Radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy: Analysis of 49 cases from a single-centre and review of the literature

Abstract

The purpose of this study was to evaluate the reliability of image-guided 14-gauge needle core biopsy in the diagnosis of radial scar without associated atypical epithelial proliferation, by comparison with definitive histological diagnosis on surgical excision. The records of 8792 consecutive image-guided 14-gauge needle core biopsy of the breast performed from January 1996 to December 2009 were reviewed. Forty-nine cases of radial scar without associated atypical epithelial proliferation were identified and compared with definitive histological diagnosis on surgical excision. The definitive histological diagnosis on surgical excision confirmed the results of image-guided 14-gauge needle core biopsy in 36 of 49 cases (73.5%), in 9 cases (18.3%) radial scar was associated with atypical epithelial proliferation, while 4 cases out of 49 cases were upgraded to carcinoma (3 cases of ductal carcinoma in situ and one case of invasive lobular carcinoma), with an underestimation rate of 8.2%. A diagnosis of radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy does not exclude a malignancy on surgical excision; consequently during the multidisciplinary discussion further assessment by surgical excision or vacuum-assisted excision, as recently reported, needs to be considered to obtain a definitive histological diagnosis.

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

“…These are more likely to be incidental in nature and their management is most controversial. The mean size of radial scars in our series was 3.11 mm, while those in other reports 3,5,7,8,11,17,18 range in size from 1 mm up to 5.0 cm. This wide range in sizes is a result of variability of inclusion criteria among different studies.…”

“…In most studies, the rate of upgrade, or underestimation of malignancy, of surgically excised radial scars has been variable, but most reported rates are in the range of 0% to 10%. 3,[5][6][7][8][9][10][11][12][13][14] However, most radiologists are not comfortable recommending clinical follow-up over surgical excision of radial scars because studies have not consistently demonstrated an upgrade rate of less than 2%, the cutoff for categorizing a lesion as ''probably benign'' according to the BI-RADS (Breast Imaging Reporting and Data System) system (BI-RADS 3). 15 The variability in reported upgrade rates may be due to several factors including variability in study design, small sample sizes, and inconsistent radiologic-pathologic concordance.…”

“…3,6,7,16 It is also worthy to note that even the high-risk lesions (LCIS, ADH, ALH) considered as pathologic upgrades could, themselves, be considered incidental microscopic findings, as they would have remained clinically occult had an excisional biopsy not been performed in these cases.…”

“…Surgical excision is largely motivated by the concern that carcinoma associated with the radial scar in the NCB has gone unsampled. Significantly variable rates of pathologic upgrade (finding a more significant lesion in the subsequent excisional biopsy) have been reported (0%-40%), 3 which further augment clinicians' misgivings about the ideal practice in this clinical scenario.…”

Management of the High-Risk Breast Lesion

“…For example, ADH is described as a ductal epithelial lesion containing some, but not all, of the features of DCIS. A diagnosis of ADH on CNB is complicated by its similar [ 4 , 5 , 12 ] 25-33* FEA [ 13 , 14 ] 9-15* Papillary breast lesion Intraductal papilloma (IDP) [ 15 ] 8* Radial scar [ 10 , 16 , 17 ] 5-9* 1.8-3…”