School of Medicine, Loma Linda, CA
ABSTRACT
Background. In 2012, the World Health Organization
(WHO) released diagnostic criteria for grading phyllodes
tumors based on histologic features. This study sought to
examine the application of the WHO criteria and the
changing epidemiology of fibroepithelial tumors.
Methods. A retrospective review of surgically excised
fibroepithelial lesions from 2007 to 2017 at a single tertiary
care institution was conducted. Data regarding the WHO
criteria (tumor border, stromal cellularity, stromal cell
atypia, stromal overgrowth, mitotic activity) and traditional
descriptors (leaf-like architecture, periductal stromal con-
densation) were collected. Clinical and pathologic
characteristics of cases with diagnoses determined before
and after 2012 were compared.
Results. During the study period, 305 fibroepithelial
tumors were identified. No significant differences were
observed in terms of mean age, race/ethnicity, presenting
symptoms, or method of diagnosis between cases diag-
nosed before and after 2012. After 2012, the findings
showed statistically significant increases in reporting of
WHO and traditional histologic features, a decrease in
diagnoses of fibroadenomas (85.9% [116/135] before vs
70.0% [119/170] after 2012), and an increase in benign
phyllodes tumors (0% [0/135] before vs 12.9% [22/170]
after 2012). Patients with a diagnosis of benign phyllodes
tumors were significantly younger than those with a diag-
nosis of borderline, malignant, or non-graded phyllodes
tumors (mean age, 25.7 ± 10.6 vs 52.8 ± 9.9, 40.7 ± 24,
46.3 ± 1.5 years, respectively; p = 0.006).
Ó Society of Surgical Oncology 2018
First Received: 23 April 2018;
Published Online: 9 July 2018
S. S. Lum, MD
e-mail: slum@llu.edu
Conclusions. The expanding use of the 2012 WHO cri-
teria has been accompanied by an increased diagnostic
frequency of benign phyllodes tumors and a decrease in
fibroadenomas. As fibroepithelial diagnoses become more
distinct, evidence-based management recommendations for
less virulent phyllodes diagnoses should be developed.
The American Cancer Society estimates that approxi-
mately 10% of women will experience a detectable breast
lump in their lifetime.1 Half of these breast masses include
fibroepithelial lesions of the breast, a majority of which are
diagnosed as fibroadenomas and rarely as phyllodes
tumors.2,3 Both fibroadenomas and phyllodes tumors are
biphasic neoplasms containing a proliferation of epithelial
and stromal components, with intersecting imaging and
histologic characteristics.4
The current literature has established the difficulty and
interobserver variability in diagnosing phyllodes tumors
and fibroadenomas.5,6 However, the clinical behavior and
management of these two tumors are drastically different.
Phyllodes tumors typically present in women between 40
and 50 years of age, whereas fibroadenomas occur in
women 10–20 years younger.6 Whereas phyllodes tumors
can locally recur and rarely metastasize, fibroadenomas can
regress with age.6 A complete surgical excision with an
attempt to obtain negative margins of 1 cm or greater is the
current National Comprehensive Cancer Network (NCCN)
guideline recommendation for phyllodes tumors.7 The
management of fibroadenomas can include follow-up
evaluation and reassurance unless clinical suspicion for
concerning features requires further intervention.8
In a series of monographs published by the International
Agency for Cancer Research, the World Health Organi-
zation (WHO) provides worldwide standards for
classification of tumors. In 2012, WHO released updated
criteria for the diagnosis and grading of phyllodes tumors
Trends in Fibroepithelial Breast Diagnoses
based on histologic features.4 Previous editions of the
WHO classification system, while recognizing the dis-
parate behavior of phyllodes tumors, described phyllodes
tumors using qualitative patterns of stromal cellularity,
cellular pleomorphism, mitotic activity, margin appear-
ance, and stromal pattern without strictly defining a grading
system.9
The 2012 WHO criteria divided phyllodes tumors into
benign, borderline, and malignant categories based on
designated degrees of stromal cellularity, stromal cell
atypia, mitotic activity, degree of stromal overgrowth, and
tumor border. Definitions of phyllodes tumor grade cate-
gories according to the updated WHO criteria are listed in
Table 1. According to these criteria, a malignant phyllodes
tumor displays markedly increased stromal cellularity and
atypia, 10 mitoses or more per 10 high-power fields
