Comparative outcomes of conventional versus endoscopic-assisted surgery for breast phyllodes tumors: a single center retrospective cohort study

Introduction

Breast phyllodes tumors (PTs) are fibroepithelial neoplasms that differ markedly from breast cancers in terms of clinical and biological behavior (1,2). According to their histological features, PTs are divided into benign, borderline, and malignant subtypes by the World Health Organization (3). Unlike breast cancer, PTs are often clinically characterized by rapid growth and a relatively high local recurrence rate. Previous studies have shown that the risk of local recurrence increases progressively with histological grade, and the recurrence rate of malignant PTs can be as high as 65% (4-8). However, surgery remains the primary treatment for PTs, while radiotherapy and chemotherapy are insensitive (9,10).

Conventional open surgery has long been widely used due to its wide field of vision and convenient operation. However, it also has problems such as obvious postoperative scars, poor breast aesthetics and heavy psychological burden on patients (11-13). Minimally invasive surgery has brought about a transformative shift in the field of surgical oncology by redefining traditional surgical concepts of operative access, precision, and patient-centered outcomes (14-16). Endoscopic breast surgery, though introduced later than in other surgical fields, has demonstrated considerable promise in both benign and malignant breast tumors (17,18). Accumulating evidence from retrospective and prospective studies supports the feasibility and safety of endoscopic approaches in breast tumors excision (19-21). These techniques have been shown to have advantages such as shorter recovery periods, less postoperative pain, and markedly better cosmetic satisfaction, as well as a comparable oncological prognosis to the traditional open approach. Despite its advantages and expanding role in breast tumor excision, the use of endoscopic-assisted techniques in the surgical treatment of PTs remains insufficiently explored.

In the past, surgical management of PTs, especially those with large tumor size or borderline to malignant histology, has favored wide excision or even total mastectomy, driven by the belief that wider surgical margins are essential to minimize the risk of recurrence (22-25). Instead of the surgical approach, the surgical margin’s width determines the recurrence of PTs (26,27). In other words, as long as the margin width is sufficient, minimally invasive endoscopic surgery remains a viable option, even for large tumors. Therefore, in light of the previous studies on PTs and endoscopic surgery used in breast tumors mentioned above, we have conducted a comparative study of endoscopic-assisted surgery (EAS) and conventional surgery (CS) in the treatment of PTs, aiming to explore whether endoscopic surgery can enhance aesthetic satisfaction while also ensuring the outcomes of PTs. We present this article in accordance with the STROCSS reporting checklist (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2026-1-0005/rc) (28).

Methods

Ethics consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Research Ethics Committee of Sun Yat-sen Memorial Hospital (No. SYSKY-2025-601-01, date: 05/08/2025). The requirement for informed consent was waived due to the retrospective nature of the study. This study was registered at the Chinese Clinical Trial Registry (No. ChiCTR2500110203) under the title “A comparative study on the outcome of conventional and endoscopic assisted phyllodes tumor resection of the breast”.

Patients enrollment

This single-center retrospective study included all patients with breast PTs (including benign, borderline and malignant) who were diagnosed and underwent surgery at Sun Yat-sen Memorial Hospital from January 2021 to March 2025. The clinicopathological data of the patients, including age, tumor size, tumor location, surgery type and pathological classification were collected and included in the analysis.

The inclusion criteria for this study were female patients aged 16 to 75 years, with a first pathological diagnosis of PT, unilateral tumor, and who underwent surgery at our center and did not receive radiotherapy or chemotherapy before the operation. The patient voluntarily underwent CS or EAS. The types of surgery were classified into three categories, including mass resection, wide resection and total mastectomy. The exclusion criteria were patients who had not undergone surgery, had bilateral tumors, were recurrent PTs, combined with distant metastases disease, breast cancer or other malignancies, and severe heart, lung, kidney or other vital organ diseases.

Mass resection was defined as complete dissection of the tumor without focusing on the tumor margin. Wide resection was defined as complete dissection of the tumor and normal tissues surrounding it to obtain a negative surgical margin. Total mastectomy was defined as simple mastectomy and subcutaneous gland resection while preserving the nipple and areola. Patients who underwent conventional open surgery were classified as the CS group, while those who received EAS were classified as the EAS group.

Propensity score matching (PSM)

This study used the PSM method for data adjustment in order to equalize the disparities in baseline characteristics between the CS group and the EAS group and lessen selection bias brought on by non-random grouping. Taking the patient’s age (≤45 or >45 years), tumor location (left or right), tumor size (≤5.0 or >5.0 cm), surgical type (mass resection, wide resection or total mastectomy) and pathological classification (benign, borderline or malignant) as covariates, the logistic regression model was utilized to calculate the propensity probability. Hypothesis test, which is also employed in this study, is the most widely used diagnostic for propensity scores (29). The matching caliper value was established at 0.1, and the matching method used the 1:3 nearest neighbor method. Standardized mean difference (SMD) was used to assess each variable’s balance following matching. If the SMD is less than 0.1, it indicates that the difference between variables is acceptable.

