Nonneoplastic and neoplastic sclerosing lesions of the breast

Sclerosing lesions of the breast encompass a spectrum of benign and malignant entities and often pose a diagnostic challenge. Awareness of key morphologic features and pitfalls in the assessment of morphology and immunophenotype is essential to avoid over- or underdiagnosis and ensure optimal clinical management. This review summarizes nonneoplastic sclerosing lesions such as radial scar/complex sclerosing lesion, sclerosing adenosis, sclerosing intraductal papilloma, sclerosing variants of ductal adenoma and nipple adenoma, and fibroadenoma with extensive sclerosis, including their clinical presentation, characteristic morphology, differential diagnostic considerations, appropriate immunohistochemical work-up, when needed, and the clinical significance. In addition, atypical or neoplastic entities (such as atypical ductal hyperplasia, ductal carcinoma in situ, low-grade adenosquamous carcinoma, and fibromatosis-like metaplastic carcinoma) that can involve these sclerosing lesions are also briefly discussed.

A Comprehensive Assessment of Radial Scars on Core Needle Biopsy in Patients with or without Breast Cancer: Upgrade Rate and Implications on Management

BACKGROUND

Radial scars/radial sclerosing lesions (RS) are benign breast lesions identified on core needle biopsy (CNB) which can upgrade to malignancy at excision. There is limited data on RS detection and upgrade rates with more sensitive imaging such as magnetic resonance imaging (MRI) and none during their detection for breast cancer workup and its implication on patient treatment decisions.

METHODS

A retrospective institutional study of RS diagnosed on CNB between January 2008 and December 2017 was conducted. Clinicopathologic and radiologic features of RS, patient treatment decisions, upgrade rates and long-term follow-up were examined.

RESULTS

We identified 133 patients with RS on CNB, of whom 106 opted for surgery for an upgrade rate to malignancy of 1.9%, 2 patients. Radial scar was diagnosed on mammogram in 60%, MRI in 25% and ultrasound in 15% of patients. In this cohort, 32 patients had their RS detected during breast cancer workup (coexistent group) and they were more likely to have their radial scar detected by MRI (60% vs. 14%, P < .001) and undergo more extensive surgery (94% vs. 75%, P = .02). Among the 27 patients electing observation of their RS, only one (3.7%) developed breast cancer.

CONCLUSIONS

Our results show an extremely low upgrade rate to malignancy of RS, regardless if there is coexisting breast cancer elsewhere. Despite this, RS still prompted more extensive surgical excisions. The findings do not support excision of RS even among breast cancer patients when identified at a separate site from their cancer.

Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy: The need for surgical excision

BACKGROUND

Management of breast lesions of uncertain malignant potential diagnosed at core needle biopsy (CNB) is controversial due to variable upstage rate (UR) with surgical excision (SE).

METHODS

We performed an IRB-approved retrospective analysis of adult women who underwent CNB demonstrating atypical ductal hyperplasia (ADH), flat epithelial atypia, radial scar, or intraductal papilloma then SE between 2010 and 2022. We evaluated CNB pathology for combination diagnoses (CD), defined as multiple primary lesions or primary with lobular neoplasia (LN), and surgical pathology for upstage.

RESULTS

719 patients were included. UR was 12.2% (88/719). CD experienced higher UR than pure (17.7% (45/254) vs. 9.2% (43/465), p ​= ​0.001). ADH/LN had the highest UR of all CD (34.6% (9/26), p ​= ​0.001). Increased size (15.6 vs. 10.5 ​mm, p ​< ​0.001), distance from nipple (79 vs. 66 ​mm, p ​< ​0.001), and personal history of breast cancer (p ​= ​0.04) were associated with UR.

CONCLUSIONS

CD was associated with increased UR. ADH/LN had the highest UR.

Underestimation Rate in the Percutaneous Diagnosis of Radial Scar/Complex Sclerosing Lesion of the Breast: Systematic Review

OBJECTIVE

 To evaluate the underestimation rate in breast surgical biopsy after the diagnosis of radial scar/complex sclerosing lesion through percutaneous biopsy.

DATA SOURCES

 A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubM: ed, SciELO, Cochrane, and Embase databases were consulted, with searches conducted through November 2020, using specific keywords (radial scar OR: complex sclerosing lesion, breast cancer, anatomopathological percutaneous biopsy AND/OR: surgical biopsy).

