Meta-analysis: Radial Scar and Breast MRI

BACKGROUND

The implementation of digital breast tomosynthesis has increased the detection of radial scar (RS). Managing this finding may be experienced as a clinical dilemma in daily practice. Breast Contrast-Enhanced MRI (CE-BMR) is a known modality in case of problem-solving tool for mammographic abnormalities. However, the data about AD and CE-BMR are scant.

OBJECTIVE

The purpose was to estimate the benefit of CE-BMR in the setting of RS detected mammographically through a systematic review and meta-analysis of the literature.

METHODS

A search of MEDLINE and EMBASE databases were conducted in 2022. Based on the PRISMA guidelines, an analysis was performed. The primary endpoint was the correlation between CE-BMR findings and definite outcome for RS (pure RS versus RS associated with atypia or malignancy).

RESULTS

Three studies were available. The negative predictive value (NPV) was 100% for each.

CONCLUSION

The high NPV could allow for deferral of a biopsy in favor of a short-interval imaging follow-up in the setting of a negative CE-BMR.

Patients with benign papilloma diagnosed on core biopsies and concordant pathology-radiology findings can be followed: experiences from multi-specialty high-risk breast lesion conferences in an academic center

BACKGROUND

To determine whether patients with benign papilloma diagnosed on core biopsy can be spared from surgery.

METHODS

We prospectively reviewed 150 consecutive core biopsy-diagnosed papilloma cases at a multi-specialty high-risk breast lesion conference to determine whether surgical excision was necessary. Of these 150 cases, 148 had concordant radiologic-pathologic features. Six were excluded due to lack of the first imaging follow-up until analysis. 112 were benign papillomas; 17 were papillomas involved by atypical ductal hyperplasia (atypical papilloma); 6 papillomas had ADH in adjacent tissue but not involving the papilloma; 2 papillomas were involved by atypical lobular hyperplasia (ALH); and 5 papillomas had ALH in adjacent tissue. Two were radiology-pathology (rad-path) discordant.

RESULTS

Thirty-nine of the 112 benign papillomas were excised with no upgrade to carcinoma; 73 were followed with no disease progression during follow-up (185-1279 days). Fifteen of 17 atypical papillomas were surgically excised with 4 (26.7%) upgraded to carcinoma. Four of the 6 patients with ADH adjacent to a benign papilloma underwent excision with 2 upgrades to carcinoma. None of the patients with papilloma, which was either involved by ALH or had ALH in adjacent tissue had upgrade or disease progression during follow-up (204-1159 days). Finally, the two cases with discordant path-rad discordant were excised with no upgrade.

CONCLUSIONS

Our data confirm that rad-path concordant benign papillomas diagnosed on core biopsy do not require surgery. It also supports the value of a formal multi-specialty review of all benign papilloma cases to create a consensus management plan.

Papilloma diagnosed on core biopsies has a low upgrade rate

CONTEXT

Surgical excision of benign intraductal papillomas (IDP) diagnosed on core needle biopsy (CNB) remains controversial.

OBJECTIVE

To examine the upgrade rate of IDPs diagnosed at core needle biopsy to carcinoma at surgical excision.

DESIGN

We identified 188 consecutive IDPs diagnosed at CNB from 2011 to 2016 with subsequent surgical excision. Radiologic, clinical, and histologic features were evaluated and correlated with upgrade rate at surgical excision.

RESULTS

Two of the 188 IDPs (1.1%) were upgraded to ductal carcinoma in situ or invasive carcinoma at excision. Features associated with upgrade rate include patient age (P = .03), largest size of papilloma on a single core at CNB (P = .04), and the presence of additional masses noted at ultrasound (P = .03).

CONCLUSIONS

Our study demonstrated a low 1.1% upgrade rate of surgically excised benign, concordant papillomas with no atypia or concurrent ipsilateral malignancy originally diagnosed on core biopsy. This data suggests that observation may be appropriate for radiologic-pathologic concordant benign IDPs diagnosed at CNB.

Meta-analysis of upgrade rates in 3163 radial scars excised after needle core biopsy diagnosis

BACKGROUND

Since concurrent malignancy may be associated with radial scars (RS) in up to 45% of RS diagnosed on core biopsy, surgical excision is usually advised. Recent very low upgrade rates have caused a re-evaluation of the need for routine surgery. We aimed to find subsets of RS at such low risk of upgrade, as to render imaging surveillance a plausible alternative to surgery.

