What is the recommended treatment for a patient with a radial sclerosing lesion and ductal epithelial hyperplasia diagnosed on a left breast biopsy?

Management of Radial Sclerosing Lesion with Ductal Epithelial Hyperplasia

Surgical excision is recommended for radial sclerosing lesions with ductal epithelial hyperplasia to ensure complete removal of the lesion and rule out associated malignancy. 1

Rationale for Surgical Management

Radial sclerosing lesions (RSLs) present a diagnostic challenge because:

• They can mimic carcinoma on mammography
• They are frequently associated with malignancy
• The presence of ductal epithelial hyperplasia increases concern for potential malignancy

Risk Assessment Factors

Several factors influence the management decision:

1. Histological features:

   • Proliferative changes (like ductal epithelial hyperplasia) significantly increase the need for excision 2
   • RSLs with epithelial atypia have higher upgrade rates

2. Radiological characteristics:

   • Architectural distortion on imaging correlates with higher excision rates 2
   • Residual calcifications or architectural distortion on post-biopsy mammogram warrant excision 2

Surgical Approach

The recommended surgical approach includes:

• Image-guided wire localization for precise removal of the lesion 1
• Proper placement of skin incision directly over the lesion, not at the wire entry point 1
• Removal of the specimen in one piece to allow proper margin assessment 1
• Specimen radiography to confirm complete removal of the mammographic abnormality 1
• Meticulous hemostasis to avoid hematoma formation 1

Technical Considerations

• For nonpalpable lesions, presurgical localization with a guide wire is essential 1
• Labeled craniocaudal and lateral films showing the hook wire should be available in the operating room 1
• The incision should be long enough to permit removal of the specimen in one piece 1
• Avoid removing the lesion in multiple fragments as this prevents proper margin assessment 1
• A post-operative mammogram should be obtained to document complete removal 1

Follow-up Recommendations

After surgical excision:

• Pathological examination of the entire specimen
• Post-operative mammogram to confirm complete removal
• Regular follow-up mammography according to standard screening guidelines

Emerging Evidence and Controversies

While recent research suggests that observation might be appropriate for some RSLs without atypia 3, 4, the presence of ductal epithelial hyperplasia in this case increases the risk profile. The most recent studies show:

• Upgrade rates to malignancy ranging from 1-9% 3, 5
• Higher risk with proliferative changes like ductal epithelial hyperplasia 2

Potential Pitfalls

1. Inadequate sampling: Ensure multiple cores are taken during initial biopsy to minimize sampling error
2. Incomplete excision: Careful attention to margin status is essential
3. Failure to recognize associated malignancy: Thorough pathological examination is critical
4. Poor cosmetic outcome: Proper surgical technique minimizes breast deformity

While some recent studies suggest observation for certain RSLs 3, 4, the presence of ductal epithelial hyperplasia in this case warrants a more cautious approach with surgical excision to ensure optimal outcomes regarding mortality and morbidity.