CTOS 2009

15 years Experience of Management of Malignant Phyllodes Tumor and Breast Sarcoma at

Princess Margaret Hospital

Princess Margaret Hospital & Mount Sinai HospitalUniversity of Toronto

Nikhilesh Patil, Charles Catton, Brian O’Sullivan, Robert Dinniwell, Anthony

Griffin, Peter C Ferguson, Rebecca Gladdy, David McCready, Martin Blackstein, Abha

Gupta, Lisa W Le, Peter Chung

CTOS 2009

Purpose

•To report the outcomes of Malignant phyllodes tumors (MPT) and breast sarcomas (BS)

CTOS 2009

Methods•Retrospective review (Jan 1991 to Dec 2006) •N = 111•3 Groups 1) MPT :75 (68%)

2) Angiosarcomas :22 (18%)3) Others :14 (14%)

• Grade:Low : 29 (26%)Intermediate : 10 (9%)High : 48 (43%)NOS : 24 (22%)

CTOS 2009

Histologic subtypes•Malignant phyllodes : 75 (68%)

•Angiosarcomas : 22 (18%)

•Sarcoma NOS : 7 (7%)

•Fibrosarcoma : 3 (3%)

•Leiomyosarcoma : 1 (1%)

•Liposarcoma : 1 (1%)

•Mxyoid NOS : 1 (1%)

•Alvelolar RMS : 1 (1%)

CTOS 2009

Surgical details•Mastectomy alone : 47 (42%)

•Mastectomy +RT : 34 (31%)

•Wide local excision/Lumpectomy alone : 11 (10%)

•Wide local excision +RT : 17 (15%)

•Margin:» Negative : 84 (76%)

» Close (<1cms) : 12 (11%)

» Positive : 13 (12%)

•2 patients were not offered sx (1 alveolar RMS because of no residual disease after chemotherapy and other large tumor with bleeding – palliative RT)

CTOS 2009

RT details• Rationale for RT : Close/+ margins in lumpectomy/mastectomy (usually deep margin in absence of removal of pectoral fascia). We consider wide margin to be >1-2cm.• N : 53 (48%)• Indication

»Adjuvant RT : 41(lumpectomy = 16, mastectomy = 25),

» Recurrent disease : 3 » Palliative : 6» Pre-op RT : 3

• Technique»Tangents : 41» IMRT : 5» Others : 6

• Median dose : 50 GY (range 20-63)

CTOS 2009

Results•Median age : 47 yrs (range 17- 83)

•Median tumor size : 5cms (range 0.5 – 27)

•Median follow up : 5.2 yrs (range 0.1 – 18.8 yrs)

•Controlled (local+distant) : 71( 64%)

•Local relapse : 4 ( 4%)

•Distant relapse : 36 (32%)

•10 patients had prior radiation (angiosarcomas) following surgery for breast cancer. Therefore did not have further rads.

CTOS 2009

0 5 10 15 20

0.0

0.2

0.4

0.6

0.8

1.0

Time (years)

Su

rviv

al

Overall SurvivalProgression Free Survival

5 years OS : 71% (95%CI: 61-80)

5 years PFS : 64% (95%CI: 54-74)

CTOS 2009

0 5 10 15 20

0.0

0.2

0.4

0.6

0.8

1.0

Time (years)

Su

rviv

al

Histology group 1Histology group 2Histology group 3

P <0.0001

1 = MPT

2= Angiosarc

3= Others

CTOS 2009

•No local failure following adjuvant RT.

•Four (3%) has local recurrence without adjuvant RT (3 angiosarcomas and 1 MPT)

CTOS 2009

Univariate and Multivariate Analysis

OAS PFS

HR(95%CI) Uni Multi HR(95%CI) Uni Multi

Histology

(2 vs 1)

4.7 (2.2 -10.3) <0.0001 0.0004 4.6 (2.3 -9.4) <0.0001 0.0001

(3 vs 1) 2.7 (0.96 -7.7) 2.5 (1.0 -6.4)

Age 1.4 (1.1 – 1.7) 0.02 0.02 1.3 (1.1 -1.6) 0.01 0.01

Tumor Size

1.7 (1.1 – 2.7) 0.04 0.03 1.3 (0.9 – 2.1) 0.23 0.13

CTOS 2009

Conclusions•Mastectomy for malignant phyllodes tumor and sarcomas of the breast achieves excellent local control.

•Wide local excision with breast conservation is feasible (+/- RT) with excellent local control in select patients

•Adjuvant radiotherapy should be considered when wide margins are not possible.

•Management of breast sarcoma should follow the same local control principles as for other sarcomas of the superficial tissues.

•Poor outcome of angiosarcomas warrants further research.

CTOS 2009

Acknowledgement

•Princess Margaret Hospital Cancer registry

•UHN Sarcoma group.

CTOS 2009

1991-2007 PMH Breast Cancer Report Visit Year The number of Patients

1991 1123

1992 1277

1993 1351

1994 1260

1995 1334

1996 1486

1997 1578

1998 1652

1999 1419

2000 1038

2001 1062

2002 968

2003 1263

2004 1423

2005 1167

2006 1335

2007 1375

Total 22111

CTOS 2009