phylloides
malignant phylloides - 11 cms in max dimension - post mastectomy - clear margins - any role for RT?
phylloides
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Summary:
post mastectomy radiation
Check the deep fascia margins ? If all are clear (>1cms) then no adjuvant RT. This is what we follow here.
Adjuvant radiotherapy (RT) for phyllodes tumors is controversial. Radiotherapy is unnecessary for benign phyllodes tumors that are widely excised. However, some data suggest that adjuvant RT should be considered for patients with histologically malignant phyllodes tumors.
Few References for Bed time reading
1. http://www.ncbi.nlm.nih.gov/pubmed/18234448
A large retrospective study of patients with malignant phyllodes tumors treated with surgical resection alone revealed suboptimal five-year local control rates (79 percent in 169 patients treated with wide excision and 91 percent in 207 patients treated with mastectomy). The authors concluded that for patients with malignant phyllodes tumors, particularly over 2 cm in diameter and treated with wide excision alone, adjuvant RT should be strongly considered. One important limitation of this study is the lack of information about margin status.
2. http://www.ncbi.nlm.nih.gov/pubmed/17931796
In a study of 443 women treated for phyllodes tumor, RT was associated with a superior local control rate at 10 years, from 59 percent to 86 percent for borderline and malignant phyllodes tumors.
3.http://www.ncbi.nlm.nih.gov/pubmed/19424757
In a prospective multi-institutional study of adjuvant RT in 46 patients with borderline malignant or malignant phyllodes tumors treated with breast conserving surgery followed by RT, there were no local recurrences with a median follow up of 56 months. Two patients with malignant phyllodes tumor died of metastatic disease.
Taken together, these results indicate that adjuvant RT appears to be effective in decreasing recurrences after breast conserving resection for borderline or malignant phyllodes tumors. Most agree that adjuvant RT is appropriate when it is not possible to obtain a wide margin of ≥1 cm of resection. It is also important to remember that, for some tumors a 1 cm margin may not be possible even with a total mastectomy, due to size or location. In such patients, radiation may be indicated even after a mastectomy.
There is less agreement about the role of adjuvant RT when wide margins ≥1 cm can be obtained. Further studies are needed to determine when adjuvant RT should be advised in the treatment of phyllodes tumors
Indeed adjuvant RT is controversial.
Look at this study from SEER database
http://www.ncbi.nlm.nih.gov/pubmed/16998937
To quote the abstract
BACKGROUND: Malignant phyllodes tumor is a rare and potentially aggressive breast neoplasm. Little information is available regarding the optimal management of these lesions and rarer still are data regarding survival. The current study used a large population database to determine prognostic factors that predict cause-specific survival (CSS). METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) for the years 1983-2002. Women receiving resection for primary nonmetastatic malignant phyllodes tumor of the breast were included (n = 821). Analyses of patient, pathologic, and treatment characteristics were performed using univariate and multivariate Cox regression analyses for the CSS endpoint. RESULTS: With a median follow-up of 5.7 years, CSS was 91%, 89%, and 89%, at 5, 10, and 15 years, respectively. Mastectomy was performed in 428 women (52%) and wide excision or lumpectomy in 393 (48%). Women undergoing mastectomy were significantly older (P = .004) and had larger tumors (P = .009). Wide excision was associated with equivalent or improved CSS relative to mastectomy on univariate and multivariate analyses. Older age predicted for cause-specific mortality on multivariate analysis. Adjuvant radiotherapy (RT) predicted for worse CSS when implemented compared with surgery alone. CONCLUSIONS: Mastectomy was not found to provide a benefit in CSS compared with wide excision in malignant phyllodes tumor of the breast. Women undergoing wide excision had at the minimum similar cancer-specific mortality compared with those who received mastectomy. The role of adjuvant RT is uncertain and requires further investigation. (c) 2006 American Cancer Society.
Santam
Although the fact that this study is from the SEER database makes it sound very important, it has several limitations - only 9% of patients got adjuvant RT, the proportion being roughly equal in all age groups. It is not clear why they got it - presumably adverse prognostic factors. No RT details are available and no margin status is available. Although there a 'corrected' comparison has been made - unless it is corrected for margin status - the correction cannot be considered optimal. It is likely that a large proportion of patients treated with adj RT had positive margins, and hence the poor outcomes.
Interestingly the so called detriment from RT is only significant in the post-mastectomy group. Since mastectomy was not determined by age - these patients likely had the largest tumors (read - even more likely to have positive or close margins).
Therefore I'd take these results with a large pinch of salt.
But I do admit that the benefit from adj RT may not be large or universal.
Evidence is difficult to conclude what to be done.Margin/size is important as in sarcoma for boderline and malignant phyllodes.
It is very difficult to predict which one recur.metastasis is lung telling it behaves as sarcoma.lymphnodes are not that common.so sarcoma radiation indication can be applied.
In our deparment , malignant phyllodes with clear margin of 1 cm we donot treat with radiotherapy.less than 1cm we treat.This is just cut and paste protocol from other institution without any discussions.
Quoted recurrence is around 20% .Chest wall radiotherapy or whole breast radiotherapy sideeffect versus benefit personally i feel better to treat than not if lesions are large like more than 10cm(mayo clinic data) or margin are less than 1 cm (deep margin also) whether mastectomy or wide local excision(after reexcision).
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