Ultrasound Obstet Gynecol 2002; 20: 64 71

Blackwell Science, Ltd

Sonographic features of phyllodes tumors of the breast

T.-C. CHAO*, Y.-F. LO*, S.-C. CHEN* and M.-F. CHEN*

*Division of General Surgery, Department of Surgery, Chang Gung University College of Medicine and Chang Gung Memorial Hospital, Taoyuan, Taiwan

KEYWORDS : Breast, Echogenicity, Fibroadenoma, Internal echo pattern, Phyllodes tumor, Retrotumor acoustic phenomenon, Sonography

ABSTRACT
Objective The aim of this study was to examine the sonographic features of phyllodes tumors of the breast. Methods Retrospective analysis of prospectively recorded sonographic features was performed on 2268 patients with phyllodes tumors or fibroadenomas during 199598. Data from 110 phyllodes tumors (76 benign, 11 borderline, 23 malignant) and 2204 fibroadenomas were analyzed. Results The patients with phyllodes tumors were older than the patients with fibroadenoma (mean standard error, 39.7 1.1 years vs. 33.4 0.3 years; P < 0.0001). Sixty-four percent of patients with phyllodes tumors were aged 3150 years, while 68.5% of those with fibroadenoma were aged 21 40 years. Phyllodes tumors were larger than fibroadenomas (5.90 0.43 cm vs. 1.95 0.03 cm; P < 0.0001). The ratio of length to anteroposterior diameter of phyllodes tumors was smaller than the ratio of length to anteroposterior diameter of fibroadenomas (1.72 0.06 vs. 1.89 0.02; P = 0.0105). Seventy-seven percent of phyllodes tumors were lobulated and 79.5% of fibroadenomas were oval. Lobulated shape of the tumor, heterogeneous echo pattern and absence of microcalcification are significant independent sonographic features in multiple logistic regression analysis to distinguish between phyllodes tumors and fibroadenoma. Benign, borderline and malignant phyllodes tumors displayed no significant differences in tumor size or the ratio of length to anteroposterior diameter. Conclusions There is a substantial overlap in the sonographic characteristics between phyllodes tumors and fibroadenoma of the breast. If lobulation and heterogeneous hypoechoic internal echoes are observed and calcifications are absent, a diagnosis of phyllodes tumors should be considered. Sonography cannot distinguish between malignant, borderline and benign phyllodes tumors.

INTRODUCTION
Phyllodes tumors of the breast are rare fibroepithelial tumors, accounting for 0.31.0% of breast tumors1,2. Although most phyllodes tumors occur in women aged 35 55 years1,3,4, cases of phyllodes tumors have occurred in adolescents and elderly women1,5,6. Although the histological criteria for the classification of phyllodes tumors are variable, they are generally divided into benign, borderline and malignant tumors5,7, or benign and malignant tumors8. Some investigators recommend follow-up of fibroadenomas with either mammography or sonography as an alternative to excision of the tumor9. On the other hand, surgery is the treatment of choice for phyllodes tumors because of their proclivity for local recurrence3,4,10,11. Benign phyllodes tumors should be treated by wide local excision and malignant tumors by mastectomy3,4,10. However, distinguishing them from fibroadenoma during physical examination is extremely difficult, except when they are quite large. At mammography, phyllodes tumors often present as welldefined, round or lobulated masses1214 resembling a fibroadenoma15,16. Fine needle aspiration cytology or core needle biopsy can accurately diagnose most breast pathologies17,18. Nevertheless, cytology and core needle biopsy may be incorrect or inconclusive; such misdiagnosis occurs most commonly when differentiating a benign phyllodes tumor from a fibroadenoma11,1922. Excisional biopsy is necessary and appropriate to confirm the diagnosis. It is difficult to persuade patients to undergo additional radical surgery after local excision and histological diagnosis of the disease and many patients decline to have this. Therefore, accurate preoperative diagnosis is necessary to avoid subsequent surgery. The sensitivity of mammographic detection diminishes in women with radiographically dense breasts23 25. Sonography is employed by many physicians to diagnose breast lesions in Chinese women since most of them have smaller and denser breasts than Western women26,27. Only a few

