Differentiation of radial scar from scirrhous carcinoma of the breast: mammographic-pathologic correlation

Beware it's benign: A unique case of concomitant benign breast pathologies

Complex sclerosing lesion (CSL)/radial scar of breast is a benign entity that can pose a diagnostic challenge due to resemblance to breast carcinoma on imaging. Hamartoma are uncommon benign tumors, composed of disorganized mixture of glandular, fibrous, and adipose tissues, which can exhibit classical imaging characteristics. Here we describe a case of concomitant CSL and hamartoma in left beast, of which CSL presented as suspicious mass on imaging but was ultimately confirmed to be benign on histopathology with 4 years of documented stability.

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.

Radial Scar: a management dilemma

Radial scar (RS) or complex sclerosing lesions (CSL) if > 10 mm is a benign lesion with an increasing incidence of diagnosis (ranging from 0.6 to 3.7%) and represents a challenge both for radiologists and for pathologists. The digital mammography and digital breast tomosynthesis appearances of RS are well documented, according to the literature. On ultrasound, variable aspects can be detected. Magnetic resonance imaging contribution to differential diagnosis with carcinoma is growing. As for the management, a vacuum-assisted biopsy (VAB) with large core is recommended after a percutaneous diagnosis of RS due to potential sampling error. According to the recent International Consensus Conference, a RS/CSL lesion, which is visible on imaging, should undergo therapeutic excision with VAB. Thereafter, surveillance is justified. The aim of this review is to provide a practical guide for the recognition of RS on imaging, illustrating radiological findings according to the most recent literature, and to delineate the management strategies that follow.

Pathologic Outcomes of Architectural Distortion on Digital 2D Versus Tomosynthesis Mammography

OBJECTIVE

The purpose of this study is to compare the risk of malignancy associated with architectural distortion detected on 2D digital mammography (DM) versus digital breast tomosynthesis (DBT).

MATERIALS AND METHODS

We performed a retrospective review of architectural distortion cases recommended for biopsy from September 2007 to February 2011, the period before DBT integration (hereafter known as the DM group), and from January 2013 to June 2016, the period after DBT integration (hereafter known as the DBT group). Medical records were reviewed for imaging findings and pathology results.

RESULTS

Architectural distortion was more commonly detected in the DBT group than the DM group (0.14% [274/202,438 examinations] vs 0.07% [121/166,661 examinations]; p < 0.001). The positive predictive value of architectural distortion for malignancy was significantly lower in the DBT group than the DM group (50.7% [139/274 cases] vs 73.6% [89/121 cases]; p < 0.001). Radial scar was the most common nonmalignant finding in both groups, but it was more common in the DBT group (33.2% [91/274] vs 11.6% [14/121]; p < 0.001). In the DBT group, architectural distortion without correlative findings on ultrasound was less likely to represent malignancy than was architectural distortion with correlative findings on ultrasound (29.2% [31/106] vs 66.5% [105/158]; p < 0.001).

CONCLUSION

Architectural distortion is more commonly detected on DBT than DM and is less likely to represent malignancy on DBT. Architectural distortion on DBT is less likely to represent malignancy if there is no sonographic correlate; however, biopsy is warranted even in the absence of a sonographic correlate, given the nearly 30% risk of malignancy in this setting.

Benign Breast Diseases: Evaluation and Management

Benign breast disease is a spectrum of common disorders. The majority of patients with a clinical breast lesion will have benign process. Management involves symptom control when present, pathologic-based and imaging-based evaluation to distinguish from a malignant process, and counseling for patients that have an increased breast cancer risk due to the benign disorder.

Radial Scars of the Breast Encountered at Core Biopsy: Review of Histologic, Imaging, and Management Considerations

OBJECTIVE

The purposes of this article are to place the controversy over the management of radial scars diagnosed at core biopsy in perspective and to define reasonable management options.

CONCLUSION

The management of radial scars after image-guided core biopsy of the breast for diagnosis remains controversial. Although current literature suggests no premalignant potential of these lesions, it does not fully explain the small but real percentage of these lesions that are upgraded to malignancy after surgical excision. This upgrade phenomenon is probably best explained by core biopsy sampling error. A recommendation minimizing this possibility based on lesion size seems reasonable.

Architectural Distortion on Mammography: Correlation With Pathologic Outcomes and Predictors of Malignancy

OBJECTIVE

The objective of our study was to determine the risk of malignancy associated with architectural distortion and to evaluate the imaging and clinical features that may contribute to the prediction of malignancy in the setting of architectural distortion.

MATERIALS AND METHODS

We performed a retrospective review of architectural distortion cases from January 1, 2004, to December 31, 2013. Imaging findings and pathology outcomes were reviewed.

RESULTS

Over the 10-year study period, architectural distortion that was considered to be suspicious for or highly suggestive of malignancy was present in 435 of 231,051 (0.2%) mammographic examinations. Cases were excluded if the main finding described was a mass with an associated feature of architectural distortion (n = 62) or if no pathology results were available (n = 4). Two hundred seventy-five cases of invasive adenocarcinoma or ductal carcinoma in situ (DCIS) were identified; the positive predictive value (PPV) was therefore 74.5% (275/369). DCIS alone was identified in only 4.1% (15/369). The most common benign finding on pathology was a radial scar or complex sclerosing lesion (27/369, 7.3%). Architectural distortion was less likely to represent malignancy on screening mammography than on diagnostic mammography (67.0% vs 83.1%, respectively; p < 0.001). Architectural distortion without a sonographic correlate was less likely to represent malignancy than architectural distortion with a correlate (27.9% vs 82.9%, respectively; p < 0.001). There was no statistically significant difference in the malignancy rate between pure architectural distortion and architectural distortion with calcifications or asymmetries (73.0% vs 78.8%; p = 0.26).