DESIGN

We performed a systematic review of the Pubmed, Cochrane and Embase databases, focusing on the following eligibility criteria: full papers, published after 1998, in English, included at least 5 RS, provided information on needle biopsy gauge and upgrade rates based on the excised lesion. For the meta-analysis, studies were grouped by the presence of histologic atypia and the core needle gauge. Study-specific and pooled upgrade rates were calculated for each subgroup.

RESULTS

49 studies that included 3163 RS with surgical outcomes are included. There were 217 upgrades to malignancies, 71 (32.7%) invasive and 144 (66.4%) DCIS. The random-effects pooled estimate was 7% (95% CI 5, 9%). Among the pre-planned subgroups, in RS assessed by 14G NCB the upgrade rates were: without atypia - 5% (95% CI 3, 8%), mixed or presence of atypia not specified - 15% (95% CI 10, 20%), with atypia - 29% (95% CI 20, 38%). For RS assessed by a mix of 8-16G cores the respective upgrade rates were 2% (95% CI 1, 4%), 12% (95% CI 6, 18%) and 11% (95% CI 3, 23%) and for RS assessed by 8-11 vacuum assisted biopsies 1% (95% CI 0, 4%), 5% (95% CI 0, 11%) and 18% for the one study of RS with atypia assessed by VAB. Surgery after VAB excision showed no upgrades. The difference across all subgroups was statistically significant.

CONCLUSION

When stratified by atypia and biopsy gauge, upgrade rates in RS are consistent and predictable. RS assessed by VABs and lacking atypia have a 1% (95% CI 0, 4%) upgrade rate to DCIS. Other groups have upgrade rates of 2-28%. This risk may be reduced by VAB excision. The results of this meta-analysis provide a decision aid and evidence-based selection criteria for surgery after a needle biopsy diagnosis of RS.

Concordant, non-atypical breast papillomas do not require surgical excision: A 10-year multi-institution study and review of the literature

PURPOSE

Non-atypical papillomas (NAPs) diagnosed on core needle biopsy (CNB) frequently undergo surgical excision due to highly variable upstaging rates. The purpose of this study is to document our dual-institution upgrade rates of NAPs diagnosed on core needle biopsy and review the upgrade rates reported in the literature.

MATERIALS AND METHODS

Following IRB approval, CNB results from Duke University (7/1/2004-6/30/2014) and the University of North Carolina Chapel Hill (1/1/04-6/30/2013) were reviewed to identify non-atypical papillomas. All cases with surgical excision or 2 years of imaging follow up were included. In addition, a literature review identified 60 published studies on upgrades of NAPs diagnosed at CNB. Cases in our cohort and the published literature were reviewed for confounding factors: [1] missing radiologic-pathologic concordance and/or discordance, [2] papillomas included with high-risk lesions, [3] high risk lesions counted as upgrades, [4] review by a nonspecialized breast pathologist, and [5] cancer incidentally detected.

RESULTS

Of the 388 CNBs in our dual-institution cohort, 136 (35%) patients underwent surgical excision and 252 (65%) patients had imaging follow up. After controlling for confounders, no cancers (0/388) were found at surgical excision or during follow up imaging. The literature review upstaging rate was 4.0% (166/4157) but 1.8% (4/227) after excluding studies with confounders. The combined upstaging rate from the literature and this study was 0.6% (4/615).

CONCLUSION

The upstaging rate for CNB diagnosed NAPs was 0% in our cohort and 0.6% overall after adjusting for confounders. This low rate does not warrant reflexive surgical excision and diagnostic imaging follow up should be discretionary.

Radial Scars of the Breast Encountered at Core Biopsy: Review of Histologic, Imaging, and Management Considerations

OBJECTIVE

The purposes of this article are to place the controversy over the management of radial scars diagnosed at core biopsy in perspective and to define reasonable management options.

CONCLUSION

The management of radial scars after image-guided core biopsy of the breast for diagnosis remains controversial. Although current literature suggests no premalignant potential of these lesions, it does not fully explain the small but real percentage of these lesions that are upgraded to malignancy after surgical excision. This upgrade phenomenon is probably best explained by core biopsy sampling error. A recommendation minimizing this possibility based on lesion size seems reasonable.

Radial scar of the breast: Is it possible to avoid surgery?

INTRODUCTION

Breast radial scar (RS) management remains controversial. The need for surgical excision is supported by the concern of an associated high-grade lesion missed in the biopsy. The aim of this study was to assess histologic upgrade rate after a percutaneous biopsy, to determine if vacuum assisted biopsy prevents the need for subsequent RS surgical resection and to evaluate the upgrade risk factors.

