What is the management of breast radial scar (also known as radial sclerosing lesion)?

From the Guidelines

Breast radial scars should be managed with excisional biopsy to rule out malignancy, as they are associated with a significant risk of adjacent cancer. When a radial scar is identified on core needle biopsy, excisional biopsy is recommended because approximately 10-20% of these lesions harbor adjacent malignancy that may not have been sampled during the initial biopsy 1. The standard approach involves wire-localized surgical excision to completely remove the lesion for thorough pathological examination. Some key points to consider in the management of breast radial scars include:

• The potential for malignancy associated with radial scars, which necessitates thorough histological evaluation 1
• The role of excisional biopsy in providing a definitive diagnosis and guiding further management
• The importance of considering the size of the lesion and the presence of atypia on initial biopsy when deciding on the management approach
• The option for close surveillance with imaging follow-up for smaller lesions without atypia, although this approach carries some risk of missing an associated cancer Following surgical excision, if no malignancy is found, routine breast cancer screening can resume without additional follow-up specific to the radial scar. If the radial scar is an incidental finding on excisional biopsy performed for another reason and has been completely removed, no further management is needed, as supported by the NCCN clinical practice guidelines in oncology 1. The concern with radial scars stems from their distorted architecture that mimics malignancy radiographically and their potential association with atypical hyperplasia or occult carcinoma, making thorough histological evaluation essential for proper management. In general, a thorough and individualized approach to the management of breast radial scars is necessary to ensure optimal patient outcomes.

From the Research

Management of Breast Radial Scar

The management of breast radial scar (also known as radial sclerosing lesion) is a topic of discussion in the medical field. According to recent studies 2, 3, 4, 5, 6, the following points can be considered:

• Surgical Excision vs. Imaging Surveillance: Studies suggest that pure radial scars do not require surgical excision when concordant and benign at image-guided breast biopsy 2. However, surgical excision should be considered for radial scars with associated high-risk lesions 2.
• Upgrade Rates to Malignancy: The upgrade rate to breast cancer when radial scar is found on core needle biopsy is very low, ranging from 0% to 5% 2, 4, 5, 6.
• Imaging Surveillance: Imaging surveillance is a reasonable approach for radial scars without atypia, particularly for those presenting as calcifications 6.
• Risk Factors for Upstaging: Features associated with higher upstaging risk include a prior breast cancer diagnosis and the presence of atypia at core needle biopsy 6.
• Management Strategies: The optimal management of radial scars is controversial, and understanding of the natural history of unresected radial scars is limited 5. However, studies suggest that active surveillance can be safely offered to patients with radial scars on needle core biopsies 5.

Key Considerations

• Patient Selection: Patient selection is crucial in determining the management approach for radial scars. Factors such as prior breast cancer diagnosis, presence of atypia, and imaging findings should be taken into account 6.
• Imaging Modalities: Different imaging modalities, such as digital mammography, digital breast tomosynthesis, and ultrasound, can be used to evaluate radial scars 3.
• Biopsy Methods: Vacuum-assisted biopsy with large core is recommended after a percutaneous diagnosis of radial scar due to potential sampling error 3.