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

Abstract

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.

Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

“…Another study demonstrating similar results is Kraft et al, where 50 of 50 patients undergoing active surveillance instead of excision did not progress on follow-up imaging (35). This is a larger cohort than in previous studies followed with imaging alone rather than surgical excision (23,33,34,38). For example, in Martaindale et al, 13 lesions were followed successfully for a median of 18 months with benign findings (33).…”

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

“…These may be the plausible reasons why SA could mimic invasive carcinoma on clinical and imaging presentation. 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 ).…”

Radial Scar: a management dilemma

“…The authors concluded that imaging surveillance could be a reasonable option for RS without atypia assessed by 8-11G VAB. Likewise, Bacci et al [ 60 ] found that VAB with a large core is reliable to exclude malignancy and allows avoiding surgical excision when there is no discordance between radiological and histological findings, and no associated atypia on biopsy. Eghtedari et al [ 61 ] observed that in a group of 54 patients with a CNB histological result of RS without atypia, no case developed malignancy during the 2 years of follow-up (95% confidence interval 0–7%).…”