(Radiographics. 1999;19:S27-S35.)
© RSNA, 1999
Radial Scar of the Breast: Radiologic-Pathologic Correlation in 22 Cases1
D. Quentin Alleva, MD,
Dana H. Smetherman, MD, MPH,
Gist H. Farr, Jr, MD and
Gunnar J. Cederbom, MD
1 From the Departments of Radiology (D.Q.A., D.H.S., G.J.C.) and Pathology (G.H.F.), Ochsner Clinic, 1514 Jefferson Hwy, New Orleans, LA 70121. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 19, 1999; revision requested April 13 and received May 7; accepted May 7. Address reprint requests to D.H.S.
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Abstract
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Twenty-two cases were reviewed in which the diagnosis of radial scar (complex sclerosing lesion) of the breast was suspected preoperatively. At mammography, the lesions had a "black star" appearance with long, thin spicules radiating from a radiolucent central area. Excisional rather than core needle biopsy was recommended in all cases. In 13 of 22 cases, including one case of atypical ductal hyperplasia, the lesions proved benign at pathologic analysis. The remaining nine cases were malignant and included one case with a low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ adjacent to the lesion. Results of this study confirm the previously reported association of atypical ductal hyperplasia and carcinoma with radial scar. Furthermore, they demonstrate that a mammographic finding suggestive of radial scar may represent a malignancy that mimics the typical imaging findings in these entities. In cases of mammographically suspected radial scar, all members of the management team as well as the patient should be made aware preoperatively of the potential for benign as well as malignant pathologic findings.
Index Terms: Breast, radial scar, 00.725 • Breast neoplasms, 00.32 • Breast neoplasms, diagnosis, 00.11, 00.1261
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INTRODUCTION
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Radial scars, or complex sclerosing lesions, are not truly scars; instead, they are idiopathic entities unrelated to prior surgery or trauma. Proposed possible causes include localized inflammatory reaction and chronic ischemia with subsequent slow infarction (1). The reported prevalence of radial scars is 0.1–2.0 per 1,000 screening mammograms and 1.7%–14% of autopsy specimens (2–4). Their major clinical significance pertains to an association with atypical ductal hyperplasia and carcinoma that is seen in up to 50% of cases (5). Excisional biopsy should be performed when imaging findings are consistent with radial scar (5,6). Core needle biopsy, fine-needle aspiration, and frozen sectioning are not routinely recommended for definitive diagnosis because the precise pathologic diagnosis of these lesions is difficult.
In this article, we describe and illustrate mammographic and pathologic findings in 22 cases of radial scar of the breast. In addition, we correlate these findings to help provide a basis for determining potential outcomes in similar cases.
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MATERIALS AND METHODS
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We reviewed all cases in which needle-localized excisional biopsy of the breast was performed at our institution between July 1994 and June 1998. In 22 cases, the interpreting radiologist suspected radial scar on the basis of imaging findings and recommended excisional rather than core needle biopsy. Mammographic and pathologic findings were correlated in these cases.
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RESULTS
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In 13 of 22 cases (59%), including one case of atypical ductal hyperplasia seen within the lesion, pathologic findings were benign. In 12 cases, the mammographic lesions were caused by benign processes including fibrosis, stromal sclerosis, apocrine metaplasia, sclerosing and blunt duct adenosis, ductal dilatation, and non–atypical ductal hyperplasia. The remaining nine cases (41%) were malignant and included invasive ductal carcinoma not otherwise specified (n = 4), invasive lobular carcinoma (n = 1), tubular carcinoma (n = 2), and ductal carcinoma in situ (n = 2). One of the latter cases demonstrated a focus of low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ adjacent to the lesion. The other case demonstrated a high-nuclear-grade comedo-type ductal carcinoma in situ without radial scar. These findings are summarized in the Table.
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DISCUSSION
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At mammography, radial scar manifests as an asymmetric density or architectural distortion with central translucent areas representing fat. Typically, there is no discrete central mass. Long, thin radiating spicules against a background of radiolucent fat create a "black star" appearance (Fig 1) (7). Radial scars are typically planar in configuration and therefore may have varying appearances on orthogonal views (Fig 2). They are not palpable regardless of size and produce no skin retraction or thickening (6,8). Associated microcalcifications have been reported (9).
