Phyllodes Tumor
A Clinicopathologic and Immunohistochemical Study of 30 Cases
Nicole Nicosia Esposito, MD; Deepak Mohan, MD; Adam Brufsky, MD, PhD; Yan Lin, PhD;
Malathy Kapali, MD; David J. Dabbs, MD
● Context.—Phyllodes tumors (PTs) of the breast are bi-
phasic neoplasms composed of epithelium and a spindle-
cell stroma. Currently, PTs are classified as benign, bor-
derline, or malignant based on histopathologic features.
However, histologic classification does not always predict
outcome.
Objective.—To determine the prognostic value of a va-
riety of clinicopathologic features and immunoreactivities
in PTs.
Design.—Sixteen benign, 8 borderline, and 6 malignant
PTs with follow-up were examined for reactivity across a
panel of immunohistochemical stains, including c-Kit, en-
dothelin 1, p16, p21, p53, and Ki-67. Clinicopathologic
features, including stromal cellularity, mitotic rate, and
margin status, were also assessed. Tumor variables were
compared among tumor subgroups and between tumors
that did and did not recur.
F ibroepithelial tumors of the breast represent a hetero-
geneous group of biphasic neoplasms that range from
benign to malignant and include fibroadenomas and phyl-
lodes tumors (PTs). Phyllodes tumors, first fully charac-
terized by Johannes Müller in 1838,1 constitute 0.3% to 1%
of all breast neoplasms and were considered benign until
the first reported case of a metastatic PT in 1931.2 The term
cystosarcoma phyllodes was initially described by Müller
based on the tumor’s ‘‘leaflike’’ projections into cystic
spaces and sarcomatous stroma. This term has since been
discouraged, as more than 70% of these lesions follow a
benign course and only rarely exhibit cystic degeneration.3
Clinically, PTs resemble fibroadenomas but tend to oc-
cur in older women. They appear mammographically as
lobulated round or oval masses with well-circumscribed
borders and rarely contain calcifications.4,5 Histologically,
PTs are characterized by a double-layered epithelial com-
Accepted for publication March 13, 2006.
From the Departments of Pathology (Dr Esposito) and Biostatistics
(Dr Lin), University of Pittsburgh, Pittsburgh, Pa; the Department of
Pathology, Cedar Sinai Medical Center, University of California, Los
Angeles (Dr Mohan); and the Departments of Hematology/Oncology
(Dr Brufsky) and Pathology (Drs Kapali and Dabbs), Magee-Womens
Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pa.
The authors have no relevant financial interest in the products or
companies described in this article.
Reprints: Nicole Nicosia Esposito, MD, Pathology Resident, Depart-
ment of Pathology, University of Pittsburgh, C901 PUH, 200 Lothrop
St, Pittsburgh, PA 15213 (e-mail: espositonc@upmc.edu).
1516 Arch Pathol Lab Med—Vol 130, October 2006
Results.—Of the 30 PTs, 4 recurred (1 benign, 2 bor-
derline, 1 malignant). One patient with a malignant tumor
died of metastatic disease 34 months after initial diagnosis.
The overall positive rate of c-Kit immunoreactivity was
13% in benign, 63% in borderline, and 67% in malignant
PTs. Endothelin 1 epithelial cytoplasmic staining was seen
in 100% of benign, 50% of borderline, and 17% of malig-
nant PTs. Additionally, p16, p21, p53, and Ki-67 were dif-
ferentially expressed among benign, borderline, and malig-
nant tumors. Positive surgical resection margins was the
only variable that significantly predicted recurrent disease
(P ⴝ .02).
Conclusions.—Stromal c-Kit positivity and epithelial en-
dothelin 1 negativity are more often associated with ma-
lignant PTs; however, only positive margin status is signif-
icantly associated with tumor behavior.
(Arch Pathol Lab Med. 2006;130:1516–1521)
ponent arranged in cleftlike ducts surrounded by a hy-
percellular spindle-celled stroma. The stromal component
is prominent and can show morphologic patterns that
range from fibroadenoma-like to frankly sarcomatous.