DATA COLLECTION

 Study selection was conducted by two researchers experienced in preparing systematic reviews. The eight selected articles were fully read, and a comparative analysis was performed.

STUDY SELECTION

 A total of 584 studies was extracted, 8 of which were selected. One of them included women who had undergone a percutaneous biopsy with a histological diagnosis of radial scar/complex sclerosing lesion and subsequently underwent surgical excision; the results were used to assess the underestimation rate of atypical and malignant lesions.

DATA SYNTHESIS

 The overall underestimation rate in the 8 studies ranged from 1.3 to 40% and the invasive lesion underestimation rate varied from 0 to 10.5%.

CONCLUSION

 The histopathological diagnosis of a radial scar/complex sclerosing lesion on the breast is not definitive, and it may underestimate atypical and malignant lesions, which require a different treatment, making surgical excision an important step in diagnostic evaluation.

The effect of delay of excisional biopsy on upstage rate for atypical ductal hyperplasia, flat epithelial atypia, intraductal papilloma, and radial scar

PURPOSE

When Core Needle Biopsy (CNB) demonstrates Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Intraductal Papilloma (IDP), or Radial Scar/Complex Sclerosing Lesion (RS), excisional biopsy (EB) is often performed to rule out underlying malignancy with upstage rates (UR) ranging between 1 and 20%. The COVID-19 pandemic led to delayed EB for many patients. We sought to evaluate whether this delay was associated with higher UR.

METHODS

We performed a retrospective analysis of women who underwent CNB and then EB for ADH, FEA, IDP, or RS between 2017 and 2021 using an IRB-approved repository. UR was evaluated by days between CNB and EB.

RESULTS

473 patients met inclusion. 55 were upstaged to cancer (11.6%). 178 patients had pure ADH on CNB and 37 were upstaged (20.8%). 50 patients had pure FEA and 3 were upstaged (6%). 132 had pure IDP and 7 were upstaged (5.3%). 98 had pure RS and 1 was upstaged (1%). 7/15 (46.7%) had a combination of diagnoses or diagnosis with palpable mass and were upstaged. Days between CNB and EB were < 60 for 275 patients (58.1%), 60-90 for 108 (22.8%), 91-120 for 43 (9.1%), and > 120 for 47 (9.9%). There was no significant difference in UR (10.9% for < 60, 14.8% for 60-90, 7% for 90-120, and 12.8% for > 120, p = 0.54). UR for ADH was clinically increased after 60 days (27.8 vs. 17.5%), but this did not reach statistical significance (p = 0.1).

CONCLUSION

Surgical delay was not associated with an increased UR.

Pure Radial Scars Do Not Require Surgical Excision When Concordant and Benign at Image-guided Breast Biopsy

OBJECTIVE

To determine the best management option (surgical excision versus imaging surveillance) following the diagnosis of pure radial scars (RSs) and RSs with associated additional high-risk lesions (HRLs) encountered on percutaneous core-needle breast biopsy.

METHODS

An IRB-approved retrospective review of the breast imaging reporting system database was performed to identify all cases of pure RS alone or RS plus an additional HRL (papilloma, atypia, lobular neoplasia) diagnosed on core-needle biopsy, from 2007 to 2016, at four breast centers in our institution. Cases with associated malignancy, discordant radiologic-pathologic results, or those lost to follow-up were excluded. The remaining cases were evaluated to determine results of either subsequent surgical excision or long-term follow-up imaging (minimum of two years). Additional data recorded included clinical presentation, breast density, personal and family history of breast cancer, lesion imaging characteristics, and biopsy method.

RESULTS

The study cohort included 111 patients with 111 lesions: 56.8% (63/111) with RS alone (pure) and 43.2% (48/111) with RS plus additional HRL(s). Out of the 63 radiologic-pathologic concordant pure RSs, there were no upgrades to malignancy in 51 subsequent surgical excisions or 12 long-term surveillance cases (0/63, 0%). Out of the 48 RSs plus additional HRL(s), there were 2 upgrades to malignancy (2/48, 4.2%).

CONCLUSION

Cases of radiologic-pathologic concordant pure RS diagnosed at core-needle biopsy do not require surgical excision. On the other hand, surgical excision should be considered for RS plus additional HRLs diagnosed at core-needle biopsy.

Upstage rate of radial scar/complex sclerosing lesion identified on core needle biopsy

BACKGROUND

We assessed the cancer upstage rate of Radial Scars (RS), and Complex Sclerosing Lesions (CSL), and risk-stratified lesions based on radiological and pathological features.