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Figure 2a. Radial scar in a 77-year-old woman. Mediolateral oblique (a), mediolateral oblique spot compression (b), and craniocaudal spot compression (c) mammograms show no discrete central mass (arrow in a and b) as well as long radiating spicules against a radiolucent background of fat (arrowheads) and demonstrate the varying appearances of radial scar on orthogonal views. These entities demonstrate architectural distortion that may be indistinguishable from architectural distortion associated with carcinoma. Pathologic analysis confirmed the diagnosis.
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Figure 2b. Radial scar in a 77-year-old woman. Mediolateral oblique (a), mediolateral oblique spot compression (b), and craniocaudal spot compression (c) mammograms show no discrete central mass (arrow in a and b) as well as long radiating spicules against a radiolucent background of fat (arrowheads) and demonstrate the varying appearances of radial scar on orthogonal views. These entities demonstrate architectural distortion that may be indistinguishable from architectural distortion associated with carcinoma. Pathologic analysis confirmed the diagnosis.
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Figure 2c. Radial scar in a 77-year-old woman. Mediolateral oblique (a), mediolateral oblique spot compression (b), and craniocaudal spot compression (c) mammograms show no discrete central mass (arrow in a and b) as well as long radiating spicules against a radiolucent background of fat (arrowheads) and demonstrate the varying appearances of radial scar on orthogonal views. These entities demonstrate architectural distortion that may be indistinguishable from architectural distortion associated with carcinoma. Pathologic analysis confirmed the diagnosis.
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Pathologic analysis of radial scar shows a stellate abnormality with slender radial bands of pale stroma extending into adjacent fat (Fig 3). Unlike carcinoma, these lesions are usually soft and exhibit minimal or no retraction of the exposed surface when bisected. Distinct central and peripheral features are typically seen at histologic analysis. There is a central sclerotic core composed of acellular connective tissue (fibrosis) and elastin deposits (elastosis). Entrapped ductules in the sclerotic core have an intact myoepithelial layer (Fig 4), a major distinguishing feature from tubular carcinoma. At the periphery, there is a corona of distorted ducts and lobules composed of benign proliferations such as sclerosing adenosis, ductal hyperplasia, cyst formation, and papillomatosis (10).
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Figure 3a. Radial scar in a 44-year-old woman. (a) Craniocaudal mammogram (magnification view) shows the typical stellate appearance of these lesions. (b) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin [H-E] stain) demonstrates characteristic histologic features including a central sclerotic core (arrowhead), radiating bands of stroma (black arrows), and peripheral ductal and lobular elements (white arrow).
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Figure 3b. Radial scar in a 44-year-old woman. (a) Craniocaudal mammogram (magnification view) shows the typical stellate appearance of these lesions. (b) Low-power photomicrograph (original magnification, x25; hematoxylin-eosin [H-E] stain) demonstrates characteristic histologic features including a central sclerotic core (arrowhead), radiating bands of stroma (black arrows), and peripheral ductal and lobular elements (white arrow).
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Figure 4a. Radial scar without proliferative changes in a 42-year-old woman. (a) Mediolateral oblique mammogram (magnification view) demonstrates radiating spicules (arrowheads) and no central mass, findings that are consistent with radial scar. (b) Photograph of the pathologic specimen (H-E stain) shows radiating bands of connective tissue with entrapped cystic glandular components having an intact myoepithelial layer. (c) Low-power photomicrograph (original magnification, x25; H-E stain) reveals nonproliferative cystic glandular elements and dense collagen. (d) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates benign nonproliferative duct units and sclerotic bands.
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Figure 4b. Radial scar without proliferative changes in a 42-year-old woman. (a) Mediolateral oblique mammogram (magnification view) demonstrates radiating spicules (arrowheads) and no central mass, findings that are consistent with radial scar. (b) Photograph of the pathologic specimen (H-E stain) shows radiating bands of connective tissue with entrapped cystic glandular components having an intact myoepithelial layer. (c) Low-power photomicrograph (original magnification, x25; H-E stain) reveals nonproliferative cystic glandular elements and dense collagen. (d) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates benign nonproliferative duct units and sclerotic bands.
