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Original Article
Phyllodes Tumors of the Breast: Natural
History, Diagnosis, and Treatment
Melinda L.Telli, MD;a Kathleen C. Horst, MD;b Alice E. Guardino, MD, PhD;a Frederick M. Dirbas, MD;c and
Robert W. Carlson, MD,a Stanford, California
Key Words
Phyllodes tumors, breast neoplasms, natural history, diagnosis, treat-
ment
Abstract
Phyllodes tumors of the breast are unusual fibroepithelial tumors
that exhibit a wide range of clinical behavior. These tumors are cat-
egorized as benign, borderline, or malignant based on a combina-
tion of histologic features. The prognosis of phyllodes tumors is
favorable, with local recurrence occurring in approximately 15% of
patients overall and distant recurrence in approximately 5% to 10%
overall. Wide excision with a greater than 1 cm margin is definitive
primary therapy. Adjuvant systemic therapy is of no proven value.
Patients with locally recurrent disease should undergo wide exci-
sion of the recurrence with or without subsequent radiotherapy.
(JNCCN 2007;5:324–330)
Historical Overview
In 1838, Johannes Müller gave a detailed description of
a large mammary tumor with a cystic appearance and
leaf-like growth pattern which he named cystosarcoma
phyllodes.1 In 1951, Treves and Sutherland2 suggested that
benign, pre-malignant, and malignant forms of this dis-
ease existed. In 1960, Lomonaco3 proposed the name tu-
mor phyllodes, thereby avoiding any implication of biologic
behavior. The World Heath Organization adopted the
terminology phyllodes tumor in 1981, and this name has
since gained widespread acceptance.4 Phyllodes tumors are
From the Departments of aMedicine, bRadiation Oncology, and
c
Surgery, Stanford University, Stanford, California.
Submitted November 2, 2006; accepted for publication November
20, 2006.
The authors have no financial interest, arrangement, or affiliation
with the manufacturers of any products discussed in the article or
their competitors.
Correspondence: Robert W. Carlson, MD, 875 Blake Wilbur Drive,
Stanford, CA 94305. E-mail: rcarlson@stanford.edu
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
unusual fibroepithelial lesions that account for less than
1% of all breast neoplasms.5,6 These tumors exhibit a wide
range of clinical behavior and represent a spectrum of
fibroepithelial neoplasms rather than a single disease
entity.7
Pathologic Features
Phyllodes tumors are characterized by the presence
of both epithelial and stromal elements, but the distin-
guishing histologic features relate to the stroma.8
Microscopically, these tumors contain elongated ductal
elements and papillary protrusions of connective tissue
lined by epithelium that produce the leaf-like appear-
ance. Marked stromal overgrowth and hypercellularity
are important features that distinguish these lesions from
the more common fibroadenomas. These lesions are cat-
egorized as benign, borderline, or malignant based on a
combination of histologic features, including stromal cel-
lular atypia, mitotic activity, stromal overgrowth, type of
tumor margin (circumscribed vs. infiltrative), and tumor
necrosis.9–11 Reported incidences of each subtype have
varied widely in the literature. On average, more than
50% are categorized as benign and approximately 25% as
malignant in most large series.7,12 Despite these classifica-
tions, histologic grade has been found to correlate poorly
with biologic behavior.13
The expression of estrogen and progesterone recep-
tors is common in the epithelial component but uncom-
mon in the stromal component of phyllodes tumors. In
one series, epithelial estrogen receptor expression was
seen in 58% and progesterone receptor expression in
75%.14 In this series, expression of hormone receptors was
related to histologic grade, with estrogen and proges-
terone receptor expression present in 67% and 77% of be-
nign, 43% and 84% of borderline, and 47% and 47% of
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Phyllodes Tumors of the Breast
Table 1 Hormone Receptor Expression in Phyllodes Tumors
Estrogen Receptor
Phyllodes Tumor Subgroup Epithelial Stromal
Benign 67% 3%
Borderline 43% 0%
Malignant 47% 5%
Adapted from Tse GM, Lee CS, Kung FY, et al. Hormonal receptors expression in epithelial cells of mammary phyllodes tumors
correlates with pathologic grade of the tumor: a multicenter study of 143 cases. Am J Clin Pathol 2002;118:522–526; used
with permission. ©2002 American Society for Clinical Pathology.
malignant phyllodes tumors, respectively (Table 1).
