Radial Scars without Atypia Diagnosed at Imaging-guided Needle Biopsy: How Often is Associated Malignancy Found at Subsequent Surgical Excision, and do Mammography and Sonography Predict which Lesions are Malignant?

Anna Linda; Chiara Zuiani; Alessandro Furlan; Viviana Londero; Rossano Girometti; Piernicola Machin; Massimo Bazzocchi

Disclosures

Am J Roentgenol. 2010;194(4):1146-1151. 

In This Article

Abstract and Introduction

Abstract

Objective. The purposes of our study were to evaluate the surgical outcome of cases of radial scar without atypia diagnosed at imaging-guided percutaneous needle biopsy and to determine whether the mammographic and sonographic features are able to predict which lesions will be upgraded to malignancy at surgical excision.
Materials and methods. The records of 4,458 consecutive imaging-guided biopsies were retrospectively reviewed. Surgical excision results were available in 62 cases in which radial scar was the highest-risk lesion at stereotactically guided or sonographically guided biopsy. The mammographic and sonographic images and surgical findings were reviewed. The underestimation rate of malignancy of percutaneous biopsy was calculated. Differences in mammographic and sonographic appearances between radial scars with and without associated malignancy were evaluated using the Fisher's exact test.
Results. The percutaneous malignancy underestimation rate was 8% (5/62): 9% (4/43) for sonography guided 14-gauge biopsies and 5% (1/19) for stereotactically guided 11-gauge vacuum-assisted biopsies (p = 1.000). Mammographic and sonographic appearances were not significantly different between radial scars with and those without associated malignancy.
Conclusion. A percutaneous diagnosis of a radial scar does not exclude associated malignancy at surgical excision. Mammographic and sonographic features of a lesion diagnosed as a radial scar at percutaneous imaging-guided biopsy do not predict which lesions will have associated malignancy at surgery. Therefore, all patients with percutaneous diagnosis of a radial scar should undergo surgical excision regardless of mammographic and sonographic appearances, until further criteria can be determined.

Introduction

Radial scar of the breast has been previously described in the literature under several different names such as radial sclerosing lesion, scleroelastotic lesion, indurative mastopathy, nonencapsulated sclerosing lesion, sclerosing papillary proliferation, and, if larger than 1.0 cm, complex sclerosing lesion.[1] Radial scar is a benign breast lesion characterized by a central fibroelastotic core with ducts and lobules radiating outward, giving the lesion its characteristic stellate appearance.[1] The presence of glands trapped at the center of the lesion may cause the lesion to be mistaken for tubular carcinoma.[2] In addition, pathologic examination of a radial scar often reveals a diverse array of pathologic findings including typical epithelial hyperplasia, adenosis, papillomatosis, atypical epithelial hyperplasia, ductal carcinoma in situ (DCIS), and early-stage invasive carcinomas.[3] The presence of all stages of mammary carcinogenesis within or adjacent to radial scars has led some investigators to speculate that radial scar represents a stage in the development of invasive carcinoma.[4,5] In fact, reports in the literature suggest that radial scar is associated with surrounding malignancy in 0–40% of the cases.[6–16]

Because radial scar is associated with underlying malignancy, a percutaneous biopsy is deemed not reliable in ruling out malignant foci at the periphery of the lesion and surgical confirmation is considered mandatory by some investigators.[6,7] Biopsy and pathologic criteria such as the absence of atypical hyperplasia in biopsy samples, retrieval of at least 12 specimens, and extensive sampling with vacuum-assisted large-core biopsy devices have been identified as factors that may spare a patient from undergoing surgical excision.[7–9,16]

To our knowledge, only a few reports in the literature have evaluated the potential role of mammographic and sonographic features in the management of radial scar diagnosed at percutaneous biopsy.[8,17–19] In most of these studies, the data are based on small series and are limited because of the lack of criteria to separate radial scars with and those without surgical follow-up.

The purposes of our study were, first, to evaluate the surgical outcome of cases of radial scar without atypia diagnosed at imaging-guided percutaneous needle biopsy and, second, to determine whether the mammographic and sonographic appearances are able to predict which lesions will be upgraded to malignancy at surgical excision.

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