Standard therapy includes complete excision with a min-
imal 1-cm margin.3,6 Overall recurrent and metastatic rates
range from 8% to 40% and 1% to 21%, respectively.5,7,8
Currently, PTs are classified as benign, borderline, or
malignant based on gross and microscopic features, in-
cluding stromal cellularity, cellular pleomorphism, mitotic
activity, margin appearance, and stromal distribution.9
Prognostic assessments based solely on histologic classi-
fication, however, can be problematic. For example, histo-
logically benign PTs have reportedly metastasized, and
many histologically malignant PTs neither recur nor me-
tastasize.3,10,11 Ancillary diagnostic tools may help to iden-
tify tumors with potentially aggressive behavior. Recently
described methods to meet this objective include immu-
nohistologic assessment of p53, Ki-67, and c-Kit.12–27
Mutations of the p53 tumor suppressor gene are one of
the most common genetic abnormalities in cancer and are
associated with increased expression in tumor cells by im-
munohistochemistry, apparently reflective of accumula-
tion of mutant p53 molecules bound to heat-shock pro-
teins. MIB-1 is a monoclonal antibody that reacts with Ki-
67, a nuclear antigen expressed in non-G0 proliferating
cells.28 Both p53 and Ki-67 have been shown to be useful
predictors of prognosis in some tumors, including endo-
metrial cancer,29 extragastrointestinal stromal tumors,30
and breast carcinoma.31
Phyllodes Tumor: A Study of 30 Cases—Esposito et al
 Table 1. List of Histologic and Immunohistochemical
Variables Examined
Histology Immunohistochemistry
Stromal cellularity p16
Mitotic rate p21
Margin status p53
Ki-67
c-Kit
Endothelin 1
Overexpression of the c-kit oncogene, which encodes a
tyrosine kinase transmembrane receptor protein, charac-
terizes gastrointestinal stromal tumors that, like PTs, show
a spectrum of behavior from benign to malignant. The
finding of c-Kit overexpression in these tumors led to the
development of targeted therapy with the Kit receptor ty-
rosine kinase inhibitor, imatinib mesylate (STI571).32 c-Kit
expression in PTs has recently been described, though
convincing c-kit mutations in these tumors are lack-
ing.20,25,27
The aim of this study was to assess the prognostic value
of histopathologic characteristics and immunohistochemi-
cal features across a panel of immunostains (Table 1) in a
study set of 30 PTs. Additionally, immunohistologic fea-
tures of benign, borderline, and malignant PTs were com-
pared in order to ascertain whether malignant progres-
sion is associated with differential marker expression and
whether such differences may be diagnostically useful.
MATERIALS AND METHODS
Case Selection
Paraffin-embedded tissue blocks and histologic slides from 29
patients diagnosed with PTs were gathered from the pathology
archives of Magee-Womens Hospital of the University of Pitts-
burgh Medical Center, Pittsburgh, Pa. The cases spanned the pe-
riod 1993 through 2002. All studies were conducted with prior
approval of the institutional review board. The standard criteria
used for distinguishing between benign, borderline, and malig-
nant PTs were applied as previously described.9
Immunohistochemistry
Formalin-fixed, paraffin-embedded sections were cut at 4 ␮m.
Dried slides were placed on the Ventana BenchMark automatic
staining system (Ventana, Tucson, Ariz) for immunohistochemi-
cal (IHC) staining. Immunohistochemical protocol included a
standard cell conditioning step with CC1 (pH 8.0; Ventana) to
unmask antigenic sites and a 32-minute incubation with antibod-
ies directed against p53 (clone DO7; Ventana), Ki-67 (clone MIB-
1, 1:200; DakoCytomation, Carpinteria, Calif), p21WAF1 (clone
DCS-60.2, 1:100; Lab Vision, Fremont, Calif), and c-Kit (CD117)
(rabbit polyclonal, 1:100; DakoCytomation). Antigen-antibody re-
activity was detected with a goat anti-mouse, goat anti-rabbit bi-
otin streptavidin/DAB detection system and counterstained with
hematoxylin (Ventana). Prior to incubating sections with p16INK4A
(clone G175-405, 1:400; BD Pharmingen, San Diego, Calif) and
endothelin 1 (ET-1) (clone TR.ET.48.5, 1:400; Affinity Bioreagents,
Golden, Colo), epitope retrieval was performed in a steamer at
95⬚C for 20 minutes in Tris base buffers. Subsequently, slides
were immunostained on the Dako Autostainer. Endogenous per-
oxidase activity was blocked with 3% hydrogen peroxide solu-
tion. Nonspecific binding was reduced with a 10% normal goat
serum block before incubation. Bound primary antibodies were
detected with a mouse nonavidin-nonbiotin polymer/DAB de-
tection (DakoCytomation) and counterstained with hematoxylin.