Expression of androgen receptors was low in all tu-
mors.
The frequency of expression and role of the tu-
mor suppressor gene p53 in phyllodes tumors is highly
variable across series. In some but not all series, p53
expression increases across the spectrum of benign to
malignant phyllodes tumors.15,16
Clonal analysis of phyllodes tumors documents
that the epithelial component is polyclonal, whereas
the stromal component is monoclonal, showing that
the stroma represents the neoplastic component of
phyllodes tumors.17,18
Clinical Presentation
The most common presentation of a phyllodes tumor
is a palpable breast mass that may be rapidly growing.
These tumors may exhibit biphasic growth and pa-
tients may present to medical attention only after
noting rapid growth in a lesion that had been stable
for years.19 Rarely, patients present with a mass de-
tected on routine screening mammography.13 Phyllodes
tumors can reach enormous proportions; tumors greater
than 20 cm have been reported in multiple series.5,13,19–22
Many series have failed to show a correlation between
tumor size and histologic subtype, because even benign
phyllodes tumors can reach great size.19,20
On examination, most patients have a smooth,
round, well-defined, firm mass that is mobile and pain-
less. Large lesions may be associated with dilated veins
visible over the skin, which may be stretched and at-
tenuated. Nipple retraction,19,23 skin ulceration,5,19,21
invasion of the chest wall,5,19,21 and bloody nipple dis-
charge21 have been reported but are rare. Palpable
axillary lymphadenopathy can be identified in up to
20% of patients, but metastatic involvement of axil-
lary lymph nodes is rare.19,24
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
Original Article 325
Progesterone Receptor Androgen Receptor
Epithelial Stromal Epithelial Stromal
77% 1% 1% 1%
84% 0% 3% 0%
47% 5% 0% 5%
Phyllodes tumors occur at a median age of 45 years,7
but cases in adolescents and the elderly have been well
described.11,13,20,21,25 Recent Surveillance, Epidemiology,
and End Result (SEER) data indicate that the mean age
at diagnosis is 50 years among patients with malignant
phyllodes tumors.26 Bilateral phyllodes tumors are re-
ported to occur rarely,21,23,24 and a case of a phyllodes
tumor arising in an accessory breast has been reported.21
Additionally, phyllodes tumors associated with gyneco-
mastia have been reported in men,27 and a bilateral
phyllodes tumor arising in ectopic axillary breast tis-
sue has been described in a man.28
Diagnosis
Unfortunately, triple assessment using clinical, radi-
ologic, and histologic examination results in low di-
agnostic accuracy in phyllodes tumors.8,29 The
deficiencies of this approach relate to the fact that
phyllodes tumors have overlapping characteristics with
benign breast disease in all 3 categories. Because the
surgical management of these lesions differs from that
of a fibroadenoma, accurate preoperative diagnosis
is optimal. Often, however, local excision of the mass
is required for diagnosis, and patients then require fur-
ther surgery to ensure adequate tumor-free margins.
Clinically, the diagnosis of a phyllodes tumor
should be considered in the differential diagnosis of a
large fibroadenoma. A history of rapid growth and at-
tainment of large size can be suggestive, but these fea-
tures cannot reliably differentiate phyllodes tumors
from other benign breast disease. On mammogram,
phyllodes tumors appear as well-defined oval, round,
or lobulated masses that mimic the radiographic ap-
pearance of a fibroadenoma.30 Associated coarse
microcalcifications are occasionally seen. On ultra-
sound, these lesions appear as solid, hypoechoic, well-
circumscribed masses.31 The presence of a cystic area
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326 Original Article
Telli et al.