Correspondence: Dr Tzu-Chieh Chao, Department of Surgery, Chang Gung Memorial Hospital, 5 Fuhsing Street, Kweishan, Taoyuan, Taiwan (e-mail: tcchao@adm.cgmh.org.tw) Accepted 20-2-02

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Phyllodes tumors of the breast authors have reported on the sonographic features of phyllodes tumors12,13,28. This study aimed to analyze the sonographic findings and evaluate the function of sonography in the diagnosis of phyllodes tumors.

Chao et al. significant (P < 0.0001). Sixty-four percent of the patients with phyllodes tumors were aged 3150 years, while 68.5% of those with fibroadenomas were aged 21 40 years (Figure 1a). Fifty-eight (52.7%) phyllodes tumors and 1131 (51.3%) fibroadenomas occurred in the right breast and 52 (47.3%) phyllodes tumors and 1073 (48.7%) in the left. The tumors were grouped as T1 ( 2 cm), T2 (> 2 cm to 5 cm) and T3 (> 5 cm). Forty-three percent of phyllodes tumors exceeded 5 cm, while 66.4% of fibroadenomas were 2 cm or smaller (Figure 1b). Phyllodes tumors were larger than fibroadenomas (5.90 0.43 cm vs. 1.95 0.03 cm; P < 0.0001). On the other hand, L/APD of phyllodes tumors was smaller than L/APD of fibroadenomas (1.72 0.06 vs. 1.89 0.02; P = 0.0105). Table 1 presents the odds and the odds ratio of phyllodes tumors for the recorded sonographic features. Most of the phyllodes tumors were lobulated with an heterogeneous internal echo pattern, and most of the fibroadenomas were oval with an homogenous internal echo pattern. Smooth margins, mildly hypoechoic echogenicity, bilateral edge acoustic shadowing, compressibility of tumor and absence of microcalcification were commonly observed in both phyllodes tumors and fibroadenoma. All tumor descriptors were

METHODS
Breast sonography with prospective recording of the sonographic features was performed for 110 phyllodes tumors (93 patients) and 2204 fibroadenomas (2175 patients) during 199598. All patients were examined with the Aloka SSD-2000 ultrasound system (Aloka Co., Ltd, Tokyo, Japan) utilizing a 7.5-MHz linear array water-bath broadband transducer. The entire breast was systematically examined after physical examination. The following sonographic tumor descriptors were recorded: shape (round, oval, lobulated, irregular), margins (smooth, sharp, indistinct, irregular), internal echo pattern (homogeneous, heterogeneous), echogenicity (hyperechoic, isoechoic, mildly hypoechoic, markedly hypoechoic), retrotumor acoustic phenomenon (none, bilateral edge shadowing, posterior shadowing, posterior enhancement), compressibility of tumor with normal probe pressure and presence of microcalcifications. In retrotumor acoustic phenomenon, marked unilateral edge shadowing and central posterior shadowing were classified as posterior shadowing. The longest dimension of the tumor in the coronal plane indicated its size. The ratio of the length parallel to the skin (L) to anteroposterior diameter (APD) of the tumor was calculated to assess the degree of elongation of the tumor29. The final diagnosis of all tumors included was confirmed upon histological examination by either core needle biopsy or excisional biopsy. Phyllodes tumors were classified as benign, borderline or malignant based on the criteria proposed by Azzopardi7 and Salvadori et al.5, and adopted by WHO30, which include tumor margin (pushing or infiltrating), stromal cellularity (slight or severe), stromal overgrowth (absent, slight, or severe), tumor necrosis (present or absent), cellular atypia (absent, slight or severe) and number of mitoses per 10 high-power fields in the most mitotically active area of the slides. The results of the continuous data were expressed as mean standard error (SE). A two-tailed unpaired t-test using Statview statistical software (SAS Institute Inc., Cary, NC, USA) was performed for comparisons within groups. P < 0.05 was considered statistically significant. Statistics included odds and odds ratios of single sonographic tumor features. The odds ratio refers to how the presence of a given finding alters the risk of phyllodes tumors. Findings that are associated with increased risk of phyllodes tumors display odds ratios greater than 1.0. A dichotomization of the tumor descriptors into fibroadenoma and phyllodes tumors features was performed on the basis of the odds of phyllodes tumors.

