Radial Scar/complex Sclerosing Lesion Research Articles

Indeterminate (B3) Breast Lesions and the Ongoing Role of Diagnostic Open Biopsy.

Introduction Due to their uncertain malignant potential, indeterminate breast lesions on core needle biopsy (CNB) require diagnostic open biopsy (DOB). This study evaluated DOB results given largely benign pathology. Lesions included are atypical papilloma, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and radial scar/complex sclerosing lesions (RS/CSL). Methodology. A retrospective audit from 2010 to 2017 analysed patients with a screen-detected suspicious lesion and indeterminate (B3) CNB diagnosis. Primary outcome was the malignancy upgrade rate, with secondary evaluation of patient factors predictive of malignancy including age, symptoms, mammogram characteristics, lesion size, biopsy method, and past and family history. Results 152 patients (median age 57 years) were included, with atypical papillomas being the largest subgroup (44.7%). On DOB histology, 99.34% were benign, resulting in a 0.66% malignancy upgrade rate. Patient characteristic analysis identified 86.84% of B3 lesions were in patients greater than 50 years old. 90.13% were asymptomatic, whilst 98.68% and 72.37% had a negative past and family history. Majority 46.71% of lesions had the mammogram characteristic of being a mass. However, with 57.89% of the lesion imaging size less than 4 mm, a corresponding 60.5% of core needle biopsies were performed stereotactically. The small malignant subgroup limited predictive factor evaluation. Conclusion Albeit a low 0.66% malignancy upgrade rate in B3 lesions, no statistically significant patient predictive factors were identified. Until predictive factors and further assessment of vacuum-assisted excision (VAE) techniques evolve, DOB remains the standard of care.

High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: imaging characteristics, outcome of surgical excision or imaging follow-up.

To evaluate imaging characteristics, outcome of surgical excision or imaging follow-up on high-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy (MRI-VABB). We retrospectively reviewed 598 lesions undergoing 9-gauge MRI-VABB from January 2015 to April 2018 to identify high risk breast lesions.We collected patient demographics, breast MRI BI-RADS descriptors, histopathological diagnosisat MRI-VABB and surgical excision, frequency of upgrade to malignancy and imaging follow-up of high-risk lesions. The x2 test and Fisher exact tests were performed for univariate analysis. 114 patients with 124/598 findings (20.7%) had high-risk lesions at MRI-VABB, includingatypical ductal hyperplasia (ADH) (21/124, 16.9%), lobular neoplasia (40/124, 32.3%), radial scar/complex sclerosing lesion (RS/CSL) (13/124, 10.5%), papillary lesions (49/124, 39.5%), and flat epithelial atypia (FEA) (1/124, 0.8%).84/124 (67.7%) high-risk lesions wereexcised.19/84 (22.6%) were upgraded to malignancy (7 invasive cancer, 12 DCIS).The upgrade rate for ADH and lobular neoplasia was7/18 (38.9%) and 9/31 (29.0%), respectively. The upgrade rate for RS/CSL was 1/10 (10%). Of the 25 papillary lesions excised, 2 (8%) demonstrated pathologic atypia and were upgraded to DCIS. The other 23 papillary lesions had no upgrade or atypia. Excised high-risk lesions showing upgrade varied from 0.4 to 6cm in length (mean 1.6cm). There was a non-significant trend (p = 0.054) between larger lesion and upgrade to malignancy;however, there were no other specific imaging features to predict malignancy upgrade. There were no specific MRI imaging characteristics of high-risk lesions to predict malignancy upgrade. Therefore, surgical excision is recommended for high-risk lesions, especially ADH or lobular neoplasia.

Abstract P5-02-06: High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: Imaging characteristics, outcome of surgical excision or imaging follow-up

