ORIGINAL RESEARCH

Malignancy Upgrade Rates of Radial Sclerosing Lesions at

Breast Cancer Screening
Pamela Yan, MD • Linda DeMello, MD • Grayson L. Baird, PhD • Ana P. Lourenco, MD
From the Department of Diagnostic Imaging, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. Received March 30,
2021; revision requested April 29; revision received September 21; accepted October 7. Address correspondence to A.P.L. (e-mail: [email protected]).
Authors declared no funding for this work.
Conflicts of interest are listed at the end of this article.

Radiology: Imaging Cancer 2021; 3(6):e210036 • https://doi.org/10.1148/rycan.2021210036 • Content codes:

Purpose: To determine the upgrade rate for biopsy-proven radial scars and radial sclerosing lesions (RS).

Materials and Methods: In this retrospective study, radiology and pathology databases from two tertiary breast centers were searched to
identify patients with biopsy-confirmed RS between March 1, 2012, and December 31, 2017, during which all mammography was
performed with digital breast tomosynthesis (DBT). Adjunct modalities such as MRI or US are performed at our centers to better
characterize lesions identified at DBT. Patient demographics, imaging, needle and excisional biopsies, and follow-up data were collect-
ed at the patient level. Clopper-Pearson interval estimate for upgrade was calculated for 95% confidence using PropCIs package with R
version 4.1.0 (R Foundation for Statistical Computing) (1).

Results: During the study period, a total of 155 885 DBT examinations were performed. From these examinations, 146 biopsy-proven
RS were identified in 142 women (median age, 58 years; age range, 26–87 years). A total of 80.1% (117 of 146) of all RS did not have
associated atypia or malignancy, and 19.9% (29 of 146) had associated atypia at initial biopsy. A total of 66.7% (78 of 117) of RS
without atypia or malignancy were surgically excised, 25.6% (30 of 117) were followed (median, 3 years; range, 1–7 years) with benign
findings on imaging, and 7.7% (nine of 117) were lost to follow-up. The rate of malignancy upgrade was 0.9% (one of 117 [95% CI:
0.02, 4.7]); one RS without concurrent atypia or malignancy demonstrated invasive carcinoma at surgical excision.

Conclusion: RS without atypia had a low upgrade rate.

© RSNA, 2021

R adial sclerosing lesions (RS) are uncommon, with a re-

ported incidence of 0.03%–0.8% of core-needle breast
biopsy results (2,3). After detection on imaging, diagnosis
of 0% (zero of 80), 0.5% (one of 219), and 1.0% (one
of 96). Most of these studies were prior to DBT or when
DBT was less commonly available. As more patients are
of RS is histologically confirmed, with histologic features imaged with DBT and more RS are identified, breast im-
frequently displaying a central fibroelastotic core with ra- agers need methods to assess optimal patient management
diating spokes of ducts and lobules (4). There is unifying options. Concerns of patient management raise the ques-
evidence that digital breast tomosynthesis (DBT) has im- tion of whether patients with RS without atypia may be
proved sensitivity for lesion detection and characterization better served with follow-up imaging rather than surgical
as compared with digital mammography (DM) (5–9) and excision. This decision is particularly relevant as more RS
has increased detection of RS (10,11). are discovered with DBT biopsy (11), and many patients
DBT has also demonstrated higher detection rates routinely undergo excision for RS without atypia (26).
of architectural distortions (AD) compared with DM We hypothesized that in the era of DBT, the rate of
(4,6,11–15). One of the common manifestations of RS malignant upgrade for RS without atypia would be low
is as AD, defined as spiculations radiating from a central enough to support imaging follow-up over surgical exci-
point without a central mass (16). In the era of DBT, a sion as the most optimal management practice. Given the
greater proportion of DBT-detected ADs are RS compared rarity of these lesions, the estimates provided here are in-
with those detected with DM (11,13,17), with one study tended to inform future power and meta-analyses.
reporting 33% of DBT-detected ADs being RS, versus
12% of DM-detected ADs being RS (13). The positive Materials and Methods
predictive value for malignancy in DBT-detected ADs is This was a Health Insurance Portability and Accountabil-
lower than that for those detected with DM (13,18), given ity Act–compliant retrospective study that was approved
the greater proportion of RS. by our institutional review board. The need for informed
Management of RS detected at core-needle biopsy re- consent was waived.
mains controversial. RS with associated atypia have higher
rates of malignant upgrade compared with RS without Study Sample
atypia (19–22) and are often excised. Multiple studies (23– We conducted a retrospective review of our radiology
25) suggest that RS found alone without associated atypia and pathology databases at two tertiary breast centers
rarely upgrade to malignancy, with respective upgrade rates to capture all instances of patients of any age with “ra-
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Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