Arch Pathol Lab Med—Vol 130, October 2006
IHC Scoring Method
Sections were scored by 3 independent reviewers (D.M., D.J.D.,
N.N.E.) for the proportion and intensity of staining. Intensity was
scored as follows: 3⫹, strong; 2⫹, moderate; 1⫹, weak; 0, no
staining. The percentage of cells positive was scored by counting
at least 50 cells in 10 high-power fields (HPFs) and expressed in
a 4-point scale (proportion score) as follows: 0, 4% or less; 1, 5%
to 33%; 2, 34% to 66%; 3, 66% or more. The combined immu-
noreactive score (CIS) was then calculated as the product of the
intensity score and the proportion score, as described by Nieza-
bitowski et al.19 p16, p21, p53, and Ki-67 were considered positive
if nuclear staining of stromal cells was present. c-Kit was consid-
ered positive if the cell membrane and cytoplasm of stromal cells
were immunoreactive, and ET-1 was considered positive if epi-
thelial cytoplasmic immunoreactivity was seen. Additionally,
overall positive marker expression between tumors that recurred
and those that did not recur was assessed.
Statistical Analysis
Kruskal-Wallis test was used in testing equality of expression
in more than 2 groups. Wilcoxon test was used in comparisons
of marker expression between 2 groups. Spearman correlation
coefficient and the test of independence were calculated to mea-
sure the correlation between different variables. Fisher exact test
(2-tailed) was used to decipher the significance of any one vari-
able’s relationship to patient outcome. No adjustments for mul-
tiple comparisons were made secondary to the limited number
of cases included in the study.
RESULTS
Clinical Features
Table 2 shows the clinical and pathologic characteristics
of 30 PTs in 29 female patients: 16 (53%) benign, 8 (27%)
borderline, and 6 (20%) malignant, including a borderline
tumor that recurred as malignant (PT-5a and PT-5b). Pa-
tients ranged in age from 27 to 90 years (mean 54 years,
median 52 years). Sixteen patients underwent segmental
mastectomy, while 9 underwent lumpectomy/excisional
biopsy and 4 had total mastectomies. Five patients had
positive margins (2 benign, 2 borderline, 1 malignant). Fol-
low-up information for 5 patients was unavailable. Four
patients experienced recurrent disease (1 benign, 2 bor-
derline, 1 malignant), 3 of whom had positive surgical
margins at original resection (P ⫽ .02). One patient (PT-3)
had evidence of disease at follow-up as noted. This pa-
tient, who was diagnosed with a malignant PT, died with
lung metastases 34 months after her initial diagnosis. Bi-
opsies of the lung metastases demonstrated high-grade
sarcomatous cells similar to the primary tumor but with
no evidence of an epithelial component.
Histopathologic Features
Benign PTs ranged from 1 to 5 cm in size (mean, 2.5;
median, 2.2). Borderline PTs ranged from 1.4 to 8.5 cm in
size (mean, 4; median, 3.5). Malignant PTs ranged from 2
to 8 cm in size (mean, 5.3; median, 5.8). Mitotic count
ranged from 1 to 2 per 10 HPFs in benign PTs, 1 to 5 per
10 HPFs in borderline PTs, and 3 to 6 per 10 HPFs in
malignant PTs.
