Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members

Diego, Emilia J.; Rosenberger, Laura H.; Deng, Xiaoyan; McGuire, Kandace P.

doi:10.1245/s10434-022-12192-x

Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members

Breast Oncology
Published: 18 July 2022

Volume 29, pages 6151–6161, (2022)
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Annals of Surgical Oncology Aims and scope Submit manuscript

Emilia J. Diego MD¹,
Laura H. Rosenberger MD, MS²,
Xiaoyan Deng MS³ &
…
Kandace P. McGuire MD⁴

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Abstract

Background

Phyllodes tumors (PTs) are rare breast neoplasms with variable clinical behavior by histologic type: benign, borderline, or malignant. Until recently, management guidelines recommended one approach for all subtypes.

Methods

A 21-question survey was sent to American Society of Breast Surgeon members to evaluate management patterns by subtype. Surgeon demographics, decisions regarding management of margins, re-excision, surveillance, and synoptic reporting were collected. Chi-square or analysis of variance (ANOVA) were used as appropriate, with significance set at p < 0.05.

Results

A total of 493 of 2969 surveys were completed for a response rate of 18.3%. Among the survey takers, 55% were fellowship trained, 72% were in practice > 10 years, and 82% performed > 100 breast cases per year. Although 25% of respondents enucleate a mass with clinical suspicion of a PT alone, this decreased to 18% if a preoperative core biopsy performed was suggestive of PT. For margin management, 47% do not re-excise positive margins for benign PTs, but 96% would for a borderline or malignant PTs (p < 0.001). Only 2% perform axillary staging for malignant PTs, and 90% refer borderline or malignant PTs for radiation. Two-year surveillance was performed by about half of respondents for benign PT. However, two-thirds of respondents would increase surveillance to 5 years for borderline or malignant PTs. Only 38% report a templated synoptic pathology report at their institution.

Conclusion

PT management patterns are evolving but still variable when looking at initial margin intent, decision for re-excision, radiation referral, pathologic reporting, and surveillance. This suggests the need for more specific management guidelines by subtype given differences in clinical behavior.

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Authors and Affiliations

Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Emilia J. Diego MD
Department of Surgery, Duke University Medical Center, Durham, NC, USA
Laura H. Rosenberger MD, MS
Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
Xiaoyan Deng MS
Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
Kandace P. McGuire MD

Authors

Emilia J. Diego MD
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Laura H. Rosenberger MD, MS
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Xiaoyan Deng MS
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Kandace P. McGuire MD
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Correspondence to Emilia J. Diego MD.

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Emilia J. Diego and Laura H. Rosenberger share co-first authorship.

Appendix 1: Survey sent to American Society of Breast Surgeons members

Demographic and practice characteristics

1.
Did you complete formal fellowship training after surgical residency?
1. a.
  SSO Accredited Breast Surgical Oncology
2. b.
  SSO / ACGME Accredited Complex General Surgical Oncology (CGSO)
3. c.
  Other Fellowship training
4. d.
  None
2.
How many years have you been in clinical practice (after completion of training)?
1. a.
  < 5 years
2. b.
  5–10 years
3. c.
  11–15 years
4. d.
  16–20 years
5. e.
  > 20 years
3.
How would you describe your practice setting?
1. a.
  Private practice general or oncologic surgeon who performs some breast surgery
2. b.
  Private practice surgeon, who performs breast-only surgery
3. c.
  Academic center, medical school faculty, who performs some breast surgery
4. d.
  Academic center, medical school faculty, who performs breast-only surgery
5. e.
  Other
4.
How many breast operations (benign or malignant) do you perform annually?
1. a.
  < 50
2. b.
  50–100
3. c.
  100–150
4. d.
  150–200
5. e.
  > 200
5.
What percentage of your clinical time is spent in the treatment of benign or malignant breast disease:
1. a.
  < 25%
2. b.
  26–50%
3. c.
  51–75%
4. d.
  > 75%

Surgical decision making

6.
What is your margin intent when performing an initial operation for a breast mass that you have clinical suspicion for a phyllodes tumor (e.g. rapid growth, lesion size, growth over time? Your margin intent is:
1. a.
  Enucleation
2. b.
  1–2 mm
3. c.
  2–10 mm
4. d.
  > 10 mm
7.
What is your margin intent when performing an initial operation for a breast mass that you have a core biopsy that suggests a phyllodes tumor (e.g. “fibroepithelial lesion” or “suspicious for phyllodes tumor”)? Your margin intent is:
1. a.
  Enucleation
2. b.
  1–2 mm
3. c.
  2–10 mm
4. d.
  > 10 mm
8.
What do you consider to be an acceptable final margin status for a benign phyllodes tumor?
1. a.
  I do not feel a negative margin is necessary for benign phyllodes
2. b.
  I feel that a close, but negative margin is acceptable, < 1 mm
3. c.
  I feel that a wider negative margin reduces local recurrences, 2–5 mm
4. d.
  I feel a wide negative margin is ideal for this tumor, which is treated exclusively with surgery, 5–10 mm
9.
How do you manage a positive margin for a benign phyllodes tumor?
1. a.
  No additional surgery, I feel treatment is complete with excision
2. b.
  No additional surgery, referral to radiation oncology for consideration
3. c.
  Margin re-excision for an attempt to obtain at least a negative margin, < 1 mm
4. d.
  Margin re-excision for an attempt to obtain a wide, 5–10 mm margin
10.
How do you manage a positive margin for a borderline/malignant phyllodes tumor?
1. a.
  No additional surgery, I feel treatment is complete with excision
2. b.
  No additional surgery, referral to radiation oncology for consideration
3. c.
  Margin re-excision for an attempt to obtain at least a negative margin, <1 mm
4. d.
  Margin re-excision for an attempt to obtain a wide, 5–10 mm margin
11.
If you omit a re-excision for a positive phyllodes tumor margin, what is that decision based upon: (please select the choice which you consider to be the most relevant):
1. a.
  An uncertain oncologic benefit
2. b.
  A frequent lack of residual phyllodes identified on re-excision
3. c.
  A potential cosmetic detriment or psychologic stress with repeat surgery
4. d.
  An increase in healthcare costs
5. e.
  Other (please specify)

