Complex sclerosing lesions and radial sclerosing lesions on core needle biopsy: Low risk of carcinoma on excision in cases with clinical and imaging concordance

Abstract

Complex or radial sclerosing lesions (CSL/RSL) are uncommon diagnoses on core needle biopsy with a reported upgrade rate ranging between 0% and 23%. As a result, their management remains controversial. In this study, we sought to determine the rate of malignancy on excision for patients with pure CSL/RSL on core biopsy, and to evaluate future breast cancer risk when CSL/RSL is managed without excision. We retrospectively reviewed 118 cases of CSL/RSL diagnosed on image-guided breast biopsies between 2005 and 2014 at our institution. Of 98 analyzed patients, 34 (35%) underwent excision and 64 (65%) were observed. Demographic and clinical variables between excision and observation groups were compared. In excised specimens, factors associated with upgrade to malignancy were evaluated. The median age at diagnosis was 49 years (range, 27-88 years). In the excision group, 3/34 cases were associated with malignancy, an overall upgrade rate of 9%. All malignant cases had core needle biopsies interpreted as discordant and were BIRADS 4B or more on imaging. In the observation group, at a median follow-up of 2.2 years, 3/64 (5%) patients developed ipsilateral cancers, all of which were distant from the index CSL/RSL. In our series, we report a 9% malignancy rate on excision of BIRADS >4C lesions characterized as CSL/RSL on core biopsy. In patients with concordant biopsies and BIRADS 4A or lower lesions who underwent observation, we found a low rate of subsequent ipsilateral cancers. Further studies are needed to confirm that for CSL/RSL in concordant core biopsies and BIRADS 4A or lower, nonpalpable lesions, observation may be a reasonable alternative to excision.

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

“…As noted by several authors, carcinomas found on surgical excision were mainly DCIS, especially of low and intermediate grade, raising the question of over diagnosis of slow‐growing lesions, for which a diagnostic delay due to non‐invasive management would not have a significant impact on prognosis …”

“…Several authors have reported a significant risk of missed associated carcinoma when RS/CSL is diagnosed on percutaneous biopsy . Others have suggested that percutaneous biopsies are reliable for excluding malignancy, especially when VALCBs are performed . This is mainly due to reports of heterogeneous series.…”

Is radial scar on core needle biopsy a risk factor for malignancy? A single‐center retrospective review and implications for management

“…Previous reviews show RS account for 5%‐9% of findings on CNB which is a significant proportion of atypical findings 6 . Upgrade rates of RS to atypia or malignancy, however, range widely (0%‐40%) 7,8 . There has also been suggestion that the type of CNB impacts upgrade rates but the general conclusion reached from this research advises observation of patients with RS and no other atypia 4,9‐12 .…”

Radiomics Based on DCE-MRI Improved Diagnostic Performance Compared to BI-RADS Analysis in Identifying Sclerosing Adenosis of the Breast

“…Although research has reported that SA may convey an approximate doubling of breast cancer risk as a single feature, the presence of sclerosing adenosis alone in a core biopsy does not require surgical excision ( 29 , 30 ). Close clinical follow-up or routine imaging is recommended ( 1 , 7 , 31 ). Accurately distinguishing SA from invasive carcinoma via a non-invasive, preoperative method is crucial to help avoid unnecessary biopsy and surgery for both patients and clinicians.…”