RESULTS
The patients with phyllodes tumors were aged 1367 years (mean SE, 39.7 1.1 years) and patients with fibroadenomas were aged 14 85 years (mean SE, 33.4 0.3 years). The difference between the two groups was statistically
Figure 1 Distribution of phyllodes tumors () and fibroadenomae () of the breast for various groups of (a) age and (b) tumor size. Tumor size: T1, 2 cm; T2, > 2 cm to 5 cm; T3, > 5 cm.

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Phyllodes tumors of the breast dichotomized according to the most significant increase in the odds for phyllodes tumors (Table 1). The descriptor shape was dichotomized as lobulated vs. oval/round/irregular; margins as indistinct vs. smooth/sharp/irregular; echogenicity as markedly hypoechoic vs. hyperechoic/mildly hypoechoic; internal echo pattern as heterogeneous vs. homogeneous; retrotumor acoustic phenomenon as posterior shadowing vs. none/posterior enhancement/bilateral edge shadowing; compressibility of tumor as noncompressible vs. compressible; and microcalcification as absence vs. presence. The first dichotomized feature in each of the categories is the sonographic feature suspicious of phyllodes tumors. The seven tumor descriptors were analyzed by logistic regression with phyllodes tumors as the dependent variable. Table 2 summarizes the results of the logistic regression

Chao et al. analysis. Shape of the tumor, internal echo pattern and presence of microcalcification are significant independent sonographic features to distinguish between phyllodes tumors and fibroadenoma. Of 110 phyllodes tumors, 76 (69.1%) were benign tumors, 11 (10.0%) were borderline tumors and 23 (20.0%) were malignant tumors. The mean age of the patients with benign, borderline and malignant phyllodes tumors was 39.1 1.4, 42.6 3.6 and 40.2 1.9 years, respectively. The difference between the groups was statistically insignificant. Sixty-six percent of benign tumors, 45.5% of borderline tumors and 69.6% of malignant tumors occurred in the patients aged 3150 years (Figure 2a). Benign (range, 0.620 cm; mean SE, 5.6 0.5 cm), borderline (range, 1.019 cm; mean SE, 6.2 1.5 cm) and malignant (range, 1.518 cm; mean SE,

Table 1 Odds of phyllodes tumors and odds ratio for each sonographic feature in phyllodes tumors and fibroadenoma Phyllodes tumors (n = 110), n (%) Shape of tumor Oval Round Lobulated Irregular Margins Smooth Sharp Sharp/indistinct Indistinct Irregular Echogenicity Hyperechoic Mildly hypoechoic Markedly hypoechoic Internal echo pattern Homogeneous Heterogeneous Retrotumor acoustic phenomenon None Posterior enhancement Bilateral edge shadowing Posterior shadowing Compressibility of tumor Yes No Microcalcification Yes No Fibroadenoma (n = 2204), n (%) Odds of phyllodes tumors

Odds ratio

22 (20.0) 1 (0.9) 85 (77.3) 2 (1.8) 97 (88.2) 3 (2.7) 1 (0.9) 7 (6.4) 2 (1.8) 4 (3.6) 89 (80.9) 17 (15.6) 39 (35.4) 71 (64.6) 41 (37.3) 6 (5.5) 46 (41.8) 17 (15.5) 77 (70.0) 33 (30.0) 2 (1.8) 108 (98.2)