Table 2 Paddington Clinicopathologic
Suspicion Score
Clinical Findings
• Sudden increase in size in a long-standing breast lesion
• Apparent fibroadenoma > 3 cm in diameter or in a
patient > 35 years
Imaging Findings
• Rounded borders/lobulated appearance at mammography
• Attenuation of cystic areas within a solid mass on
ultrasonography
Fine Needle Aspiration Findings
• Presence of hypercellular stromal fragments
• Indeterminate features
Any 2 features mandate core biopsy
Adopted from Jacklin RK, Ridgway PF, Ziprin P, et al.
Optimising preoperative diagnosis in phyllodes tumour of
the breast. J Clin Pathol 2006;59:454-459; with permission
from BMJ Publishing Group Ltd.
within a solid mass on ultrasound suggests the diagno-
sis of phyllodes tumor.30
Using fine needle aspiration (FNA) to diagnose
a phyllodes tumor is associated with an excessive rate
of false-negative results and an overall accuracy esti-
mated at 63%.8 Accuracy of FNA is often compro-
mised by inadequate sampling, because these tumors
tend to have a very heterogeneous composition. Core
biopsy, although subject to the same potential for sam-
pling error, is associated with higher accuracy than
FNA. In a recent article, Jacklin et al.8 concluded that
core biopsy is potentially the most useful method of
preoperatively diagnosing phyllodes tumor. To help
clinicians select patients for core needle biopsy, they
formulated a set of criteria that they refer to as the
Paddington Clinicopathologic Suspicion Score (Table
2). The intraoperative diagnosis of phyllodes tumor us-
ing frozen section is often inaccurate, as is the case
with intraoperative frozen section diagnosis of other
breast masses. Chen et al.21 reported an accurate diag-
nosis using frozen section in only 41.6% of cases in
their series of 172 patients with phyllodes tumor.
Prognostic Factors
The clinical course of phyllodes tumors can be unpre-
dictable, although in most patients the prognosis is
favorable. Poor correlation exists between histologic
features and biologic behavior. In most large series,
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
Table 3 Prognostic Factors Implicated in the
Risk for Local and Distant Recurrence
in Phyllodes Tumors
Implicated in Implicated in
Risk for Local Risk for Distant
Prognostic Factor Recurrence Recurrence
Tumor size No Yes
Histologic grade Unclear Yes
Positive margin Yes
Stromal overgrowth Yes
Prior local recurrence NA No
approximately 25% of phyllodes tumors are catego-
rized as malignant and more than 50% are character-
ized as benign.7,12 Benign lesions have the potential to
recur locally and rarely at distant sites,19 and cases of
benign tumors transforming into higher-grade lesions
at recurrence have been reported.19,21,23,32 Despite hav-
ing an increased risk for distant spread, malignant le-
sions follow an indolent clinical course in most patients
with 15-year cause-specific survival rates of approxi-
mately 89%.26 Because of the unpredictable nature of
these lesions, experts have suggested that all phyllodes
tumors be regarded as having malignant potential.7
Many studies have attempted to identify histo-
logic and clinical prognostic factors implicated in the
risk for local and distant recurrence. This is difficult
because of the rarity of this tumor, differences in patho-
logic interpretation, and selection bias for the type of
treatment provided in various series. Despite these
impediments, several important observations have
been made (Table 3). The literature does not suggest
a correlation between tumor size and increased risk
for local recurrence,11,13,21,29 although size has been im-
plicated in the risk for developing distant disease.29 A
positive surgical margin is the most powerful predic-
tor of local recurrence.13,22,29 Local recurrence does not
correlate with an increased risk for distant disease21,29
and does not seem to affect survival.11 The literature
is divided on the relationship between histologic grade
and risk for local recurrence. Some series suggest an
increase in local recurrence among borderline and ma-
lignant lesions,11 but this has not been found in other
large series.13,19–21,29 In contrast, the development of
metastatic disease has been shown to correlate with
grade,19,20,29 and experts have estimated that 20% of
patients with malignant tumors will develop metasta-
tic disease.7 Stromal overgrowth has been identified as
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Phyllodes Tumors of the Breast
Figure 1 Estimated cause-specific survival adjusted for age category
(< 50, 50–59, 60–69, 艌70 years). Adapted from Macdonald OK,
Lee CM, Tward JD, et al. Malignant phyllodes tumor of the breast:
association of primary therapy with cause-specific survival from the
Surveillance, Epidemiology, and End Results (SEER) program. Cancer
2006;107:2127–2133; with permission from John Wiley & Sons, Inc.