PATIENTS AND METHODS

This was a uni-institutional retrospective study of consecutive patients with RS histologically diagnosed from January 2010 to December 2015.

RESULTS

A total of 113 cases of RS were diagnosed. We verify that there was a histologic upgrade in 22 (19.5%) cases. The upgrade risk factors were the type of biopsy performed, the presence of atypia, the presence of calcifications and the number of fragments obtained in the biopsy (p < 0.05). The biopsy type was vacuum assisted in 25 (22.1%). The upgrade rate in the vacuum assisted biopsy group was 4.0%, whereas in the standard core needle biopsy group was 23,9% (p = 0.041).

DISCUSSION AND CONCLUSION

We demonstrated that the risk of upgrade after a RS diagnosis depends on the type of biopsy performed, the presence of atypia, the presence of calcifications and the number of fragments obtained. When a standard core biopsy is performed the risk of upgrade and malignancy is not negligible, and surgery is indicated. When the biopsy is vacuum assisted, the risk of upgrade and malignancy is significantly decreased and so the indication for excisional biopsy seems not to be so imperative.

Mammographically Occult Asymptomatic Radial Scars/Complex Sclerosing Lesions at Ultrasonography-Guided Core Needle Biopsy: Follow-Up Can Be Recommended

An increasing number of radial scars are detected by ultrasound (US), but their management is controversial. This study investigated the upgrade rate in mammographically occult radial scars/complex sclerosing lesions without epithelial atypia at US-guided 14-gauge core needle biopsy in asymptomatic patients. Nineteen mammographically occult benign radial scars/complex sclerosing lesions (median size, 7 mm; range, 3-23 mm) were included. Patients underwent surgical excision (n = 10) or vacuum-assisted excision, with follow-up US at least 6 mo after benign vacuum-assisted excision results (n = 8), or underwent US follow-up for 2 y after core needle biopsy (n = 1). Any cases with change in diagnosis to high-risk lesions or malignancy at excision were considered upgrades. The upgrade rate was 0.0%. Based on US findings, 15.8% (3/19) were Breast Imaging Reporting and Data System (BI-RADS) category 3, 68.4% (13/19) were BI-RADS category 4a and 15.8% (3/19) were BI-RADS category 4b. Follow-up with US can be considered for mammographically occult benign radial scar/complex sclerosing lesions diagnosed by US core needle biopsy in asymptomatic patients.

Advocating Nonsurgical Management of Patients With Small, Incidental Radial Scars at the Time of Needle Core Biopsy: A Study of 77 Cases

Context

Radial scars are benign sclerosing lesions that are routinely excised when diagnosed in a needle core biopsy. Optimal management for patients with incidental and small (≤5 mm) radial scars is uncertain.

Objective

To assess pathologic upgrade of radial scars diagnosed in needle core biopsy samples and identify a subset of patients who could benefit from conservative management.

Design

Patients with a diagnosis of radial scar in a needle core biopsy who underwent excision of the biopsied area were identified. Radial scars greater than 5 mm in size and those with coexisting atypia, carcinoma, and papillary lesions were excluded. After histologic-radiographic correlation, rates of pathologic upgrade were assessed.

Results

Seventy-seven radial scars diagnosed in 66 patients were included. Overall, 9 of 77 (12%) showed upgrade to a high-risk lesion (6 lobular carcinoma in situ, 2 atypical ductal hyperplasia, 1 atypical lobular hyperplasia), while none (0%) showed upgrade to invasive carcinoma or ductal carcinoma in situ. One of 22 incidental radial scars (4.5%) showed upgrade on excision versus 6 of 36 (16.7%) for radial scars considered to be the radiographic target (P = .23). Older age was associated with upgrade (P &lt; .001).

Conclusions

No incidental or small (≤5 mm) radial scars excised revealed invasive carcinoma or ductal carcinoma in situ on excision. Provided there is good pathologic-radiologic concordance, it appears reasonable for these patients to be managed conservatively.