Axillary Staging

12.
Do you perform axillary staging (sentinel lymph node biopsy or axillary node dissection) when excising a phyllodes tumor?
1. a.
  No
2. b.
  Yes, for malignant phyllodes only
3. c.
  Yes, for borderline/malignant tumors only
4. d.
  Yes, for all phyllodes tumor grades

Pathology Reporting

13.
There is currently no College of American Pathologists (CAP) Cancer Protocol or synoptic reporting template for phyllodes tumors. Synoptic reporting for phyllodes would likely include the multiple stratified histopathologic parameters that determine the final phyllodes classification including; (1) degree of stromal cellularity and (2) atypia, (3) presence of stromal overgrowth, (4) mitotic count, and (5) nature of the tumor border.

Does your institution report these tumors using a synoptic-like reporting template, which consistently includes the multiple stratified histopathologic parameters that determined the final phyllodes classification?
1. a.
  I am not sure
2. b.
  No, I believe it is reported variably depending on the pathologist
3. c.
  No, I believe it is reported as only subtype (Benign, Borderline, Malignant), pathologic tumor size, and margin status, with minimal additional details
4. d.
  Yes, I believe we use a phyllodes template that includes these histopathologic details

Radiation decision making

14.
The NCCN guidelines support the consideration of radiation therapy where a phyllodes recurrence would create significant morbidity. Following excision of a benign phyllodes tumor, do you routinely refer to radiation oncology for a discussion regarding use of adjuvant radiation therapy?

CHOOSE ALL THAT APPLY
1. a.
  No, I feel benign phyllodes do not require radiation therapy
2. b.
  No, I only refer benign phyllodes if recommended by multidisiplinary tumor board
3. c.
  Yes, if the benign phyllodes was managed with breast conservation
4. d.
  Yes, only if the benign phyllodes has a positive margin
5. e.
  Yes, I refer all benign phyllodes tumors for a radiation oncology discussion

15.
The NCCN guidelines support the consideration of radiation therapy where a phyllodes recurrence would create significant morbidity. Following excision of a borderline/malignant phyllodes tumor, do you routinely refer to radiation oncology for a discussion regarding use of adjuvant radiation therapy?

CHOOSE ALL THAT APPLY
1. a.
  No, I feel borderline/malignant phyllodes do not require radiation therapy
2. b.
  No, I only refer borderline/malignant phyllodes if recommended by multidisiplinary tumor board
3. c.
  Yes, if the borderline/malignant phyllodes was managed with breast conservation
4. d.
  Yes, only if the borderline/malignant phyllodes has a positive margin
5. e.
  Yes, I refer all borderline/malignant phyllodes tumors for a radiation oncology discussion

Surveillance and Follow Up

Following complete definitive management of a benign phyllodes tumor, how do you manage their follow up in your surgical clinic? Chose the answer closest to your current clinical practice? Chose the answer closest to your current clinical practice:

16.
Do you follow patients in your practice after excision of a benign phyllodes tumor?
1. i.
  Yes
2. ii.
  No, PRN only

17.
I perform a clinical breast exam:
1. i.
  Every 6 months for 2 years, then PRN
2. ii.
  Every 6 months for 5 years, then PRN
3. iii.
  Every 6 months for 2 years, annually until year 5 then PRN
4. iv.
  Annually for 2 years, then PRN
5. v.
  Annually for 5 years, then PRN
6. vi.
  Other

18.
I order imaging of the breast:
1. i.
  Every 6 months for 2 years, then PRN
2. ii.
  Every 6 months for 5 years, then PRN
3. iii.
  Every 6 months for 2 years, annually until year 5 then PRN
4. iv.
  Annually for 2 years, then PRN
5. v.
  Annually for 5 years, then PRN
6. vi.
  Other

Following complete definitive management of a borderline/malignant phyllodes tumor, how do you manage their follow up in your surgical clinic? Chose the answer closest to your current clinical practice:

19.
Do you follow patients in your practice after excision of a borderline/malignant phyllodes tumor?
1. i.
  Yes
2. ii.
  No, PRN only

20.
I perform a clinical breast exam:
1. i.
  Every 6 months for 2 years, then PRN
2. ii.
  Every 6 months for 5 years, then PRN
3. iii.
  Every 6 months for 2 years, annually until year 5 then PRN
4. iv.
  Annually for 2 years, then PRN
5. v.
  Annually for 5 years, then PRN
6. vi.
  Other

21.
I order imaging of the breast:
1. i.
  Every 6 months for 2 years, then PRN
2. ii.
  Every 6 months for 5 years, then PRN
3. iii.
  Every 6 months for 2 years, annually until year 5 then PRN
4. iv.
  Annually for 2 years, then PRN
5. v.
  Annually for 5 years, then PRN
6. vi.
  Other

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Diego, E.J., Rosenberger, L.H., Deng, X. et al. Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members. Ann Surg Oncol 29, 6151–6161 (2022). https://doi.org/10.1245/s10434-022-12192-x

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Received: 29 June 2022
Accepted: 29 June 2022
Published: 18 July 2022
Issue Date: October 2022
DOI: https://doi.org/10.1245/s10434-022-12192-x

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Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members