1751 (79.5) 129 (5.8) 222 (10.1) 102 (4.7) 1842 (83.6) 60 (2.7) 154 (7.0) 40 (1.8) 108 (4.9) 69 (3.1) 1904 (86.4) 231 (10.5) 1907 (86.5) 298 (13.5) 839 (38.1) 233 (10.6) 1108 (50.3) 24 (1.1) 1996 (90.6) 208 (9.4) 85 (3.9) 2119 (96.1)

0.012 0.008 0.383 0.020 0.053 0.050 0.007 0.175 0.019 0.058 0.047 0.074 0.021 0.238 0.049 0.026 0.042 0.708 0.039 0.159 0.024 0.051

1.62 1.00 49.40 2.50 7.57 7.14 1.00 25.00 2.71 1.24 1.00 1.58 1.00 11.65 1.91 1.00 1.62 27.63 1.00 4.12 1.00 2.17

Table 2 Multiple logistic regression analysis of dichotomized tumor descriptors in 2314 breast tumors 95% confidence interval of odds ratio 0.027 0.078 0.2552.973 0.5502.814 0.1140.335 0.6173.211 0.3241.280 0.0420.917

Coefficient Shape Margins Echogenicity Internal echo pattern Retrotumor acoustic phenomenon Compressibility Microcalcification SE, standard error of coefficient. 3.089 0.138 0.219 1.635 0.342 0.441 1.624

SE 0.273 0.626 0.416 0.275 0.421 0.351 0.785

Chi-square 128.150 0.048 0.275 35.212 0.661 1.576 4.286

Odds ratio 0.046 0.871 1.244 0.195 1.408 0.644 0.197

P < 0.0001 0.8260 0.5997 < 0.0001 0.4163 0.2093 0.0384

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Phyllodes tumors of the breast 6.8 0.9 cm) tumors did not significantly differ in size. Forty percent of benign tumors, 36.4% of borderline tumors and 56.5% of malignant tumors exceeded 5 cm (Figure 2b). Furthermore, L/APD ratio of benign (range, 1.002.95; mean SE, 1.72 0.06), borderline (range, 0.723.68, mean SE, 1.89 0.30) and malignant (range, 1.002.87, mean SE, 1.65 0.11) tumors did not significantly differ. Table 3 displays the sonographic features of benign, borderline and malignant phyllodes tumors. Microcalcification was rarely present and intramural cysts were discovered in only three tumors (two benign and one malignant). No sonographic features specifically distinguished between malignant, borderline and benign phyllodes tumors (Figures 3 6).

Chao et al. 3-MHz transducer (six benign phyllodes tumor, one with coexistent invasive papillary carcinoma and one with coexistent in situ ductal carcinoma and in situ lobular carcinoma). They demonstrated that a typical phyllodes tumor is an ovoid or lobulated, smooth walled mass exhibiting weak or intermediate internal echoes. The internal echoes were either uniform or scattered. Buchberger et al.12 reviewed sonographic findings in 10 phyllodes tumors (nine benign tumors and one malignant tumor). All 10 tumors were circumscribed with smooth margins and had weak or intermediate-level internal echoes. Seven of them were lobulated, two were oval and one was round. In another sonographic study of 30 phyllodes tumors, Liberman et al.28 did not describe the shape and margins of the tumor, but they showed that most of the malignant and benign phyllodes tumors exhibited hypoechoic internal echotexture and retrotumor acoustic enhancement. In addition, representative tumors displayed an heterogeneous internal echo pattern26. In a recent study of 12 phyllodes tumors, Jorge Blanco et al.21 indicated that all tumors were smooth margined and 10 of them were lobulated. The internal echo pattern was heterogeneous in seven and homogeneous in three. These findings imply that most phyllodes tumors are lobulated and have an heterogeneous internal

DISCUSSION
Most of the phyllodes tumors in the present study were lobulated tumors with smooth margins, mildly hypoechoic internal echoes and an heterogeneous internal echo pattern (Table 1, Figures 36). Descriptions of the sonographic features of phyllodes tumors in the literature are rare. In 1983, Cole-Beuglet et al.13 described ultrasound findings in eight phyllodes tumors studied with water-path scanners and a

Figure 2 Distribution of benign (), borderline ( ) and malignant ( ) phyllodes tumor of the breast for various groups of (a) age and (b) tumor size. Tumor size: T1, 2 cm; T2, > 2 cm to 5 cm; T3, > 5 cm.