Surgical procedures

In the EAS group, a single axillary incision of 3 to 8 centimeters was used for dissection of mammary glandular tissue, tumor resection and breast reconstruction. Patients who underwent total mastectomy in the EAS group would inject the tumescent solution into the subcutaneous tissue before skin flap development, and use scissors to create the skin flap. The tumescent solution is made up of 250 mL of saline and 0.5 mL of 1:1,000,000 epinephrine. In the CS group, radial or elliptical incisions with a length ranging from 3 to 20 centimeters on the breast surface will be selected based on the location and size of the tumor. Patients in the CS group did not get an injection of tumescent solution.

Statistical analysis

The median and range were used to summarize continuous data, and the t test was used to compare groups. Frequencies and percentages were used to represent categorical variables, and the Chi-squared (χ²) test or Fisher exact test were used to assess group differences. Local recurrence-free survival (LRFS) and postoperative cosmetic satisfaction were the study’s main endpoints, while overall survival (OS) and distant metastasis-free survival (DMFS), intraoperative indicators and the incidence of postoperative complications were its secondary endpoints. The postoperative cosmetic satisfaction was evaluated by the BREAST-Q scale at 3 months after the operation. Due to the diversity of surgical types, for the convenience of follow-up, we only selected the questions of satisfaction with breasts, psychological well-being, and sexual well-being in the BREAST-Q scale. By using the Kaplan-Meier (K-M) method, the survival curves of LRFS, DMFS, and OS were computed. The follow-up period ended on June 30, 2025. It was deemed statistically significant when P<0.05. All analyses were conducted using R version 4.1.2. Artificial intelligence was not used in the research and manuscript development.

Results

Baseline characteristics

This study comprised 351 individuals with breast PTs after screening, 294 of whom were in the CS group and 57 of whom were in the EAS group. Following a 1:3 propensity score ratio match, 200 patients (147 in the CS group and 53 in the EAS group) were included in the analysis (Figure 1). Table 1 presents the baseline clinicopathological data of all patients before and after PSM. The majority (71.5%) of patients were 45 years or younger, with a median age of onset of 39 years (range, 16–75 years). The age of onset did not differ statistically significantly between the two groups, but the SMD was greater than 0.1. The patient’s left and right sides experienced nearly identical incidences. Nearly two-thirds (65.5%) of the patients had a maximum tumor diameter of ≤5.0 cm, and the median tumor size was 4.0 cm (range, 1.0–26.0 cm). Similarly, there was no statistically significant difference in tumor size between the two groups and the SMD was less than 0.1. More than half (53.8%) of the patients underwent mass resection, nearly one-third (29.9%) of the patients underwent wide resection, and only a small proportion (16.2%) of the patients chose total mastectomy. There was no significant difference among these three surgical methods between two groups. In terms of pathological classification, more than half (51.0%) of the patients were benign PTs, approximately one-third (36.8%) were borderline tumors, and only 12.2% were malignant. Likewise, the two groups’ pathological classifications did not differ statistically. Before PSM, although there were no statistical differences between the two groups of patients in terms of age, tumor location, tumor size, surgical type and pathological classification, the SMD was greater than 0.1 regarding the age and tumor location. No significant variations in baseline data were observed between the two groups (P>0.05) and SMD less than 0.1 after PSM (Figure 2).

Figure 1 Flow diagram of patients screening. CS, conventional surgery; EAS, endoscopic-assisted surgery; PT, phyllodes tumor.

Figure 2 SMD of variables before and after PSM. Before matching, the SMD values of age and tumor location were greater than 0.1, and the SMD values of all variables were less than 0.1 after matching. SMD, standardized mean difference; PSM, propensity score matching.

Intraoperative indicators and cosmetic satisfaction

Before PSM, the EAS group’s operation time was noticeably longer than the CS group’s (83.77±26.81 vs. 73.44±34.66 min, P=0.01), while the intraoperative blood loss was less than the CS group, although there was no statistical difference (19.70±22.41 vs. 23.70±56.09 mL, P=0.60). In the BREAST-Q scale scores at 3 months after surgery, the EAS group had significantly higher satisfaction with breasts (76.81±9.15 vs. 69.21±9.64, P<0.001) and psychological well-being (91.16±6.69 vs. 85.17±11.71, P<0.001) than the CS group. After PSM, the two groups’ operation time, satisfaction with breasts and psychological well-being all showed statistically significant differences, just as they did prior to PSM. Intraoperative blood loss and sexual well-being, however, did not differ significantly (Table 2).