an important independent histologic predictor of dis-
tant recurrence.20
A multivariate analysis of 821 patients diagnosed
with malignant phyllodes tumors between 1983 and
2002 in the SEER program database assessed the
impact of age, race, year of diagnosis, size of primary
tumor, and type of local therapy on cause-specific
survival.26 Increased age was the only nontreatment
factor associated with decreased survival (Figure 1).
Use of mastectomy plus external beam radiation ther-
apy was also associated with a poor prognosis, proba-
bly related to the advanced nature of tumors treated
with both modalities.
Primary Surgical Management
Local recurrence occurs in approximately 15% of pa-
tients with phyllodes tumors and is more frequent af-
ter inadequate excision.7 Distant failure occurs in
approximately 5%–10% of cases overall and in ap-
proximately 20% of malignant lesions.7, 12 Tumor biol-
ogy seems to dictate metastatic potential, and this risk
does not seem to be influenced by the choice of local
treatment.33 Given these observations, the primary
surgical objective is to attain definitive local control.
Wide local excision with margins of greater than
1 cm is the preferred primary treatment.13,19–21,34
Microscopic projections of tumor often extend into
the pseudocapsule of normal compressed breast tissue
that surround these lesions.35 Therefore, achieving a
1-cm microscopic margin frequently requires remov-
ing more tissue than would be expected based on gross
inspection. Simple enucleation of the tumor, as is
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
Original Article 327
commonly used in the treatment of fibroadenoma, is
inadequate treatment for phyllodes tumors.11,20,33 In a
series of 101 patients, most of whom (99%) had patho-
logically negative margins after surgery, Chaney et al.20
reported a low actuarial 10-year rate of local recur-
rence (8%), suggesting that the risk for local recur-
rence can be significantly decreased but not eliminated
when negative margins are obtained.
Historically, mastectomy was the standard surgical
treatment for all phyllodes tumors.5 More recently,
breast-conservative approaches have been increasingly
used. In the series by Chaney et al.,20 approximately
half the patients were treated with breast conservation
and half with mastectomy. Only 4 local recurrences
were seen, and these occurred equally in both groups.
Other large series have shown similar findings.19,25 A re-
cent analysis by Macdonald et al.26 used the SEER data-
base to determine prognostic factors that predicted
cause-specific survival among 821 patients with malig-
nant phyllodes tumor. In this retrospective analysis,
wide excision was associated with equivalent or im-
proved cause-specific survival relative to mastectomy
in a multivariate analysis. These data, similar to all ret-
rospective series, are potentially confounded by physi-
cian selection bias regarding the type of surgery
performed. However, given the overall low rate of lo-
cal failure with breast-conserving surgery, breast con-
servation is the preferred primary therapy if negative
margins can be obtained with an acceptable cosmetic
result. In cases in which breast conservation is not pos-
sible because of large tumor size relative to breast vol-
ume, total mastectomy is appropriate.13,19,20
When phyllodes tumor is diagnosed only after
narrow margin excision, re-excision to obtain mar-
gins of greater than 1 cm is indicated.13,34 Simple mas-
tectomy may be required to achieve this. The primary
mode of spread of phyllodes tumors is through
hematogenous dissemination. Although axillary lym-
phadenopathy is present in approximately 20% of
patients with phyllodes tumors, only approximately
5% of patients will have axillary metastases at lymph
node dissection.13 The current literature supports the
role of axillary lymph node staging only in cases where
clinically pathologic nodes are found on examination.11,13
Role of Adjuvant Systemic Therapy
The adjuvant use of chemotherapy or hormonal ther-
apy has no proven role in treating phyllodes tumors.