Imaging and Biopsy Interpretation

Abbreviations
Imaging performed during the study period included screen-
AD = architectural distortions, BI-RADS = Breast Imaging Report-
ing and Data System, DBT = digital breast tomosynthesis, DCIS = ing and diagnostic DBT mammography (full-field digital
ductal carcinoma in situ, DM = digital mammography, RS = radial mammography and DBT, 2012–2014; DBT and synthesized
sclerosing lesion mammography, 2014–2017), US (diagnostic and screen-
Summary ing), and MRI (high-risk screening and extent of disease in
Radial sclerosing lesions without associated atypia detected at screen-
new cancer diagnoses). Imaging was interpreted by one of
ing had a low malignancy potential. 13 fellowship-trained board-certified breast radiologists with
1–25 years of experience (including A.P.L. and L.D.). Image-
Key Points guided biopsies were performed using the modality in which
n Only one radial sclerosing lesion (RS) without atypia (0.9%; one the lesion of interest was best visualized and was performed by
of 117 [95% CI: 0.02, 4.7]) was upgraded to an invasive carci- the same group of breast radiologists. Histopathologic find-
noma.
ings were interpreted by fellowship-trained board-certified
n All RS (100%; 30 of 30) without atypia followed with imaging
(median, 3 years; range, 1–7 years) rather than excision were be- pathologists, and histopathologic results for all lesions were
nign. collected from needle biopsy and surgical excisional biopsy
reports. The interpreting pathologist determined whether the
Keywords core-needle biopsy showed radial scar, complex sclerosing le-
Mammography, Breast
sion, atypia, or malignancy according to standard pathologic
standards applied in clinical practice. Radiologic-histopath-
dial scar,” “radial sclerosing lesion,” or “complex sclerosing ologic concordance and discordance were determined by the
lesion” identified at core-needle biopsy of the breast between radiologist performing the biopsy by assessing if histopatho-
March 1, 2012, and December 31, 2017. We included all logic findings were representative of the imaging findings.
patients who had histologically verified RS, radial scar, or At our institution, cases of RS are generally not presented in
complex sclerosing lesion, excluding sclerosing adenosis, multidisciplinary conferences. In the case of discordance, the
sclerosed papillomas, and incidental RS (for example, those radiologist and pathologist may confer personally.
completely excised and separate from the imaging target).
Pathology reports were reviewed, and lesions were separated Statistical Analysis
into two cohorts: those without associated malignancy or Data were analyzed to determine the rate of malignancy up-
atypia and those with associated atypia. Lesions with other grade upon surgical excision of RS. Given the rarity of these
associated nonatypia pathologic features were categorized as lesions, estimates are intended for subsequent meta and power
RS without associated atypia. Pathologic slides were not re- analyses and, as such, are provided as counts and percentages.
reviewed for this study. Clopper-Pearson interval estimate for upgrade was calculated
for 95% confidence using PropCIs package with R 4.1.0 (R
Image Acquisition Foundation for Statistical Computing) (1). Comparisons be-
DBT images were obtained with Selenia Dimensions units tween present study data and pooled results from the literature
(Hologic), US with iU22 (Philips Healthcare), and MRI were conducted using generalized linear modeling assuming
pre- and postcontrast enhancement with dedicated breast a binomial distribution with the GLIMMIX procedure with
coils at 1.5 T (Siemens Magnetom Symphony) or 3 T (Sie- SAS software version 9.4 (SAS Institute). Demographics are
mens Verio). provided at the patient level. Analyses were conducted by the
statistical author (G.L.B.).
Data Collection
The electronic medical record was accessed to identify the fol-
Results
lowing: (a) patient age, (b) initial imaging findings prompting
biopsy, (c) imaging modalities where findings were visible, (d) Demographics
Breast Imaging Reporting and Data System (BI-RADS) assess- A total of 155 885 screening DBT were performed during the
ment, (e) imaging modality used for biopsy, (f ) biopsy needle study period. A total of 142 patients with 146 biopsy-proven
gauge, (g) number of samples taken and pathologic results of RS were identified from a search of the pathology database.
needle biopsy, (h) results of excisional biopsy if performed, (i) One patient had three RS and two patients had two RS. All pa-
time interval to most recent available follow-up imaging, (j) tients were women with median age of 58 years (range, 26–87
follow-up imaging modalities, and (k) follow-up imaging find- years). Average predicted lifetime risk of breast cancer for pa-
ings through October 2020. tients for whom Gail score was obtainable (n = 73) was 12.0%
Data were entered into the Health Insurance Portability and (range, 2.3%–38.6%).
Accountability Act–compliant REDCap database (Vanderbilt
University) (27). Upgrade to malignancy was defined as discov- Manifestation on Imaging
ery of ductal carcinoma in situ (DCIS) or invasive carcinoma at Of our cohort, the majority (71.9%, 105 of 146) of RS were
the same site as RS upon surgical excision. found at screening DBT; 16.4% (24 of 146) were found at