Oncologic safety

The median follow-up was 23.77 months at the study follow-up deadline (15.73 months in EAS group and 25.02 months in CS group). Table 3 presents the oncological outcome data of the followed patients. The overall local recurrence rate was 4.6%, among which it was 1.8% for benign tumors, 6.2% for borderline tumors, and 11.6% for malignant tumors. The distant metastasis rate was 1.1%, and the specific mortality rate was 0.8%, both of which only occurred in patients with malignant tumors. After PSM, patients in the EAS group had lower rates of local recurrence, distant metastasis and mortality than those in the CS group, although there was no statistically significant difference (Table 3). Figure 3 presents the K-M survival curves regarding LRFS, DMFS and OS. The survival results after PSM were consistent with those before PSM, and the EAS group’s and the CS group’s survival outcomes did not differ significantly. The 2- and 3-year LRFS of the EAS group were 97.0%, the 2-year LRFS of the CS group was 94.8%, and the 3-year LRFS was 93.4%, with no statistical difference [hazard ratio (HR), 0.336; 95% confidence interval (CI): 0.080–1.408; P=0.27]. The 2-year DMFS of the EAS group and the CS group were 100% and 97.5% respectively, which were the same as the 3-year DMFS (HR, 0.000; 95% CI: 0.000–0.000; P=0.33). The 2-year OS was 100% in the EAS group and 98.3% in the CS group. Similarly, it was consistent with the 3-year OS (HR, 0.000; 95% CI: 0.000–0.000; P=0.44).

Figure 3 Kaplan-Meier survival curves of LRFS, DMFS, and OS before and after PSM. (A) LRFS before PSM. (B) LRFS after PSM. (C) DMFS before PSM. (D) DMFS after PSM. (E) OS before PSM. (F) OS after PSM. Kaplan-Meier survival analysis showed no statistically significant differences between the EAS group and the CS group in LRFS, DMFS, and OS, whether before or after matching. CS, conventional surgery; DMFS, distant metastasis-free survival; EAS, endoscopic-assisted surgery; LRFS, local recurrence-free survival; OS, overall survival; PSM, propensity score matching.

Postoperative complications

In terms of complications, neither group of patients presented with flap ischemia or necrosis, nipple-areola complex necrosis, or implant infection. In the EAS group, only 2 patients had postoperative hemorrhage, which was classified as grade I according to the Clavien-Dindo classification and no other complications occurred. A little number of patients presented with postoperative hemorrhage, hematoma and effusion, incision infection, poor wound healing and implant rupture in the CS group (Table 4). Except for the implant rupture which required general anesthesia surgery for treatment and was classified as Clavien-Dindo grade IIIb, the others were all classified as grade I.

Discussion

This study is the first to use PSM to rigorously compare the outcomes of EAS and conventional open surgery specifically for patients with breast PTs. Our findings demonstrate that EAS is a safe and feasible substitute to conventional open surgery, offering comparable oncological safety while providing significant advantages in postoperative cosmesis and psychological well-being. Although EAS was associated with a longer operative time, this was counterbalanced by a superior complication profile and profoundly higher patient satisfaction, positioning it as a valuable treatment modality in the modern management of this rare breast neoplasm.

A paramount concern in the surgical treatment of PTs is oncological safety, particularly the risk of local recurrence. PTs, especially borderline and malignant subtypes, are known for their potential to recur locally (4-6). A critical finding of our study is that there were no statistically significant differences in LRFS, DMFS, or OS between the EAS and CS groups, both before and after PSM. The 3-year LRFS for the EAS group was an excellent 97.0%, comparable to the 93.4% in the CS group (P=0.27). This result strongly suggests that the minimally invasive approach of EAS does not compromise the thoroughness of tumor resection or increase the risk of recurrence. These findings align with a growing body of literature on minimally invasive breast surgery for breast cancer, which has consistently shown that endoscopic and robotic techniques can achieve oncological outcomes equivalent to CS (17,19-21). Lai et al. conducted a retrospective analysis of 3,426 primary operable breast cancers and found that there were no significant differences between the endoscopicassisted surgery and the conventional approach in terms of LRFS, DMFS, or OS (21). Similarly, the research results of Wan et al. indicated that in the long-term oncological outcomes of early breast cancer, LRFS, regional recurrence-free survival, DMFS, and OS did not differ statistically significantly between the minimal access breast surgery group and the conventional breast surgery group (17). Our study extends the principle of non-inferiority to the specific context of PTs, providing crucial evidence to support its adoption.

