The prognosis of benign and malignant phyllodes tumors is variable (154,155,157,162,172).
Tumors judged to be benign phyllodes tumors can recur locally in up to 10% of patients (159–161). Recurrence is associated with margin involvement, whereas mortality correlates with size and grade (173). In a series reviewing only high-grade malignant phyllodes tumors, size and excision margins were associated with local recurrence and metastatic spread, and mastectomy may be required to achieve complete surgical excision (174). Malignant phyllodes tumors tend to recur locally and occasionally may metastasize to the lung, although brain, pelvic, and bone metastases also may occur (160–162). The stromal component of the tumor is malignant and metastasizes, behaving like a sarcoma. Axillary involvement is extremely unusual. Often, the appearance of metastasis is the first sign that a phyllodes tumor is malignant.
Chemotherapy for metastatic phyllodes tumors should be based on regimens for sarcoma, not adenocarcinoma (159). Radiation therapy generally is not used in the treatment of phyllodes tumors. In the presence of a bulky tumor, positive margins, recurrence, or malignant histology, radiation therapy may be of some benefit (175).
Nipple Discharge Nipple discharge is a presenting breast symptom in 4.5% of patients seeking evaluation of a breast symptom, with 48% spontaneous and 52% provoked (176). Nipple discharge that does not occur spontaneously has no pathologic significance. Provoked or self-induced nipple discharge should be managed by reassurance and instruction to discontinue manipulation. Spontaneous nipple discharge is more likely to be associated with an underlying pathologic problem than provoked discharge. Although it is a distressing finding, spontaneous nipple discharge is infrequently found to be associated with carcinoma, ranging from 4% to 10% (176–178). Nipple discharge can be caused by neoplastic or nonneoplastic processes (179). Nonneoplastic processes include galactorrhea, physiologic changes resulting from mechanical manipulation, parous condition, periductal mastitis, subareolar abscess, fibrocystic change, and mammary duct ectasia. Neoplastic causes of nipple discharge in nonlactating women are solitary intraductal papilloma, carcinoma, papillomatosis, squamous metaplasia, and adenosis (176,179,180). Extramammary causes are related to hormones and drugs (179). Following are the important characteristics of the discharge and other factors to be evaluated by history and physical examination (180): 1.
Nature of discharge (serous, bloody, or milky) 2.
Association with a mass 3.
4.
5.
Discharge that is spontaneous (persistent or intermittent) or expressed by pressure at a single site or on entire breast 6.
Relation to menses 7.
8.