Radial Sclerosing Lesions Research Articles

Radial sclerosing lesions found on core needle biopsy: excision can be safely avoided.

Radial sclerosing lesions (RSLs) are benign breast lesions composed of glandular and epithelial proliferations with stellate architecture and fibro-elastotic stroma, which can mimic invasive carcinoma on imaging. Surgical management following a core biopsy diagnosis of RSLs remains controversial. We retrospectively identified core biopsies with RSLs without atypia who underwent subsequent surgical excision between 2015 and 2021. All core biopsy slides were reviewed to confirm the diagnosis. Imaging was reviewed to determine radiological-pathological concordance. An upgrade was defined as invasive carcinoma or ductal carcinoma in situ (DCIS) in the excision. The final cohort consisted of 130 core biopsies from 124 women (median age = 52 years, range = 27-76). The imaging modality was mammogram in 52 (40%) cases, MRI in 52 (40%) and ultrasound in 26 (20%). One hundred and seven (82%) core biopsies were vacuum-assisted and 23 (18%) were ultrasound-guided without vacuum assistance. The median lesion size on imaging was 9 mm (range = 2-41). Overall, two (1%) cases were upgraded at excision, including one microinvasive lobular carcinoma and one 2 mm focus of invasive mammary carcinoma with associated DCIS. In both cases, the upgraded foci of carcinoma were not closely associated with the biopsy site and were considered incidental upgrades. This study adds to the body of literature supporting observation, rather than routine excision of radial sclerosing lesions without atypia.

Imaging and Management of Radial Scars and Complex Sclerosing Lesions.

Radial scars and complex sclerosing lesions, often collectively referred to as radial sclerosing lesions (RSLs), are breast lesions characterized by sclerotic stroma with entrapped epithelial elements. RSLs have imaging features that overlap with those of breast malignancy and often become the target of imaging-guided biopsy given their suspicious imaging appearance. These can be identified in isolation or can also be associated with atypia or other high-risk lesions that have intrinsic malignant potential, increasing the risk of carcinoma and affecting prognosis and management of RSLs. Because of this, management of these lesions remains controversial. Traditional management has been surgical excisional biopsy. However, as more RSLs are identified (because digital breast tomosynthesis allows identification of more architectural distortions), optimal management is evolving. Physicians in some practices are using a multidisciplinary approach to the management of RSLs when deciding on surgical excision of these lesions versus imaging follow-up. These discussions also incorporate individual patient risk factors and greater patient informed medical decision making. Reported upgrade rates of RSLs at core needle biopsy vary and can depend on the sampling method, number of samples, gauge of the needle, target being sampled, and radiologic-pathologic concordance or discordance. A precise sampling technique also allows greater accuracy of diagnosis and lower upgrade rates for these lesions, with radiologic-pathologic correlation as an integral component for further management decisions. The authors review the overall histopathologic, clinical, and imaging features of RSLs and discuss appropriate management based on currently available data regarding upgrade rates. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Rethinking Routine Surgical Excision for all Radial Sclerosing Lesions of the Breast

IntroductionThe need for routine surgical excision of a radial sclerosing lesions (RSL) of the breast identified on percutaneous biopsy remains controversial, as contemporary upgrade rates are lower than historically cited. Materials and methodsA prospectively-maintained database of high-risk breast biopsies undergoing multidisciplinary review at a single institution was queried to identify cases of RSL from 2/2015 to 11/2020. Demographic, radiologic, and pathologic variables were summarized using frequencies and analyzed in association with RSL excision status using mixed-effects logistic regression or Fisher's exact tests. Results217 RSL were identified, diagnosed at a mean age of 57 y. The median imaging size was 1.3 cm and the majority had estimated >50% of the target removed by core needle biopsy. 32.3% underwent surgical excision of the RSL biopsy site and 2/70 (2.9%) upgraded to ductal carcinoma in situ (DCIS) on final surgical pathology. Upgrade was significantly higher for atypical RSL (P = 0.02). None of the RSL (n = 60) without atypia who had undergone excision were upgraded. For those omitting surgical excision, there was no subsequent breast cancer diagnosis at the RSL site over a mean follow-up of 23 mo. ConclusionsSurgical excision may be omitted for RSL without atypia as this group has 0% risk of upgrade after multidisciplinary review.

Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

Purpose To determine the upgrade rate for biopsy-proven radial scars and radial sclerosing lesions (RS). Materials and Methods In this retrospective study, radiology and pathology databases from two tertiary breast centers were searched to identify patients with biopsy-confirmed RS between March 1, 2012, and December 31, 2017, during which all mammography was performed with digital breast tomosynthesis (DBT). Adjunct modalities such as MRI or US are performed at our centers to better characterize lesions identified at DBT. Patient demographics, imaging, needle and excisional biopsies, and follow-up data were collected at the patient level. Clopper-Pearson interval estimate for upgrade was calculated for 95% confidence using PropCIs package with R version 4.1.0 (R Foundation for Statistical Computing) (1). Results During the study period, a total of 155 885 DBT examinations were performed. From these examinations, 146 biopsy-proven RS were identified in 142 women (median age, 58 years; age range, 26-87 years). A total of 80.1% (117 of 146) of all RS did not have associated atypia or malignancy, and 19.9% (29 of 146) had associated atypia at initial biopsy. A total of 66.7% (78 of 117) of RS without atypia or malignancy were surgically excised, 25.6% (30 of 117) were followed (median, 3 years; range, 1-7 years) with benign findings on imaging, and 7.7% (nine of 117) were lost to follow-up. The rate of malignancy upgrade was 0.9% (one of 117 [95% CI: 0.02, 4.7]); one RS without concurrent atypia or malignancy demonstrated invasive carcinoma at surgical excision. Conclusion RS without atypia had a low upgrade rate. Keywords: Mammography, Breast © RSNA, 2021.

Digital Mammography Stereotactic Biopsy versus Digital Breast Tomosynthesis-guided Biopsy: Differences in Biopsy Targets, Pathologic Results, and Discordance Rates.

Background Digital breast tomosynthesis (DBT)-guided biopsy is increasingly used in practice. It is important to know expected changes in biopsy targets, pathologic results, and discordance rates. Purpose To compare biopsy target types, pathologic results, and discordance rates for 2 years preceding and 2 years following implementation of DBT-guided biopsy. Materials and Methods All 9-gauge vacuum-assisted core biopsies from a single tertiary breast center that used digital mammography (DM) stereotactic guidance from 2013 to 2015 and DBT-guided biopsy from 2015 to 2017 were retrospectively reviewed. All mammographic examinations were performed with DBT. Patient demographics, biopsy target type, pathologic reports, surgical excision specimens when available, breast density, and imaging follow-up results were recorded. Biopsy targets and discordance rates between radiologic and pathologic examinations were compared between the two biopsy groups. Generalized mixed modeling was used to examine results before and after DBT-guided biopsy. Results A total of 1313 women underwent 1405 breast biopsies: 643 by using DM (August 2013 to July 2015) (median age, 56 years; interquartile range, 49-66 years) and 762 by using DBT (August 2015 to July 2017) (median age, 58 years; interquartile range, 50-67 years), (P = .58). Calcifications were the most common biopsy target for both groups, constituting 89.9% (578 of 643) of DM-guided biopsies and 71.1% (542 of 762) of DBT-guided biopsies (P = .03). The rate of architectural distortion biopsies was 2.0% (13 of 643) with DM-guided biopsy and 17.7% (135 of 762) with DBT-guided biopsy (P = .01). Although overall malignancy rate was similar for DM-guided biopsy (27.8% [179 of 643]) and DBT-guided biopsy (24.8% [191 of 762], P = .54), DBT-guided biopsy helped identify a similar percentage of invasive malignancies (37.4% [72 of 191] vs 29.0% [52 of 179] at DM P = .35), but more radial sclerosing lesions (8.3% [95% confidence interval {CI}: 6.0, 10.0] vs 1.7% [95% CI: 1.0, 3.1]) (P = .01). The discordance rate was 1.4% (95% CI: 1.0, 2.7) with DM-guided biopsy and 4.5% (95% CI: 3.2, 6.3) with DBT-guided biopsy (P = .01). Of the 34 discordant DBT-guided biopsies, 30 were architectural distortions. Conclusion With the transition to digital breast tomosynthesis-guided biopsy, more architectural distortions were biopsied, more radial sclerosing lesions were identified, and more discordance existed in radiologic and pathologic examinations, with a similar percentage of carcinomas diagnosed. © RSNA, 2020 Online supplemental material is available for this article.