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Figure 4c. Radial scar without proliferative changes in a 42-year-old woman. (a) Mediolateral oblique mammogram (magnification view) demonstrates radiating spicules (arrowheads) and no central mass, findings that are consistent with radial scar. (b) Photograph of the pathologic specimen (H-E stain) shows radiating bands of connective tissue with entrapped cystic glandular components having an intact myoepithelial layer. (c) Low-power photomicrograph (original magnification, x25; H-E stain) reveals nonproliferative cystic glandular elements and dense collagen. (d) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates benign nonproliferative duct units and sclerotic bands.
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Figure 4d. Radial scar without proliferative changes in a 42-year-old woman. (a) Mediolateral oblique mammogram (magnification view) demonstrates radiating spicules (arrowheads) and no central mass, findings that are consistent with radial scar. (b) Photograph of the pathologic specimen (H-E stain) shows radiating bands of connective tissue with entrapped cystic glandular components having an intact myoepithelial layer. (c) Low-power photomicrograph (original magnification, x25; H-E stain) reveals nonproliferative cystic glandular elements and dense collagen. (d) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates benign nonproliferative duct units and sclerotic bands.
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As expected, we discovered cases of various atypical findings and ductal carcinoma in situ associated with radial scar (Fig 5). In addition, there were malignancies that mimicked the mammographic appearance of these entities (Figs 6–8). In some instances, findings at excisional biopsy were benign. The presence of radiolucent fat within a radial scar at mammography does not exclude malignancy: It may be impossible to differentiate the central radiolucent core of this entity from superimposed background fat.
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Figure 5a. Radial scar with a focus of ductal carcinoma in situ in a 71-year-old woman. (a-c) Standard craniocaudal (a), craniocaudal (magnification view) (b), and 90° mediolateral (c) mammograms demonstrate the varying appearances of these lesions on orthogonal views. (d) Photograph of the pathologic specimen (H-E stain) illustrates typical entrapped peripheral ductal and lobular elements and a central focus of ductal carcinoma in situ (arrow). (e) Intermediate power photomicrograph (original magnification, x100; H-E stain) displays clusters of intraductal neoplastic cells, a finding that is compatible with low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ.
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Figure 5b. Radial scar with a focus of ductal carcinoma in situ in a 71-year-old woman. (a-c) Standard craniocaudal (a), craniocaudal (magnification view) (b), and 90° mediolateral (c) mammograms demonstrate the varying appearances of these lesions on orthogonal views. (d) Photograph of the pathologic specimen (H-E stain) illustrates typical entrapped peripheral ductal and lobular elements and a central focus of ductal carcinoma in situ (arrow). (e) Intermediate power photomicrograph (original magnification, x100; H-E stain) displays clusters of intraductal neoplastic cells, a finding that is compatible with low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ.
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Figure 5c. Radial scar with a focus of ductal carcinoma in situ in a 71-year-old woman. (a-c) Standard craniocaudal (a), craniocaudal (magnification view) (b), and 90° mediolateral (c) mammograms demonstrate the varying appearances of these lesions on orthogonal views. (d) Photograph of the pathologic specimen (H-E stain) illustrates typical entrapped peripheral ductal and lobular elements and a central focus of ductal carcinoma in situ (arrow). (e) Intermediate power photomicrograph (original magnification, x100; H-E stain) displays clusters of intraductal neoplastic cells, a finding that is compatible with low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ.
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Figure 5d. Radial scar with a focus of ductal carcinoma in situ in a 71-year-old woman. (a-c) Standard craniocaudal (a), craniocaudal (magnification view) (b), and 90° mediolateral (c) mammograms demonstrate the varying appearances of these lesions on orthogonal views. (d) Photograph of the pathologic specimen (H-E stain) illustrates typical entrapped peripheral ductal and lobular elements and a central focus of ductal carcinoma in situ (arrow). (e) Intermediate power photomicrograph (original magnification, x100; H-E stain) displays clusters of intraductal neoplastic cells, a finding that is compatible with low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ.
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Figure 5e. Radial scar with a focus of ductal carcinoma in situ in a 71-year-old woman. (a-c) Standard craniocaudal (a), craniocaudal (magnification view) (b), and 90° mediolateral (c) mammograms demonstrate the varying appearances of these lesions on orthogonal views. (d) Photograph of the pathologic specimen (H-E stain) illustrates typical entrapped peripheral ductal and lobular elements and a central focus of ductal carcinoma in situ (arrow). (e) Intermediate power photomicrograph (original magnification, x100; H-E stain) displays clusters of intraductal neoplastic cells, a finding that is compatible with low-nuclear-grade cribriform and micropapillary ductal carcinoma in situ.