Figure 3 Ultrasound images of benign phyllodes tumor. (a) A palpable left breast tumor in a 25-year-old woman. The image reveals a 2-cm, oval, mildly hypoechoic tumor with smooth margins, homogeneous internal echo pattern and no retrotumor acoustic phenomenon. (b) A right breast tumor in a 38-year-old woman. The image reveals a 4-cm, oval, mildly hypoechoic tumor with smooth margins, homogeneous internal echo pattern, bilateral edge shadowing and posterior acoustic enhancement. (c) A palpable right breast tumor in a 36-year-old woman. The image reveals a 1.8-cm, round, markedly hypoechoic tumor with smooth margins, homogeneous internal echo pattern and bilateral edge shadowing. (d) A right breast tumor in a 45-year-old woman. The image reveals a 5.5 cm, lobulated, mildly hypoechoic tumor with smooth margins, homogeneous internal echo pattern and no retrotumor acoustic phenomenon.

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Phyllodes tumors of the breast echo pattern. On the other hand, a fibroadenoma generally has oval contours with an homogeneous internal echo pattern. In the present series, only 10.1% of fibroadenomas displayed lobulated contours and 13.5% had an heterogeneous internal echo pattern (Table 1). Our findings are consistent with those reported by other investigators29,31,32. Lobulated tumors are discovered in only 1522% of fibroadenomas and an heterogenous internal echo pattern in 1235% of the lesions29,31,32. Sonography is less sensitive than mammography in detecting microcalcification. However, the currently popular high-frequency transducers can demonstrate a higher percentage of mammographically visible calcifications than lower-frequency transducers3335. Calcifications appear as bright punctate echoes. Mirocalcification is more seldom present in benign breast lesions36; however, 3.9% of fibroadenomas in this series displayed microcalcification. In contrast, only two phyllodes tumors presented microcalcification (Table 1). Absence of microcalcification, in addition to lobulated shape and heterogeneous internal echo pattern, comprises a significant independent sonographic feature in multiple logistic regression analysis. Therefore, lobulated tumors, heterogeneous internal echo texture and absence of microcalcifications are characteristic sonographic features to distinguish between phyllodes tumors and fibroadenoma. Retrotumor acoustic phenomenon is one of the sonoTable 3 Descriptive sonographic characteristics of phyllodes tumors Sonographic findings Shape Round Oval Lobulated Irregular Margins Smooth Sharp Sharp/indistinct Indistinct Irregular Echogenicity Hyperechoic Isoechoic Mildly hypoechoic Markedly hypoechoic Internal echo pattern Homogeneous Heterogeneous Retrotumor acoustic shadowing None Posterior enhancement Bilateral edge shadowing Posterior shadowing Compressibility Compressible Noncompressible Microcalcification Yes No Intramural cysts Yes No Benign (n = 76) Borderline (n = 11) Malignant (n = 23)

