Navigating the Surgical Nuances of Inflammatory Breast Cancer and Phyllodes Tumors

The management of rare and aggressive breast pathologies requires a delicate balance between oncologic rigor and the preservation of patient quality of life. For inflammatory breast cancer and phyllodes tumors, the standard surgical playbook is rapidly evolving.

In an interview hosted by CancerNetwork^®, Kathie-Ann Joseph, MD, MPH, FACS, discussed how advancements in neoadjuvant systemic therapy are opening doors for breast conservation in inflammatory breast cancer, a disease traditionally requiring radical excision. She also clarified the shifting margin requirements for the phyllodes spectrum, highlighting the move away from aggressive 1-cm margins for benign cases toward a more nuanced, pathology-driven approach for malignant presentations.

Joseph is chief of breast surgery and codirector of the Breast Oncology Program at Rutgers Cancer Institute and Jack & Sheryl Morris Cancer Center; associate chief surgical officer for system integration and quality at RWJBarnabas Health; director of breast surgical services for RWJBarnabas Health Southern Region; and professor of surgery at Rutgers Robert Wood Johnson Medical School.

Transcript:

Inflammatory breast cancers are something that requires multidisciplinary care. Usually, these patients get chemotherapy up front. They’re usually not surgical candidates right off the bat. What’s great is that there are more patients now who are having such a great response. What happens is these patients are presenting with what we call peau d’orange, which is French for orange peel. The patient’s breast looks like an orange peel. That’s because the lymphatics, the dermal lymphatics, the lymphatics in the skin, are filled with tumor cells. If the skin already has a tumor in it and it’s usually diffuse, we generally can’t preserve the skin, and so we have to do a mastectomy. With the advances in the treatment options, there’s a growing number of patients who have what we call a complete pathological response. That means that not only is there a complete pathological response of the tumor in the breast and the lymph nodes but also in the skin as well. There’s an evolving change in how we’re managing this, and we’re often offering certain patients breast conservation, which is nice.

With phyllodes tumors, there are different types of phyllodes tumors. There are benign phyllodes tumors, and there are also malignant tumors as well. The malignant ones are the ones that we’re most concerned about. It’s important in those situations that we get clear margins and wider margins, because we don’t want them to recur. They’re not your garden-variety invasive cancers that we like to think about when patients come in, the benign ones, [that] we know that we can get as long as we don’t have positive margins, [where] they’re good and we can just follow them. They’re a spectrum of a disease. We’re learning more and more about them. We used to think that, in the past, we had to get all of them, we had to have 1-cm margins around them. We’re taking a lot of tissue from these women. We know that for the benign phyllodes tumors, as long as there’s no tumor on the ink and the pathology report says that the margins are good, it could be a 1-mm margin. We’re usually good, and we don’t have to take as much. For these borderline and malignant phyllodes tumors, it’s important to get as clear a margin as possible. If you can get 1 cm, that’s important. That would be golden. If you need to get a mastectomy to achieve that, then you should. A lot of times, it’s not necessary. It just depends on the size of the tumor.