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328 Original Article
Telli et al.
Chaney et al.20 proposed that adjuvant chemother-
apy be considered for patients with histologic evi-
dence of stromal overgrowth, particularly when the
tumor size is greater than 5 cm, because these patients
seem to have the greatest risk for developing distant
disease. However, because systemic therapy has had
limited value in patients with metastatic phyllodes
tumors, it is not expected to be effective in the adju-
vant setting, and no randomized data are available. Tse
et al.14 suggested that the potential role of endocrine
therapy in treating phyllodes tumors is limited be-
cause hormone receptors are primarily expressed on
the epithelial component of the tumors, their expres-
sion is inversely related to the degree of malignancy,
and the stromal component of phyllodes tumors is
the component implicated in metastatic spread. Thus,
there is no role for measuring hormone receptors in
these tumors.
Role of Adjuvant Radiation Therapy
The role of adjuvant breast or chest wall radiotherapy
is controversial. Most experience is based on case re-
ports of patients with chest wall recurrences. Because
of the important relationship between excision mar-
gin and the risk for local recurrence, some experts
have suggested that adjuvant radiation at doses of 50
to 60 Gy be considered in patients for whom negative
surgical margins cannot be attained.13,20 The use of ad-
juvant radiation in patients with a resection margin
of 1 cm or larger is not recommended.20,34 However,
no high-level evidence supports the role of adjuvant
radiotherapy in phyllodes tumors.
In a series of 37 patients with malignant phyllodes
tumors, Pandey et al.22 administered 45 to 50 Gy of
radiation to 69% of patients, including all patients
treated with wide excision alone and those experienc-
ing recurrent phyllodes tumors after resection of the
recurrent disease. In this study, the 5-year disease-free
survival rate was 61.2% among patients who under-
went adjuvant radiotherapy versus 51.4% among those
who did not. Cox proportional hazard survival analy-
sis, however, showed no statistically significant ad-
vantage to radiotherapy (P = .47). The recent analysis
of SEER data found that the use of adjuvant radio-
therapy predicted a worse cause-specific survival com-
pared with surgery alone among 821 patients with
malignant phyllodes tumors. In this series, however,
only 9% of patients underwent radiotherapy, and pa-
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
tients selected for radiotherapy were probably those
with larger tumors with narrow tumor-free or involved
margins.26
Management of Locally
Recurrent Disease
In approximately 15% of cases of phyllodes tumor, the
clinical course will be complicated by one or more lo-
cal recurrences.7 General consensus is that these recur-
rences result from failure of primary surgical treatment,
although the biologic behavior of the tumor may be
an important determinant. de Roos et al.29 found that
the development of one local recurrence seemed to
predispose to further episodes of local recurrence re-
gardless of the histologic subtype or type of initial sur-
gery. Most tumors recur within 2 years of initial
surgery,19,25 although tumors recurring as soon as 1
month25 and as late as 17 years36 after initial surgery
have been reported. Some series have found that the
time to local recurrence is shortest among patients
with the malignant subtype compared with those with
benign and borderline lesions.11 Generally, phyllodes
tumors recur with the same histology as that of the
initial disease, but cases of transformation to more ag-
gressive tumors have been reported.20,21,23,25 In most pa-
tients, local recurrence is not associated with distant
metastases.21,29
Cases of successful treatment of patients with mul-
tiple recurrent tumors have been reported.3 However,
some authors believe that mastectomy should be con-
sidered after the first recurrence of borderline or ma-
lignant lesions,11 whereas others believe that
mastectomy should be considered after any second re-
currence.13 Chaney et al.20 suggest that adjuvant ra-
diotherapy may be appropriate after resection of
recurrent disease. Mangi et al.13 reported a case of a pa-
tient with a high-grade tumor recurrence that could
not be fully excised surgically. This patient was treated
with radiotherapy to the chest wall and remained free
of disease for 84 months after recurrence. The NCCN
Breast Cancer Clinical Practice Guidelines in
Oncology support re-excision with wide margins for
locally recurrent disease.34 Some members of the
NCCN guidelines panel recommend local radiation
therapy to the remaining breast or chest wall after re-
section of a local recurrence, but this recommendation
is controversial.