The most significant advantage of EAS identified in our study lies in its superior aesthetic and psychological outcomes. Patients in the EAS group reported markedly higher scores in the “satisfaction with breasts” and “psychological well-being” domains of the BREAST-Q scale 3 months after surgery. This is a crucial endpoint, as the cosmetic result of breast surgery profoundly impacts a patient’s quality of life, body image, and psychosocial recovery (2). Traditional surgery for PTs, which often requires wide local excision, can result in considerable scarring and breast deformity, leading to significant psychological distress. By utilizing small, strategically placed incisions, often hidden in the axilla region, EAS preserves the natural contour and appearance of the breast, thereby minimizing the aesthetic and psychological trauma associated with surgery. This finding is consistent with numerous reports in oncoplastic and endoscopic breast cancer surgery, which highlight improved patient satisfaction as a primary benefit of these advanced techniques (12,30,31). In addition, Kim et al. believed that compared with conventional breast surgery, endoscopic-assisted or robot-assisted surgery has the advantage of reducing the length of skin incisions (15). Shorter and more concealed skin incisions may result in better psychological and aesthetic outcomes as well as less pain for the patient, which could shorten their hospital stay and lessen the surgeons’ burden (32). However, due to the design of the retrospective study, the data on the length of the patients’ skin incisions and the degree of postoperative pain were not collected adequately, which limited the analysis of these two important factors.

From the surgical operation perspective, our study observed that EAS had a significantly longer operative time than CS. This is a well-documented characteristic of endoscopic procedures, attributable to the need to create a working space, the challenges of instrument manipulation in a confined area, and the meticulous dissection required for tissue preservation. However, it is important to note that this was associated with a trend toward less intraoperative blood loss and a significantly lower rate of short-term complications in the EAS group. Moreover, as demonstrated by Hung et al. in a multi-center study, a distinct learning curve exists for endoscopic mastectomy, with operative times decreasing significantly after approximately initial 15 cases (33). As surgeon experience accumulates, the operative duration of EAS is expected to shorten, narrowing the gap with conventional methods and further enhancing its feasibility.

This study possesses several strengths. The primary strength is the use of PSM, which effectively minimized selection bias inherent in this non-randomized, retrospective analysis. By balancing covariates such as age, tumor location, tumor size, surgery type and pathological type, we created two highly comparable cohorts, thus strengthening the validity of our conclusions. Furthermore, to our knowledge, this is the first dedicated comparative study of CS and EAS for PTs, addressing a significant gap in the literature and providing valuable data for this rare disease. Our research also has some deficiencies. Firstly, our findings may not be as broadly applicable as they could be due to the retrospective, single-center approach. Secondly, the median follow-up duration is relatively short for assessing the full spectrum of local recurrence and only the BREAST-Q scale 3 months after surgery was available, without the scores from preoperative and even 6 months or 1 year after the surgery for a comprehensive comparison. Thirdly, the cohort consisted predominantly of benign and borderline tumors, with only 12.2% of cases being malignant. Therefore, the study was underpowered to draw firm conclusions about the efficacy and safety of EAS for malignant PTs, which represent a higher-risk subgroup. Future studies should focus specifically on this population.

Conclusions

This PSM retrospective study provides robust evidence that EAS is a safe and feasible treatment option for patients with breast PTs. It achieves oncological outcomes comparable to CS while offering transformative benefits in cosmetic satisfaction and psychological well-being, with an acceptable complication profile. For patients, particularly younger individuals with high aesthetic expectations, EAS represents a significant advancement in patient-centered surgical care. To further characterize the function of EAS in the management of all subtypes of PTs, particularly the malignant subtype, future prospective, multicenter trials with larger cohorts and longer follow-up are necessary.

Acknowledgments

The authors would like to thank the Department of Breast Surgery and the Clinical Research Center of Sun Yat-sen Memorial Hospital for their assistance in data management and statistical support.

Footnote

Reporting Checklist: The authors have completed the STROCSS reporting checklist. Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2026-1-0005/rc

Data Sharing Statement: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2026-1-0005/dss

Peer Review File: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2026-1-0005/prf

Funding: This work was supported by National Science and Technology Major Project (No. 2024ZD0519800 to E.S.; No. 2024ZD0519802 to Y.N.; No. 2025ZD0543900 to D.H. and Y.N.), National Natural Science Foundation of China (Nos. 82473458 and 82173054 to Y.N.; Nos. 82572107 and 82541037 to D.H.), Guangdong Provincial Key Laboratory of Cancer Pathogenesis and Precision Diagnosis and Treatment (No. 2024B1212030002 to Y.N.), and Science and Technology Projects in Guangzhou (No. 2025A03J4276 to Y.N.; No. 2025A03J4194 to D.H.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2026-1-0005/coif). E.S. serves as an unpaid editorial board member of Translational Breast Cancer Research from March 2026 to February 2028. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Research Ethics Committee of Sun Yat-sen Memorial Hospital (No. SYSKY-2025-601-01, date: 05/08/2025). The requirement for informed consent was waived due to the retrospective nature of the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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