Follow-up for Complex Sclerosing Lesion of the Breast
After surgical excision of a complex sclerosing lesion (radial scar) with benign pathology, patients should undergo physical examination with or without mammography or ultrasound every 6-12 months for 1-2 years, then return to routine annual screening mammography if the lesion remains stable. 1
Understanding Complex Sclerosing Lesions
Complex sclerosing lesions (CSL) and radial scars are proliferative lesions without atypia that fall into the category of benign breast disease. 1 These lesions are architecturally complex and can mimic malignancy on imaging, making definitive mammographic and sonographic differentiation from stellate carcinoma impossible. 2 However, when pathology confirms a benign CSL without associated atypia or malignancy, the management pathway is straightforward.
Post-Excision Surveillance Protocol
Initial Follow-up Phase (1-2 years)
- Perform physical examination every 6-12 months with or without imaging (mammography or ultrasound) for 1-2 years to assess stability. 1
- The follow-up interval may vary based on clinical suspicion, but the standard is 6-12 months. 1
- If the lesion increases in size during surveillance, surgical excision is required. 1
Return to Routine Screening
- After 1-2 years of stability, patients return to routine age-appropriate screening mammography. 1
- For women 40 years and older, this means annual screening mammography. 1
Critical Distinction: Atypia Changes Everything
The surveillance protocol above applies only when final pathology confirms benign CSL without atypia. 1 This is a crucial distinction:
- If pathology reveals atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, or flat epithelial atypia (proliferative lesions with atypia), the patient requires surgical excision if not already performed, followed by consideration of risk-reduction therapy according to breast cancer risk reduction guidelines. 1
- Proliferative lesions with atypia carry significantly higher breast cancer risk, with one study showing 25% of women with excision for proliferative lesions with atypia developing breast cancer. 1
Common Pitfalls to Avoid
Pathology-Imaging Concordance is Mandatory
- Always verify concordance between imaging findings and biopsy results. 3
- Discordance between imaging and pathology mandates repeat biopsy or surgical excision, regardless of benign pathology on core needle biopsy. 3
- CSL can harbor focal areas of atypia or malignancy that may be missed on limited core needle sampling. 3
Don't Confuse CSL with Other Proliferative Lesions
- Complex sclerosing lesions are distinct from sclerosing adenosis, which is also a benign proliferative lesion but has different characteristics. 4, 5
- Both CSL and sclerosing adenosis are classified as proliferative lesions without atypia and follow similar surveillance protocols when benign. 1
Recognize When More Intensive Screening is Needed
- Some benign breast diseases, particularly those with atypia, can elevate a woman's risk to higher-than-average, warranting earlier or more intensive screening including possible MRI. 1
- However, benign CSL without atypia does not automatically warrant high-risk screening protocols. 1
Evidence Quality Note
The most recent and authoritative guideline is the 2022 ACR Appropriateness Criteria, which clearly categorizes complex sclerosing lesions as proliferative lesions without atypia and provides specific surveillance intervals. 1 The 2018 NCCN guidelines provide concordant recommendations regarding the 6-12 month follow-up protocol for benign lesions. 1 Studies examining 6-month versus annual screening intervals for nonproliferative and proliferative lesions without atypia found no improvement in cancer detection rates with shorter intervals. 1