K. Nimtz1, K. Hookim2, A. Sevrukov3, T. Tsangaris1, A. Willis1, A. Berger1, M. Lazar1 1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Pathology,Philadelphia, PA, USA 3Thomas Jefferson University,Radiology,Philadelphia, PA, USA
Introduction: Quantifying the risk of upgrade to malignancy with radial scars has been an ongoing challenge in the breast cancer research community. Previous reviews show radial scars account for 5-9% of findings on core needle biopsy. The upgrade rate varies from 0-40% making management of radial scars controversial. Multiple studies have investigated the association of radial scar and malignancy, with recent studies indicating lower rates. The lack of consensus on the optimal management highlights the need for further analysis of radial scar and its risk of upgrade to malignancy. We sought to identify our institutional upgrade rate of radial scar identified on core needle biopsy.
Methods: An IRB approved retrospective review of pathology and radiology databases from 2010 to 2017 was performed to identify radial scar found on core needle biopsy. We excluded patients with malignancy associated with radial scar and those who did not undergo surgical excision. The initial imaging findings prompting the core needle biopsy as well as the upgrade rate to malignancy (invasive ductal/lobular carcinoma and ductal carcinoma in situ) on surgical excision were assessed.
Results: We identified 127 patients with radial scar on a core needle biopsy. Due to malignancy associated with radial scar, no surgical excision or incomplete records, we excluded 75 patients leaving 52 patients for analysis. Of these, 4 of 52 (7.7%) patients had an upgrade to malignancy upon surgical excision of the radial scar—2 with DCIS and 2 with invasive ductal cancer. All 4 of these patients had findings on both mammography and ultrasound. Eight patients had atypia associated with radial scar on core needle biopsy, two of which were upgraded to malignancy at the time of surgical excision. The rate of upgrade for radial scar alone on core needle biopsy was 2 of 44 (4.5%). Of the 44 patients with radial scar alone on core needle biopsy, 15 (34%) were found to have atypia (6 with flat epithelial atypia, 5 with atypical ductal hyperplasia, 2 with lobular carcinoma in situ, one with atypical lobular hyperplasia and one with both atypical ductal and lobular hyperplasia) on surgical excision.
Conclusion: With the increasing use of digital tomosynthesis, it is possible that more radial scars will be identified on core needle biopsy. Although the upgrade rate to malignancy was only 4.5%, there was a substantial upgrade rate of pure radial scar to some type of atypia which could alter subsequent management. Additionally, one-quarter of radial scars with atypia upgraded to malignancy on excision. For these reasons, careful consideration should be given to re-excision of core needle biopsy showing radial scar with and without atypia.