METHODS

Characteristics of RS/CSL treated from 2013 to 2018 were examined for features associated with cancer.

RESULTS

78 RS/CSL were found on core needle biopsy (CNB) and surgically excised. 9 (11.5%) lesions were upstaged. Upstaged patients were older (66 vs 51, p = 0.033). More upstaged lesions were accompanied by a mass on both mammography (87.5% vs. 30.0%, p = 0.005) and ultrasound (100.0% vs. 62.8%, p = 0.043). 20.5% of lesions biopsied under ultrasound guidance with small needles (14-18G) were upstaged, but no lesions biopsied under stereotactic guidance with large needles (9-12 G) with vacuum assistance were upstaged (p = 0.009).

CONCLUSIONS

Excision of RS/CSL seen on CNB is warranted, especially if the patient is older, the CNB is performed under ultrasound guidance with small needles, or if a mass is present on imaging.

High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management

OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.

Management of high-risk breast lesions diagnosed on core biopsies and experiences from prospective high-risk breast lesion conferences at an academic institution

BACKGROUND

The management of high-risk breast lesions diagnosed on image-guided core biopsy remains controversial. We implemented a high-risk breast conference attended by breast pathologists, imagers, and surgeons to prospectively review all contemporary cases in order to provide a consensus recommendation to either surgically excise or follow on imaging at 6-month intervals for a minimum of 2 years.

METHODS

Between May, 2015 and June, 2019, 127 high-risk lesions were discussed. Of these 127 cases, 116 had concordant radiology-pathology (rad-path) findings. The remaining 11 patients had discordant rad-path findings. Of the 116 concordant cases, 6 were excluded due to lack of the first imaging follow-up until analysis. Of the remaining 110 patients, 43 had atypical ductal hyperplasia (ADH), 12 had lobular carcinoma in situ (LCIS), 19 had atypical lobular hyperplasia (ALH), 33 had radial scar (RS), 2 had flat epithelial atypia (FEA), and 1 had mucocele-like lesion (ML). We recommended excision for ADH if there were > 2 ADH foci or < 90% of the associated calcifications were removed. For patients with LCIS or ALH, we recommended excision if the LCIS or ALH was associated with microcalcifications or the LCIS was extensive. We recommended excision of RS when < 1/2 of the lesion was biopsied. We recommended all patients with FEA and ML for 6-month follow-up.

RESULTS

Following conference-derived consensus for excision, of the 27 ADH excised, 9 were upgraded to invasive carcinoma or ductal carcinoma in situ. Of the six LCIS cases recommended for excision, none were upgraded. Nine excised radial scars revealed no upgrades. Additionally, 3 patients with ADH, 2 with ALH, 1 with LCIS, and 2 with RS underwent voluntary excision, and none were upgraded. All other patients (13 with ADH, 5 LCIS, 17 ALH, 22 RS, 2 FEA and 1 ML) were followed with imaging, and none revealed evidence of disease progression during follow-up (187-1389 days). All 11 rad-path discordant cases were excised with 2 upgraded to carcinoma.

CONCLUSIONS

The results of this prospective study indicate that high-risk breast lesions can be successfully triaged to surgery versus observation following establishment of predefined firm guidelines and performance of rigorous rad-path correlation.

[Histological lesions of risk of breast carcinoma. Survival guide for the general pathologist]

Proliferative epithelial lesions are risk factors for breast cancer. They are a heterogeneous group of lesions in which the presence of atypia is related to varying degrees of risk. They should be considered in the differential diagnosis with benign lesions, in situ ductal carcinoma and infiltrating carcinoma. An accurate histopathological diagnosis is important in choosing the best therapeutic option, including vacuum assisted biopsy and surgery. We revise diagnostic criteria and the differential diagnosis of usual ductal hyperplasia, radial scar and complex sclerosing lesions, distinct types of adenosis, papillary lesions, atypical ductal hyperplasia, flat epithelial atypia and lobular neoplasia in situ. Furthermore, we summarize the degree of risk associated with the different conditions and management possibilities.

Management of radial scars/complex sclerosing lesions of the breast diagnosed on vacuum-assisted large-core biopsy: is surgery always necessary?

