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

A Comprehensive Assessment of Radial Scars on Core Needle Biopsy in Patients with or without Breast Cancer: Upgrade Rate and Implications on Management

BACKGROUND

Radial scars/radial sclerosing lesions (RS) are benign breast lesions identified on core needle biopsy (CNB) which can upgrade to malignancy at excision. There is limited data on RS detection and upgrade rates with more sensitive imaging such as magnetic resonance imaging (MRI) and none during their detection for breast cancer workup and its implication on patient treatment decisions.

METHODS

A retrospective institutional study of RS diagnosed on CNB between January 2008 and December 2017 was conducted. Clinicopathologic and radiologic features of RS, patient treatment decisions, upgrade rates and long-term follow-up were examined.

RESULTS

We identified 133 patients with RS on CNB, of whom 106 opted for surgery for an upgrade rate to malignancy of 1.9%, 2 patients. Radial scar was diagnosed on mammogram in 60%, MRI in 25% and ultrasound in 15% of patients. In this cohort, 32 patients had their RS detected during breast cancer workup (coexistent group) and they were more likely to have their radial scar detected by MRI (60% vs. 14%, P < .001) and undergo more extensive surgery (94% vs. 75%, P = .02). Among the 27 patients electing observation of their RS, only one (3.7%) developed breast cancer.

CONCLUSIONS

Our results show an extremely low upgrade rate to malignancy of RS, regardless if there is coexisting breast cancer elsewhere. Despite this, RS still prompted more extensive surgical excisions. The findings do not support excision of RS even among breast cancer patients when identified at a separate site from their cancer.

Executive Summary of the Early-Onset Breast Cancer Evidence Review Conference

The Centers for Disease Control and Prevention launched the Bring Your Brave campaign to increase knowledge about early-onset breast cancer, defined as breast cancer in women aged 18-45 years. The American College of Obstetricians and Gynecologists convened a panel of experts in breast disease from the Society for Academic Specialists in General Obstetrics and Gynecology to review relevant literature, validated tools, best practices, and practice guidelines as a first step toward developing educational materials for women's health care providers about early-onset breast cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at an in-person meeting of stakeholder professional and patient advocacy organizations in April 2019. This article summarizes the relevant literature, existing guidance, and validated tools to guide health care providers in the prevention, early detection, and special considerations of early-onset breast cancer. Substantive knowledge gaps were noted and summarized to provide guidance for future research.

Reducing indications for radial scar surgical excision in Slovenian breast cancer screening program

PURPOSE

Management of the radial scar (RS)/complex sclerosing lesion (CSL) diagnosed by core needle biopsy (CNB) in breast cancer screening population (BCSP) is controversial due to its intrinsic malignant potential. We aimed to determine (i) the rate of upgrade of the RS/CSL to malignant lesions and (ii) radiological characteristics and CNB histopathological findings of the lesions related to the upgrade of the RS/CSL to malignant lesions after surgical excision in our BCSP.

PATIENTS AND METHODS

Database of Slovenian National Breast Cancer Screening Program was checked for terms RS/CSL in all patients who underwent CNB in the period 2008-2018. The ratios of upgrade from CNB RS/SCL to malignant lesions after surgical excision were calculated with specific interest to the radiological characteristics and the CNB patohistologically findings of the lesions.

RESULTS

Of 162 patients with diagnosis of RS/CSL on the CNB, 121/156 (78%) cases underwent surgical excision. 6 of 121 (5%) cases were upgraded to a malignant diagnosis in surgical specimen, 3 cases of invasive carcinoma and 3 cases of DCIS, respectively. Five of the upgraded cases (5/6, 83.3%) showed atypical epithelial proliferative lesions (AEPL) on CNB. In one upgraded case without AEPL the lesion presented as 33 mm architectural distortion with microcalcifications on the mammogram.

CONCLUSIONS

In BCSP setting RS/CSL without AEPL/papilloma and those measuring less than 2 cm in the largest diameter can be followed radiologically. Increasing the number of cores and adequate sampling of the periphery and the centre of the RS/CSL improves the pick-up rate of associated atypia/malignancy.