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

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.

Next generation sequencing of the nidus of early (adenosquamous proliferation rich) radial sclerosing lesions of the breast reveals evidence for a neoplastic precursor lesion.

We sought to determine if adenosquamous proliferation of early cellular radial sclerosing lesions of the breast harbours hot spot mutations and to help clarify its relationship to low‐grade adenosquamous carcinoma as a potential form of early neoplasia. Four low‐grade adenosquamous carcinomas, early radial sclerosing lesions from 13 individuals, and 4 benign proliferative breast lesions were microdissected and assessed with a 50‐gene Hot‐spot cancer panel. Early radial sclerosing lesions were selectively microdissected concentrating on their adenosquamous proliferation (nidus). Hot spot mutations in PIK3CA were detected in ten (77% of) radial sclerosing lesions, in one low‐grade adenosquamous carcinoma, and in usual ductal hyperplasia and apocrine adenosis. Over three quarters of individuals with cellular (adenosquamous proliferation rich) early radial sclerosing lesions tested harboured somatic mutations in PIK3CA suggesting that adenosquamous proliferation is a clonal lesion. Its relationship to low‐grade adenosquamous carcinoma remains unclear in view of the small sample size and unmatched radial sclerosing lesions and low‐grade adenosquamous carcinomas.

Clinical and Radiologic Follow-up Study for Biopsy Diagnosis of Radial Scar/Radial Sclerosing Lesion without Other Atypia.

To determine the incidence of malignancy for radial scars (RS)/radial sclerosing lesions (RSL) without associated atypia or malignancy identified at needle biopsy. Retrospective review of the pathology data base from January 2004 to July 2013 yielded 100 needle biopsies diagnosed as RS/RSL without associated atypia/malignancy. The RS/RSL was considered "incidental" if the target was calcifications and "targeted" if imaging revealed a mass, architectural distortion, or suspicious magnetic resonance imaging enhancement. The electronic medical record was used to identify surgical pathology, follow-up imaging, and clinical course; all pathology slides and imaging were reviewed by a board-certified pathologist and radiologist, respectively. Patient age, laterality, RS/RSL size, microcalcifications, and associated benign lesions were recorded. Among 100 cases, 54 were "incidental" and 46 were "targeted." In the incidental group, 14 underwent excision, 30 had imaging follow-up, and 10 were lost to follow-up. In the targeted group, 27 underwent excision, 11 had imaging follow-up, and 8 were lost to follow-up. Atypia was identified in four excisions: three from the incidental group and one from the targeted group. Among these, three had negative imaging follow-up (mean 45 months; range 15-60 months); the fourth patient (one of the incidental group) underwent excision alone. One of the 27 "targeted" patients who underwent excision developed ductal carcinoma in situ of the contralateral breast at 96 months. There have been no ipsilateral malignancies. We found no evidence of associated malignancy at excision for either incidental or targeted biopsies of RS/RSL without atypia. Our study suggests that close imaging follow-up is adequate for patients with RS/RSL without associated atypia/malignancy on needle biopsy.