Chao et al. graphic characteristics to differentiate between benign and malignant breast tumors32,3639. Posterior enhancement is considered an indeterminate sonographic feature and posterior shadowing a feature of a malignant tumors32,36,38,39. Posterior enhancement was observed in 5077% of phyllodes tumors in the studies of Cole-Beuglet et al.13, Buchberger et al.12 and Liberman et al.28, but posterior shadowing was only seen in 07% of cases. However, posterior shadowing was demonstrated in 15.5% of phyllodes tumors and posterior enhancement in only 5.5% of tumors in the present study (Table 1). On the other hand, bilateral edge shadowing was discovered in 41.8% of phyllodes tumors (43.4% of benign, 45.5% of borderline and 34.8% of malignant tumors) and in 50.3% of fibroadenomas. There is no description of bilateral edge shadowing of phyllodes tumors in the published literature. Such shadowing is considered to be a characteristic sonographic feature of benign breast tumors32,36,38,39. Our findings suggest that the retrotumor acoustic phenomenon does not characterize phyllodes tumors and it is not a significant feature to distinguish benign from malignant phyllodes tumors. Cole-Beuglet et al.13 reported an intramural cyst in a phyllodes tumor. They proposed that the diagnosis of phyllodes tumor should be considered if intramural cysts within a large, lobulated, solid breast mass were imaged. In the studies of Buchberger et al.12, Liberman et al.28 and Jorge Blanco

Total (n = 110)

0 19 56 1 68 3 1 3 1 3 1 63 9 29 47 29 2 33 12 59 17 2 74 2 74

1 1 9 0 9 0 0 2 0 0 0 8 3 4 7 3 2 5 1 6 5 0 11 0 11

0 2 20 1 20 0 0 2 1 0 0 18 5 6 17 9 2 8 4 12 11 0 23 1 22

1 22 85 2 97 3 1 7 2 3 1 89 17 39 71 41 6 46 17 77 33 2 108 3 107

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Phyllodes tumors of the breast et al.21, intramural cysts were present in six of 10 (60%), seven of 30 (23%) and eight of 12 (66.7%) tumors, respectively. However, intramural cysts, suggesting focal necrosis or degeneration, were not frequently observed in the phyllodes tumors in the present study (Table 2). Therefore, intramural cysts are not pathognomonic for phyllodes tumors. Intramural cysts can occasionally be observed in other well-circumscribed tumors, such as medullary carcinoma or fibroadenoma40. Some investigators have employed tumor size to indicate malignant phyllodes tumor4,28,41. Hawkins et al.41 reported that tumors larger than 10 cm displayed a higher incidence of metastases. Liberman et al.28 reported that tumors 3 cm or greater at mammography suggested malignancy. In a recent study of 55 patients affected by phyllodes tumors, Zissis et al.4 revealed that the median size of benign and malignant phyllodes tumors was 3 cm and 7.25 cm, respectively. However, although malignant tumors were larger than benign tumors in the present series, benign and malignant phyllodes tumors were of similar size. Our findings resemble those of Reinfuss et al.3. In their study of 170 phyllodes tumors, 66.3% (61/92) of benign tumors and 66.1% (39/59) of malignant tumors exceeded 5 cm. Tumor size is therefore not

Chao et al. a characteristic indicator of malignant phyllodes tumors. Sonographic characteristics are employed to differentiate benign from malignant breast tumors. These characteristics overlap somewhat36,39,42 but the characteristic sonographic findings of benign tumors include round or oval shape, mildly hypoechoic internal echotexture, smooth borders or a pseudocapsule, homogeneous internal echoes, no central posterior acoustic shadowing, normal surrounding tissue and slight change of shape by probe pressure compression29,32,36,37,43 45. Typical features of malignant breast tumors include irregular shape, irregular margins, marked hypoechogenicity, a surrounding echogenic rim or halo and posterior acoustic shadowing29,36,37,43,4547. In the present study, 15.6% of phyllodes tumors displayed marked hypoechogenicity and 15.5% exhibited posterior acoustic shadowing (Table 1). On the other hand, many phyllodes tumors reveal sonographic features suggesting benign lesions, such as smooth margins (88.2%), mild hypoechogenicity (80.9%) and bilateral edge shadowing (41.8%) (Table 1). In conclusion, our findings demonstrate a substantial overlap in sonographic characteristics between phyllodes tumors and fibroadenoma. The patients with phyllodes tumors were older than those with fibroadenoma. The mean size of phyllodes tumors exceeded that of fibroadenomas. Most