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

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.

Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry

Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.

Radial scar of the breast: Is it possible to avoid surgery?

INTRODUCTION

Breast radial scar (RS) management remains controversial. The need for surgical excision is supported by the concern of an associated high-grade lesion missed in the biopsy. The aim of this study was to assess histologic upgrade rate after a percutaneous biopsy, to determine if vacuum assisted biopsy prevents the need for subsequent RS surgical resection and to evaluate the upgrade risk factors.

PATIENTS AND METHODS

This was a uni-institutional retrospective study of consecutive patients with RS histologically diagnosed from January 2010 to December 2015.

RESULTS

A total of 113 cases of RS were diagnosed. We verify that there was a histologic upgrade in 22 (19.5%) cases. The upgrade risk factors were the type of biopsy performed, the presence of atypia, the presence of calcifications and the number of fragments obtained in the biopsy (p < 0.05). The biopsy type was vacuum assisted in 25 (22.1%). The upgrade rate in the vacuum assisted biopsy group was 4.0%, whereas in the standard core needle biopsy group was 23,9% (p = 0.041).

DISCUSSION AND CONCLUSION

We demonstrated that the risk of upgrade after a RS diagnosis depends on the type of biopsy performed, the presence of atypia, the presence of calcifications and the number of fragments obtained. When a standard core biopsy is performed the risk of upgrade and malignancy is not negligible, and surgery is indicated. When the biopsy is vacuum assisted, the risk of upgrade and malignancy is significantly decreased and so the indication for excisional biopsy seems not to be so imperative.

Radial Scar at Image-guided Needle Biopsy: Is Excision Necessary?

Optimal management of a lesion yielding radial scar (RS) without epithelial atypia on breast biopsy is controversial. In this single-institution study spanning 17 years, 53 patients with this biopsy diagnosis were evaluated in terms of clinical, radiologic, and pathologic features and outcomes. RSs were categorized as either "incidental" or as the "targeted" lesion according to defined criteria. Of 48 patients who underwent surgical excision after a diagnosis of RS on biopsy, only 1 had an "upgrade" diagnosis of malignancy (2%). No "incidental" RS was associated with the presence of malignancy on surgical excision. Meta-analysis of 20 RS excision studies demonstrated an overall upgrade rate of 10.4%, with a higher rate in patients with a diagnosis of RS with atypia (26%). The upgrade rate for RS without atypia was 7.5% overall. The lower rate of upgrade to malignancy in this study (2%) is likely related to the thorough radiologic-pathologic review undertaken. In the setting of multidisciplinary agreement and careful radiologic-pathologic correlation, it may be appropriate for patients with a biopsy diagnosis of RS without atypia to forego surgical excision in favor of imaging follow-up.

Radial scar/complex sclerosing lesions: a clinicopathologic correlation study from a single institution

Radial scars (RSs) or complex sclerosing lesions (CSLs) of the breast are benign radiologic and histologic entities. With the introduction of population-based screening programs, their incidence has increased to 0.03% to 0.09% of all core needle biopsies (CNBs). They can pose diagnostic difficulty because their radiologic and histologic appearances mimic carcinoma. We retrospectively searched for and reviewed all cases of RS/CSL diagnosed on image-guided CNB from January 1, 1994, to August 31, 2013, at a single institution. We also assessed the pathologic reports from excisional biopsies to identify cases upstaged to atypia or neoplasm. After exclusions, 100 CNBs were identified from 97 women, which showed RS/CSL without concomitant atypia. Mean age of the women was 52.9 years. Thirty-five women (38/100 CNBs, 38%) had follow-up excision. The median size of the excised RS/CSLs was 1.2 cm; 69% were larger than 1.0 cm. Almost all excised cases (92%) showed radiologic and pathologic concordance, and 79% were designated as suspicious for malignancy (Breast Imaging Reporting and Data System level 4). The most common findings of 38 follow-up excisional biopsies were residual RS (22 [58%]), atypical lobular hyperplasia (5 [13%]), and no residual lesion (5 [13%]). Eleven excisional biopsies (29%) were upstaged to invasive or in situ carcinoma or to atypical hyperplasia. Follow-up excisional biopsy is warranted for RS/CSLs, specifically those larger than 1.0 cm with worrisome radiographic findings or with radiologic and pathologic discordance. Approximately 29% of cases were upstaged to in situ or invasive carcinomas or other high-risk lesions in our study.