(HPFs), stromal overgrowth, and infiltrative tumor mar-
gins. In contrast, a benign phyllodes tumor displays mildly
increased stromal cellularity, minimal nuclear atypia, four
or fewer mitoses per 10 high-power fields, no stromal
overgrowth, and well-defined borders. Fibroadenomas are
well circumscribed benign growths of epithelial and stro-
mal tissue that can display characteristics similar to those
of benign phyllodes tumors, such as mild stromal cellu-
larity and rare mitoses.6
Although identification of these key histologic criteria is
important for the diagnosis and prediction of the clinical
behavior shown by phyllodes tumors versus fibroadeno-
mas, application of these criteria has not been universally
implemented. Although recent studies acknowledge the
WHO criteria, WHO-defined histologic criteria may be
missing10 or reported using non-WHO thresholds (e.g., a
bimodal rather than a trimodal category for mitotic activ-
ity).11 With the availability of more specific diagnostic
definitions, this study aimed to examine the application of
the current WHO criteria and the changing epidemiology
of fibroepithelial tumors in a tertiary care institution.
TABLE 1 World Health Organization phyllodes grading criteriaa
Benign
Tumor border Well-defined
Stromal cellularity Cellular, usually mild, may be non-
uniform or diffuse
Stromal cell atypia None to mild
Mitotic activity \ 5 per 10 HPFs
Stromal overgrowth Absent
Malignant heterologous Absent
elements
HPF high-power field
a
Although these features are often observed in combination, they may not always be present simultaneously. The presence of malignant
heterologous elements is sufficient for a diagnosis of malignant phyllodes tumors even in the absence of other histologic criteria
3089
METHODS
A retrospective review conducted within the Loma
Linda University pathology database examined all
fibroepithelial lesions diagnosed from 1 January 2007 to 1
June 2017. A text search was conducted for ‘‘phyllodes’’
and ‘‘fibroadenoma’’ in the diagnosis line, comments, or
history section of all pathology reports.
In our pathology department, fibroepithelial lesions not
otherwise classified have standardized reporting in the
comment line regarding a differential diagnosis of phyl-
lodes versus fibroadenoma. Hence, all fibroepithelial cases
were captured. Breast pathology interpretation is per-
formed by all pathologists in the department, with second
review performed routinely for malignant diagnoses and at
the discretion of the reviewing pathologist for non-malig-
nant diagnoses. No breast-specific pathologists were
included among 16 pathology faculty members during the
study period, and no formal departmental in-service train-
ing regarding 2012 WHO breast tumor classification
updates was performed. Cases were retrieved for study if
final pathology reports were available from patients who
underwent surgical excision, including those for whom the
primary diagnosis of the breast was not a fibroepithelial
lesion.
Tumors were classified according to the final pathologic
diagnosis listed on the pathology report as phyllodes not
specified (NOS), benign phyllodes, borderline phyllodes,
malignant phyllodes, fibroadenoma, cellular fibroadenoma,
or fibroepithelial lesion NOS. Data regarding reporting of
histologic features defined in the WHO criteria (tumor
border, stromal cellularity, degree of stromal overgrowth,
stromal cell atypia, and mitotic activity per 10 HPFs) and
traditional descriptors (leaf-like architecture, periductal
stromal condensation) were collected from surgical
pathology reports. Pathology reports were evaluated for
documentation of the presence or absence of reports on
Borderline Malignanta
Well-defined, may be focally infiltrative Infiltrative
Cellular, usually moderate, may be non- Cellular, usually marked
uniform or diffuse or diffuse
Mild or moderate Marked
5–9 per 10 HPFs C 10 per 10 HPFs
Absent or very focal Often present
Absent May be present
3090
each histologic feature, and when available, qualitative
descriptors according to WHO reporting guidelines (e.g.,
number of mitotic figures, mild vs moderate vs marked
stromal cellularity).
Demographic and clinical data were collected from
electronic medical records including age, race and ethnic-
ity, and presenting symptoms. Pathologic diagnoses and
documentation of histologic features present in pathology
reports before and since 2012 were compared to evaluate
the impact of the release of WHO breast tumor classifica-
tion standards.
Statistical analyses with Pearson Chi square test of
independence for categorical variables and Kruskal–Wallis
