Surgical margins for borderline and malignant phyllodes tumours

Abstract

Background: Phyllodes tumours represent less than 1% of all UK breast neoplasms. Histological features allow classification into benign, borderline or malignant, which has a significant impact on prognosis and recurrence. Currently, there is no consensus for the optimal surgical excision margin. This systematic review aims to provide a comparative summary of outcomes (local recurrence, metastasis and survival) for borderline and malignant phyllodes tumours resected with either ≥1cm or <1cm margins.

Methods: MEDLINE and Embase were systematically searched (1990 to July 2019), in line with PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa scale.

Results: Ten retrospective studies were included (Newcastle-Ottawa scale mean score: 5.6, range: 8-4). Nine reported local recurrence rates, four reported distant metastasis and four reported survival. Meta-analysis pooling demonstrated no statistically significant difference between <1cm and ≥1cm margins in terms of local recurrence rates (relative risk [RR] 1.43, 95% confidence interval [95% CI] 0.70 - 2.93; p=0.33, n=456), distant metastasis (RR 1.93, 95% CI 0.35 - 10.63; p=0.45, n=72) or mortality (RR 1.93, 95% CI 0.42 - 8.77; p=0.40, n=58) for borderline and malignant tumours. Additionally, two studies demonstrated no significant difference in local recurrence for borderline tumours excised with <0.1cm margins compared to ≥1cm.

Conclusion: Current evidence suggests that margins <1cm may provide adequate tumour excision. This could enable breast conservation in patients with smaller breast-to-tumour volume ratios, with improved cosmetic outcomes and patient satisfaction. A prospective, multi-institutional trial would be appropriate to further elucidate the safety of smaller margins.

Keywords: Borderline; Clearance; Malignant; Margin; Phyllodes tumour; Recurrence; Surgery; Survival.

Figure 1

PRISMA flowchart for the selection and exclusion of studies.

Figure 2

Pooled results of local recurrence rates for borderline and malignant phyllodes tumours (PTs) excised with less than 1cm compared with 1cm or greater margins. An asterisk (*) denotes authors with statistically significant data.

Figure 3

Funnel plot for assessment of publication bias.

Figure 4

Pooled results of distant metastasis and mortality rates for borderline and malignant phyllodes tumours (PTs) excised with less than 1cm compared with 1cm or greater margins. An asterisk (*) denotes authors with statistically significant data.