Radial Scars Without Atypia Diagnosed at Imaging-Guided Needle Biopsy

Results

Final Pathology Results

Of the 62 lesions, five (8%) proved to be malignant at surgical excision; 40 (65%), high risk; and the remaining 17 (27%), benign. Carcinomas associated with radial scars were three DCIS, two low-grade and one intermediate-grade DCIS; one grade 1 invasive ductal carcinoma, not otherwise specified; and one grade 2 invasive lobular carcinoma. Of the 40 high-risk lesions, 33 (82.5%) were radial scar, six (15%) were atypical ductal hyperplasia, and one (2.5%) was flat epithelial atypia. Of the 17 benign lesions, eight (47%) were fibrocystic changes, seven (41%) were sclerosing adenosis, and two (12%) were usual ductal hyperplasia.

The percutaneous biopsy underestimation rate of malignancy 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).

A summary of all cases of malignant lesions diagnosed as radial scars without atypia at percutaneous biopsy is shown in Table 1.

Mammographic Findings

Thirty-eight (61%) of the 62 lesions were detected on mammography: 19 (50%) were shown as architectural distortions, 11 (29%) as calcifications, and eight (21%) as masses.

Based on the results of surgical excision, three of five malignancies (60%) were detected on mammography. Malignancies were found in one of 19 architectural distortions (5%), in two of 11 lesions presenting as microcalcifications (18%), and in none of eight masses (0%) (p = 0.291).

In the first case of microcalcifications, a hypoechoic mass was shown on sonography, and percutaneous biopsy was performed under sonographic guidance. In the second case, the only finding was a cluster of indeterminate microcalcifications (Fig. 1), and percutaneous biopsy was performed under stereotactic guidance with an 11-gauge vacuum-assisted biopsy device; 13 specimens were obtained. This lesion was upgraded to low-grade DCIS at surgical excision.

(Enlarge Image)

Figure 1.

54-year-old woman with radial scar without atypia found at stereotactically guided 11-gauge vacuum-assisted biopsy that was upgraded to low-grade ductal carcinoma in situ at excisional biopsy (lesion 1 in Table 1).
A, Magnification mammogram shows clustered amorphous calcifications (arrow).
B, Radiograph of biopsy specimens shows calcifications (arrow) in one of 13 specimens.

Sonographic Findings

Forty-five of 62 lesions (73%) were detected on sonography: 17 (38%) were categorized as a circumscribed mass and 28 (62%), as a noncircumscribed mass.

Based on the results of surgical excision, four of five malignancies (80%) were detected on sonography. All four malignancies (14%) were found among noncircumscribed masses, whereas none (0%) was found among circumscribed masses (p = 0.281). One example of a noncircumscribed mass that was upgraded to malignancy, an intermediate-grade DCIS, at surgical excision is shown in Figure 2. Percutaneous biopsy was performed under sonographic guidance using an automated biopsy gun with a 14-gauge needle, and five specimens were obtained.

(Enlarge Image)

Figure 2.

57-year-old woman with family history of breast cancer with radial scar without atypia found at 14-gauge biopsy. Lesion was upgraded to intermediate-grade ductal carcinoma in situ at excisional biopsy (lesion 4 in Table 1). Sonogram shows 10-mm oval hypoechoic mass with parallel orientation and no vascularity in lower outer quadrant of left breast. Bilateral mammograms (not shown) were negative.

Cite this: 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? - Medscape - Apr 01, 2010.

Table 1. Imaging and Biopsy Features of Five Lesions Diagnosed as Radial Scars Without Atypia at Percutaneous Biopsy Resulting in Malignancy at Surgical Excision
Lesion No.	Lesion			Biopsy				Surgical Results
Lesion No.	Mammographic Appearance	Sonographic Appearance	Size (mm)	Type of Guidance	Needle Size	Vacuum-Assisted Device	No. of Samples	Surgical Results
1^a	Calcifications	–	5	Stereotactic	11-gauge	Yes	13	DCIS (low grade)
2	Calcifications	Mass	15	Sonographic	14-gauge	No	6	DCIS (low grade)
3	Architectural distortion	Mass	22	Sonographic	14-gauge	No	5	ILC
4^b	–	Mass	10	Sonographic	14-gauge	No	5	DCIS (intermediate grade)
5	–	Mass	9	Sonographic	14-gauge	No	5	IDC

Note–Dash (–) indicates no relevant findings, DCIS = ductal carcinoma in situ, ILC = invasive lobular carcinoma, IDC = invasive ductal carcinoma.
^a See Figure 1.
^b See Figure 2.

Table 2. Frequency of Malignancy in Lesions Yielding Radial Scars at Percutaneous Biopsy
Study [Reference No.]	No. of Radial Scars at Core Biopsy (No. of Surgically Excised Lesions)	Type of Core Needle Biopsy	Needle Size	No. of Lesions	Malignancy Underestimation Rate, % (No. of Lesions Upgraded/Total No. of Lesions)
Study [Reference No.]		Type of Core Needle Biopsy	Needle Size	No. of Lesions	Radial Scars With Atypia at Core Biopsy	Radial Scars Without Atypia at Core Biopsy	Overall
López-Medina et al. [6]	43 (43)	Large core	14-gauge	43	40 (2/5)	16 (6/38)	19 (8/43)
Cawson et al. [7]	62 (62)	Large core	14-gauge	62	NA	NA	6 (4/62)
Brenner et al. [8]	157 (102)	Large core	14- and 12-gauge	65	14 (1/7)	9 (5/58)	9 (6/65)
		VAB	11- and 14-gauge	92	32 (7/22)	0 (0/70)	8 (7/92)
Resetkova et al. [9]	80 (19)	VAB	11- and 9-gauge	80	0 (0/14)	0 (0/66)	0 (0/80)
Dahlstrom et al. [10]	6 (3)	Large core	14-gauge	6	–	0 (0/6)	0 (0/6)
Lee et al. [11]	4 (4)	Large core	14-gauge	4	–	25 (1/4)	25 (1/4)
Meyer et al. [12]	4 (4)	Large core	14-gauge	4	–	0 (0/4)	0 (0/4)
Jackman et al. [13]	5 (5)	Large core	14-gauge	5	–	40 (2/5)	40 (2/5)
Philpotts et al. [14]	9 (8)	Large core	14-gauge	4	0 (0/1)	0 (0/3)	0 (0/4)
		VAB	11-gauge	5	0 (0/1)	0 (0/4)	0 (0/5)
Apesteguía et al. [15]	2 (2)	VAB	11-gauge	2	–	0 (0/2)	0 (0/2)
Becker et al. [16]	161 (90)	Large core	14-gauge	124	25 (6/24)	5 (5/100)	9 (11/124)
		VAB	11-gauge	37	17 (2/12)	0 (0/25)	5 (2/37)
This study	62 (62)	Large core	14-gauge	43	–	9 (4/43)	9 (4/43)
		VAB	11-gauge	19	–	5 (1/19)	5 (1/19)

Note–Dash (–) indicates no cases. VAB = vacuum-assisted biopsy, NA = not available.

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