CONCLUSION

The PPV of architectural distortion for malignancy is 74.5%. Architectural distortion is less likely to represent malignancy if detected on screening mammography than on diagnostic mammography or if there is no sonographic correlate.

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.

Breast cancer risk associated with the diagnosis of a microhistological radial scar (RS): retrospective analysis in 10 years of experience

PURPOSE

To retrospectively assess the risk of breast cancer associated with the radial scar (RS) microhistological diagnosis, also taking into consideration the percutaneous biopsy devices used, as well as the different performances of the mammographic systems (analogical, digital and tomosynthesis) in the radiological diagnosis of RS.

MATERIALS AND METHODS

Between March 2002 and November 2011, 80 RSs were identified using the analogical, digital and tomosynthesis mammographic systems. Based on the microhistological examination, the patients were divided into three groups [RS without hyperplasic-proliferative lesions (HPL); RS with HPL; RS with cancer] and we assessed the risk of cancer associated with RS in the first and second group. We evaluated the mammographic features and the BI-RADS categories assigned to RSs, the biopsy devices used and the differences between the pathological examination and the microhistological diagnosis (p < 0.05).

RESULTS

Based on the microhistological examination, 51/80 patients were included in the first group (9 of them not subjected to surgery), 25/80 in the second group and 4/80 in the third one. At the final histological examination, there were 7/42 (16.7%) cancers in the first group and 8/25 (32%) in the second group. The largest number of microhistological underestimation occurred in the patients who were subjected to core biopsy (15 cases) (p < 0.05). Tomosynthesis improved (p < 0.05) the identification of the RS.

CONCLUSIONS

22.3% of the RSs was associated with cancer. Given that at microhistological examination 16.7% of the RS without HPL was cancer at pathology, the surgical excision is preferred. Tomosynthesis was useful to detect parenchymal distortions.

Surgical excision of radial scars diagnosed by core biopsy may help predict future risk of breast cancer

Radial scars (RS's) are benign breast lesions known to be associated with carcinomas and other high-risk lesions (HRL's). The upgrade rate to carcinoma after core biopsy revealing RS is 0-40 %. We sought to determine the outcomes of RS with and without HRL diagnosed by core biopsy. Patients who underwent core biopsy revealing RS without carcinoma at our institution between 1/1996 and 11/2012 were identified from a surgical pathology database. Retrospective chart review was utilized to classify patients as RS-no HRL or RS-HRL. HRL was defined as ADH, LCIS, and/or ALH. We determined upgrade rate to carcinoma at surgical excision, and upgrade to HRL for RS-no HRL patients. Univariate analysis was performed to identify risk factors for upgrade in RS-no HRL patients. 156 patients underwent core biopsy revealing RS, 131 RS-no HRL (84 %), and 25 RS-HRL (16 %). The overall rate of upgrade to invasive carcinoma was 0.8 % (1/124). 1.0 % (1/102) of RS-no HRL and 13.6 % (3/22) of RS-HRL patients were upgraded to DCIS (P = 0.0023). The upgrade of RS-no HRL to HRL at excision was 21.6 % (22/102). By univariate analysis, RS-no HRL with radiologic appearance of a mass/architectural distortion had a significantly higher rate of upgrade to HRL or carcinoma compared with calcifications (P = 0.03). Excision of RS to rule out associated invasive carcinoma is not warranted, given a <1 % rate of upgrade at excision. However, excision to evaluate for non-invasive cancer or HRL may be considered to help guide clinical decision-making about use of chemoprevention.

Histological analysis of benign breast imaging reporting and data system categories 4c and 5 breast lesions in imaging study

PURPOSE

The objective of this study was to analyze the histology of breast lesions categorized as Breast Imaging Reporting and Data System (BI-RADS) 4c or 5 breast lesions during the imaging evaluation, but diagnosed as benign during the histological evaluation.

MATERIALS AND METHODS

We retrospectively reviewed 71 breast lesions categorized as BI-RADS 4c or 5 during imaging study, but diagnosed as benign upon histological evaluation.

RESULTS

Breast lesions were classified into six groups upon histological analysis: intraductal papilloma (18 cases), inflammatory group (15 cases), fibroepithelial tumor (14 cases), clustered microcalcification (10 cases), minimal histological alteration (10 cases), and adenosis (4 cases). Sclerosis and architectural complexity were associated with most of the biopsies that were morphologically similar to malignancy.

CONCLUSION

Among 71 cases categorized as 4c or 5 during the imaging study, but diagnosed as benign upon histological examination, intraductal papilloma was the most frequently identified histological lesion. These 71 cases exhibited histological characteristics of sclerosis and/or complex/complicated features that should be histologically differentiated from malignancy during evaluation.

