Phyllodes Tumor Page 1 of 4

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients. TREATMENT/FOLLOW UP
PATIENT INITIAL Close clinical
Fibroadenoma
PRESENTATION EVALUATION follow-up

Benign or borderline See Page 2 for Surveillance

Benign or Wide excision4
● History and physical exam Review final
borderline without axillary
Clinical suspicion of ● Ultrasound pathology
phyllodes tumor staging
phyllodes tumor: ● Diagnostic bilateral Malignant phyllodes5 See Breast Sarcoma algorithm
● Palpable mass mammography for women
● Rapid growth age ≥ 30 years
1
● Imaging with ultrasound ● Lifestyle risk assessment Borderline phyllodes 6-month follow up
2
suggestive of ● Core needle biopsy
Fibroepithelial ultrasound
fibroadenoma except for ● Discuss Goal Concordant
lesion or Excisional Review final Fibroadenoma and benign phyllodes ● If no growth, observe
size (> 2 cm) and/or Care (GCC) with patient indeterminate biopsy7 pathology tumors (wide excision not needed) ● If growth, wide
history of rapid growth or if clinically indicated, with pathology6 excision with follow
Patient Representative3 up as indicated
Malignant phyllodes5
Malignant
See Breast Sarcoma algorithm
phyllodes5

Invasive or
See Breast Cancer - Invasive Stage I-III or
in situ breast
Breast Cancer- Ductal Carcinoma in Situ (DCIS) algorithms
cancer
1
See Physical Activity, Nutrition, and Tobacco Cessation Treatment algorithms; ongoing reassessment of lifestyle risks should be a part of routine clinical practice
2
Fine needle aspiration will not distinguish fibroadenoma from phyllodes tumor in most cases. In general, core needle biopsy is the preferred method for diagnostic biopsy.
3
GCC should be initiated by the Primary Oncologist. If Primary Oncologist is unavailable, Primary Team/Attending Physician to initiate GCC discussion and notify Primary Oncologist. Patients, or if clinically indicated, the Patient
Representative should be informed of therapeutic and/or palliative options. GCC discussion should be consistent, timely, and re-evaluated as clinically indicated. The Advance Care Planning (ACP) note should be used to document
GCC discussion. Refer to GCC home page (for internal use only).
4
There is no high level evidence to support a margin width of at least 10 mm and an ideal margin width remains to be determined. Re-excision may need to be considered in relation to factors such as tumor characteristics, size, and
cosmesis. For benign pathology, re-excision of a negative margin is not recommended regardless of margin width. See Suggested Readings for updated information.
5
Obtain molecular sequencing if patient is eligible for clinical trials. For patients with malignant phyllodes tumor or stromal overgrowth on pathology review, referral to a multidisciplinary sarcoma center is appropriate. Refer to
Breast Sarcoma algorithm.
6
Recommend review by pathologist experienced in phyllodes tumor and to correlate with imaging findings and physical examination. Core biopsy may not provide definitive evaluation (tumor heterogeneity and inability to assess
for infiltrating margins). Cases are discussed at the Multidisciplinary Clinical Management Conference (CMC) for Benign Breast Lesions for management recommendations.
7
Excisional biopsy if recommended at CMC. Excisional biopsy includes complete mass removal, but without the intent of obtaining widely negative surgical margins.
Department of Clinical Effectiveness V10
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by Executive Committee of the Medical Staff on 10/17/2023
 Phyllodes Tumor Page 2 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
Note: Consider Clinical Trials as treatment options for eligible patients.

SURVEILLANCE PATIENT EVALUATION TREATMENT

PRESENTATION

History and physical exam Re-excision with

● Consider post-
● Ultrasound No metastatic histologically negative
operative radiation
● Diagnostic bilateral disease margins without
(category 2B)3
mammography axillary staging
1
● Core needle biopsy
● CT chest/abdomen/pelvis
with contrast if recurrent
malignant phyllodes tumor
Yes ● Discuss Goal Concordant
Metastatic disease management following
History and physical exam with age appropriate Care (GCC) with patient
Locally recurrent principles of soft tissue sarcoma (see Adult
breast imaging as clinically indicated every or if clinically indicated, Metastatic disease
breast mass? Soft – Tissue Sarcoma for Clinical Stage III
6 months for 2 years, then annually for 5 years with Patient Representative2 algorithm)