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Phyllodes Tumors of the Breast
Management of Metastatic Disease
Based on data from large cases series, it is estimated that
approximately 5%–10% of patients with phyllodes
tumors will develop distant disease, although the in-
cidence of metastatic disease among patients with ma-
lignant tumors is estimated at approximately 20%.7,12
Metastatic lesions histologically contain only stromal
elements and are devoid of epithelial elements.6 A
metastatic phyllodes tumor carries a poor prognosis,
with an average survival of less than 2 years.5 In a se-
ries of 170 patients, Reinfuss et al.19 found that among
patients with metastatic disease, 93% developed metas-
tases within 3 years and the median survival was 4
months. In this series, 3 patients initially diagnosed
with benign tumors developed metastatic disease, and
this phenomenon has been described in several other
series.13,20,21 de Roos et al.29 reported a median survival
of 17 months, ranging from 12 to 145 months. The
most common sites of distant disease are the lung,
bone, and abdominal viscera,7 although metastases
have been reported in the brain,19,20 heart,37 soft tis-
sues of the neck,21 thigh,6 pelvis,20 and oral cavity.38
Clinical experience with chemotherapy for
metastatic phyllodes tumors is limited. Multiple single-
agent and combination regimens have been used with
varying success. Responses, when they occur, are gen-
erally of short duration. Single-agent cyclophos-
phamide and ifosfamide have been associated with
complete responses in a limited number of patients.39
A case report of doxorubicin and cisplatin documented
a complete response and good palliation,40 whereas
another report documented activity of etoposide and
cisplatin.41 Among patients treated with ifosfamide,
Hawkins et al.39 reported prolonged complete responses
in 2 patients lasting 26 months (single-agent ifos-
famide) and greater than 61 months (ifosfamide and
doxorubicin). Burton et al.41 found that hormonal
therapy was ineffective in a small number of patients
with hormone receptor–positive disease. The NCCN
recommends that treatment of metastatic disease fol-
low the algorithm outlined in the NCCN Soft Tissue
Sarcoma Clinical Practice Guidelines in Oncology42
(the most recent version is available online at
http://www.nccn.org).
In addition to chemotherapy, radiation can be
useful to palliate sites of painful disease.41 Buchanan
et al.6,43 recommend considering limited resection of
solitary sites of metastatic disease, because isolated
reports of long-term survival have been described.
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
Original Article 329
Summary
Phyllodes tumors of the breast are rare tumors that
present as rapidly growing breast masses and are often
misdiagnosed as fibroadenomas. These tumors have
both an epithelial and stromal component and may be
benign, borderline, or malignant in histology. They
have a propensity for local recurrence, but systemic
metastasis occurs in only approximately 5% to 10% of
patients overall and approximately 20% of those with
the malignant subtype. Long-term cause-specific sur-
vival among patients with the malignant subtype is
approximately 90%. Local excision with a 1-cm or
larger tumor-free margin is definitive therapy after ini-
tial diagnosis. Local radiation therapy after breast-
conserving therapy or mastectomy may be considered
when adequate excision margins cannot be attained.
Adjuvant systemic therapy has no proven value.
Patients experiencing local recurrences after ini-
tial therapy should undergo wide excision of the recur-
rence with or without subsequent local radiation
therapy. Patients with metastatic disease should be
managed, as appropriate, following treatment guide-
lines for patients with metastatic soft tissue sarcoma.
References
1. Fiks A. Cystosarcoma phyllodes of the mammary gland—Muller’s
tumor. For the 180th birthday of Johannes Muller. Virchows
Arch A Pathol Anat Histol 1981;392:1–6.