The radial scar of the breast diagnosed at core needle biopsy

The radial scar (RS) or complex sclerosing lesion (CSL) of the breast represents a management dilemma on diagnosis at breast core needle biopsy because of the risk of associated malignancy identified only upon surgical excision. To determine our experience, we retrospectively reviewed core needle biopsies performed at the Darlene G. Cass Breast Imaging Center from 2006 to 2011, identifying 67 patients with RS or CSL, and correlated histology at excisional biopsy with core biopsy results. Of the 67 cases, 6 (9%) were associated with malignancy at surgical excision. The average size of the RS or CSL was 1.42 cm. In conclusion, RS or CSL diagnosed at core needle biopsy still warrants surgical excision because of the significant percentage (9%) of cases with associated malignancy.

A radial sclerosing lesion mimicking breast cancer on mammography in a young woman

A spiculated mass on a mammogram is highly suggestive of malignancy. We report the case of a 32-year-old woman with a radial sclerosing lesion that mimicked breast cancer on mammography. She visited her physician after palpating a lump in her left breast. Mammography showed architectural distortion in the upper inner quadrant of the left breast. Ultrasonography showed a low echoic area with an ambiguous boundary. Core needle biopsy was performed because of the suspicion of malignancy. Histological examination did not reveal any malignant cells. After 6 months, the breast lump became larger and the patient was referred to our hospital. Mammography performed in our hospital showed a spiculated mass, and therefore mammotome biopsy was performed. Histological examination revealed dense fibroelastic stroma with a wide variety of mastopathic changes, leading to a diagnosis of a radial sclerosing lesion. One year after the biopsy, the lump on her left breast had disappeared and mammography showed no spiculated mass.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Pure and mixed tubular carcinoma of the breast: mammographic and sonographic differential features

Objective

We wanted to evaluate the mammographic and sonographic differential features between pure (PT) and mixed tubular carcinoma (MT) of the breast.

Materials and Methods

Between January 1998 and May 2004, 17 PTs and 14 MTs were pathologically confirmed at our institution. The preoperative mammography (n = 26) and sonography (n = 28) were analyzed by three radiologists according to BI-RADS.

Results

On mammography, a mass was not detected in eight patients with PT and in one patient with MT (57% vs. 8%, respectively, p = 0.021), which was statistically different. The other findings on mammography and sonography showed no statistical differences between the PT and MT, although the numerical values were different. When the lesions were detected mammographically, an irregularly shaped mass with a spiculated margin was more frequently found in the MT than in the PT (100% vs. 83%, respectively, p = 0.353). On sonography, all 28 patients presented with a mass and most lesions showed as not being circumscribed, hypoechoic masses with an echogenic halo. Surrounding tissue changes and posterior shadowing were more frequently found in the MT than in the PT (75% vs. 50%, respectively, p = 0.253, 58% vs. 19%, respectively, p = 1.000). An oval shaped mass was more frequently found in the PT than in the MT (44% vs. 25%, respectively; p = 0.434).

Conclusion

PT and MT cannot be precisely differentiated on mammography and sonography. However, the absence of a mass on mammography or the presence of an oval shaped mass would favor the diagnosis of PT. An irregularly shaped mass with surrounding tissue change and posterior shadowing on sonography would favor the diagnosis of MT and also a less favorable prognosis.

Ultrasound imaging features of radial scars of the breast

Radial scars of the breast are common benign lesions, which are often radiologically occult. When they are detected by imaging, they are most often found by mammography. Radial scars are usually impalpable and have traditionally been localized for core biopsy and hookwire placement preoperatively by mammographic guidance. Stereotactic biopsy and localization is often difficult. Ultrasound-guided core biopsies and hookwire placement have the potential to provide a more accurate needle placement. The aim of this study was to determine the proportion of radial scars detectable by ultrasound and the feasibility of carrying out core biopsies and hookwire localization ultrasonographically. A retrospective review of the records of 7236 women was undertaken to determine those who had a histological diagnosis of radial scar. A total of 44 radial scars in 43 women were found, of which 40 had images that were available for analysis. Sixty-eight per cent of radial scars are visible on ultrasound, most commonly seen as hypoechoic areas/masses. Parenchymal distortion without a hypoechoic mass was seen in 22%. In 8%, the lesion was appreciably better visualized by ultrasound when compared with mammography. In one case, the lesion was detected on ultrasound and not detected by mammography. At least two-thirds of mammographically detected radial scars can be visualized on ultrasound. These should be submitted to preoperative core biopsy and hookwire localization under ultrasound control.

Tubular carcinoma of the breast: Mammographic, sonographic, clinical and pathologic findings

PURPOSE

To determine and quantitate the radiological characteristics of tubular carcinoma of the breast, to report clinical and pathologic findings and to define findings at follow-up.

MATERIALS AND METHODS

A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 32 histopathologically proven pure tubular carcinoma of the breast. Analysis included history; findings at physical examination, mammography, and sonography (US) at the time of diagnosis and in postoperative follow-up and histopathological results.