Figure 4 Ultrasound images of benign phyllodes tumor. (a) A left breast tumor in a 42-year-old woman. The image reveals an oval, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and marked unilateral edge acoustic shadowing. (b) A left breast tumor in a 32-year-old woman. The image reveals a 2.1-cm, lobulated, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and marked unilateral edge shadowing. (c) A left breast tumor in a 46-year-old woman. The image reveals a 9-cm, lobulated, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and bilateral edge shadowing. (d) A left breast tumor in a 41-year-old woman. The image reveals a 2.5-cm, lobulated, mildly hypoechoic tumor with heterogeneous internal echo pattern and marked bilateral edge shadowing. The margins are smooth in the upper part of the tumor and indistinct in the lower part.

Figure 5 Ultrasound images of borderline phyllodes tumor. (a) A right breast tumor in a 56-year-old woman. The image reveals a 5-cm, oval, markedly hypoechoic tumor with smooth margins, homogeneous internal echo pattern, bilateral edge shadowing and posterior enhancement. (b) A palpable right breast tumor in a 39-year-old woman. The image reveals a 4.2-cm, lobulated, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and marked unilateral edge acoustic shadowing. (c) A right breast tumor in a 46-yearold woman. The image reveals a 2.8-cm, lobulated, mildly hypoechoic tumor with smooth margins, intramural echogenic septum and no retrotumor acoustic phenomenon.

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Phyllodes tumors of the breast

Chao et al.
3 Reinfuss M, Mitus J, Duda K, Stelmach A, Rys J, Smolak K. The treatment and prognosis of patients with phyllodes tumor of the breast. Cancer 1996; 77: 910 6 4 Zissis C, Apostolikas N, Konstantinidou A, Griniatsos J, Vassilopoulos PP. The extent of surgery and prognosis of patients with phyllodes tumor of the breast. Breast Cancer Res Treat 1998; 48: 20510 5 Salvadori B, Cusumano F, Del Bo R, Delledonne V, Grassi M, Rovini D, Saccozzi R, Andreola S, Clemente C. Surgical treatment of phyllodes tumors of the breast. Cancer 1989; 63: 2532 6 6 Keelan PA, Myers JL, Wold LE, Katzmann JA, Gibney DJ. Phyllodes tumor: clinicopathologic review of 60 patients and flow cytometric analysis in 30 patients. Hum Pathol 1992; 23: 104854 7 Azzopardi JG. Sarcoma in the breast. In Benningron J, ed. Problems in Breast Pathology, vol. II. Major Problems in Pathology. Philadelphia: WB Saunders Company, 1979: 355 9 8 Treves N, Sunderland DA. Cystosarcoma phyllodes of the breast: a malignant and benign tumor. A clinicopathological study of seventyseven cases. Cancer 1951; 4: 1286332 9 Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology 1991; 179: 463 8 10 Mangi AA, Smith BL, Gadd MA, Tanabe KK, Ott MJ, Souba WW. Surgical management of phyllodes tumors. Arch Surg 1999; 134: 48773 11 de Roos WK, Kaye P, Dent DM. Factors leading to local recurrence or death after surgical resection of phyllodes tumors of the breast. Br J Surg 1999; 86: 396 9 12 Buchberger W, Strasser K, Heim K, Muller E, Schrocksnade H. Phylloides tumor: findings on mammography, sonography, and aspiration cytology in 10 cases. AJR Am J Roentgenol 1991; 157: 715 9 13 Cole-Beuglet C, Soriano RZ, Kurtz AB, Meyer JE, Kopans DB, Goldberg BB. Ultrasound, X-ray mammography, and histopathology of cystosarcoma phylloides. Radiology 1983; 146: 481 6 14 Feder JM, de Paredes ES, Hogge JP, Wilken JJ. Unusual breast lesions: radiologic-pathologic correlation. Radiographics 1999; 19: S1126 15 Cosmacini P, Zurrida S, Veronesi P, Bartoli C, Coopmans de Yoldi GF. Phyllodes tumor of the breast: mammographic experience in 99 cases. Eur J Radiol 1992; 15: 11 4 16 Page JE, Williams JE. The radiologic features of phyllodes tumor of the breast with clinico-pathological correlation. Clin Radiol 1991; 44: 812 17 Meyer JE, Smith DN, Lester SC, Kaelin C, DiPiro PJ, Denison CM, Christian RL, Harvey SC, Selland DL, Durfee SM. Large-core needle biopsy of nonpalpable breast lesions. JAMA 1999; 281: 1638 41 18 Florentine BD, Cobb CJ, Frankel K, Greaves T, Martin SE. Core needle biopsy. A useful adjuvant to fine-needle aspiration in selected patients with palpable lesions. Cancer 1997; 81: 33 9 19 Dershaw DD, Liberman L. Stereotactic breast biopsy: indications and results. Oncology 1998; 12: 90716 20 Shimizu K, Masawa N, Yamada T, Okamoto K, Kanda K. Cytologic evaluation of phyllodes tumors as compared to fibroadenomas of the breast. Acta Cytol 1994; 38: 8917 21 Jorge Blanco A, Vargas Serrano B, Rodriguez Romero R, Martinez Cendejas E. Phyllodes tumors of the breast. Eur Radiol 1999; 9: 356 60 22 Berg WA, Hruban RH, Kumar D, Singh HR, Brem RF, Gatewood OM. Lessons from mammographic-histologic correlation of large-core needle breast biopsy. Radiographics 1996; 16: 1111 30 23 Ma L, Fishell E, Wright B, Hanna W, Allan S, Boyd NF. Case control study of factors associated with failure to detect breast cancer by mammography. J Natl Cancer Inst 1992; 84: 7815 24 Fajardo L, Hillman BJ, Frey C. Correlation between breast parenchymal patterns and mammographers certainty of diagnosis. Invest Radiol 1988; 23: 505 8 25 Jackson VP, Hendrick RE, Feig SA, Kopans DB. Imaging of the radiographically dense breast. Radiology 1993; 188: 297301 26 Alagaratnam TT, Wong J. Limitations of mammography in Chinese females. World J Surg 1985; 36: 1757