2. Treves N, Sutherland DA. Cystosarcoma phyllodes of the breast:
a malignant and benign tumor. A clinicopathological study of
seventy-seven cases. Cancer 1951;4:1286–332.
3. Lomonaco F. [Phyllode tumors of the breast (cystosarcoma phyllodes
of J. Muller)]. Tumori 1960;46:156–184 [in Italian].
4. Histological typing of breast tumors. Tumori 1982;68:181–198.
5. Dyer NH, Bridger JE, Taylor RS. Cystosarcoma phylloides. Br J Surg
1966;53:450–455.
6. Buchanan EB. Cystosarcoma phyllodes and its surgical management.
Am Surg 1995;61:350–355.
7. Parker SJ, Harries SA. Phyllodes tumours. Postgrad Med J
2001;77:428–435.
8. Jacklin RK, Ridgway PF, Ziprin P, et al. Optimising preoperative
diagnosis in phyllodes tumour of the breast. J Clin Pathol
2006;59:454–459.
9. Azzopardi JG, Ahmed A, Millis RR. Problems in breast pathology.
Major Probl Pathol 1979;11:i-xvi, 1–466.
10. Pietruszka M, Barnes L. Cystosarcoma phyllodes: a clinicopatho-
logic analysis of 42 cases. Cancer 1978;41:1974–1983.
11. Salvadori B, Cusumano F, Del Bo R, et al. Surgical treatment of
phyllodes tumors of the breast. Cancer 1989;63:2532–2536.
12. Anderson BO, Lawton TJ, Lehman CD, et al. Phyllodes tumors. In:
Harris JR, Lippman ME, Morrow M, et al., eds. Diseases of the Breast,
3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004.
JN053_Jrnl_50308Telli.qxd 3/6/07 1:45 AM Page 330
330 Original Article
Telli et al.
13. Mangi AA, Smith BL, Gadd MA, et al. Surgical management of
phyllodes tumors. Arch Surg 1999;134:487–492; discussion
492–493.
14. Tse GM, Lee CS, Kung FY, et al. Hormonal receptors expression in
epithelial cells of mammary phyllodes tumors correlates with patho-
logic grade of the tumor: a multicenter study of 143 cases. Am J Clin
Pathol 2002;118:522–526.
15. Dacic S, Kounelis S, Kouri E, et al. Immunohistochemical profile of
cystosarcoma phyllodes of the breast: a study of 23 cases. Breast J
2002;8:376–381.
16. Tse GM, Lui PC, Scolyer RA, et al. Tumour angiogenesis and p53
protein expression in mammary phyllodes tumors. Mod Pathol
2003;16:1007–1013.
17. Noguchi S, Aihara T, Koyama H, et al. Clonal analysis of benign and
malignant human breast tumors by means of polymerase chain re-
action. Cancer Lett 1995;90:57–63.
18. Noguchi S, Motomura K, Inaji H, et al. Clonal analysis of fibroade-
noma and phyllodes tumor of the breast. Cancer Res 1993;53:
4071–4074.
19. Reinfuss M, Mitus J, Duda K, et al. The treatment and prognosis of
patients with phyllodes tumor of the breast: an analysis of 170 cases.
Cancer 1996;77:910–916.
20. Chaney AW, Pollack A, McNeese MD, et al. Primary treatment of
cystosarcoma phyllodes of the breast. Cancer 2000;89:1502–1511.
21. Chen WH, Cheng SP, Tzen CY, et al. Surgical treatment of phyl-
lodes tumors of the breast: retrospective review of 172 cases. J Surg
Oncol 2005;91:185–194.
22. Pandey M, Mathew A, Kattoor J, et al. Malignant phyllodes tumor.
Breast J 2001;7:411–416.
23. Deodhar SD, Joshi S, Khubchandani S. Cystosarcoma phyllodes.
J Postgrad Med 1989;35:98–103.
24. Norris HJ, Taylor HB. Relationship of histologic features to behav-
ior of cystosarcoma phyllodes. Analysis of ninety-four cases. Cancer
1967;20:2090–2099.