RESULTS

Fifty-nine percent of the patients (n=19) presented with a palpable mass. The mammographic findings were a mass in 23 (72%), a mass with microcalcifications in 2 (6%), asymmetric focal density in 1 (3%), architectural distortion in 1 (3%) and negative in 5 (16%) of the 32 patients. Most (96%) masses had spiculated margins. US depicted 30 masses in 29 patients, all of which were hypoechoic, mostly (n=27, 90%) with posterior acoustic shadowing. The cancer was clinically occult in 41% (n=13), mammographically occult in 16% (n=5), and sonographically occult in 6% (n=2) of the patients. Histologically, the tumor was multifocal in 3% (n=1) of the patients. Four (13%) patients developed contralateral breast carcinoma at follow-up.

CONCLUSION

Tubular carcinoma has a variety of presentations, but it is mostly seen on mammography as a small spiculated mass, and on sonography as an irregular mass with posterior acoustic shadowing. Although tubular carcinoma is known as a well-differentiated tumor with excellent prognosis, the mammographic follow-up of the contralateral breast is important.

Are the criteria of Tabar and Dean still relevant to radial scar?

OBJECTIVE

Aschoff's center of proliferation (ACP), poses significant problems of differential diagnosis both in imagery and histology with infiltrating carcinoma. Up to now the criteria of Tabar and Dean (classical criteria) are considered as diagnostically relevant.

MATERIAL

A retrospective study of 113 cases, enabled us to study their clinical, radiological and histological aspects.

RESULTS

The ACP is a subclinical and seldom palpable entity (12%). The radiological signs of ACP are quite variable. The classical criteria lack specificity and are observed only in 48% of our stellate images. Whereas the frequency of microcalcifications is high (58.5% of the cases), their presence and their type are not predictive of an associated malignancy. The echographic diagnosis of ACP could be made in 55% of the cases but the echographic semiology lacked specificity. We noticed an associated atypical epithelial hyperplasia in 28.5% of the cases, intraductal or lobular in situ carcinoma in 9% and/or a ductal invasive carcinoma in 2% of the cases. Neither tumor size, age of the patients, nor any radiological signs were predictive of such an association.

CONCLUSIONS

The classical criteria are not completely reliable and are observed only in half of our stellate images, whereas microcalcifications are often present but are not predictive of an associated malignancy.

Non-palpable ductal carcinoma in situ (DCIS) with microinvasion arising in a radial scar presenting with spiculation alone on mammograms: a case report

A case of ductal carcinoma in situ (DCIS) with microinvasion arising in a radial scar of the breast is presented. A 57-year-old woman visited our hospital with bloody discharge from her left nipple. There were no abnormal findings on cytology, carcinoembryonic antigen (CEA) level of nipple discharge was <500 ng/ml, and mammograms were normal. After 2 years of careful periodic follow-up, spiculation without a central core appeared on mammograms. The CEA level of the nipple discharge increased to 1,000 ng/ml. Ductgraphy showed a connection between the duct with the discharge and the center of the spiculation. Since these findings suggested malignancy, she underwent segmentectomy of the breast, and pathological examination showed a radial scar and DCIS with microinvasion in the ducts within the radiating bands of fibrous tissues. We discuss the characteristics of a radial scar and its relationship to breast cancer based on our experience and a review of the literature.

[Architectural distortion and diagnostic difficulties]

Identification of architectural distortion requires a good practice of mammography. Prevalence is estimated at 6% of detected abnormalities in screening programs. Under this denomination are gathered focal architectural distortion with predictive positive value (PPV) of 10% and stellate images without central densification, which are more suspicious (PPV 50%). In order to establish a diagnosis, false images must be eliminated by other views. Minimal architectural distortion have to be investigated by other techniques (sonography, MRI percutaneous biopsy) in order to define the best strategy for further management. Stellate images suggestive of radial scars must be surgically removed. The relationships between radial scars and tubular carcinoma are discussed. A particular attention is required for post traumatic or post surgical scars if it exist a high risk of local recurrence or controlateral carcinoma specially after conservative or oncoplastic surgery.

Can sonography be used to help differentiate between radial scars and breast cancers?

The aim of this study was to determine whether sonography can help differentiate radial scars (RS) from breast cancers. Series of 75 consecutive mammographic screen-detected RS and carcinomas were reviewed: shape, orientation, echotexture, halo, acoustic attenuation and architectural distortion were compared for sonographic RS and cancers. RS were 43% sonopositive (25/58 examined) vs. 93% sonopositive carcinomas (68/73 examined); P<0.001. Of 22 RS and 66 cancers available for film review, findings were: echogenic halo in zero RS vs. 38 cancers (0% vs. 58%); tiny sonographic cysts in 3 RS vs. zero carcinomas (14% vs. 0%); assessment category malignant vs. indeterminate/suspicious (8% vs. 59%, P<0.001); breast architecture disruption (43% vs. 91%, P<0.001); sound attenuation (55% vs. 86%, P<0.005), taller-than-wide shape (36% vs. 56%, P=0.11). RS showed echogenic components more than cancers (32% vs. 9%, P=0.016). Jagged margins were equally seen (77% vs. 76%, P=0.89). The findings suggest that sonographic differences can help discriminate between RS and carcinomas.