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 Yan et al

ing or diagnostic DBT initially, though the diagnostic lesion

Table 1: Imaging and Biopsy Characteristics of Patients
Found to Have RS was better visualized with other modalities in the above cases
of US or MRI findings (Table 1).
Parameter Data
Initial imaging modality RS visualized Imaging Assessment
with A majority of the lesions (97.3%, 142 of 146) were catego-
Screening DBT 71.9 (105) rized as BI-RADS category 4 by the radiologist, indicating a
Diagnostic DBT 16.4 (24) suspicious abnormality where biopsy should be considered. A
US or MRI 11.6 (17) total of 0.7% (one of 146) of the radiographic lesions were
Initial imaging findings assessed as BI-RADS 3; 1.4% (two of 146) were assessed as
Mass at DBT 33.6 (49) BI-RADS 5, and 0.7% (one of 146) were assessed as BI-RADS
AD at DBT 27.4 (40) 6 (patient with newly diagnosed breast cancer who underwent
Calcifications at DBT 25.3 (37)
additional biopsy for indeterminate microcalcifications). This
lesion would have been better assessed as BI-RADS 4, as ad-
Asymmetry at DBT 2.7 (4)
ditional biopsy was recommended for a lesion distinct from the
Mass at US 3.4 (5)
known malignancy.
Enhancing mass at MRI 4.8 (7)
The radiologist who performed the biopsy recommended
Nonmass enhancement at MRI 2.7 (4) excision for 81.5% (119 of 146) of the detected RS. For 4.1%
Management recommendation following (six of 146) of the lesions, the radiologist recommended surgi-
biopsy when available cal consultation for consideration of excision versus imaging
Excision 81.5 (119) follow-up. For 11.6% (17 of 146) of the lesions, the radiolo-
Surgical consultation 4.1 (6) gist recommended imaging follow-up. One lesion (one of 146,
Imaging follow-up 11.6 (17) 0.7%) went directly to excision, as needle biopsy was not fea-
BI-RADS category at initial imaging sible. The radiologist recommendations were not available in
BI-RADS 3 0.7 (1) 2.0% (three of 146), and 2.7% (four of 146) were assessed as
BI-RADS 4 97.3 (142) discordant and recommended for excision, including one RS
BI-RADS 5 1.4 (2) with atypia (Table 1).
BI-RADS 6* 0.7 (1) A total of 79.5% (93 of 117) of the lesions without atypia
Biopsy needle gauge and modality at initial biopsy were recommended for excision and 0.9% (one
9-gauge vacuum-assisted DBT 50.7 (74) of 117) of these were upgraded at excision. This was assessed
as concordant following needle biopsy and was recommended
14-gauge spring-loaded US 24.7 (36)
for excision.
12-gauge vacuum-assisted US 15.8 (23)
9-gauge vacuum-assisted MRI 6.2 (9)
Biopsy Modalities
Surgical excisional biopsy 2.7 (4)
Details of image-guided biopsies, including needle type and
Median no. of biopsy samples
number of samples obtained, are shown in Table 1.
12-gauge vacuum-assisted US 3 (2–4)†
14-gauge spring-loaded US 5 (1–5)† Histopathologic Assessment
9-gauge vacuum-assisted MRI and 6 (5–12)† Of the 146 biopsy-proven RS lesions, 80.1% (117 of 146)
DBT
demonstrated radial scar without associated atypia or cancer
Note.—Unless otherwise indicated, data are percent of radial at the biopsy site and were classified as RS without atypia. The
sclerosing lesions (RS), with numbers in parentheses (n = 146). remaining 19.9% (29 of 146) had concurrent atypia at the bi-
BI-RADS = Breast Imaging Reporting and Data System, DBT = opsy site (Fig 1).
digital breast tomosynthesis.
*This lesion would have been better assessed as BI-RADS 4, as Of the 29 RS with atypia, 14% (four of 29) were upgraded to
additional biopsy was recommended for a lesion distinct from DCIS or carcinoma at the time of surgical excision. The remain-
the known malignancy. ing 86% (25 of 29) had no upgrade at surgical excision. Of the RS
†
Data are median with range in parentheses. with atypia at initial biopsy, 41% (12 of 29) had atypia at excision:
21% (six of 29) had lobular neoplasia, and 48% (14 of 29) had
atypical ductal hyperplasia, with some having more than one type
diagnostic DBT. Of the 146 biopsy-proven RS, 33.6% (49 of of atypia at the biopsy site. Specific pathologic features at needle
146) manifested on DBT images as a mass, 27.4% (40 of 146) biopsy and surgical excision of the four RS lesions with atypia that
as an AD, 25.3% (37 of 146) as calcifications, and 2.7% (four were upgraded at surgical excision are presented in Table 2.
of 146) as asymmetry. A total of 3.4% (five of 146) were best Of the 117 RS lesions without atypia, 66.7% (78 of 117) were
visualized at US as a mass; 4.8% (seven of 146) were best visu- surgically excised. The remaining 33.3% (39 of 117) were either
alized as an enhancing mass on MR images and 2.7% (four of lost to follow-up (7.7%, nine of 117) or showed benign findings
146) as nonmass enhancement. All patients underwent screen- at follow-up imaging (25.6%, 30 of 117), with median follow-up