Radial scars and subsequent breast cancer risk: a meta-analysis

Background

The relationship between radial scars and breast cancer is unclear, as the results of different studies are inconsistent. We aim to solve the controversy and assess the breast cancer risk of radial scars.

Methods

Case-control or cohort studies about radial scars and breast cancer risk published in PubMed, Web of Science and the Cochrane Library from 2000 to 2013 were searched. Heterogeneity for the eligible data was assessed and a pooled odds ratio (OR) with 95% confidence interval (CI) was calculated.

Results

Five observational studies involving 2521 cases and 20290 controls were included in our study. From pooled analysis, radial scars were found to have a 1.33 fold increased risk of breast cancer, but which was not significant (P = 0.138). Sample size contributed to heterogeneity. In subgroup analysis, the results pooled from studies with sample size >2000 show that presence of radial scars was associated with 1.6 times breast cancer risk compared to absence of radial scars. Radial scars increased the risk of breast cancer among women with proliferative disease without atypia, but no significant association between radial scars and carcinoma was noted among women with atypical hyperplasia.

Conclusions

Radial scars tend to be associated with an increased breast cancer risk. Radial scars should be considered among women with proliferative disease without atypia, while atypical hyperplasia is still the primary concern among women with both radial scars and atypical hyperplasia.

Anatomical-radiological correlations: architectural distortions

Architectural distortions consist of convergence areas and local retractions at the border of the gland. The authors examine the semiologic features of the distortions and their different causes, together with their pathological anatomy correlations. The predominant benign causes are the proliferative Aschoff body and the main malignant cause is infiltrating lobular carcinoma.

Variability and errors when applying the BIRADS mammography classification

To standardize mammographic reporting, the American College of Radiology mammography developed the Breast Imaging Reporting and Data System (BIRADS) lexicon. However, wide variability is observed in practice in the application of the BIRADS terminology and this leads to classification errors. This review analyses the reasons for variations in BIRADS mammography, describes the types of errors made by readers with illustrated examples, and details BIRADS category 3 which is the most difficult category to use in practice.

The influence of family history and histological stratification on breast cancer risk in women with benign breast disease: a meta-analysis

PURPOSE

Benign breast disease (BBD) is an important risk factor for subsequent breast cancer. However, it is unclear whether breast cancer risk is higher in cases of atypical ductal hyperplasia (ADH) than atypical lobular hyperplasia (ALH). Furthermore, it is unclear whether family history increases risk in women with various subtypes of BBD.

METHODS

We searched the electronic database of PubMed for case-control studies about the subsequent breast cancer risk of BBD, and a meta-analysis was conducted.

RESULTS

Of ten inclusive studies, nine were eligible for subsequent breast cancer risk of histological subtype, including 2,340 cases and 4,422 controls, and four were eligible for investigating the influence of family history on subtypes of BBD, including 1,377 cases and 2,630 controls. Relative to non-proliferative disease (NP), all subtypes of BBD increased subsequent risk, and risk for women with ALH (OR = 5.14, 95% CI 3.52-7.52) may be higher than for women with ADH (OR = 2.93, 95% CI 2.16-3.97). Compared to women without family history and proliferative disease, women with a first-degree family history and atypical hyperplasia (AH) were at highest risk (OR = 4.87, 95% CI 2.89-8.20). Relative to women without family history, women with a first-degree family history had an increased breast cancer risk in different histological subtypes of BBD except for AH (OR = 1.39, 95% CI 0.82-2.37).

CONCLUSION

This meta-analysis strongly suggested that women with AH, especially for ALH and AH combined with a first-degree family history, were at high risk, for whom risk-reduction options should be considered.