Prevalence of mammary alterations in women assisted in a municipality in the state of Paraná

The purpose of this quantitative and retrospective study was to analyze the prevalence of mammary alterations from 1304 women in the city of Francisco Beltrão-Paraná (PR), Brazil, registered in the SISMAMA system, from a Regional Health Center in Paraná State. Between 2009 and 2012, data was collected in May and June 2013 and statistically analyzed. The results showed that 694 (53.2%) of women were under 49 years old, 1126 (86.3%) had no increased risk for developing breast cancer, and 1205 (92.5%) underwent mammography screening. Color and tracking information were omitted in most entries.The BI-RADS category 0 (inconclusive result) was the most prominent. Categories with higher chances of malignancy (BI-RADS 4 and 5) prevailed in the left breast in women older than 50. Diagnosis of radial sclerosing lesions associated with infiltrating ductal carcinoma was predominant in 53.0% (n = 9) of the histopathological exams. We conclude that these findings are partially supported by the literature.

Pathologic diagnosis and differential diagnosis of low-grade adenosquamous carcinoma of breast and syringomatous adenoma of nipple

To investigate the pathologic and immunohistochemical features, diagnosis and differential diagnosis of low-grade adenosquamous carcinoma of the breast and syringomatous adenoma of the nipple. Six cases of low-grade adenosquamous carcinoma of the breast and four cases of syringomatous adenoma of the nipple were examined histologically and immunohistochemically (MaxVision method), and the literature was reviewed. The two types of tumors were similar in morphology, but located in different regions with low-grade adenosquamous carcinoma being present in the deep parenchyma and syringomatous adenoma in nipple. Both types of tumors were composed mainly of well-differentiated glands with angulated, comma shaped or polliwog appearance in a disordered infiltrative pattern. The tumor cells also formed solid tubules, strips or nests, with frequent areas of squamoid differentiation. Mitosis was rare. The interstitial tissue showed abundant spindle cells or sclerotic fibrosis with mixed inflammatory cells infiltration. One case of low-grade adenosquamous carcinoma showed a concomitant malignant adenomyoepithelioma, and another case showed concomitant spindle cell metaplastic carcinoma. One case of syringomatous adenoma involved the deep parenchyma. Immunohistochemistry of low-grade adenosquamous carcinoma showed that CK5/6 and p63 were positive in the outer layer of the glands and the squamoid epithelium, and CD10 was also positive in the outer layer of the glands. ER and HER2 were negative, and PR was also negative except for one case in which the spindle cells were positive for CK5/6, AE1/AE3 and PR focally. Immunostaining of syringomatous adenoma demonstrated that p63 and CK5/6 were positive in the outer layer of the glands and the squamoid epithelium. Calponin, SMA, ER, PR and HER2 were all negative. Low-grade adenosquamous carcinoma of the breast and syringomatous adenoma of the nipple are similar in morphology and immunohistochemical phenotype, while the biological features are opposite due to different locations. The differential diagnoses include tubular carcinoma, adenosquamous carcinoma, radial sclerosing lesions and others.

Role of core needle biopsy in the treatment of radial scar

Invasive tumor or ductal carcinoma in situ occur in radial sclerosing lesions in one third of the cases therefore, surgical excision is mandatory.Forty-five patients with radial scar morphology were examined. Ultrasound guided fine-needle aspiration biopsy (FNAB) and core biopsy (CB) were performed in all cases. The postoperative pathological findings were compared to the results of preoperative biopsies.Sensitivity of preoperative percutaneous biopsies (FNAB and CB) was 17.6% and 70.6%, false-negative rate was 82.4% with FNAB and 29.4% with CB. The negative predictive value was 48.1% and 84.8% respectively. Had we done preoperative cytology only, we would have had to perform a two-step procedure (sentinel lymph node biopsy) in 7 patients (15.6%), while with preoperative core biopsy it has decreased to 2 patients (4.4%).Preoperative CB in small radial stellate lesions is recommended to achieve accurate diagnosis in order to avoid a two-step surgical procedures.