Abstract PURPOSE To evaluate imaging characteristics, outcome of surgical excision or imaging follow-up on high-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy (MRI-VAB). MATERIALS AND METHODS We retrospectively reviewed 581 lesions, to include benign, high-risk and malignant lesions, undergoing 9-gauge MRI-VAB from January 2015 to April 2018. We collected patient demographics, risk factors and indications, breast MRI BI-RADS descriptors, histopathological diagnosis at MRI-VAB and surgical excision, frequency of upgrade to malignancy and imaging follow-up of high-risk lesions found in this period. RESULTS 101 patients with 107/581 (18.4% of all lesions) had high risk lesions at MRI-VAB, including atypical ductal hyperplasia (ADH)(n=19/107, 17.8%), lobular neoplasia (n=35/107, 32.7) including atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), ALH plus LCIS, papillary lesions (n=44/107, 41.1%), radial scar/complex sclerosing lesion (RS/CSL)(n=8/107, 7.5%) and flat epithelial atypia (FEA)(n=1/107, 1%). 71/107 (66.4%) high risk lesions were excised. 16/71 (22.5%) were upgraded to malignancy (4 invasive cancer, 12 DCIS). The upgrade rate for ADH and lobular neoplasia was 5 /16 (31.3%) and 8/26 (30.8%) respectively. The upgrade rate for RS/CSL was 1/6 (16.7%). Of the 22 papillary lesions excised, 2 (9.1%) demonstrated pathologic atypia and were upgraded to DCIS. The other 20 papillary lesions had no upgrade or atypia. Excised high risk lesions showing upgrade varied from 0.4 to 6 cm in length (average 2.1 cm). Increasing size correlated with tendency towards increased upgrade to malignancy, but there were no other specific imaging features to predict malignancy upgrade. CONCLUSION There were no specific MRI imaging characteristics of high-risk lesions to predict malignancy upgrade. Therefore, surgical excision is recommended for high risk lesions especially ADH or lobular neoplasia. Additionally, non-atypical papillomas did not demonstrate malignancy upgrade in our small study. And further larger studies may demonstrate that these lesions may not need to be surgically excised. Citation Format: Okamoto S, Covelli JD, DeMartini WB, Daniel BL, Ikeda DM. High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: Imaging characteristics, outcome of surgical excision or imaging follow-up [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-06.

P5-09-04: Predictors of Malignancy and Surgical Outcomes Following Indeterminate Core Needle Biopsy in the British Breast Screening Programme.

Abstract Background: The National Health Service Breast Screening Programme (NHSBSP) invites women between 50 and 70 years for mammography every three years, with abnormal imaging leading to further assessment. Core needle biopsy (CNB) is the standard for obtaining a definitive pre-operative diagnosis. However a proportion of CNBs will be reported as showing indeterminate pathology, with uncertain malignant potential. This necessitates surgical diagnostic excision biopsy, with attendant potential morbidity, and highlights the importance of pre-operative diagnosis. This study aimed to categorise the histological lesions prompting B3 classification arising within a screening programme, and to quantify the definitive surgical outcomes following excision biopsy. Material and Methods: Data was collected retrospectively from January 2000 — December 2010, including demographic details, radiological presentation, relevant clinical findings, results of preoperative investigations, reports of diagnostic excision biopsy and subsequent surgical management. Patients were included if they had a B3 CNB result and subsequent excision biopsy, following attendance for screening mammography. Primary outcome was classification of B3 lesions and positive predictive values (PPV) for malignancy. Secondary outcomes were subsequent surgical procedures. Results: There were 239 B3 lesions, representing 7.1% of all CNB carried out within the screening programme. Mean patient age was 55.6 years, and median lesion size was 14.5 mm (range: 4–25mm). Eighty seven lesions (36.4%) were malignant on excision: 28 (11.7%) invasive and 52 (21.8%) in situ. Lesion specific PPVs for malignancy were as follows: phyllodes tumour 50.0%, atypical ductal hyperplasia 40.0%, columnar cell lesion 40.0%, papillary lesion 26.7%, lobular neoplasia in situ 26.7%, and radial scar/complex sclerosing lesions (RS/CSL) 25.9%. The PPV of RS/CSL with atypia was 65.2%, and without 25.8%. Of 87 malignant cases, 55 (63.2%) went on to have a further surgery. 27 (50.9%) had re-excision of surgical margins, 10 (18.2%) had a mastectomy, 8 (14.5%) had a wide local excision, 2 had an axillary biopsy and one patient had a quadrantectomy. 18 patients had two further operations, the second was most commonly an axillary clearance, and 3 patients had three further operations. Discussion: B3 lesions are heterogeneous in nature, and continue to mandate surgical excision, demonstrated by a PPV of 36.4%, the highest reported figure in the literature to date. B3 CNB represents a significant surgical workload, demonstrated by the fact that 63.2% cases go on to have further surgery, and that 8.8% will require more than one further operation. Currently there is no pre-operative investigation that reliably predicts the likelihood of B3 associated malignancy. It has been demonstrated that the use of large volume vacuum assisted biopsy can reduce the rate of under diagnosis of both in situ and invasive malignancy, and this would clearly reduce the requirement for repeated surgery reported in this study. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-09-04.

Breast Cancer in Association with Radial Scar/Complex Sclerosing Lesion (rs/csl): Long Term Follow Up and Risk of Subsequent Breast Cancer

Breast Cancer in Association with Radial Scar/Complex Sclerosing Lesion (rs/csl): Long Term Follow Up and Risk of Subsequent Breast Cancer

Predisposition to breast cancer: the risk associated with radial scar/complex sclerosing lesions (RS/CSL)

Predisposition to breast cancer: the risk associated with radial scar/complex sclerosing lesions (RS/CSL)

Benign sclerosing lesions of the breast

Benign sclerosing lesions of the breast comprise primarily sclerosing adenosis and radial scar/complex sclerosing lesions (RS/CSL). Other benign lesions which may become fibrosed and malignant tumours frequently associated with a schirrous reaction, may enter their differential diagnosis either radioloigcally or on pathological examination. This review focuses on the pre-operative diagnosis and operative pathology of these lesions with particular reference to their prognosis and recent trends in their management.

Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening

Breast needle core biopsy (NCB) is now a commonplace diagnostic procedure in breast cancer screening, providing accurate diagnoses of both benign and malignant lesions. However, NCB may result in the borderline diagnoses of lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4). The aim was to study a large series of B3 cases from population-based screening subjects in order to evaluate positive predictive values (PPVs) for malignancy. The results of 523 NCBs of women screened over a 7-year period (1999-2006) in the East Midlands region, UK, with a B3 diagnosis who underwent surgical excision, were reviewed and compared with the final excision histology. Five percent of NCBs were reported as B3. The most frequent histological subtypes were atypical intraductal epithelial proliferation (AIDEP) and radial scar/complex sclerosing lesion (RS/CSL). Final excision histology was benign in 417 (80%) and malignant in 106 (20%) subjects (60 ductal carcinoma in situ and 46 invasive carcinoma). Lesion-specific PPVs were as follows: AIDEP 32%; lobular neoplasia (LN) 30%; RS/CSL with AIDEP or LN 24%; RS/CSL without atypia 9%; papillary lesion with AIDEP or LN 36%; and papillary lesion without atypia 4%. Five of the 32 fibroepithelial lesions with cellular stroma were phyllodes tumours (four benign and one borderline). None of the five mucinous lesions on NCB was malignant. Our results show that approximately one-fifth of NCB of screen-detected breast lesions classified as B3 are malignant on excision, and the likelihood of malignancy varies substantially between different histological subtypes.

The fine needle aspiration biopsy diagnostic criteria of proliferative breast lesions: A retrospective statistical analysis of criteria for papillomas and radial scar lesions

This study aimed to analyze statistically the accuracy of fine needle aspiration biopsy cytological criteria in diagnosing epithelial hyperplasia with atypia (EHA), papillary lesions (PAP), and radial scar/complex sclerosing lesions (RS/CSL). The 42 criteria studied were extracted from a literature review and those developed and used in our department. Cytological cases with diagnoses of EHA, PAP, and RS/CSL for the period of 1997-2001 were correlated with relevant histological follow-up and the positive predictive power of these diagnoses have been presented in an earlier publication. Some 77 cases with definite, specific histological diagnoses of atypia or a more severe lesion, PAP and RS/CSL, were reviewed and scored using 55 cytological criteria. As the group of EHA and RS/CSL yielded a smaller number of cases, these were grouped together in the statistical analysis and compared to PAP. The cytological features, which were most diagnostic for PAP, were stellate (Odds ratio 1.75) and meshwork (Odds ratio 3.29) tissue fragments, while the presence of tubular structures was inversely proportional to the histological outcome of PAP. True papillary fragments were uncommon and not statistically significant in diagnosing PAP of the breast.

Radial scar lesions of the breast diagnosed by needle core biopsy: analysis of cases containing occult malignancy

Aim: To identify and review cases of false negative needle core biopsy (NCB) in the preoperative investigation of radial scar/complex sclerosing lesion (RS/CSL) lesions—that is, benign NCB from RS/CSL which...

Radial scar, complex sclerosing lesion and risk of breast cancer. Analysis of 175 cases in Northern Ireland

Background Controversy exists over the nomenclature and clinical significance of radial scar/complex sclerosing lesion (RS/CSL) of the breast. A retrospective analysis of cases diagnosed from 1988 to 2001 in Northern Ireland was performed to determine if any clinical difference exists between the diagnoses of radial scar and complex sclerosing lesion, and establish if lesions suggestive of RS/CSL require excision and/or follow-up. Patients Patients with a diagnosis of RS/CSL from 1988 to 2001 were identified from the databases of the pathology laboratories serving specialist breast surgical units and the Northern Ireland Breast Screening Programme. Results True RS/CSL was confirmed in 175 of 230 cases. There was no difference between RS and CSL regarding associated pathology in the specimen. 16.9% of cases identified at symptomatic clinics were associated with carcinoma in situ, and 15.7% with invasive breast carcinoma, compared to 4.7 and 2.3%, respectively in the screen detected group. One later carcinoma was found. Conclusions There is no clinical difference between the entities radial scar and complex sclerosing lesion. RS/CSL require excision due to their association with malignancy. In the absence of any independent risk factor for carcinoma no further follow-up of patients with RS/CSL is required.