Stellate images: anatomic and radiologic correlations

The stellate images are the most well-known and most typical finding in the diagnosis of breast cancer. Its positive predictive value is very high. However, in some cases, the stellate images can correspond to benign lesions. Stellate images require high quality mammograms, precise analysis, and as always in senology, confirmation by clinical examination, ultrasound if necessary, and in the case of palpable lesions, cytology. In this work, we will study malignant and benign stellate images mammographic-pathologic correlation as well as the importance of stellate images in the detection of non-palpable lesions. The typical stellate finding is correlated with the phenomena of fibrosis and elastosis and it is impossible to distinguish benign spicules from malignant spicules on mammography. We will present guidelines in the face of stellate image. Stellate images are for the most part suggestive of malignant lesions, and their discovery should lead to suspicion of cancer until the contrary is proven.

A Probabilistic Expert System That Provides Automated Mammographic–Histologic Correlation:Initial Experience

OBJECTIVE

We sought to determine whether a probabilistic expert system can provide accurate automated imaging-histologic correlations to aid radiologists in assessing the concordance of mammographic findings with the results of imaging-guided breast biopsies.

MATERIALS AND METHODS

We created a Bayesian network in which Breast Imaging Reporting and Data System (BI-RADS) descriptors are used to convey the level of suspicion of mammographic abnormalities. Our system is a computer model that links BI-RADS descriptors with diseases of the breast using probabilities derived from the literature. Mammographic findings are used to update pretest probabilities (prevalence of disease) into posttest probabilities applying Bayes' theorem. We evaluated the histologic results of 92 consecutive imaging-guided breast biopsies for concordance with the mammographic findings during radiology-pathology review sessions. First, radiologists with no knowledge of the biopsy results chose BI-RADS descriptors for the mammographic findings. After the histologic diagnosis was revealed, the radiologists assessed concordance between the pathologic results and the mammographic findings. We then input the information gathered from these sessions into the Bayesian network to produce an automated mammographic-histologic correlation.

RESULTS

We had a sampling error rate of 1.1% (1/92 biopsies). Our expert system was able to integrate pathologic diagnoses and mammographic findings to obtain probabilities of sampling error, thereby enabling us to identify the incorrect pathologic diagnosis with 100% sensitivity while maintaining a specificity of 91%.

CONCLUSION

Our probabilistic expert system has the potential to help radiologists in identifying breast biopsy results that are discordant with mammographic findings and discovering cases in which biopsy sampling errors may have occurred.

Computer-Aided Detection (CAD) in Screening Mammography:Sensitivity of Commercial CAD Systems for Detecting Architectural Distortion

OBJECTIVE

Computer-aided detection (CAD) algorithms have successfully revealed breast masses and microcalcifications on screening mammography. The purpose of our study was to evaluate the sensitivity of commercially available CAD systems for revealing architectural distortion, the third most common appearance of breast cancer.

MATERIALS AND METHODS

Two commercially available CAD systems were used to evaluate screening mammograms obtained in 43 patients with 45 mammographically detected regions of architectural distortion. For each CAD system, we determined the sensitivity for revealing architectural distortion on at least one image of the two-view mammographic examination (case sensitivity) and for each individual mammogram (image sensitivity). Surgical biopsy results were available for each case of architectural distortion.

RESULTS

Architectural distortion was deemed present and actionable by a panel of expert breast imagers in 80 views of the 45 cases. One CAD system detected distortion in 22 of 45 cases of distortion (case sensitivity, 49%) and in 30 of 80 mammograms (image sensitivity, 38%); it displayed 0.7 false-positive marks per image. Another CAD system identified distortion in 15 of 45 cases (case sensitivity, 33%) and 17 of 80 mammograms (image sensitivity, 21%); it displayed 1.27 false-positive marks per image. Sensitivity for malignancy-caused distortion was similar to or lower than sensitivity for all causes of distortion.

CONCLUSION

Fewer than one half of the cases of architectural distortion were detected by the two most widely available CAD systems used for interpretations of screening mammograms. Considerable improvement in the sensitivity of CAD systems is needed for detecting this type of lesion. Practicing breast imagers who use CAD systems should remain vigilant for architectural distortion.

Mammographic features of nonpalpable spiculated lesions

OBJECTIVE

To evaluate the mammographic features of nonpalpable spiculated lesions in order to find differentiating findings between malignant and benign pathologies.

MATERIALS AND METHODS

Standard mammograms of 27 patients with 28 nonpalpable spiculated lesions were evaluated retrospectively. Two dimensions of dense centre of the spiculated lesions were measured and the mean dimensions were compared in analysing the malignant and benign features. Fine radiolucent lines between dense spicules were noted.

RESULTS

Thirteen spiculated lesions (46.4%) were malignant and 15 were benign. Eleven malignant lesions (84.6%) have dense centre larger than 5 mm, whereas only four benign lesions (26.7%) had a dense core larger than 5 mm. There were fine radiolucent lines parallel to dense spicules in 5 malignant lesions (38.5%) and in 13 benign lesions (86.7%). Only one invasive carcinoma and one radial scar with florid ductal epithelial hyperplasia and papillomatosis had punctate calcifications. The sensitivity and specificity of the dense core larger than 5 mm for malignancy were 84.6% and 73.3%, respectively. The sensitivity of radiolucent lines for benign lesions was 86.7% and the specificity was 61.5%.

CONCLUSION

When the dense centre of a nonpalpable spiculated lesion is larger than 5 mm, the probability of malignant pathology increases. The fine radiolucent lines between dense spicules may indicate benign etiology. However, there is no reliable mammographic feature differentiating benign spiculated lesions from carcinomas. Therefore, all of them should be diagnosed pathologically unless they are postsurgical.