Immunohistochemistry
Table 2 shows the CIS for p16, p21, p53, c-Kit, and ET-
1. p16, p21, and p53 stained the nuclei of stromal cells,
and their respective mean CIS scores are represented in
Figure 1. Table 3 shows the overall rate of positivity
among benign, borderline, and malignant PTs. Table 4
demonstrates the overall rate of immunoreactivities, as
Phyllodes Tumor: A Study of 30 Cases—Esposito et al 1517
 Table 2. Clinical and Histopathologic Characteristics of 29 Patients With Phyllodes Tumor of the Breast*
p16 p21 p53 Ki-67 c-Kit ET-1 Mitosis/ Size, Months to
Code No. CIS CIS CIS LI, % CIS CIS SC 10 HPF cm Margin Recur Age, y Outcome Outcome
Benign
PT-2 1 0 0 ⬍1 0 6 Low 1 4 Negative Unk 30 Unk
PT-6 2 0 0 ⬍1 0 6 Moderate 1 2 Negative No 51 A-NED 25
PT-8 2 0 2 5 0 1 Low 1 2.5 Positive No 51 A-NED 43.5
PT-9 9 2 2 ⬍1 6 2 Moderate 2 1.3 Negative No 53 A-NED 23
PT-10 0 0 1 5 0 2 Moderate 2 2 Negative No 52 A-NED 37
PT-11 2 0 0 10 0 1 Moderate 1 3 Negative Unk 51 Unk
PT-12 2 0 0 ⬍1 0 1 Moderate 2 2 Negative No 57 A-NED 36
PT-13 0 0 0 5 0 1 Moderate 1 4.5 Negative Unk 51 Unk
PT-14 2 0 0 5 2 4 Moderate 2 1.5 N/A† No 47 A-NED 29
PT-15 0 0 1 5 0 1 Low 1 2.3 Negative No 52 A-NED 58
PT-17 0 0 0 0 0 4 Low 1 1.7 Negative No 47 A-NED 58
PT-20 1 0 0 ⬍1 0 1 Moderate 2 2.3 Positive Yes‡ 59 A-NED 110
PT-21 6 0 0 5 0 1 Moderate 1 3.5 Negative No 42 A-NED 39
PT-22 1 0 0 ⬍1 0 4 Low 2 5 Negative Unk 43 Unk
PT-26 9 6 1 10 0 2 Moderate 2 1 Negative No 55 A-NED 24
PT-27 2 1 0 ⬍1 0 4 Moderate 2 1.8 Negative No 62 A-NED 16
Borderline
PT-1 2 0 1 20 0 0 Moderate 3 3 Negative Unk 63 Unk
PT-4 0 2 2 10 2 4 Moderate 3 4 Negative No 39 A-NED 31
PT-5a 2 4 2 5 6 1 Moderate 2 3 Negative Yes‡ 90 A-NED 90
PT-16 2 2 2 10 2 1 Moderate 3 3 Negative No 46 A-NED 58
PT-18 9 6 2 40 6 0 Moderate 4 8.5 Negative No 50 A-NED 49
PT-23 6 0 0 20 0 0 Low 1 5 Negative No 87 A-NED 19
PT-24 6 4 6 60 4 0 High 5 4 Positive Yes 33 A-NED 35
PT-25 1 1 2 40 0 1 Low 1 1.4 Positive No 56 A-NED 35
Malignant
PT-3 0 2 2 20 9 1§ High 5 8 Positive Yes 84 D-ED 34
PT-5b 2 2 3 40 9 0§ Moderate 3 6 Negative No 90 A-NED 90
PT-7 6 2 2 20 3 0 High 4 5.6 Negative No 27 A-NED 32.5
PT-19 9 6 3 40 6 0 High 6 2 Negative No 62 A-NED 50
PT-28 9 0 0 30 0 0 High 4 6.5 Negative No 77 A-NED 24
PT-29 9 2 3 40 0 0§ High 5 3.8 Negative No 61 A-NED 23
* CIS indicates combined immunoreactive score; LI, labeling index; ET-1, endothelin1; SC, stromal cellularity; HPF, high-power field; recur,
recurrence; Unk, unknown; A-NED, alive without evidence of disease; and D-ED, deceased with evidence of disease.
† Unable to assess margins due to fragmented specimen.
‡ PT-20 recurred twice, 2 and 7 years after the initial diagnosis, respectively. PT-5a recurred as a malignant PT (PT-5b) 5 months after the initial
resection.