Cicatriz radial/lesão esclerosante complexa: aspectos radiológicos com correlação clínica, ultra-sonográfica e anatomopatológica

OBJETIVO: Estudar, retrospectivamente, as várias formas de apresentação da cicatriz radial/lesão esclerosante complexa (CR/LEC) na mamografia, correlacionando-as com o exame clínico e os achados ultra-sonográficos. Os achados histopatológicos e a associação da CR/LEC com hiperplasia atípica e carcinoma são discutidos. MATERIAIS E MÉTODOS: Foi realizado estudo retrospectivo de 926 lesões impalpáveis em 901 pacientes submetidas a biópsia excisional após localização pré-cirúrgica, do arquivo do Centro de Diagnóstico por Imagem e do Hospital Santa Rita, Vitória, ES, no período de outubro de 1993 a dezembro de 2001, nas quais 57 pacientes tiveram diagnóstico histopatológico de CR/LEC. RESULTADOS: A idade variou de 31 a 84 anos (média de 49 anos). As lesões foram palpáveis em dez casos. Na mamografia, 48 casos se apresentaram como distorção arquitetural, e com a mesma freqüência o nódulo espiculado e a densidade assimétrica, quatro casos cada. As microcalcificações foram detectadas na mamografia em 14 casos e em 20 quando o espécime cirúrgico foi avaliado. A ultra-sonografia foi realizada em 51 casos, tendo expressão em 17 como área hipoecóica irregular com atenuação acústica posterior. Houve 42 casos de CR/LEC sem ou com proliferação típica, nove casos com proliferação epitelial atípica e seis casos com carcinoma infiltrativo associado. CONCLUSÃO: Não é possível fazer diagnóstico diferencial de CR/LEC com câncer pelos métodos de imagem e a biópsia excisional deve ser realizada.

Cytologic features of 22 radial scar/complex sclerosing lesions of the breast, three of which associated with carcinoma: Clinical, mammographic, and histologic correlation

Radial scar/complex sclerosing lesion (RS/CSL) of the breast has become more frequently detected with the increasing performance of mammography as a screening test. The clinical, mammographic, and cytologic features of 22 cases of histologically proved breast RS/CSL, 3 of which associated with carcinoma arising at the periphery of the lesion, were reviewed. Clinical examination and mammography did not show specific features in differentiating RS/CSL from carcinoma of the breast. Cytology of RS/CSL without associated malignant changes was dominated by bland epithelial clusters and bipolar naked nuclei. Apocrine cells, papillary clusters, foam cells, and fibrillary elastoid material were also frequently seen. At the cytologic review, only one case of RS with apocrine adenosis, showing atypical cells, was diagnosed as suspicious. Two of the three cases of CSL with associated carcinoma in situ were cytologically characterized by the presence of single atypical cells. In the third case, characterized by a small tubular carcinoma near to CSL, fine-needle aspiration cytology revealed few tubular clusters without myoepithelial cells. Although cytology of RS/CSL without associated carcinoma does not seem characteristic, in most cases a diagnosis of benignancy can be performed correctly. The application of fine-needle aspiration cytology to mammographic lesions with features suggesting RS/CSL may permit a better planning of these lesions.

Is there a role for fine-needle aspiration in radial scar/complex sclerosing lesions of the breast?

The fine-needle aspiration cytology (FNA) from 12 mammographically detected, histologically confirmed radial scar/complex sclerosing lesions (RS/CSL) and their corresponding mammography were reviewed. Six aspirates were obtained by palpation, four by ultrasound guidance, and two by stereotactic guidance. Of the eight lesions with sufficient material five (62.5%) were reported as benign, two (25%) as atypical, and one (12.5%) as suspicious. It is proposed that FNA for RS/CSL should not be performed, and lesions require excision for histologic assessment.

Fine needle aspiration cytology of breast in invasive carcinoma of tubular type and in radial scar/complex sclerosing lesions.

Fine needle aspirates (FNA) from 31 invasive carcinomas of tubular type and 22 radial scar/complex sclerosing lesions (RS/CSL), diagnosed in Edinburgh between 1986 and 1991, were reviewed. The lesions in this study varied in size and palpability at presentation, but are of increasing interest in the differential diagnosis of non-palpable areas of increased mammographic density. In agreement with previously published information, it was found that the tubular cancers were usually selected for biopsy following aspiration, but less often definitively diagnosed as malignant. Nearly 50% of the RS/CSL group were correctly reported benign on cytology, but in 40%, biopsy was recommended to exclude malignancy. In addition, cytological features helpful in suggesting malignancy in aspirates from tubular cancers, also raised suspicion in aspirates from the RS/CSL group, with a risk of overdiagnosis of cancer.