No

Continue surveillance

1
Fine needle aspiration will not distinguish fibroadenoma from phyllodes tumor in most cases. In general, core needle biopsy is the preferred method for diagnostic biopsy.
2
GCC should be initiated by the Primary Oncologist. If Primary Oncologist is unavailable, Primary Team/Attending Physician to initiate GCC discussion and notify Primary Oncologist. Patients, or if clinically
indicated, the Patient Representative should be informed of therapeutic and/or palliative options. GCC discussion should be consistent, timely, and re-evaluated as clinically indicated. The Advance Care Planning
(ACP) note should be used to document GCC discussion. Refer to GCC home page (for internal use only).
3
There is no prospective randomized data supporting the use of radiation treatment with phyllodes tumor. However, in the setting where additional recurrence would create significant morbidity (e.g., chest wall
recurrence following salvage mastectomy) radiation therapy may be considered, following the same principles that are applied to the treatment of soft tissue sarcoma. Radiation therapy is considered for malignant
phyllodes tumor after wide local excision lesions over 2 cm or after mastectomy for lesions over 5 cm based on the retrospective review of 478 patients analyzed by Pezner, et al., 2008.

Department of Clinical Effectiveness V10

Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by Executive Committee of the Medical Staff on 10/17/2023
 Phyllodes Tumor Page 3 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

SUGGESTED READINGS

Boland, P. A., Ali Beegan, A., Stokes, M., Kell, M. R., Barry, J. M., O'Brien, A., & Walsh, S. M. (2021). Management and outcomes of phyllodes tumours - 10 year experience.
Breast Disease, 10.3233/BD-201059. Advance online publication. doi:10.3233/BD-201059
Lu, Y., Chen, Y., Zhu, L., Cartwright, P., Song, E., Jacobs, L., & Chen, K. (2019). Local recurrence of benign, borderline, and malignant Phyllodes tumors of the breast: A
systematic review and meta-analysis. Annals of Surgical Oncology, 26(5), 1263–1275. doi:10.1245/s10434-018-07134-5
MD Anderson Institutional Policy #CLN1202 - Advance Care Planning Policy. Advance Care Planning (ACP) Conversation Workflow (ATT1925)
National Comprehensive Cancer Network. (2023). Breast Cancer (NCCN Guideline. Version 3.2023). Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/
breast.pdf
Neron, M., Sajous, C., Thezenas, S., Piperno-Neumann, S., Reyal, F., Laé, M., … French Sarcoma Group (GSF-GETO). (2020). Surgical margins and adjuvant therapies in
malignant Phyllodes tumors of the breast: A multicenter retrospective study. Annals of Surgical Oncology, 27(6), 1818–1827. doi:10.1245/s10434-020-08217-y

Pezner, R. D., Schultheiss, T. E., & Paz, I. B. (2008). Malignant phyllodes tumor of the breast: Local control rates with surgery alone. International Journal of Radiation Oncology,
Biology, Physics, 71(3), 710-713. doi:10.1016/j.ijrobp.2007.10.051
Rosenberger, L. H., Thomas, S. M., Nimbkar, S. N., Hieken, T. J., Ludwig, K. K., Jacobs, L. K., … Jakub, J. W. (2021). Contemporary multi-institutional cohort of 550 cases of
Phyllodes tumors (2007-2017) demonstrates a need for more individualized margin guidelines. Journal of Clinical Oncology: Official Journal of the American Society of
Clinical Oncology, 39(3), 178–189. doi:10.1200/JCO.20.02647
Sars, C., Sackey, H., Frisell, J., Dickman, P. W., Karlsson, F., Kindts, I., … Lindqvist, E. K. (2023). Current clinical practice in the management of phyllodes tumors of the breast:
An international cross-sectional study among surgeons and oncologists. Breast Cancer Research and Treatment, 199(2), 293-304. doi:10.1007/s10549-023-06896-1
Toussaint, A., Piaget-Rossel, R., Stormacq, C., Mathevet, P., Lepigeon, K., & Taffé, P. (2021). Width of margins in phyllodes tumors of the breast: The controversy drags on? -A
systematic review and meta-analysis. Breast Cancer Research and Treatment, 185(1), 21–37. doi:10.1007/s10549-020-05924-8