Radial scar/complex sclerosing lesions: a clinicopathologic correlation study from a single institution

Radial scars (RSs) or complex sclerosing lesions (CSLs) of the breast are benign radiologic and histologic entities. With the introduction of population-based screening programs, their incidence has increased to 0.03% to 0.09% of all core needle biopsies (CNBs). They can pose diagnostic difficulty because their radiologic and histologic appearances mimic carcinoma. We retrospectively searched for and reviewed all cases of RS/CSL diagnosed on image-guided CNB from January 1, 1994, to August 31, 2013, at a single institution. We also assessed the pathologic reports from excisional biopsies to identify cases upstaged to atypia or neoplasm. After exclusions, 100 CNBs were identified from 97 women, which showed RS/CSL without concomitant atypia. Mean age of the women was 52.9 years. Thirty-five women (38/100 CNBs, 38%) had follow-up excision. The median size of the excised RS/CSLs was 1.2 cm; 69% were larger than 1.0 cm. Almost all excised cases (92%) showed radiologic and pathologic concordance, and 79% were designated as suspicious for malignancy (Breast Imaging Reporting and Data System level 4). The most common findings of 38 follow-up excisional biopsies were residual RS (22 [58%]), atypical lobular hyperplasia (5 [13%]), and no residual lesion (5 [13%]). Eleven excisional biopsies (29%) were upstaged to invasive or in situ carcinoma or to atypical hyperplasia. Follow-up excisional biopsy is warranted for RS/CSLs, specifically those larger than 1.0 cm with worrisome radiographic findings or with radiologic and pathologic discordance. Approximately 29% of cases were upstaged to in situ or invasive carcinomas or other high-risk lesions in our study.

[Breast surgeon role in the management of high-risk breast lesions]

Diagnostics of high-risk breast lesions have increased these last years with the augmentation of breast percutaneous biopsies. They are lesions that confer an enlarged risk of breast cancer, either because of an increased probability of finding cancer after open surgery, a possible evolution toward in situ or invasive cancer, or because of an increased probability of developing breast cancer over the long term. Much progress has been made these last years in their histological diagnostic, classification and pathogenesis. Nevertheless, no consensus exists to date on the management of these "high-risk" lesions. In particular, surgical indications and follow-up modalities remain controversial for each histological type. In this review, the principal factors that could impact surgical decision and long-term follow-up are discussed with areas of controversy highlighted.

Radiologic-pathologic correlation at breast MR imaging: what is the appropriate management for high-risk lesions?

Breast magnetic resonance (MR) imaging is increasingly performed for a variety of indications, most commonly with the goal of detecting breast cancer. Percutaneous biopsy (usually under MR guidance or ultrasound if there is a correlating finding) is commonly used to evaluate suspicious imaging findings detected on MR imaging with the goal of identifying malignancy. It is important to be familiar with the characteristics and management of high-risk lesions detected or biopsied under MR guidance. This review focuses on the appearance of a variety of breast lesions detected on MR imaging that require excision with focus on pathologic correlation.

Solitary intraductal papillomas of the breast: MRI features and differentiation from small invasive ductal carcinomas

OBJECTIVE

Intraductal papilloma of the breast can resemble invasive ductal carcinoma (IDC). The purpose of this study was to characterize MRI features of solitary intraductal papillomas and identify features that differentiate intraductal papillomas from small IDCs.

MATERIALS AND METHODS

Forty-four intraductal papillomas and 49 small (diameter≤2.0 cm) IDCs confirmed by histopathology were included. Analysis of MR findings included morphology, signal intensity preenhancement, time-signal intensity curve (TIC), enhancement degree, and evolution of enhancement pattern on dynamic contrast-enhanced MRI (DCE-MRI), and diffusion-weighted imaging. The chi-square test and independent-samples Student t test were performed.

RESULTS

Of 44 intraductal papillomas, 27 (61.4%) were round or oval and 17 (38.6%) were irregular in shape, whereas 38 of 49 (77.6%) IDCs showed irregular or lobular shape (p<0.001). Smooth margins were seen in 43.2% (19/44) of the intraductal papillomas and 8.2% (4/49) of the IDCs. Most intraductal papillomas and IDCs showed slightly higher signal intensity on T2-weighted images. On DCE-MRI, 68.2% (30/44) of intraductal papillomas and 12.2% (6/49) of IDCs showed an early homogeneous or heterogeneous to delayed rimlike enhancement pattern (p=0.000). The difference in early-phase enhancement rates between intraductal papillomas (155.41%±19.15%) and IDCs (176.40%±35.61%) was significant (p=0.001). Differences in TIC and apparent diffusion coefficient values between the two groups were not significant.

CONCLUSION

A low early-phase enhancement rate and evolution of the DCE-MRI enhancement pattern from homogeneous or heterogeneous enhancement to rim enhancement is more likely to suggest intraductal papilloma than IDC.