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.

Fourteen-gauge needle core biopsy of mammographically evident radial scars: is excision necessary?

BACKGROUND

Radial scars are benign lesions that may mimic breast carcinoma on mammography and usually are managed by excision biopsy. The authors report their experience with stereotactic needle core biopsy (SNCB) in sampling these lesions.

METHODS

A prospective study examined a consecutive series of 75 mammographically detected radial scars from a population-based screening program. In patients who were sampled by SNCB followed by surgical biopsy, the histologic findings of core biopsy and the gold standard of excision biopsy were compared.

RESULTS

Sixty-three patients were sampled by core biopsy: SNCB was used in 55 patients (87.0%), and ultrasound-guided needle core biopsy (UNCB) was used in 8 patients (13%). One patient who underwent SNCB did not undergo a follow-up excision biopsy. Radial scars were diagnosed preoperatively by core biopsy in 51 of 62 patients who underwent excision (82%; 95% confidence interval [95%CI], 70-91%). The sensitivity for SNCB was 85% (95%CI, 73-94%), and the sensitivity for UNCB was 63% (95%CI, 24-91%). Of 54 patients who underwent SNCB and excision, 4 patients had coexistent ductal carcinoma in situ (DCIS) at the time they underwent surgical excision: SNCB identified DCIS in 1 patient and identified atypical ductal hyperplasia (ADH) in 3 patients. In the entire group of 75 radial scars, 5 scars were associated with DCIS (7%), and there were no invasive carcinomas. ADH was present in association with 42 of 74 radial scars that were excised surgically (57%). Twenty-nine of those radial scars were sampled preoperatively by SNCB. ADH was found in 21 patients (72%; 95CI, 53-87%).

CONCLUSIONS

The sensitivity of SNCB in the identification of radial scars was 85%. In four patients with associated DCIS, SNCB revealed either ADH or DCIS, both of which required excision. These findings suggest that patients with SNCB-proven radial scars among a screened population can be managed safely by mammographic follow-up, provided there is no associated DCIS, ADH, or lobular carcinoma in situ. Spiculated abnormalities with discordant SNCB results require surgical biopsy.

Percutaneous core needle biopsy of radial scars of the breast: when is excision necessary?

OBJECTIVE

. This study was conducted to evaluate the outcome of cases of radial scar diagnosed by percutaneous core needle biopsy.

MATERIALS AND METHODS

Of 198 nonpalpable lesions diagnosed with radial scars found at core needle biopsy, 157 lesions constituting the study group had undergone surgical excision (n = 102) or mammographic surveillance after biopsy for at least 24 months (median, 38 months; n = 55). Mammographic lesion type, lesion size, biopsy guidance method, biopsy device, number of specimens per lesion, and presence of atypical hyperplasia at percutaneous biopsy were retrospectively analyzed. Results were compared with histologic findings at surgery or mammographic findings during surveillance.

RESULTS

. Carcinoma was found at excision in 28% (8/29) of lesions with associated atypical hyperplasia at percutaneous biopsy and 4% (5/128) of lesions without associated atypia (p < 0.0001). In the latter group, carcinoma was found at excision in 3% (2/60) of masses, 8% (3/40) of architectural distortions, and 0% (0/28) of microcalcification lesions. Malignancy was missed in 9% (5/58) of lesions biopsied with a spring-loaded device and in 0% (0/70) of lesions biopsied with a directional vacuum-assisted device (p = 0.01); and in 8% (5/60) of lesions sampled with less than 12 specimens per lesion and 0% (0/68) sampled with 12 or more specimens (p = 0.015). Lesion type, maximal lesion diameter, and type of imaging guidance (stereotactic or sonographic) were not significant factors in determining the presence of malignancy.

CONCLUSION

. Diagnosis of radial scar based on core needle biopsy is likely to be reliable when there is no associated atypical hyperplasia at percutaneous biopsy, when the biopsy includes at least 12 specimens, and when mammographic findings are reconciled with histologic findings. When the lesion diagnosed by core needle biopsy as radial scar does not meet these criteria, excisional biopsy is indicated.

Complex sclerosing lesion: the lesion is complex, the management is straightforward

BACKGROUND

Complex sclerosing lesion (CSL) and its smaller counterpart, the radial scar (RS), are frequently seen pathological entities. They are clinically asymptomatic and, prior to the implementation of mammographic screening, were most commonly found incidentally during pathological examination of other biopsied lesions. Complex sclerosing lesions are being detected regularly on mammograms due to widespread screening; many of their features resemble those of malignancy. Management varies and has been controversial.

METHODS

Twenty-three cases of CSL detected during the first prevalent round of screening at BreastScreen Western Sydney (from February 1993 until June 1995) are presented and reviewed. Assessment was by a combination of radiological, clinical and cytological work-up prior to surgical biopsy. In addition, 126 spiculated carcinomas detected in the same period were reviewed and compared.