A review of needle core biopsy diagnosed radial scars in the Welsh Breast Screening Programme

INTRODUCTION

Radial scars are benign breast lesions; their appearance on mammography may, however, mimic carcinoma. Needle core biopsy is performed for pre-operative diagnosis and, currently in Wales, all lesions with benign biopsy results are surgically excised. We have reviewed all cases of needle core biopsy-diagnosed radial scars from the Welsh breast screening programme, Breast Test Wales (BTW), and investigated the outcome of radial scars based on histology from surgical excision in order to evaluate the appropriateness of the current management of these lesions in Wales.

PATIENTS AND METHODS

All needle core biopsy diagnosed radial scars were identified from the BTW screening database from the start of screening in 1989 until the end of 2007.

RESULTS

A total of 118 patients were diagnosed with radial scars on needle core biopsy; two patients had bilateral radial scars. Median patient age was 54 years (range, 49-68 years). Ninety-five lesions (79%) were thought to be pure radial scars on needle core biopsy; however, only 81 pure radial scars were identified on excision biopsy histology. Carcinoma was present in seven patients and ductal carcinoma in situ in nine patients at excision biopsy. In two patients, the cancers occurred in lesions reported as pure radial scars on needle core biopsy. Twenty-two lesions showed atypical ductal or lobular hyperplasia (ADH/ALH) or both on excision biopsy; 14 of these lesions were classed as pure radial scars by needle core biopsy.

CONCLUSIONS

All core biopsy diagnosed radial scars, presenting as screen detected abnormalities, should be excised due to their association with premalignant and malignant conditions.

The Treatment of Radial Scars in the Modern Era—Surgical Excision is not Required

The clinical significance of isolated radial scars (RS) diagnosed on core needle biopsy (CNB) remains unclear. By determining the pathologic concordance rate, we sought to define the indications for surgical excision for RS diagnosed on CNB. Between January 1994 and December 2007, 38 RS were diagnosed by CNB. Twenty-eight underwent surgical excision with 27 (96%) patients having further benign diagnoses. One patient, who was found to have invasive cancer on CNB, was also found to have malignancy on open biopsy. Fourteen lesions were diagnosed by 8-gauge, 13 lesions by 11-gauge, and one lesion by 14-gauge biopsy needles. Seven studies met inclusion criteria for analysis; 341 lesions with follow-on surgical biopsy were identified. Sixteen (5%) radial scars were found to harbor malignancy and all were percutaneously biopsied with 14-gauge needles. With the inclusion of the current study, none of the isolated radial scars diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-on surgical biopsy. Based on the current review, histologic radial scars are infrequently associated with occult malignancy and do not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.

A multi-center prospective cohort study of benign breast disease and risk of subsequent breast cancer

OBJECTIVE

We used a nested case-control design within a large, multi-center cohort of women who underwent a biopsy for benign breast disease (BBD) to assess the association of broad histologic groupings and specific histologic entities with risk of breast cancer.

METHODS

Cases were all women who had a biopsy for BBD and who subsequently developed breast cancer; controls were individually matched to cases and were women with a biopsy for BBD who did not develop breast cancer in the same follow-up interval as that for the cases. After exclusions, 1,239 records (615 cases and 624 controls) were available for analysis. We used conditional logistic regression to estimate odds ratios and 95% confidence intervals (CIs).

RESULTS

Relative to non-proliferative BBD/normal pathology, the multivariable-adjusted odds ratio for proliferative lesions without atypia was 1.45 (95% CI 1.10-1.90), and that for atypical hyperplasia was 5.27 (95% CI 2.29-12.15). The presence of multiple foci of columnar cell hyperplasia and of complex fibroadenoma without atypia was associated with a non-significantly increased risk of breast cancer, whereas sclerosing adenosis, radial scar, and papilloma showed no association with risk.

CONCLUSION

Our results indicate that, compared to women with normal pathology/non-proliferative disease, women with proliferative disease without atypia have a modestly increased risk of breast cancer, whereas women with atypical hyperplasia have a substantially increased risk.

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

AIMS

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.

METHODS AND RESULTS

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.

CONCLUSIONS

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.