§ Endothelin 1 was diffusely positive in the stromal cells, though the epithelium was only focally positive in PT-3 and negative in PT-5b and PT-29.

Table 3. Overall Positive Immunoreactivities by

Tumor Subgroup
Benign, % Borderline, % Malignant, %
(n ⴝ 16) (n ⴝ 8) (n ⴝ 6)
p16 75 88 83
p21 19 75 83
p53 31 88 83
c-Kit 13 63 67
Endothelin 1 100 50 17

Table 4. Overall Positive Immunoreactivities and Rate

of Positive Resection Margins in Tumors That Did and
Figure 1. Mean immunoreactivities among phyllodes tumors. CIS in- Did Not Recur*
dicates combined immunoreactive score; ET-1, endothelin 1. ⫺ Recurrence, % ⴙ Recurrence, %
(n ⴝ 21) (n ⴝ 4) P Value

well as rate of positive margin status, between tumors that p16 81 75 ⬎.99
p21 52 75 .60
did not recur and those that recurred with corresponding p53 62 75 ⬎.99
P values. Briefly, c-Kit stromal cell immunoreactivity was c-Kit 38 75 .29
observed in 13% of benign PTs, 63% of borderline PTs, ET-1 67 75 ⬎.99
and 67% of malignant PTs. Endothelin 1 epithelial cyto- ⫹ Margin 9 75 .02
plasmic staining was seen in 100% of benign PTs (Figure * Statistical analysis was limited to patients with known follow-up
2, a and b), 50% of borderline PTs, and 17% of malignant only and thus excluded 5 cases. ET-1 indicates endothelin 1.

1518 Arch Pathol Lab Med—Vol 130, October 2006 Phyllodes Tumor: A Study of 30 Cases—Esposito et al
Figure 2. Endothelin 1 immunoreactivity in a benign phyllodes tumor (PT-2). a, A double-layered epithelium forms clefts and rests on a spindle-
celled stroma (hematoxylin-eosin, original magnification ⫻200). b, Diffuse epithelial cytoplasmic immunoreactivity for endothelin 1 (immunope-
roxidase, original magnification ⫻200).
Figure 3. Endothelin 1 immunoreactivity in a malignant phyllodes tumor (PT-29). a, A hypercellular stroma with a rare epithelial-lined cleft
(hematoxylin-eosin, original magnification ⫻100). b, The epithelial component is negative for endothelin 1 while the stroma demonstrates multi-
focal immunoreactivity (immunoperoxidase, original magnification ⫻100).

PTs. Diffuse ET-1 immunoreactivity in myoepithelial cell
nuclei was also seen in most PTs. Additionally, the cyto-
plasm of stromal cells demonstrated focal ET-1 positivity
in 2 benign PTs (PT-17 and PT-22) and diffuse positivity
in 3 malignant PTs (PT-3, PT-5b, and PT-29) (Figure 3, a
and b). As stated above, only ET-1 epithelial cytoplasmic
immunoreactivity was considered in CIS calculations.
Mean Ki-67 scores (median scores) for benign, borderline,
and malignant PTs were 3% (2.5%), 26% (20%), and 32%
(35%). Ki-67 was differentially expressed among different
tumor grades (P ⬍ .001). It did not differentiate between
borderline and malignant tumors (P ⬎ .99).
All markers, except for p16, were differentially ex-
pressed among tumor grades (Table 5) and showed simi-
lar expression patterns, with significant differences in ex-
pression between benign tumors and borderline and ma-
lignant tumors.
c-Kit was positively correlated with p21 (P ⬍ .001), p53
(P ⬍ .001), and Ki-67 (P ⫽ .02), and marginally correlated
with ET-1 expression (P ⫽ .07). Endothelin 1 expression
negatively correlated with p16 (P ⫽ .01), p53 (P ⫽ .01),
Arch Pathol Lab Med—Vol 130, October 2006
and Ki-67 (P ⬍ .001) expression. Endothelin 1 had a mar-
ginal inverse correlation with c-Kit expression (P ⫽ .07).
Additionally, ET-1 negatively correlated with mitotic count
(P ⬍ .001) and stromal cellularity (P ⫽ .01).