AIMS

The diagnosis of radial scars/complex sclerosing lesions (RSs/CSLs) onpercutaneous biopsy carries a risk of histological underestimation. Consequently, surgical excision is often performed in order to exclude a possible associated malignancy. The aim of this study was to assess the rate of 'upgrade to carcinoma' upon subsequent surgical excision of RS/CSL cases diagnosed on vacuum-assisted large-core biopsy (VALCB). We also analysed the risk factors for upgrade in order to determine a subset of patients who could avoid surgery and benefit from conservative management with clinical and imaging follow-up.

METHODS AND RESULTS

This was a retrospective observational single-centre study on 174 consecutive RS/CSL cases diagnosed on VALCB from May 2008 to October 2015. Univariate analysis was performed to identify clinical, radiological and histological risk factors for upgrade. Surgical excision was performed following VALCB diagnosis of 88 RS/CSL cases with or without associated atypia. The overall rate of surgical upgrade to carcinoma was 9.1% (8/88). None of the benign biopsies without atypia was surgically upgraded. Additional to atypia, risk factors for upgrade were non-incidental finding of the RS/CSL, the mammographic appearance, and the number of fragments obtained during the biopsy procedure (P < 0.05).

CONCLUSION

We demonstrate that VALCB revealing an RS/CSL is reliable for excluding malignancy when there is no associated atypia and when radiological and histological findings are concordant. In such cases, surgery can be avoided in favour of clinical and imaging follow-up. When an RS/CSL is associated with atypia, the decision to perform surgical excision depends on other associated risk factors.

Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry

Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.

Excision or Observation: The Dilemma of Managing High-Risk Breast Lesions

There is an enduring dilemma on the appropriate management of high-risk breast lesions; is surgical excision always warranted or can conservative management be utilized? We present cases of high-risk breast lesions diagnosed at core needle biopsy at our institution along with relevant factors to consider for appropriate management. We conclude that a nuanced approach is warranted over the broad stroke approach of surgical excision of all high-risk breast lesions.

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.

Radial scars/complex sclerosing lesions of the breast: radiologic and clinicopathologic correlation

Background

We investigated the radiologic and clinical findings of radial scar and complex sclerosing lesions, and evaluated the rate of pathologic upgrade and predicting factors.

Methods

From review of our institution’s database from January 2006 to December 2012, we enrolled 82 radial scars/complex sclerosing lesions in 80 women; 51 by ultrasound guided core needle biopsy, 1 by mammography-guided stereotactic biopsy, and 38 by surgical excision. The initial biopsy pathology revealed that 53 lesions were without high risk lesions and 29 were with high risk lesions. Radiologic, clinical and pathological results were analyzed statistically and upgrade rates were calculated.

Results

Of the 82 lesions, 64 (78.0%) were surgically excised. After surgical excision, two were upgraded to DCIS and two were upgraded to lesions with high risk lesions. The rate of radial scar with high risk lesions was significantly higher in the surgical excision group (11.1% vs. 42.2%, p = 0.015), which also demonstrated larger lesion size (10.7 ± 6.5 vs. 7.1 ± 2.6 mm, p = 0.001). The diagnoses with high risk lesions on final pathological results showed older age (52.9 ± 6.0 years vs. 48.4 ± 6.7 years, p = 0.018).

Conclusions

Radial scars with and without high risk lesions showed no statistically significant differences in imaging, and gave relatively low cancer upgrade rates.

Electronic supplementary material

The online version of this article (10.1186/s12880-018-0279-z) contains supplementary material, which is available to authorized users.

Radial scar on image-guided breast biopsy: is surgical excision necessary?

PURPOSE

Radial scar's stellate appearance may mimic carcinoma mammographically and histologically. Management of radial scar (RS) found on breast core needle biopsies (CNB) ranges from excision to clinical observation due to the variation in reported upgrades to malignancy at surgical excision. We examined the upgrade rate in patients with RS detected on CNB at our institution and reviewed the current literature.

METHODS

A retrospective study was conducted of all cases with RS diagnosed on CNB between December 2006 and March 2017 at our institution. Inclusion criteria were patients with "pure" RS and RS associated with high-risk lesions (HRL). Upgrade was defined as invasive or non-invasive cancer in the excisional biopsy.

RESULTS

157 cases were identified with RS on CNB, and 122 cases met inclusion criteria. Of these 122 cases, 91 (75%) had pure RS on CNB while 31 (25%) had associated atypia or HRL. 81 (66%) of patients proceeded to excisional biopsy and 41 (34%) did not. Two patients (1.6% of total) were found to have a low-grade invasive ductal carcinoma (0.6 and 0.8 cm) upon surgical excision. None of the remaining 120 patients developed an ipsilateral breast cancer with a mean of 32.3-month follow-up.