RESULTS

Fourteen RS/CSL (62%) had lucent centres and nine (38%) had a central mass; three had been diagnosed provisionally as RS/CSL. Spicule lengths ranged from 25 to 90 mm; central masses ranged from 5 to 50 mm; and mass:spicule length ratio ranged from 1.2:1 to 1:10. Calcification (benign or indeterminate) was present in six cases (29%). No RS/CSL contained 'suspicious' calcifications, whereas 120 of 126 carcinomas (95%) had a central mass and six (5%) had a lucent centre (spicule lengths: 10-90 mm; central mass: 5-40 mm; and mass:spicule length ratio: 1.1:1-1:10). Twenty-one spiculated carcinomas (17%) contained microcalcifications (14 benign or indeterminate; seven suspicious). Provisional radiological diagnosis (PRD) after mammogram, with or without ultrasound, for histologically confirmed RS/CSL, was RS/CSL in 18 cases (78%), carcinoma in four cases (17%) and equivocal in one case (5%). For eight (6.5%) spiculate carcinomas the PRD was RS/CSL prior to histological diagnosis. The RS/CSL were detected with equal frequency in right and left breasts, and 22 (96%) lesions occurred in the upper breast. Seven RS/CSL (31%) and 83 spiculated carcinomas (65%) had been described as 'palpable' but most were subtle. Twelve fine-needle aspiration biopsies were performed (six 'palpable' lesions (no radiological guidance); four with ultrasound guidance and two with stereotactic guidance), and five (62.5%) of eight adequate lesions were reported as benign, two (25%) were reported as atypical, and one (12.5%) was reported as suspicious.

CONCLUSIONS

Definitive mammographic and sonographic differentiation of RS/CSL and stellate-type carcinoma is impossible. For screen-detected lesions that may be RS/CSL, the appropriate surgical procedure is a small but adequate biopsy using guidewire or other localization methods with optimal cosmetic incision.

Multiple 14G stereotactic core biopsies in the diagnosis of mammographically detected stellate lesions of the breast

AIM

The aim of this retrospective study was to measure the accuracy of stereotactic guided 14 gauge core biopsy in distinguishing between benign and malignant causes of a mammographically detected stellate breast lesion and to assess the impact of the number of core samples taken on the sensitivity for detection of malignancy.

MATERIALS AND METHODS

Seventy-two patients with mammographically detected stellate lesions of the breast formed the study group. All patients in the study group underwent multiple 14 gauge core biopsies using prone stereotactic breast biopsy equipment. The diagnostic accuracy of the technique was measured by retrospectively comparing the outcome with the core biopsy results. The result of each core sample was separately recorded to allow analysis of the effect of increasing the number of samples on accuracy.

RESULTS

Nine of 72 (12%) did not have surgery. Forty of 72 (56%) had a benign surgical outcome and 23/72 (32%) a malignant surgical outcome [7/72 (10%) non-invasive, 16/72 (22%) invasive carcinoma]. The absolute sensitivity for multiple stereotactic guided core biopsies of stellate lesions for the detection of malignancy was 78% with a complete sensitivity of 100%. The sensitivity for the detection of invasive carcinoma was 94% (15 out of 16 patients). No statistically significant improvement in sensitivity was shown for multiple samples vs one sample, but in two patients, malignant tissue was only found in core samples 6-9, the first five cores showing atypia only.

CONCLUSION

Multiple stereotactic guided 14 gauge core biopsies accurately distinguish malignant from benign causes of stellate breast lesions. When core biopsy histology is malignant, therapeutic surgery can be planned. When the core biopsy shows typical features of a benign radial scar, diagnostic surgical excision may not be required to confirm the diagnosis.Kirwan, S. E., (2000). Clinical Radiology55, 763-766.

Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needle biopsy: clinical importance

PURPOSE

To assess the outcome of papillary lesions, radial scars, or lobular carcinoma in situ (LCIS) diagnosed at stereotactic core-needle biopsy (SCNB).

MATERIALS AND METHODS

Retrospective review of 1,236 lesions sampled with SCNB yielded 22 papillary lesions, nine radial scars, and five LCIS lesions. Diffuse lesions such as papillomatosis, papillary ductal hyperplasia, papillary ductal carcinoma in situ (DCIS), and atypical lobular hyperplasia were not included. The mammographic findings, associated histologic features, and outcome were assessed for each case.

RESULTS

Sixteen papillary lesions were diagnosed as benign at SCNB. Of these, five were benign at excision, and 10 were unremarkable at mammographic follow-up. At excision of an unusual lesion containing a microscopic papillary lesion, DCIS was found. Three of four papillary lesions suspicious at SCNB proved to be papillary carcinomas; the fourth had no residual carcinoma at excision. Eight of nine radial scars were excised, which revealed atypical hyperplasia in four scars but no malignancies. One LCIS lesion was found at excision to contain DCIS.

CONCLUSION

Benign or malignant papillary lesions were accurately diagnosed with SCNB in the majority of cases. Cases diagnosed as suspicious for malignancy or with atypia or unusual associated histologic findings should be excised. No malignancies were found at excision of radial scars diagnosed at SCNB. Surgical removal of these lesions following SCNB may not be routinely necessary. DCIS was found in one lesion diagnosed as LCIS at SCNB, which suggests that removal of these lesions may be prudent.

Radial scar

Radial scars attract interest due to its mammographic appearance and pathology. It is still unclear whether it is a benign or premalignant condition. This article reviews the clinical feature, pathology and its relation to malignancy.

Role of sonography in evaluation of radial scars of the breast

OBJECTIVE

We investigated the usefulness of sonography in revealing radial scars suspected on mammography.