analysis of variance for continuous variables were used
(NCSS 11 Statistical Software, 2016; NCSS, LLC, Kays-
ville, UT, USA, ncss.com/software/ncss). A p value lower
than 0.05 was considered significant. This study was
approved by the Loma Linda University Institutional
Review Board.
RESULTS
From 1 January 2010 to 1 June 2017, 305 surgically
excised fibroepithelial tumors had a final pathology report
available for review. The patient and pathology charac-
teristics are listed in Table 2. The mean age of the patients
was 32.1 ± 17.5 years, and the median age was 25 years
(range, 11–80 years). Non-Hispanic white patients com-
prised 36.7% of the study population, followed by
Hispanic, patients (10.2%) Asian/Pacific Islander patients
(33.1%), non-Hispanic black patients (8.9%), and patients
of other race or ethnicity (6.2%). Where the initial pre-
senting sign or symptom was available, the most
commonly reported findings were a palpable mass in
62.7%, screening imaging finding in 21.3%, and pain in
4.5% of the patients. The most commonly used initial
method of diagnosis for these patients was surgical exci-
sion in 83.3%, with 16.7% having their diagnosis
determined by a percutaneous needle biopsy.
Overall, the final pathologic diagnoses were phyllodes
NOS (2%), benign phyllodes (7.2%), borderline phyllodes
(2.6%), malignant phyllodes (2.0%), fibroadenoma
(77.1%), cellular fibroadenoma (6.6%), and fibroepithelial
lesion NOS (2.6%). Table 3 lists reported tumor sizes by
diagnosis.
Cases available for review comprised 135 (44.3%) from
2007 to 2011 and 170 (55.7%) from 2012 to 2017. In a
comparison of cases with a diagnosis determined before
and since 2012, the findings showed no significant differ-
ences in mean age (32.4 ± 17.0 before vs
31.8 ± 17.9 years since 2012; p = 0.5), distribution of race
and ethnicity (p = 0.3), presenting symptoms (p = 0.1), or
J. Chang et al.
method of diagnosis (p = 0.2). Documentation of the
presence or absence of each of the five WHO criteria or
two traditional histologic criteria ranged from 0 to 11.1%
of the final surgical pathology reports in 2007–2011 and
from 5.9 to 30.0% of the reports in 2012–2017 (p \ 0.01
for all features except stromal overgrowth in which
p = 0.05). Where WHO criteria were reported, qualitative
descriptors according to WHO terminology were used in
documenting stromal cellularity for 100% (61/61) of cases,
mitotic activity for 95.9% (47/49) of cases, stromal cell
atypia for 94.9% (56/59) of cases, stromal overgrowth for
100.0% (12/12) of cases, and tumor borders for 100.0%
(37/37) of cases.
Analysis of the final pathologic diagnoses in 2012–2017
(n = 170) compared with 2007–2011 (n = 135) demon-
strated a significant decrease in diagnoses of fibroadenomas
during the more recent period (85.9% [116/135] before
2012 vs 70% [119/170] thereafter). All 22 cases of benign
phyllodes tumors in this series occurred in the more recent
period (0% [0/135] before 2012 vs 12.9% [22/170] there-
after). Changes in the proportion of other diagnoses
aggregated by period are listed in Table 2 and per year in
Fig. 1.
The comparison of patient ages for each diagnosis is
presented in Table 4. In the 2012–2017 period, the patients
with a diagnosis of benign phyllodes tumors were signifi-
cantly younger (25.7 ± 10.6 years) than those with a
diagnosis of borderline (52.8 ± 9.9 years), malignant
(40.7 ± 24 years), or NOS phyllodes (46.3 ± 1.5 years)
tumors (p = 0.006).
DISCUSSION
Whereas breast masses are a common clinical scenario,
phyllodes tumors have traditionally represented a rare
diagnosis, comprising 0.3 to 1% of all breast tumors.12 The
clinical outcomes for all phyllodes range from local
recurrence reported for 6.3 to 32% of patients to metastasis
reported for 1.7 to 40% of patients.12–16 Positive final
margin (tumor transected) and stromal atypia or over-
growth have been identified as independent predictors of
clinical behavior.17–19 Due to a propensity for local
recurrence and rare axillary or distant metastasis with
malignant phyllodes tumors, the current NCCN guidelines
recommend confirmatory surgical excision when core
needle biopsy cannot definitively rule out phyllodes tumor
and wide local excision with an attempt to achieve at least
1-cm margins for a confirmed diagnosis of phyllodes.
Although phyllodes tumors can exhibit varying patterns
of behavior,6 the NCCN management guidelines do not
distinguish among benign, borderline, or malignant sub-
types.7 In contrast, fibroadenomas represent one of the
Trends in Fibroepithelial Breast Diagnoses 3091

