What is the recommended treatment approach for a patient with a malignant and recurrent phyllodes tumor of the breast with axillary lymph node involvement after a simple mastectomy?

Treatment of Malignant and Recurrent Phyllodes Tumor with Axillary Lymph Node Involvement Post-Simple Mastectomy

For this rare presentation of malignant recurrent phyllodes tumor with proven axillary lymph node metastasis after simple mastectomy, you should proceed with completion axillary lymph node dissection followed by adjuvant radiotherapy to the chest wall and regional nodes, plus consideration of systemic chemotherapy using a sarcoma-based regimen such as doxorubicin plus ifosfamide. 1, 2, 3

Surgical Management of Axillary Disease

Complete the axillary lymph node dissection (levels I-II) since pathologic lymph node involvement is confirmed. 1, 2, 4

• While phyllodes tumors rarely metastasize to lymph nodes (prevalence 1.1-3.8%), when proven metastatic disease exists, axillary dissection is warranted 2, 4
• The standard teaching that "axillary staging is not necessary" applies only to clinically negative nodes—your patient has proven nodal involvement, which changes management 5, 6
• Aim to retrieve at least 10 lymph nodes for accurate staging, extending dissection to level III only if gross disease is apparent in level II nodes 7

Critical pitfall to avoid: Do not skip axillary dissection based on general phyllodes guidelines that state "no axillary staging needed"—those recommendations apply to clinically node-negative disease 6. Your patient has pathologically confirmed nodal metastasis, making this a rare but documented scenario requiring complete surgical clearance 2, 4.

Adjuvant Radiotherapy Strategy

Administer post-mastectomy radiotherapy to the chest wall and regional lymph nodes given the combination of recurrent disease, malignant histology, and proven nodal involvement. 7, 5, 1

• Post-mastectomy RT is strongly recommended for patients with involved axillary nodes 7
• Target the chest wall to 50-60 Gy using standard fractionation or hypofractionated schemes (15-16 fractions at 2.5-2.67 Gy) 7
• Include regional nodal irradiation (supraclavicular and axillary regions) given documented nodal involvement 7
• For recurrent malignant phyllodes specifically, radiotherapy improves local control from 34-42% to 90-100% at 5 years, though it does not improve overall survival 5
• The National Comprehensive Cancer Network specifically recommends radiotherapy when "additional recurrence would create significant morbidity," which applies to your post-mastectomy recurrent scenario 5, 1

Accelerated hypofractionated radiotherapy has shown effectiveness in locoregional control of malignant phyllodes tumors with acceptable toxicity. 3

Systemic Chemotherapy Considerations

Consider palliative/adjuvant chemotherapy using sarcoma-based regimens, as phyllodes tumors are sarcomas and approximately 20% of malignant phyllodes develop distant metastasis. 2, 3, 8

Recommended chemotherapy regimens based on available evidence:

• Doxorubicin plus ifosfamide has demonstrated complete remission in metastatic malignant phyllodes 8
• Nab-paclitaxel, cisplatin, and liposomal doxorubicin (biweekly for 12 cycles) achieved complete regression of lung metastases in a recurrent malignant phyllodes case 3
• The combination regimen showed acceptable toxicity and high effectiveness in eradicating metastatic lesions 3

Important caveat: While general phyllodes guidelines state chemotherapy has "no proven role," these recommendations are based on routine adjuvant use in early-stage disease 6. Your patient has high-risk features (malignant histology, recurrence, nodal metastasis) that warrant treating this as a soft tissue sarcoma with aggressive systemic therapy 1, 3, 8.

Surveillance for Distant Metastasis

Obtain chest CT imaging immediately, as the lung is the most common site of distant metastasis in malignant phyllodes tumors. 1, 2, 8, 4

• Approximately 20% of patients with malignant phyllodes develop distant metastasis, predominantly to lungs 2
• Synchronous lung metastases have been documented at presentation in cases with nodal involvement 4
• If pulmonary metastases are identified, treat according to soft tissue sarcoma guidelines with consideration of aggressive multimodal therapy 6, 3, 8

Multidisciplinary Management Approach

Refer this patient to a specialist sarcoma center for pathology review and multidisciplinary team discussion involving both breast cancer and sarcoma specialists. 5, 1, 6

• Malignant phyllodes tumors should be discussed at both breast cancer and sarcoma multidisciplinary team meetings to ensure appropriate risk stratification 5, 6
• This ensures coordination between surgical oncology, radiation oncology, and medical oncology with sarcoma expertise 5, 1

What NOT to Do

• Do not use endocrine therapy—despite 58% containing ER and 75% containing PR, hormonal therapy does not reduce recurrence or death in phyllodes tumors 6
• Do not omit radiotherapy based on older guidelines stating RT has "no proven benefit"—newer evidence shows significant local control improvement in high-risk cases 5, 1
• Do not treat internal mammary nodes routinely—phyllodes are sarcomas, not epithelial breast cancers, and nodal metastases beyond the axilla are exceedingly rare 5
• Do not consider immediate reconstruction—delay reconstruction until after radiotherapy completion and when local recurrence risk has diminished (typically 2 years) 5, 6

Prognostic Considerations

Your patient faces significant risk given the combination of malignant histology, recurrence, and the exceptionally rare finding of nodal metastasis. 2, 4

• The 5-year disease-free survival for malignant phyllodes is 66.1%, but nodal involvement likely worsens this prognosis 6
• Axillary node metastasis occurs in less than 1% of phyllodes cases, making this an extremely high-risk presentation 2, 9
• However, aggressive multimodal treatment including surgery, radiotherapy, and chemotherapy has achieved complete remission even in metastatic cases 3, 8