What is the management approach for patients with sclerosing adenosis and radial sclerosis?

Management of Sclerosing Adenosis and Radial Sclerosis

Both sclerosing adenosis and radial sclerosing lesions (radial scars) require tissue diagnosis via core needle biopsy or surgical excision because they cannot be reliably distinguished from malignancy by imaging alone, and management depends entirely on whether atypia is present on pathology.

Initial Diagnostic Approach

Imaging Characteristics and Limitations

Sclerosing Adenosis:

• Presents as irregular masses, microcalcification clusters (39-44%), asymmetrical opacity, architectural distortion, or focal acoustic shadowing on ultrasound 1, 2
• No distinctive radiological features exist that can differentiate it from malignancy 1, 2
• Can mimic carcinoma on mammography, ultrasound, and even MRI with irregular masses or regional non-mass enhancement with increased vascularity 1

Radial Sclerosing Lesions (Radial Scars):

• Typically appear as architectural distortion with or without associated spiculated mass on tomosynthesis 3
• Manifest as stellate lesions on mammography in most cases 4, 5
• Often occult or show subtle distortion with adjacent cysts on ultrasound 3
• Imaging findings cannot distinguish benign lesions from those that will upgrade to malignancy at surgery 3

Mandatory Tissue Diagnosis

Core needle biopsy is the appropriate first diagnostic step for both lesions, as imaging alone cannot exclude malignancy 1, 3, 2.

• Image-guided core needle biopsy (preferably ultrasound-guided vacuum-assisted biopsy) should be performed for tissue diagnosis 1, 2
• Surgical excisional biopsy is required when core biopsy is technically not feasible 4, 2

Management Algorithm Based on Pathology Results

Radial Sclerosing Lesions WITH Atypia

Surgical excision is essential for radial scars/complex sclerosing lesions with associated atypia, as they carry a 16-29% upgrade rate to malignancy 3.

• Any atypia detected on core needle biopsy mandates complete surgical excision 3
• This includes atypical ductal hyperplasia, atypical lobular hyperplasia, or any other atypical epithelial proliferation 3

Radial Sclerosing Lesions WITHOUT Atypia

For radial scars ≤1 cm without atypia, imaging surveillance can be considered as an alternative to surgical excision, given the <3% upgrade rate to malignancy 3.

• Lesions >1 cm have higher upgrade rates and should undergo surgical excision even without atypia 3
• Imaging follow-up protocol (when excision is deferred): serial mammography and ultrasound at 6-month intervals initially, then annually if stable 3

Sclerosing Adenosis

Sclerosing adenosis without atypia can be managed with imaging surveillance after core needle biopsy confirms the diagnosis 2.

• Core needle biopsy is sufficient for diagnosis when concordant with imaging findings 2
• No alterations suggesting malignancy were noted during follow-up of patients managed conservatively after core needle biopsy 2
• Surgical excision is indicated if: imaging-pathology discordance exists, atypia is present, or patient preference 2

Long-term Surveillance Considerations

Cancer Risk Assessment

Sclerosing adenosis is associated with a doubling of breast cancer risk, requiring ongoing surveillance even after benign diagnosis 1.

• Continue routine screening mammography per standard guidelines for women at moderately increased risk 1
• The exact role in carcinogenesis remains unclear, but the association warrants continued vigilance 1

Critical Pitfalls to Avoid

Do not rely on imaging characteristics alone to exclude malignancy - both sclerosing adenosis and radial scars can perfectly mimic carcinoma radiologically, including spiculated margins, architectural distortion, and suspicious enhancement patterns 1, 3, 4, 5

Do not assume microcalcifications help differentiate benign from malignant - microcalcifications in sclerosing adenosis can be localized in contiguous adenosis and are not useful criteria to distinguish from carcinoma 4

Do not skip surgical excision for radial scars with any degree of atypia - the 16-29% upgrade rate to malignancy makes excision non-negotiable regardless of lesion size 3

Do not perform surgical excision reflexively for all radial scars - small (≤1 cm) radial scars without atypia have <3% upgrade rates and can be safely followed with imaging, avoiding unnecessary surgery 3

Recognize that palpability does not exclude radial scar - although typically described as non-palpable, radial scars can present as palpable masses 5