TABLE 2 Patient and pathology characteristics

Variable Overall 2007–2011 2012–2017 P valuea
(n = 305) n (%) (n = 135) n (%) (n = 170) n (%)

Race/ethnicity Asian/Pacific Islander 31 (10.2) 10 (7.8) 21 (13.0) 0.3

Hispanic 101 (33.1) 45 (34.9) 56 (34.8)
Non-hispanic black 27 (8.9) 16 (12.4) 11 (6.8)
Non-hispanic white 112 (36.7) 48 (37.2) 64 (39.8)
Other 19 (6.2) 10 (7.8) 9 (5.6)
Missing 15 (4.9)
Presenting symptoms Pain 11 (4.5) 1 (0.9) 10 (8.1) 0.1
Mass 153 (62.7) 76 (71.1) 77 (62.1)
Skin dimpling 1 (0.4) 0 (0.0) 1 (0.8)
None/found on 53 (21.3) 24 (22.6) 28 (22.6)
screening imaging
More than one 8 (3.3) 4 (3.8) 4 (3.2)
complaint
Other 5 (2.1) 1 (0.9) 4 (3.2)
Missing 14 (5.7)
Type of biopsy Needle biopsy 51 (16.7) 18 (13.3) 33 (19.4) 0.2
Surgical excision 254 (83.3) 117 (86.7) 137 (80.6)
Histologic feature documented in Traditional Leaf-like architecture 34 (11.2) 6 (4.4) 28 (16.5) 0.0009
pathology report Periductal stromal 27 (8.9) 0 (0.0) 27 (15.9) \ 0.0001
condensation
WHO Stromal cellularity 61 (20.0) 10 (7.4) 51 (30.0) \ 0.0001
Stromal cellular 59 (19.3) 15 (11.1) 44 (25.9) 0.001
atypia
Mitotic activity 49 (16.1) 8 (5.9) 41 (24.1) \ 0.0001
Border infiltration 37 (12.1) 8 (5.9) 29 (17.1) 0.003
Stromal overgrowth 12 (3.9) 2 (1.5) 10 (5.9) 0.05
Pathologic diagnosis Phyllodes, NOS 6 (2.0) 3 (2.2) 3 (1.8) \ 0.0002
Benign phyllodes 22 (7.2) 0 (0.0) 22 (12.9)
tumor
Borderline phyllodes 8 (2.6) 3 (2.2) 5 (2.9)
tumor
Malignant phyllodes 6 (2.0) 3 (2.2) 3 (1.8)
tumor
Fibroadenoma 235 (77.1) 116 (85.9) 119 (70.0)
Cellular fibroadenoma 20 (6.6) 10 (7.4) 10 (5.9)
Fibroepithelial lesion, 8 (2.6) 0 (0.0) 8 (4.7)
NOS
WHO World Health Organization, NOS not specified
a
Chi square p value for comparison of 2007–2011 with 2012–2017