Magnetic resonance imaging of radial sclerosing lesions (radial scars) of the breast

PurposeTo identify magnetic resonance (MR) imaging (MRI) features of radial sclerosing lesions (RSLs) of the breast. Methods and materialsThe radiologic and pathologic records for 4629 consecutive patients undergoing MR examinations of the breast were retrospectively reviewed. Patients who received a pathologic diagnosis of RSL without atypia or carcinoma at surgical excision were identified. The MR images were evaluated according to the BI-RADS-MRI lexicon by two experienced breast radiologists. The frequency of morphologic and kinetic patterns and of BI-RADS-MRI assessment categories was calculated. ResultsTwenty-nine patients with 29 surgically excised RSL were identified.Nine (31%) RSL were MR-occult; the remaining 20 (69%) RSL presented as masses (10/20, 50%), architectural distortions (5/20, 25%), non-mass lesions (4/20, 20%), and focus (1/20, 5%). Kinetic analysis was performed in 18 RSL: enhancement features were benign in 9 (50%) cases, suspicious in 7 (39%) cases and indeterminate in 2 (11%) cases. Twelve (41%) MR examinations were assessed as suspicious (BI-RADS-MRI 4 and 5), and 17 (59%) as negative (BI-RADS-MRI 1) or benign (BI-RADS-MRI 2 and 3). ConclusionRSLs are often visualized on MR imaging. Just as in mammography and sonography, RSL can have variable morphologic and kinetic features, and not infrequently they can mimic invasive carcinoma of the breast.

Accuracy of stereotactic vacuum-assisted biopsies in a community population.

106 Background: Stereotactic core biopsy in mammographically detected lesions permits histologic confirmation previous to surgery planning. We evaluated the use of stereotactic vacuum-assisted biopsy (VAB) for diagnosing suspicious, mammographically detected breast lesions in a community population. Furthermore, we determined the level of agreement between the pathology findings of VAB and the final surgical excisional biopsy. Methods: We retrospectively evaluated the results of 128 consecutive stereotactic VAB with 9-gauge needles performed over a period of 1 year in our community population. The imaging histologic concordance was ascertained for each lesion. We also evaluated concordance between VAB results and surgical excision results. Results: For the 128 patients included Breast Imaging Reporting and Data System (BI-RADS) staging showed BI-RADS 3: 4%; BI-RADS 4: 91%; and BI-RADS 5: 5%. VAB demonstrated 65 (51%) benign lesions, 31(24%) indeterminate lesions and 32 (25%) malignant lesions. The 31 indeterminate lesions included atypical ductal hyperplasia (n=13), lobular neoplasia (n=4), papillary lesions (n=12), radial sclerosing lesions (n=5), and flat epithelial atypia (n=13). Surgical excision was performed on 52 patients, and pathology demonstrated; 4 benign, 19 indeterminate, and 29 malignant lesions. There was one (3%) underestimation of an indeterminate lesion and there were 8 (25%) underestimations of malignant lesions after surgical excision. We did not observe any post-biopsy complications. Conclusions: Stereotactic VAB with a 9-gauge needle is a reliable method for diagnosing mammographically detected breast lesions in a community population.