25. Zurrida S, Bartoli C, Galimberti V, et al. Which therapy for unex-
pected phyllode tumour of the breast? Eur J Cancer 1992;28:654–657.
26. Macdonald OK, Lee CM, Tward JD, et al. Malignant phyllodes tu-
mor of the female breast: association of primary therapy with cause-
specific survival from the Surveillance, Epidemiology, and End Results
(SEER) program. Cancer 2006;107:2127–2133.
27. Pantoja E, Llobet RE, Lopez E. Gigantic cystosarcoma phyllodes in
a man with gynecomastia. Arch Surg 1976;111:611.
28. Konstantakos AK, Graham DJ. Cystosarcoma phyllodes tumors in
men. Am Surg 2003;69:808–811.
© Journal of the National Comprehensive Cancer Network | Volume 5 Number 3 | March 2007
29. de Roos WK, Kaye P, Dent DM. Factors leading to local recurrence
or death after surgical resection of phyllodes tumours of the breast.
Br J Surg 1999;86:396–399.
30. Jorge Blanco A, Vargas Serrano B, Rodriguez Romero R, et al.
Phyllodes tumors of the breast. Eur Radiol 1999;9:356–360.
31. Chao TC, Lo YF, Chen SC, et al. Sonographic features of phyllodes
tumors of the breast. Ultrasound Obstet Gynecol 2002;20:64–71.
32. Tan EY, Hoon TP, Yong WS, et al. Recurrent phyllodes tumours of
the breast: pathological features and clinical implications. ANZ J Surg
2006;76:476–480.
33. Hajdu SI, Espinosa MH, Robbins GF. Recurrent cystosarcoma phyl-
lodes: a clinicopathologic study of 32 cases. Cancer 1976;38:1402–1406.
34. Carlson RW, Anderson BO, Burstein HJ, et al. The NCCN breast
cancer clinical practice guidelines in oncology, version 1, 2007.
Available at: http://www.nccn. org/professionals/physician_gls/
PDF/breast.pdf. Accessed January 30, 2007.
35. August DA, Kearney T. Cystosarcoma phyllodes: mastectomy,
lumpectomy, or lumpectomy plus irradiation. Surg Oncol 2000;
9:49–52.
36. Haagensen CD. Cystosarcoma Phyllodes, Disease of the Breast. 3rd
ed. Philadelphia: WB Saunders; 1986:284–312.
37. Kessinger A, Foley JF, Lemon HM, et al. Metastatic cystosarcoma
phyllodes: a case report and review of the literature. J Surg Oncol
1972;4:131–147.
38. Cooney BM, Ruth GJ, Behrman DA, et al. Malignant cystosarcoma
phyllodes of the breast metastatic to the oral cavity: report of a case
and review of the literature. Oral Surg Oral Med Oral Pathol
1988;66:599–604.
39. Hawkins RE, Schofield JB, Wiltshaw E, et al. Ifosfamide is an active
drug for chemotherapy of metastatic cystosarcoma phyllodes. Cancer
1992;69:2271–2275.
40. Allen R, Nixon D, York M, et al. Successful chemotherapy for cys-
tosarcoma phyllodes in a young woman. Arch Intern Med 1985;145:
1127–1128.
41. Burton GV, Hart LL, Leight GS Jr, et al. Cystosarcoma phyllodes.
Effective therapy with cisplatin and etoposide chemotherapy. Cancer
1989;63:2088–2092.
42. Demetri GD, Baker LH, Benjamin R, et al. The NCCN soft tissue
sarcoma clinical practice guidelines in oncology, version 3, 2006.
Available at: http://www.nccn. org/professionals/physician_gls/PDF/
sarcoma.pdf. Accessed January 30, 2007.
43. Buchanan EB. Re: Surgical removal of metastatic phyllodes tumor:
this should be strongly considered for the solitary lesion as long as
cosmetic and functional disability is not excessive. Am Surg
2003;69:633; comment 61:350–355.