most common benign breast diagnoses, for which conser-
vative management can be an appropriate
recommendation.8,20 Clinical management of fibroadeno-
mas ranges from non-operative surveillance for
asymptomatic fibroadenomas in patients younger than
35 years to ultrasound-guided cryoablation or surgical
excision.8,21,22 Recently, as part of the Choosing Wisely
campaign to improve quality and control health care
expenditures, the American Society of Breast Surgeons
listed routine removal of biopsy-proven fibroadenomas
smaller than 2 cm as one of the top five procedures clini-
cians and patients should question in the area of benign
breast disease.20
Findings from the current report demonstrate the com-
plexity of fibroepithelial designation. In our study,
malignant phyllodes tumors represented only 2% of all
3092 J. Chang et al.

TABLE 3 Comparison of size for pathologic diagnoses (n = 66) earlier period and 75.9% of diagnoses in the more recent
n Mean Median SD
period. Because the patient cohorts were similar with
regard to age, race and ethnicity, presenting symptoms, and
Phyllodes NOS 5 3.4 2.5 2.5 biopsy method in the two periods, these statistically sig-
Benign phyllodes tumor 11 1.9 1.5 1.8 nificant opposing trends in diagnoses of benign phyllodes
Borderline phyllodes tumor 6 8.3 5.9 8.5 tumors versus fibroadenomas in our population suggest that
Malignant phyllodes tumor 2 17.5 17.5 17.7 since 2012, the increased incidence of benign phyllodes
Fibroadenoma 37 2.0 1.5 1.4 tumors has been due to reclassification of fibroepithelial
Cellular fibroadenoma 2 3.2 3.2 3.1 lesions using new diagnostic criteria.
Fibroepithelial lesion, NOS 3 1.6 2 1.1 Because benign phyllodes tumors and fibroepithelial
p value 0.01 NOS have been noted only since 2012, we analyzed
SD standard deviation, NOS not specified
pathologic diagnosis by age between 2012 and 2017 only.
Older reports demonstrated that the median age at pre-
sentation of phyllodes tumors is 42–45 years12 and that
fibroadenomas have a peak incidence at 20–40 years.2
surgically excised breast masses, with a relatively Lending further support to our hypothesis that patients with
stable annual incidence during the 10-year study period. In a diagnosis of benign phyllodes tumors represent migration
the more recent period, two entities, benign phyllodes of previous fibroadenoma diagnoses is the observation in
tumor and fibroepithelial NOS, made up respectively 12.9 the current study that those with a diagnosis of benign
and 4.7% of diagnoses, yet had never been identified in the phyllodes, cellular fibroadenomas, fibroadenomas, and
preceding 5 years. Concurrently, fibroadenomas and cel- fibroepithelial NOS are similarly younger in age than those
lular fibroadenomas made up 93.3% of diagnoses in the with the remaining phyllodes designations. The mean age

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Phyllodes NOS 0.0% (0) 0.0% (0) 4.0% (1) 4.0% (1) 3.1% (1) 0.0% (0) 4.6% (2) 0.0% (0) 0.0% (0) 0.0% (0) 7.1% (1)

