Outcome of radial scar/complex sclerosing lesion associated with epithelial proliferations with atypia diagnosed on breast core biopsy: results from a multicentric UK-based study

Abstract

AimsThe clinical significance of radial scar (RS)/complex sclerosing lesion (CSL) with high-risk lesions (epithelial atypia) diagnosed on needle core biopsy is not well defined. We aimed at assessing the upgrade rate to ductal carcinoma in situ (DCIS) and invasive carcinoma on the surgical excision specimen in a large cohort with RS/CSL associated with atypia.Methods157 women with a needle core biopsy diagnosis of a RS/CSL with atypia and follow-up histology were studied. Histological findings, including different forms of the atypical lesions and final histological outcome in the excision specimens, were retrieved and analysed, and the upgrade rates for malignancy and for invasive carcinoma were calculated.Results69.43% of the cases were associated with atypical ductal hyperplasia (ADH) or atypia not otherwise classifiable, whereas lobular neoplasia was seen in 21.66%. On final histology, 39 cases were malignant (overall upgrade rate of 24.84%); 12 were invasive and 27 had DCIS. The upgrade differed according to the type of atypia and was highest for ADH (35%). When associated with lobular neoplasia, the upgrade rate was 11.76%. The upgrade rate’s variability was also considerably lower when considering the upgrade to invasive carcinoma alone for any associated lesion.ConclusionsThe upgrade rate for ADH diagnosed on needle core biopsy with RS is similar to that of ADH without RS and therefore should be managed similarly. RS associated with lobular neoplasia is less frequently associated with malignant outcome. Most lesions exhibiting some degree of atypia showed a similar upgrade rate to invasive carcinoma. Management of RS should be based on the concurrent atypical lesion.

Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

“…In contrast, the rate of upgrade was 14% (four of 29) for RS with associated atypia. The proportion of RS without atypia or malignancy that we found ( The upgrade rate for RS associated with atypia in this study was 14%, which is within the range of upgrade rates reported previously (upgrade rate of 35% [38 of 108] for RS with atypical ductal hyperplasia [32] and upgrade rates of 17% [one of six] and 10% for RS with atypia [five of 49] [33,34]). These upgrade rates support surgical excision as an optimal management decision for patients with RS with atypia at biopsy.…”

“…In one study of DBT-biopsied RS by Martaindale et al, a similar upgrade rate of 2.8% (one of 36) was reported for cases without atypia at biopsy (33). Interestingly, Rakha et al demonstrated that the upgrade rate for RS and concurrent atypical ductal hyperplasia was similar to the upgrade rate of atypical ductal hyperplasia alone (32), supporting the hypothesis that atypical ductal hyperplasia is likely the main contributor to malignant potential.…”

“…As Cohen et al postulated, biopsy sampling error may contribute to radiologic-histopathologic discordance and to falsenegative findings (31,32,36). Our single upgraded RS without atypia was 7 mm in size and had three samples taken with a 12-gauge needle.…”

Radial Scar: a management dilemma

“…In their opinion, VAE is always recommended in cases of RS with atypia, and if no additional atypia is found, surveillance with annual mammography is suggested. In cases where further atypia is found, the management should include open surgical excision [57]. In an interesting study of Özçağlayan et al [58], breast lesion excision system (BLES) has been evaluated as a secure procedure that can provide high diagnostic success and serve as a therapeutic method in high-risk lesions, such as RS, with high complete excision rates.…”

Significance of adenosquamous proliferation in breast lesions

“…In this setting, imaging-based follow-up is appropriate. 44 Rhaka et al 45 found that the overall upgrade rate to carcinoma on excision following core biopsy of a high-risk RS/CSL was nearly 25% and was highest for ADH in which the upgrade rate was similar to that of ADH not occurring in the context of an RS/CSL. They concluded that the management of RS/CSL should be based on a concurrent atypical lesion detected at core biopsy.…”