Study Questions Excision of Radial Sclerosing Breast Lesions

Diana Mahoney

November 05, 2012

BOSTON — Most of the fully excised radial sclerosing lesions (RSLs) of the breast without atypia collected over an 11-year period from a single institution failed to show any evidence of atypia or malignancy on excision, a new study shows.

These findings challenge the widespread approach of complete surgical removal of these lesions, Aditi Khandelwal, BSc, from the Jewish General Hospital in Montreal, Quebec, Canada, reported here at the American Society for Clinical Pathology 2012 Annual Meeting. The research was conducted under the direction of senior investigator Dragana Pilavdzic, MD, also from the Jewish General Hospital.

Historically, surgical excision of RSLs, including radial scars and complex sclerosing lesions with or without atypia on core biopsy, has been standard practice to ensure complete resection of potential concomitant or associated carcinomas or epithelial atypias.

Recently, complete excision using a percutaneous vacuum-assisted stereotactically guided-core needle biopsy device has been suggested as an alternative approach, Khandelwal explained during her poster presentation.

"There is a lack of evidence to demonstrate that these benign lesions eventually become malignant. It has been suggested that complete resection may not be necessary, and that nonsurgical management with mammographic follow-up may be a preferable course of treatment," she said.

To evaluate the likelihood of malignant transformation of RSLs of the breast, which mimic invasive carcinoma on mammography and histology, the researchers searched the pathology archives of the Jewish General Hospital from 2000 to 2011. They identified 23 women (mean age, 54.4 years) with architectural distortions on breast imaging diagnosed as radial scar without associated atypia or malignancy on core needle biopsy who had subsequent surgical excision.

"We only included patients for whom entire excisions were submitted in toto for microscopic examination," Khandelwal stated. "We tabulated primary diagnosis, imaging results, and other findings on core needle biopsy and surgical excision, and we confirmed histological diagnoses with a second review of all of the slides," she said.

On review, there was no evidence of atypia or malignancy for 91.3% of the specimens, Khandelwal reported. "Only 2 of the 23 cases showed an incidental finding of atypical lobular hyperplasia," she said.

The high concordance rate between diagnosis on stereotactic or ultrasound-guided core needle biopsy and subsequent surgical excision suggests that the majority of patients undergoing complete resection could be managed as effectively with careful review of imaging findings and clinical information after the core biopsy report confirming the diagnosis of RSL without atypia, Khandelwal noted.

"Indications for the complete surgical removal of these lesions should be guided by a high index of suspicion for concomitantly associated lesions in the vicinity or away from the index lesion on imaging findings or by clinical history in high-risk patients," she said. Determining future associated risks for malignancy in these patients will require examination of long-term follow-up data. Studies to confirm the correlation between radiology and pathology findings should be undertaken to support the more conservative management, she noted.

Zeeshan A. Shah, MD, from the Baylor Health Care System in Dallas, Texas, argued that the data to date are insufficient to suspend the practice of complete resection for RSLs.

In a recent retrospective review of core needle biopsies performed at the Baylor Health Darlene G. Cass Women's Imaging Center from 2006 to 2011 (Proc [Bayl Univ Med Cent]. 2012;25:3-5), Dr. Shah and colleagues identified 67 patients with RSL and correlated histology at excisional biopsy with core biopsy results. At surgical excision, malignancy was identified in 6 cases, "and 2 of the 6 patients with malignant features were younger than 50 years old, which is notable because malignancy in RSL is considered rare in patients younger than 50," he told Medscape Medical News. Dr. Shah was not involved the current study.

He described the 9% malignancy rate that his group observed as "noteworthy." He believes that all RSLs should be surgically excised, even in the absence of malignant components at core needle biopsy, especially because of the lack of predictive imaging characteristics.

Ms. Khandelwal and Dr. Shah have disclosed no relevant financial relationships.

American Society for Clinical Pathology (ASCP) 2012 Annual Meeting: Poster 24. Presented November 2, 2012.