Benign Phyllodes 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 3.7% (1) 4.6% (2) 2.9% (1) 3.7% (1) 34.8% (8) 64.3% (9)

Borderline Phyllodes 0.0% (0) 0.0% (0) 0.0% (0) 8.0% (2) 3.1% (1) 0.0% (0) 4.6% (2) 0.0% (0) 3.7% (1) 4.4% (1) 7.1% (1)
Malignant Phyllodes 4.4% (1) 0.0% (0) 4.0% (1) 4.0% (1) 0.0% (0) 0.0% (0) 4.6% (2) 0.0% (0) 0.0% (0) 4.4% (1) 0.0% (0)
Fibroadenoma 91.3% (21) 96.7% (29) 92.0% (23) 92.0% (19) 75.0% (24) 81.5% (22) 72.7% (32) 82.9% (29) 74.1% (20) 56.5% (13) 21.4% (3)
Cellular Fibroadenoma 4.4% (1) 3.3% (1) 0.0% (0) 8.0% (2) 18.8% (6) 7.4% (2) 6.8% (3) 6.8% (3) 7.4% (2) 0.0% (0) 0.0% (0)
Fibroepithelial NOS 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 7.4% (2) 2.3% (1) 2.3% (2) 5.7% (3) 0.0% (0) 0.0% (0)

FIG. 1 Trends in pathologic diagnoses annually 2007–2017 (p \ 0.0001)

Trends in Fibroepithelial Breast Diagnoses 3093

TABLE 4 Comparison of age 2007–2011 2012–2017

at pathologic diagnoses by
period n Mean Median SD n Mean Median SD

Phyllodes NOS 3 45.6 50 17.9 3 46.3 46 1.5

Benign phyllodes tumor NA NA NA NA 19 25.7 23 10.6
Borderline phyllodes tumor 3 58.7 50 18.6 5 52.8 54 9.9
Malignant phyllodes tumor 3 35.3 36 11.0 3 40.7 53 24.0
Fibroadenoma 108 32.8 30 16.5 116 32.4 25 18.7
Cellular fibroadenoma 10 16 16.5 2.9 9 19.2 16 8.3
Fibroepithelial lesion, NOS NA NA NA NA 8 29.6 16.5 19.5
p value 0.0002 0.006
SD standard deviation, NOS not specified, NA not applicable