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Figure 6a. Tubular carcinoma in a 65-year-old woman. (a) Craniocaudal mammogram (magnification view) demonstrates the classic "black star" appearance of architectural distortion (arrows). (b) Low-power photomicrograph (original magnification, x25; H-E stain) depicts radiating bands of reactive stroma (arrows). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows irregularly distributed neoplastic ducts in a background of reactive stroma, a finding that is characteristic of tubular carcinoma.
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Figure 6b. Tubular carcinoma in a 65-year-old woman. (a) Craniocaudal mammogram (magnification view) demonstrates the classic "black star" appearance of architectural distortion (arrows). (b) Low-power photomicrograph (original magnification, x25; H-E stain) depicts radiating bands of reactive stroma (arrows). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows irregularly distributed neoplastic ducts in a background of reactive stroma, a finding that is characteristic of tubular carcinoma.
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Figure 6c. Tubular carcinoma in a 65-year-old woman. (a) Craniocaudal mammogram (magnification view) demonstrates the classic "black star" appearance of architectural distortion (arrows). (b) Low-power photomicrograph (original magnification, x25; H-E stain) depicts radiating bands of reactive stroma (arrows). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows irregularly distributed neoplastic ducts in a background of reactive stroma, a finding that is characteristic of tubular carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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Figures 7, 8. (7) Lobular carcinoma in a 55-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms (magnification view) reveal the typical radiolucent center of radial scar. It is often difficult to distinguish superimposed background fat from the central radiolucent core of these entities at mammography. (c) High-power photomicrograph (original magnification, x200; H-E stain) demonstrates infiltrating neoplastic cells in a single file pattern (arrows), a finding that is characteristic of lobular carcinoma. (8) Infiltrating ductal carcinoma in a 70-year-old woman. (a) Craniocaudal mammogram (magnification view) shows architectural distortion with no obvious central mass. (b) Radiograph of the excised pathologic specimen more clearly depicts a central mass (arrow). (c) High-power photomicrograph (original magnification, x200; H-E stain) shows islands of neoplastic cells in a background of fat and reactive stroma, a finding that is consistent with invasive ductal carcinoma.
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There is considerable debate about the clinical and prognostic significance of radial scars and the exact relationship between these entities and carcinoma. Some authors classify the former as benign lesions (11,12). Andersen and Gram (6) suggested that they have only a passive role in the development of in situ carcinoma. Wellings and Alpers (1) concluded that radial scars are simply markers for increased risk of carcinoma development.
The results of our study support the findings of Frouge et al (3), who found carcinoma in 50% of cases that demonstrated mammographic findings of radial scar. They recommended surgical excision for lesions with these imaging findings but cautioned against extensive surgery because all the carcinomas detected in their series had a good prognosis regardless of whether they were associated with radial scar. Sloane and Mayers (13) found various types of carcinoma in radial scars but did not encounter comedo-type ductal carcinoma in situ or grade 3 invasive ductal carcinoma. Still other investigators have hypothesized that radial scar is a form of early tubular carcinoma (14) or that tubular carcinoma originates in this entity (15). Tubular carcinomas that consist of more than 75% tubular elements have a more favorable prognosis than invasive ductal carcinoma not otherwise specified (16).
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CONCLUSIONS
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The results of our study support the use of excisional rather than core needle biopsy when radial scar is suspected at mammography. The entire lesion must be made available to the pathologist to allow accurate and confident diagnosis. The pathologic heterogeneity of this entity as well as various associated atypical and malignant conditions may lead to a false-negative benign diagnosis at core needle biopsy. In addition, there are malignancies that simulate the imaging appearance of radial scar. Finally, the treating physician and the patient should be made aware of the high prevalence of carcinoma in lesions that meet the mammographic criteria for radial scar. It is critical that the radiologist communicate the potential outcomes in such cases and the true meaning of the term radial scar to the other members of the management team and to the patient.
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Footnotes
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See the commentary by Greenberg.
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References
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Related Article
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Invited Commentary • Author's Response
- Julianne S. Greenberg and Dana H. Smetherman
RadioGraphics 1999 19: 36-37.
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Abstract
INTRODUCTION