COMMENT
Phyllodes tumors of the breast are rare neoplasms that
typically behave in a benign fashion. However, up to 35%
of patients ultimately die from histologically malignant
PTs. In these cases, standard treatment includes mastec-
tomy or wide local excision. Axillary lymph node dissec-
tion is currently not performed routinely, as the rate of
lymph node metastases is less than 1%.33 Unlike infiltrat-
ing ductal and lobular carcinomas, in which the utility of
adjuvant treatment is well known, the role of postopera-
tive radiotherapy and chemotherapy remains to be fully
established in the treatment of PTs.34,35
Compounding treatment decisions is the lack of reliable
histologic indicators that predict recurrence. Different
studies have regarded stromal overgrowth,15,36–38 infiltrat-
ing margins,15,39 high mitotic rate,24 and degree of stromal
Phyllodes Tumor: A Study of 30 Cases—Esposito et al 1519
 Table 5. P Values Representing Ability of Immunohistochemical Stains to Differentiate Among Different Tumor Grades
p21
Benign vs (borderline and malignant) .001
Benign vs borderline .006
Benign vs malignant .006
Borderline vs malignant ⬎.99
atypia39,40 as important predictors of recurrence and/or
prognosis, while others have disagreed with these find-
ings.33,41 A positive margin status is the most consistent
indicator of local recurrence, and a recent multivariate
analysis showed that negative margins reduced recur-
rence hazards by 51.7%.42 However, not all patients with
margin involvement develop recurrence, and malignant
PTs may recur in up to 46% and metastasize in up to 33%
of cases despite excision or mastectomy with adequate
margins.12,33,43 Such conflicting results highlight the need
for markers that can more reliably predict patient outcome.
Proposed indicators to fulfill this objective include Ki-67,
p53, and c-Kit.
Mean reported Ki-67 labeling indexes (LIs) range from
1.3% to 4.7% for benign, 6% to 16% for borderline, and
12% to 50% for malignant PTs.16,19,21 Our analysis dem-
onstrated similar indexes for benign and malignant PTs
(3.6% and 32%, respectively), but our survey of 8 border-
line PTs demonstrated a mean Ki-67 LI of 26%. Addition-
ally, Ki-67 LIs among those tumors that recurred ranged
from less than 1% to 60%. Thus, proliferative fraction of
cells as assessed by Ki-67 does not appear to be a reliable
predictor of tumor recurrence.
Recently, c-Kit stromal expression was reported to be
increased in malignant PTs compared to benign PTs.20,27
In a study by Tse et al,25 c-Kit was not related to recur-
rence or metastasis. We found that c-Kit expression was
differentially expressed among tumor grades, but the dif-
ference in its expression between borderline and malig-
nant PTs was not significant (P ⫽ .39), and c-Kit expres-
sion did not significantly correlate with tumor recurrence
(P ⫽ .29). The significance of c-Kit expression in these
tumors is thus uncertain, especially since not all c-Kit im-
munoreactive tumors have been shown to harbor c-kit mu-
tations.20,27
Studies have shown that increased p53 expression is as-
sociated with a pathologic diagnosis of malignant PT, with
increasing p53 expression correlating with increasing
grade and known negative prognostic factors.13,17,23,24 In-
consistent with these findings, however, is the lack of cor-
relation between increased p53 expression and recurrence
or long-term survival.15,26 A study by Niezabitowski et al,19
however, found expression of p53 to be an independent
prognostic factor for disease-free survival in a multivariate
analysis. We found significantly increased p53 expression
in borderline and malignant PTs versus benign PTs. Sim-
ilar to c-Kit, the difference in p53 expression between bor-
derline and malignant PTs was not significant (P ⫽ .43).
To our knowledge, p21 expression in PTs has not been
previously reported. Similar to p53 expression, p21 ex-
pression was significantly increased in borderline and ma-
lignant PTs versus benign PTs, while there was no signif-
icant difference in p21 expression between borderline and
malignant PTs (P ⬎ .99).