CONCLUSIONS

We found a very low upgrade rate to breast cancer when RS was found on CNB with or without associated HRL. Our results are consistent with other reported series. Our data do not support surgical excision for RS but rather close clinical follow-up for patients with RS on CNB.

Core Needle Biopsy of the Breast: An Evaluation of Contemporary Data

Benign and atypical lesions associated with breast cancer risk are often encountered in core needle biopsies (CNBs) of the breast. For these lesions, the rate of "upgrade" to carcinoma in excision specimens varies widely in the literature. Many CNB studies are limited by a lack of radiological-pathological correlation, consistent criteria for excision, and clinical follow-up for patients who forego excision. This article highlights contemporary diagnostic criteria and outcome data that would support an evidence-based approach to the management of these nonmalignant lesions of the breast diagnosed on CNB.

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.

Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review

Optimal management of high-risk breast lesions detected by mammogram yielding atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia on core needle biopsy is controversial. This is a single-institution retrospective review of 5750 core needle biopsy cases seen over 14.5 years, including 249 (4.3%), 72 (1.3%), 50 (0.9%), 37 (0.6%), and 54 (0.9%) cases of atypical ductal hyperplasia, flat epithelial atypia, atypical lobular hyperplasia, lobular carcinoma in situ, and radial scar without atypia, respectively. Patient age, radiologic characteristics, needle gauge, and excision diagnoses were recorded. Of 462 high-risk cases analyzed, 333 (72%) underwent excision. Upgrade rate to ductal carcinoma in situ, pleomorphic carcinoma in situ, or invasive mammary carcinoma was 18% for atypical ductal hyperplasia, 11% for flat epithelial atypia, 9% for atypical lobular hyperplasia, 28% for lobular carcinoma in situ, and 16% for radial scar. Carcinoma diagnosed on excision was more likely to be in situ than invasive, and if invasive, more likely to be low grade than high grade. Overall, cases that were benign (vs high risk or carcinoma) on excision were less likely to have residual calcifications after biopsy (17% vs 27%, P=0.013), and more likely to have a smaller mass size (<1 cm) (82% vs 50%, P=0.001). On subgroup analysis, atypical ductal hyperplasia cases that were benign (vs high risk or carcinoma) on excision were more likely to have smaller mass size (<1 cm) (P=0.025). Lobular neoplasia diagnosed incidentally (vs targeted) on core needle biopsy was less likely to upgrade on excision (5% vs 39%, P=0.002). A comprehensive literature review was performed, identifying 116 studies reporting high-risk lesion upgrade rates, and our upgrade rates were similar to those of more recent larger studies. Careful radiological-pathological correlation is needed to identify high-risk lesion subgroups that may not need excision.

Radial scars diagnosed on breast core biopsy: Frequency of atypia and carcinoma on excision and implications for management

AIMS

The risk of finding carcinoma in excisions following a core needle biopsy diagnosis of radial scar is not well defined and clinical management is variable. The aim of this study is to determine the frequency of high-risk lesions, ductal carcinoma in situ, and invasive carcinoma in excisions following a core biopsy diagnosis of radial scar.

METHODS AND RESULTS

Dedicated breast pathologists and radiologists correlated the histologic and radiologic findings and categorized radial scars as the target lesion or an incidental finding. High-risk lesions were defined as atypical hyperplasia or classical lobular carcinoma in situ. Of the 79 radial scars identified over a 14-year period, 22 were associated with atypia or carcinoma in the core biopsy. Thirty-seven (37) of the 57 benign radial scars underwent excision with benign findings in 30 (81%), high-risk lesions in six (16%), and flat epithelial atypia in one (3%). There were no upgrades to carcinoma. One patient with a benign radial scar developed a 3-mm focus of intermediate-grade estrogen receptor-positive ductal carcinoma in situ in the same quadrant of the ipsilateral breast 72 months after excision. One patient with an incidental un-excised benign radial scar was diagnosed with ductal carcinoma in situ at a separate site of suspicious calcifications.

CONCLUSIONS

In this series, none of the benign radial scars was upgraded to carcinoma. Radial scar was the targeted lesion in all cases with high-risk lesions on excision. Surgical excision may not be mandatory for patients with benign incidental radial scars on core biopsy.