[Most common benign epithelial breast diseases: diagnosis, treatment and cancer risk]

As a consequence of breast imaging development and increased interventional radiology, benign epithelial breast diseases (BEBD) represent a growing percentage of breast pathology diagnoses. BEBD include numerous entities such as cysts, fibrosis, adenosis, duct ectasia, which require neither surgery nor follow-up. Some BEBD have to be individualized (radial scars, papillomas, complex sclerosing adenosis, lobular intraepithelial neoplasia, flat epithelial atypia, atypical hyperplasia), being preinvasive lesions or markers of increased breast cancer risk, or being associated with suspect radiological aspect. BEBD should be managed in a pluridisciplinar way and correctly diagnosed by percutaneous biopsies or surgical specimens. The goals of surgery vary according to lesions. It always allows a complete surgical specimen analysis and therefore a search for atypical or cancerous cells. Surgery can also have a preventive role by reducing the risk of potential malignant transformation. Finally, it enables in some cases the excision of a radiologically suspect mass. So the aim of this review is to give a clinical and morphological description of most common BEBD, underlying their cancer risk, specific diagnosis, therapeutic, follow-up and psychological repercussions.

Interventional breast imaging: current procedures and assessing for concordance with pathology

Minimally invasive breast biopsy procedures performed for suspicious imaging findings have expanded the role of breast imaging in the management of breast diseases. The first portion of this article reviews the current procedures for performing a core-needle biopsy under stereotactic, ultrasound, and MR imaging guidance. The second portion of the article addresses the management of the patient after the biopsy, including assessment for concordance of radiology and pathology findings and potential underestimation of disease.

Current Status of Breast MR Imaging Part 2. Clinical Applications

Magnetic resonance (MR) imaging is emerging as the most sensitive modality that is currently available for the detection of primary or recurrent breast cancer. Although this technique has been shown to be an extremely powerful diagnostic tool, it is still relatively rarely used in clinical practice, as compared with other applications of MR imaging such as for musculoskeletal or brain and spine imaging. This is the second of a two-part series on the current status of breast MR. Part two provides an overview of the use of breast MR imaging in clinical patient care, the body of evidence that supports its use. A discussion is provided on the many controversies that exist regarding breast MR imaging for preoperative staging and for screening.

Risk of neoplastic transformation in asymptomatic radial scar. Analysis of 117 cases

BACKGROUND

Radial scar (RS) is a benign breast lesion but a variable percentage of cases are associated with atypical epithelial proliferations and cancer. Previous studies have shown that patient age and the size of RS are correlated to a potential neoplastic transformation.

METHOD

We collected 117 asymptomatic patients with suspected RS following a mammogram, histologically confirmed. The clinical, pathological and immunophenotypical analysis is reported. The cases are subdivided into three different groups: (1) RS "Pure", without epithelial atypia; (2) RS associated with epithelial atypical hyperplasia; (3) RS with cancer.

RESULTS

"Pure" RS was detected in 55 patients (47%); the mean age was 48.1 years and the mean size 0.94 cm. RS associated with atypical epithelial hyperplasia was identified in 25 cases (21%) with a mean age of 53.1 years and a mean size of 0.98 cm. Carcinoma in RS was observed in 37 cases (32%); the mean age was 55.5 years and the mean size was 1.16 cm. The mean age was statistically significant (P = 0.004) in separating RS with cancer from the two other RS groups. The size of RS was not sufficiently statistically significant (P = 0.2) to differentiate the risk. Atypical lesions and cancers showed a morphology and marker of low-grade aggressiveness.

CONCLUSION

RS seems to represent a natural model of carcinogenesis starting from a proliferative lesion in patients of less than 50 years of age and developing into an atypical and later into a carcinomatous lesion. The fact that most carcinomas arising in RS are low grade also favors this hypothesis. All RS should be excised.

Benign breast biopsy diagnosis and subsequent risk of breast cancer

BACKGROUND

We examine benign breast biopsy diagnoses as reported by community pathologists in New Mexico and investigate associations with future breast cancer development.