Phyllodes tumors are composed of both stroma and ep-
ithelium. Whether both components are neoplastic is con-
1520 Arch Pathol Lab Med—Vol 130, October 2006
p53 Ki-67 c-Kit Endothelin 1
⬍.001 ⬍.001 .004 ⬍.001
⬍.001 ⬍.001 .02 .007
.003 ⬍.001 .006 ⬍.001
.43 .42 .39 .26
troversial. Noguchi et al44 found that monoclonality is lim-
ited to the stromal cells. Sawyer et al,45 however, demon-
strated unique allelic imbalances in both the stromal and
epithelial components. A potential mediator between the
epithelial and stromal component of PTs is ET-1, a small
vasoactive peptide and member of the endothelin family,
which has diverse paracrine and autocrine actions. En-
dothelin 1 expression is increased in various human ma-
lignancies, including breast carcinoma, and has been
shown to induce mitosis in human breast fibroblasts and
carcinoma cells. Interestingly, while endothelin expression
is limited to the epithelium, endothelin receptor expres-
sion is observed only in the stromal cells of cultured hu-
man breast tissue.46 These findings suggest that ET-1 re-
leased from breast epithelial cells acts on adjacent stromal
tissue in a paracrine manner. Additional tumor-promoting
properties of ET-1 that have been described include pro-
motion of angiogenesis by induction of vascular endothe-
lial growth factor47 and modulation of the invasive capac-
ity of neoplastic cells by activation of matrix metallopro-
teinases.48
In the only previously published study of ET-1 expres-
sion in PTs, ET-1 concentrations by radioimmunoassay of
benign PT tumor extracts were significantly increased
when compared to fibroadenomas, and ET-1 immunore-
activity was restricted to epithelial cells.49 We sought to
further elucidate the potential role of ET-1 in PT patho-
genesis by examining ET-1 expression by IHC in benign,
borderline, and malignant PTs. We found significantly
higher ET-1 expression in the epithelium of benign PTs
compared to borderline or malignant lesions, and ET-1 ex-
pression negatively correlated with mitotic count and stro-
mal cellularity. This is comparable to the findings of Saw-
yer et al50 of decreased or absent Wnt and ␤-catenin epi-
thelial expression in malignant PTs compared to benign
PTs, and suggests that the epithelium exerts an effect on
the adjacent stroma which is lost with malignant progres-
sion. We also observed focal immunoreactivity in the cy-
toplasm of stromal cells in 2 benign PTs and diffuse pos-
itivity in the cytoplasm of stromal cells in 3 malignant
PTs, one of which metastasized and ultimately led to the
patient’s death (PT-3), and another which represented a
malignant recurrence of a previously resected borderline
tumor (PT-5b). The significance of stromal ET-1 expression
is uncertain, though it parallels the findings of Tse et al51
of increasing vascular endothelial growth factor expres-
sion by PT stromal cells with increasing degree of malig-
nancy. It is possible that increased ‘‘aberrant’’ expression
of ET-1 by stromal cells in malignant PTs results in vas-
cular endothelial growth factor induction and subsequent
neovascularization, thus promoting tumor progression.
Alternatively, stromal ET-1 positivity may represent ET-1
receptor expression. The latter hypothesis may be ex-
plained by a concomitant decrease in epithelial ET-1 ex-
pression in malignant tumors resulting in up-regulation
Phyllodes Tumor: A Study of 30 Cases—Esposito et al
of stromal ET-1 receptors and immunohistochemical de-
tection.
In conclusion, our findings support the conclusions of
other authors in that p53, Ki-67, and c-Kit are differen-
tially expressed in PTs and aid in distinguishing benign
from borderline or malignant PTs. However, marker ex-
pression did not significantly correlate with tumor behav-
ior. Rather, the only significant clinicopathologic parame-
ter that predicted tumor recurrence was positive surgical
resection margins. Additionally, we have shown that ET-1
immunoreactivity is significantly decreased in the epithe-
lium of malignant PTs, supporting the previously pro-
posed theory that the development of autonomously pro-
liferating stroma is a key event in PT malignant progres-
sion.50 Additional studies with larger sample sizes are
needed to explore the potential role of ET-1 in PT patho-
genesis, and in particular the significance, if any, of stro-
mal cell ET-1 expression.
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