Figure 6 Ultrasound images of malignant phyllodes tumor. (a) A palpable right breast tumor in a 30-year-old woman. The image reveals a 4.6-cm, oval, mildly hypoechoic tumor with smooth margins, homogeneous internal echo pattern and no retrotumor acoustic phenomenon. (b) A left breast tumor in a 43-year-old woman. The image reveals a 2.7-cm, lobulated, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and marked unilateral edge shadowing. (c) A left breast tumor in a 48-year-old woman. The image reveals a 9.5-cm, lobulated, markedly hypoechoic tumor with indistinct margins, heterogeneous internal echo pattern, marked bilateral edge shadowing and posterior enhancement. (d) A right breast tumor in a 32-year-old woman. The image reveals a 3-cm, lobulated, mildly hypoechoic tumor with smooth margins, heterogeneous internal echo pattern and posterior acoustic shadowing.

phyllodes tumors were well-defined, lobulated tumors with mildly hypoechoic internal echoes, smooth margins and had an heterogeneous internal echo pattern. Lobulated shape, heterogeneous internal echo pattern and absence of microcalcification were significant independent sonographic features to distinguish phyllodes tumors from fibroadenomas in the multiple logistic regression analysis. Sonography cannot distinguish between malignant, borderline and benign phyllodes tumors. Color Doppler sonography has been used to distinguish malignant from benign tumors4851; however, the reliability of color Doppler sonography in the diagnosis of phyllodes tumors requires further study. If sonographic features suggest phyllodes tumors, excisional biopsy should be performed to establish an accurate diagnosis.

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