METHODS

Using data collected between 1992 and 2000 by the New Mexico Mammography Project and cancer data through 2003 from the New Mexico Tumor Registry, we calculated breast cancer rates following 14,602 benign breast biopsies for women ages 30 to 89 years. For comparison, we also calculated the breast cancer rate following 215,283 normal screening mammograms. Hazard ratios (HR) are presented.

RESULTS

We identified 480 subsequent breast cancer diagnoses among 14,602 women with benign breast biopsies and 4,402 breast cancer diagnoses among 215,283 women with mammograms assigned a "negative" or "benign finding" assessment. Histologic diagnoses in absence of atypia had an age-adjusted HR of 1.95 [95% confidence interval (95% CI), 1.77-2.15]. Among low-risk histologic diagnoses, the strongest associations with subsequent breast cancer development included adenosis, apocrine metaplasia, calcifications, and ductal hyperplasia. Fibroadenoma, inflammation, and cysts did not exhibit an association with breast cancer development. Women with low-risk diagnoses and breast tissue characterized as fatty or with scattered densities had a HR of 2.09 (95% CI, 1.68-2.60), whereas women with low-risk histologic diagnoses and dense breasts had a HR of 3.36 (95% CI, 2.83-3.99).

CONCLUSIONS

The observed breast cancer occurrence contributes to evidence of increased risk following benign biopsy. The risk associated with histologic diagnoses in absence of atypia was twice the risk experienced by women with normal mammogram evaluations and may be modified by breast density.

Benign breast diseases: classification, diagnosis, and management

Benign breast diseases constitute a heterogeneous group of lesions including developmental abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms. In this review, common benign lesions are summarized and their relationship to the development of subsequent breast cancer is emphasized.

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 contained malignancy on excision.

METHODS AND RESULTS

A total of 11 false negative NCB in RS/CSL lesions from 281 (3.9%) were identified (6 cases: B1, 2 cases: B2 and 3 cases: B3). In 6 of 11 cases a radial scar or stromal sclerosis was seen in NCB. Localisation biopsy showed duct carcinoma in situ in six cases, duct carcinoma in situ with invasive carcinoma in three and invasive carcinoma in two. In all 11 cases, needle tracks were identified as missing the malignant epithelium by a mean of 5 mm (median:4 mm; range:1-20 mm). In 9 of 11 cases, the malignancy was missed by <6 mm.

CONCLUSIONS

Despite evidence of accurate targeting of lesions, the use of NCB instead of fine needle aspiration cytology has not eliminated the problem of false negative biopsy in RS/CSL, and excision is recommended.

Interdependence of radial scar and proliferative disease with respect to invasive breast carcinoma risk in patients with benign breast biopsies

BACKGROUND

Radial scars (RS) are benign breast lesions that have been implicated as independent risk factors for invasive breast carcinoma (IBC).

METHODS

A retrospective cohort study of 9556 women who underwent biopsy between 1950-1986 and enrolled in the Nashville Breast Cohort was performed to investigate the association between RS in a benign breast biopsy and the risk of IBC. The risk associated with RS and coexistent proliferative disease (PD) was assessed adjusting for age at biopsy using a Cox hazards regression analysis with time-dependent covariates.

RESULTS

RS were identified in 880 women (9.2%). The average follow-up time was 20.4 years. Sixty-two women (7.0%) with RS developed IBC compared with 5.5% of controls. The relative risk of IBC associated with RS was 1.82 (95% confidence interval [95% CI], 1.2-2.7) at 10 years. Restricting the analysis to women age > 49 years increased the risk to 2.14 (95% CI, 0.6-2.8). These risks decreased with increasing years of follow-up. Approximately 92% of women with RS also had PD, but RS were present in only 1.3% of biopsies without PD. Analyses stratifying relative risk with regard to PD found RS to minimally elevate the relative risk of subsequent IBC.

CONCLUSIONS

RS in the absence of PD is uncommon. Although the presence of RS in a benign breast biopsy mildly elevates the risk of IBC risk, the current analysis indicated that this risk can be largely attributed to the category of coexistent PD. In women with both RS and atypical hyperplasia, recommendations for interventions beyond biopsy should be based on the extent of atypical hyperplasia.