Pathological study of radial sclerosing lesions

To investigate the pathological diagnostic features and the differential diagnosis of radial sclerosing lesions of the breast. Morphological observation and immunohistochemistry were applied to forty-four cases of radial sclerosing lesions of the breast. All forty-four patients were females, the mean age was 40.3 years (range 17 to 54 years). In the 31 consultation cases, 13 were misdiagnosed as carcinoma. The lesions had a radiating outline, and a central scar area where squeezed or pressed irregular shaped tubules were frequently seen. Dilated tubules and proliferated ducts or lobules were seen radically arranged at the periphery accompanied sometimes with the apocrine glands or columnar cell metaplasia and hyperplasia. Aside, there were 14 cases displaying necroses and 8 cases showing atypical ductal hyperplasia. Immunostaining showed myoepithelial cells around the pseudo-infiltrating tubules, and the florid proliferating epithelial cells were positive for CK5/6. Radial sclerosing lesions of the breast possess characteristic histological features, and may be misdiagnosed as carcinoma. The lesions should be differentiated from ductal carcinoma in situ, lobular neoplasia, tubular carcinoma and invasive ductal carcinoma.

Apocrine Ductal Carcinoma In Situ Involving a Sclerosing Lesion With Adenosis: Report of a Case

Apocrine metaplasia is a ubiquitous component of the mammary fibrocystic change spectrum. Although mostly associated with cysts, apocrine metaplasia can also present as a proliferative lesion, rarely with cytologic atypism. Apocrine atypia is characterized by 3-fold nuclear enlargement, multiple nucleoli, and hyperchromatism and generally arises in florid or radial sclerosing lesions. Dramatic apocrine atypia may be very difficult to distinguish from apocrine ductal carcinoma in situ. The latter is distinguished from apocrine atypia by greater extent of the lesion (>0.4 cm) and the presence of greater nuclear pleomorphism with nuclear membrane irregularity. The clinical significance of apocrine atypia is poorly understood and reflects the lack of published outcome studies. Herein, I report a case in which apocrine ductal carcinoma in situ presented as atypical apocrine adenosis in a needle core breast biopsy. It illustrates the problem of assessing apocrine atypia and apocrine ductal carcinoma in situ in small samples.

Apocrine Ductal Carcinoma In Situ Involving a Sclerosing Lesion With Adenosis: Report of a Case

Apocrine metaplasia is a ubiquitous component of the mammary fibrocystic change spectrum. Although mostly associated with cysts, apocrine metaplasia can also present as a proliferative lesion, rarely with cytologic atypism. Apocrine atypia is characterized by 3-fold nuclear enlargement, multiple nucleoli, and hyperchromatism and generally arises in florid adenosis or radial sclerosing lesions. Dramatic apocrine atypia may be very difficult to distinguish from apocrine ductal carcinoma in situ. The latter is distinguished from apocrine atypia by greater extent of the lesion (>0.4 cm) and the presence of greater nuclear pleomorphism with nuclear membrane irregularity. The clinical significance of apocrine atypia is poorly understood and reflects the lack of published outcome studies. Herein, I report a case in which apocrine ductal carcinoma in situ presented as "atypical apocrine adenosis" in a needle core breast biopsy. It illustrates the problem of assessing apocrine atypia and apocrine ductal carcinoma in situ in small samples.

Management of radial sclerosing lesions of the breast diagnosed using percutaneous vacuum-assisted core needle biopsy: recommendations for excision based on seven years’ of experience at a single institution

Radial sclerosing lesions (RSLs) of the breast are benign lesions that can mimic carcinoma on mammography and are frequently associated with malignancy. Guidelines for the selection of patients with RSL on core needle biopsy who require surgical excision are not well defined. We describe the clinical management of RSL diagnosed using a percutaneous vacuum-assisted 9- or 11-gauge stereotactically guided core needle biopsy (SCNB) device. We retrospectively evaluated data on patients with mammographically detected RSLs sampled by SCNB between 2001 and 2007. Demographic data, the size and type of lesion and histological findings were correlated with subsequent surgical excision data. Clinical and radiological follow-up data were collected. Among 80 patients with RSLs, 19 underwent surgical excision, and 61 had mammographic surveillance only. RSLs associated on imaging with an underlying architectural distortion were more frequently excised than those associated with calcifications (P = 0.003). The presence of residual calcifications/architectural distortion on post-biopsy mammogram significantly correlated with subsequent excision (P = 0.00003). Proliferative and/or atypical RSLs were more often excised than nonproliferative RSLs (P = 0.00001). In two patients, proliferative RSL was upgraded to atypical RSL on excision. Clinical and mammographic follow-up for a mean of 32 months (standard deviation, ± 23) in the group without excision showed no cancer. Architectural distortion on imaging, residual abnormality on post-biopsy mammogram and the presence of proliferative changes and/or epithelial atypia on SCNB were parameters leading to increased performance of surgical excision in our series. No diagnoses were upgraded to malignancy after excision of RSLs, suggesting that more extensive sampling by a 9- or 11-gauge SCNB device, followed by meticulous correlation of radiological and pathological findings and close clinical/radiological follow-up, could obviate surgical excision in the majority of RSL cases without associated atypia on SCNB.