CONCLUSION

Many radial scars are visible on sonography and, when visible, may present features virtually identical to those of carcinoma of the breast. Findings indicative of a radial scar are often more conspicuous on sonography than on mammography; thus, sonography may have a definitive role when evaluating subtle findings suggestive of a radial scar or when features of a radial scar are evident on only one mammographic view and cannot be localized with certainty.

Radial scar of the breast: mammographic enigma in pre- and postmenopausal women

OBJECTIVE

The aim of the study was to investigate the incidence and the mammographic features of the lesions suggestive of radial scar (RS).

METHODS

We reviewed 31883 mammograms of women in pre and postmenopause and we found 23 (0.072%) images suggestive of RS. Twelve out of 23 (52%) women were in premenopause and 11 out of 23 (48%) in postmenopause, respectively. Histologic diagnosis was made on the surgical biopsy specimen.

RESULTS

We described mammographic features of these lesions. On 23 biopsy specimens of mammograms suggestive of RS, histology pointed out 11 (48%) radial scars, 3 (13%) sclerosing adenosis and 9 (39%) carcinomas.

CONCLUSIONS

In our case histories we found 11 (0.034%) radial scars among 31883 performed mammographies. Mammographic findings suggestive of RS provide remarkable diagnostic problems because numerous aspects at mammography suggestive of this lesion can be found also both in case of sclerosing adenosis and carcinomas making differential diagnosis impossible. The finding of mammographic features suggestive of RS imposes performance of targeted surgical biopsy for the correct diagnosis.

Neoplastic and Malignant Lesions Involving or Arising in a Radial Scar: A Clinicopathologic Analysis of 17 Cases

Seventeen radial scars (RSs) containing or secondarily involved by lobular neoplasia (n = 8), ductal carcinoma in situ (DCIS) (n = 3), and invasive carcinoma (n = 6) are described. The patients ranged in age from 44 to 84 years with an average age of 58. Nine lesions presented as a palpable mass; three of the palpable masses were due to a variety of benign lesions associated with a radial scar. Eight radial scars were detected incidentally as a result of screening mammography; three of these cases manifested as stellate lesions. All lesions were unilateral. Microscopically, all radial scars had a stellate configuration, with a central fibroelastic core from which numerous ductules radiated. In eight cases, lobular neoplasia (LN) involved the peripheral ductules in a patchy fashion; seven of these cases were graded as LN 2 and one as LN 1. A grade II intraductal carcinoma with solid and cribriform patterns was noted in three cases, one of which was noteworthy because the central core contained DCIS (grade II) distorted by the dense fibroelastic tissue, mimicking an invasive pattern. An immunostain for actin demonstrated the presence of myoepithelial cells surrounding all the entrapped ductules confirming their noninvasive nature. An invasive carcinoma was present in the remaining six cases; these were predominantly focal and in the peripheral region of the radial scar. While all invasive carcinomas were well differentiated and ductal in type with abundant tubule formation, only one was a classic tubular carcinoma. In all six cases it was difficult to detect the malignant infiltrating nature of the lesion because of the associated stromal fibrosis and distortion of surrounding tubular structures. The occurence of neoplastic and malignant lesions involving or arising in a radial scar has received scant attention in the literature. This series indicates that the ducts and lobules emanating from radial scars can serve, albeit rarely, as the milieu for the development of or secondary involvement by lobular neoplasia, intraductal, or invasive carcinoma. It should be emphasized that these cases reflect a highly select group of problematic radial scars in a high-volume consultation practice; the vast majority of radial scars encountered in routine practice of surgical pathology are benign. At present there is no evidence that the scar element of the lesion serves as a precursor or promoter of the various neoplastic changes.

Tubular carcinoma of the breast: mammographic and sonographic features

OBJECTIVE

The purpose of this study was to define specific mammographic and sonographic features of tubular carcinoma of the breast.

MATERIALS AND METHODS

Seventeen pathologically confirmed cases of tubular carcinoma were characterized retrospectively by two radiologists. Mammograms and sonograms were available for all patients.

RESULTS

Fifteen of the 17 tubular carcinomas appeared as irregularly shaped masses with spiculated margins on mammography. Sixteen of the 17 masses had central densities. Spicules longer than the diameter of the central lesion were noted in eight (53%) of 15 tubular carcinomas. Eight tubular carcinomas had associated calcifications, with calcifications suspected of being malignant in four cases. On sonography, 15 hypoechoic masses were seen. The margins of the masses on sonography were described as ill-defined in 14 (93%) of the 15 cases. Posterior acoustic shadowing was present in 14 of the 15 cases.

CONCLUSION

Tubular carcinomas are usually seen on mammography as irregularly shaped masses with central densities and spiculated margins, and most tubular carcinomas can be identified on sonography as hypoechoic masses with ill-defined margins and posterior acoustic shadowing. Although the mammographic and sonographic features of tubular carcinoma are not sufficiently specific to differentiate tubular carcinomas from radial scars, sonography can be useful for guiding biopsies and evaluating for multifocal and multicentric disease.

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.

Radial scars: a review of 30 cases

Radial Scars/Complex Sclerosing Lesions are benign breast lesions that are seen more frequently now with the advent of screening mammography. These lesions need to be excised surgically in the absence of classical diagnostic features.

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.