of the patients with a diagnosis of benign phyllodes in the
current study was 25.7 ± 10.6 years. The young age of the
patients with benign phyllodes tumors was closer to the age
of those with a diagnosis of fibroadenomas, both since
2012 (32.4 ± 18.7 years) and before 2012
(32.8 ± 16.5 years), in contrast to the older age at diag-
nosis of phyllodes tumors before publication of the WHO
standards.2,12
Although the 2012 WHO Breast Tumor Classification
system provides a framework for categorizing phyllodes
tumors into benign, borderline, and malignant grades, as
shown in Table 1,4,6 the application of these standards has
been ambiguous and challenging. Overlap of histologic
features and subjectivity in reporting have led to difficulty
distinguishing fibroadenomas, particularly cellular
fibroadenomas, from benign phyllodes tumors.5,23,24 No
objective criteria exist for separating minimal/mild from
moderate and marked degrees of stromal hypercellularity
and atypia, and reliance on nuanced pathologists’ judgment
may confound attempts at grading consistency.
In a study evaluating the degree of interobserver vari-
ability between specialist breast pathologists in classifying
a group of fibroepithelial lesions, only two of the 21 cases
(9.5%) achieved uniform agreement regarding whether the
lesion represented a cellular fibroadenoma or a phyllodes
tumor.5 Intratumoral heterogeneity adds to the difficulty in
distinguishing phyllodes from fibroadenomas.
The use of percutaneous needle biopsy to diagnose
breast pathology lends further challenges to the manage-
ment of fibroepithelial tumors. Rates of upgrade to
phyllodes when fibroepithelial lesions are noted on core
biopsy have ranged from 18.8 to 37.5%.25–27 These retro-
spective reviews using diagnoses determined primarily
before 2012 have shown that upgrade to phyllodes tumor is
variously associated with increasing age, lesion size, and
histologic characteristics.25–27 Such variability challenges
preoperative decision making regarding the extent of
resection and determination of appropriate margin width.
Nevertheless, the pathologist’s comment of concern for a
phyllodes tumor and the surgeon’s selection bias for
excision have consistently been demonstrated to improve
sensitivity and specificity of core biopsy in predicting
phyllodes on final pathology.25–27 To improve upon
pathologists’ ability to better distinguish types of fibroep-
ithelial lesions, numerous studies have investigated
immunohistochemical markers, but to date, none has
proved to be useful in everyday practice, and histologic
characteristics remain the current gold standard.14,28,29
Our study demonstrated a significant increase in the
proportion of pathology reports mentioning both WHO
histologic criteria and traditional histologic descriptors of
phyllodes tumors in the more recent period. However,
despite increases in reporting the presence or absence of
WHO histologic characteristics since 2012, occasional
reports used language incongruous with WHO definitions,
and overall reporting remained poor, with a majority of
reports failing to mention one or more of these features.
This study was limited by its small size and the selection
bias inherent in retrospective reviews. We hypothesize that
more widespread adoption of WHO criteria after 2012 led
to changes in reporting patterns by 2016, but due to the
large number of pathologists and the limited sample size,
analysis of interobserver variability and multivariable
analysis of factors associated with pathologic diagnoses
were not performed. For fibroadenoma diagnoses, final
tumor size was not reported in the majority of cases.
Hence, comparison of tumor size by diagnosis and year
could not be analyzed. The median age of our patient
population was 25 years, and most of the patients under-
went surgical excision as their diagnostic procedure rather
than percutaneous core biopsy, likely due to low suspicion
of adenocarcinoma. Increasing size, increased breast can-
cer risk, patient anxiety, and shared decision-making
models are considerations when primary surgical excision
of fibroadenomas is performed for young patients.30,31
3094
These factors may have played a role in the current study,
but the indication for primary surgical excision was not
recorded.
In our study of tumor classification, we did not address
clinical follow-up assessment. Previous reports have rec-
ommended a 2-year surveillance period after initial
excision for both phyllodes and fibroadenomas.31–33 A
recent literature review of 12 published reports describing
management of benign phyllodes tumors found no signif-
icant difference in recurrence rate between studies aiming
for a 10-mm margin (7.9%) and studies aiming for a 1-mm
margin (5.7%).34 The authors advocate for smaller margins
for benign phyllodes tumors than currently recommended
by the NCCN.7, 34 That benign phyllodes tumors appear to
be adequately treated with close margin excision supports
our theory that some benign phyllodes tumors diagnosed
currently may have been diagnosed and treated as a
fibroadenoma before 2012. Further evaluation of the clin-
ical outcomes for our cohorts may add to the understanding
of the impact that the evolving diagnoses of fibroadenomas
and benign phyllodes tumors has on resource utilization.
CONCLUSIONS
The expanding use of discrete WHO criteria may lead to
better prediction of the biologic behavior of tumors across
the fibroepithelial spectrum. Whether the rising incidence
of benign phyllodes tumors is due to reclassification of
historically described fibroadenoma with the use of WHO
criteria or to other factors requires further investigation.
Because no standardized synoptic reporting or clinical
pathology protocols currently exists for the diagnosis of a
fibroepithelial lesion, an objective scoring system may
need to be developed to determine whether histologic
parameters have equal importance in predicting behavior.
Evidence-based management recommendations for less
virulent fibroepithelial diagnoses should be developed for
recognition of the recent trend in the diagnosis of benign
phyllodes tumors in young patients.
DISCLOSURES The authors report no financial disclosures
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