When is a diagnosis of sclerosing adenosis acceptable at core biopsy?

To determine concordance of imaging findings and diagnosis of sclerosing adenosis at histopathologic core biopsy and to establish the accuracy of core biopsy when cancer was coexistent. From a database of 1,166 percutaneous biopsies in which sclerosing adenosis was reported, 88 (7.5%) lesions were identified, and imaging and histopathologic findings were reviewed for concordance. Sclerosing adenosis proved to be a minor component at core biopsy for 44 lesions, including one invasive ductal carcinoma, one ductal carcinoma in situ (DCIS), one focus of atypical ductal hyperplasia (ADH), and one atypical lobular hyperplasia. Sclerosing adenosis was a major (> or =50%) component for 44 lesions, including four malignancies, all DCIS manifested as clustered calcifications (pleomorphic [n = 2] or amorphous [n = 2]), and seven foci of ADH manifested as amorphous calcifications. In 30 patients with 33 lesions without atypia or malignancy, sclerosing adenosis was the major finding at core biopsy (21 lesions at 14-gauge core biopsy and 12 at 11-gauge vacuum-assisted biopsy); these patients formed the study population. Mammographic (33 lesions) and sonographic (18 lesions) features were recorded. Twenty-seven lesions had at least 20-month follow-up (n = 25) or excision (n = 2). One spiculated mass was considered discordant and was excised, showing a prospectively unrecognized radial sclerosing lesion with several 2-5-mm foci of invasive tubular and lobular carcinoma. Seventeen (53%) of 32 lesions manifested as masses; 10 (59%) were circumscribed, five (29%) were indistinctly marginated (one with punctate calcifications), and two (12%) were partially circumscribed and partially obscured (one with amorphous calcifications). Fifteen (47%) lesions manifested as clustered calcifications; nine (60%) were amorphous and indistinct, four (27%) were pleomorphic, and two (13%) were punctate. Of 27 lesions with acceptable follow-up, 26 (96%) were believed to have been accurately sampled at core biopsy. Of six radial sclerosing lesions associated with the original 88 lesions, only three (50%) were prospectively recognized. Sclerosing adenosis is an acceptable result at core biopsy of circumscribed masses and nonpalpable indistinctly marginated masses and for clustered amorphous, pleomorphic, and punctate calcifications. Recognition and reporting of coexistent radial sclerosing lesions is encouraged and may prompt excision. Malignancy can be seen with sclerosing adenosis; core biopsy was accurate in six (86%) of seven coexistent malignancies in this series.

Radial sclerosing lesion of the breast: mammographic features.

The authors present the clinical, mammographic, and pathologic findings in seven patients with radial sclerosing lesions (RSLs) who had a nonpalpable stellate lesion at mammography. Although the radiographic findings were suggestive of RSL in six of seven patients, diagnostic excisional biopsy was recommended for all. One RSL had associated microcalcifications localized in contiguous adenosis. The authors did not find this a useful criterion to differentiate RSL from carcinoma. Similarly, the presence of either a lucent or dense central core was not radiographically diagnostic. Surgical excision of these stellate lesions is therefore required.