Department of Clinical Effectiveness V10

Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by Executive Committee of the Medical Staff on 10/17/2023
 Phyllodes Tumor Page 4 of 4
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

DEVELOPMENT CREDITS
This practice algorithm is based on majority expert opinion of the Breast Center providers at the University of Texas MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following:
Core Development Team Leads
Isabelle Bedrosian, MD (Breast Surgical Oncology)
Ashleigh Guadagnolo, MD, MPH (Radiation Oncology)
Kelly K. Hunt, MD (Breast Surgical Oncology)
Henry M. Kuerer MD, PhD (Breast Surgical Oncology)
Melissa P. Mitchell, MD (Radiation Oncology)
Debu Tripathy, MD (Breast Medical Oncology)

Workgroup Members
Constance Albarracin, MD (Anatomical Pathology) Gabriel N. Hortobagyi, MD (Breast Medical Oncology) Vinod Ravi, MD (Sarcoma Medical Oncology)
Dejka M. Araujo, MD (Sarcoma Medical Oncology) Rosa F. Hwang, MD (Breast Surgical Oncology) Erika Resetkova, MD (Anatomical Pathology)
Elsa Arribas, MD (Diag Rad – Breast Imaging) Nuhad K. Ibrahim, MD (Breast Medical Oncology) Merrick I. Ross, MD (Surgical Oncology)
Banu K. Arun, MD (Breast Medical Oncology) Kimberly B. Koenig, MD (Breast Medical Oncology) Aysegul A. Sahin, MD (Pathology Admin)
Robert C. Bast Jr., MD (Translational Research) Savitri Krishnamurthy, MD (Pathology Admin) Lumarie Santiago, MD (Diag Rad – Breast Imaging)
Robert S. Benjamin, MD (Sarcoma Medical Oncology) Deanna L. Lane, MD (Diag Rad – Breast Imaging) Simona F. Shaitelman, MD (Radiation Oncology)
Therese Bevers, MD (Cancer Prevention) Huong Carisa Le-Petross, MD (Diag Rad – Breast Imaging) Benjamin Smith, MD (Radiation Oncology)
Daniel J. Booser, MD (Breast Medical Oncology) Heather Lillemoe, MD (Breast and Sarcoma Surgical Oncology) Eric A. Strom, MD (Radiation Oncology)
Abenaa Brewster, MD (Clinical Cancer Prevention) Jennifer Litton, MD (Breast Medical Oncology) W. Fraser Symmans, MD (Anatomical Pathology)
Aman U. Buzdar, MD (Clinical Research) Anthony Lucci, MD (Breast Surgical Oncology) Nina Tamirisa, MD (Breast Surgical Oncology)
Abigail S. Caudle, MD (Breast Surgical Oncology) Joseph A. Ludwig, MD (Sarcoma Medical Oncology) Vicente Valero, MD (Breast Medical Oncology)
Sarah M. DeSnyder, MD (Breast Surgical Oncology) Funda Meric-Bernstam, MD (Invest. Cancer Therapeutics) Mary Lou Warren, DNP, APRN, CNS-CC♦
Mark J. Dryden, MD (Diag Rad – Breast Imaging) Lavinia P. Middleton, MD (Anatomical Pathology) Gary J. Whitman, MD (Diag Rad – Breast Imaging)
Olga N. Fleckenstein, BS♦ Tamara Miner Haygood, MD (Diag Rad – Musculoskeletal Imaging) Wendy Woodward, MD (Radiation Oncology)
Sharon H. Giordano, MD (Health Svcs Research – Clinical) Shreyaskumar Patel, MD (Sarcoma Medical Oncology) Wei Yang, MD (Diag Rad – Breast Imaging)
Karen Hoffman, MD (Radiation Oncology) George H. Perkins, MD (Radiation Oncology) Wendong Yu, MD, PhD (Anatomical Pathology)

♦
Clinical Effectiveness Development Team
Department of Clinical Effectiveness V10
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by Executive Committee of the Medical Staff on 10/17/2023