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Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

Figure 1: Flow diagram of cases of radial sclerosing lesions (RS) and radial scars with and without atypia at core
biopsy and results of excision or imaging follow-up. AD = architectural distortions, ADH = atypical ductal hyperplasia, CA =
carcinoma, DBT = digital breast tomosynthesis, DCIS = ductal carcinoma in situ.

Table 2: Biopsy and Histopathologic Findings in Patients with RS with Atypia at Initial Biopsy and Upgraded to Malig-
nancy at Surgical Excision

Parameter Patient 1 Patient 2 Patient 3 Patient 4

Clinical history Screening Screening Biopsy-proven malig- Biopsy-proven malig-
nancy in right breast, nancy in right breast,
11-o’clock position 10-o’clock position
Imaging findings Calcifications at DBT, Architectural distortion 14-mm focal area of Calcifications at DBT, right
right breast, 10-o’clock at DBT, 9-mm mass at enhancement at MRI, breast, 8-o’clock position
position US, left breast, 2-o’clock 8-mm mass at US, right
position breast, 4-o’clock position
Biopsy modality Stereotactic 9-gauge US 14-gauge spring-load- US 14-gauge spring-loaded Stereotactic 9-gauge
vacuum-assisted biopsy ed biopsy biopsy vacuum-assisted biopsy
No. of biopsy 7 4 5 6
samples
Initial needle biopsy At least ADH, radial scar, Complex sclerosing lesion RS with atypia and micro- ADH and flat epithelial
pathology report calcifications present with columnar cell calcifications atypia involving a com-
associated with ADH, alteration, hyperplasia, plex sclerosing lesion
and benign ducts and focal atypia, and focal
stroma microcalcifications
Surgical excisional DCIS, pTis pNx cMx, Invasive lobular carcino- DCIS with cancerization Focal DCIS with RS
pathology report solid and cribriform ma, ER1, PR1, Her2− of lobules, solid and
type, nuclear grade 2–3 cribriform type, nuclear
of 3, with focal necro- grade 1–2 of 3
sis and calcification,
no evidence of invasive
carcinoma
Note.—ADH = atypical ductal hyperplasia, DBT = digital breast tomosynthesis, DCIS = ductal carcinoma in situ, ER1 = estrogen recep-
tor–positive, Her2− = human epidermal growth factor receptor 2–negative, PR1 = progesterone receptor–positive, RS = radial sclerosing
lesion.

of 3 years (range, 1–7 years). One hundred percent (30 of 30) of at US (Fig 2D, 2E). Mammogram obtained after biopsy clip
RS lesions without atypia that were followed with imaging alone placement shows the clip in the abnormality (Fig 2F, 2G), but
were benign. the US biopsy image (Fig 2E) shows the needle slightly superficial
One RS without atypia at biopsy was upgraded to invasive to the mass. This patient had a history of contralateral breast can-
carcinoma (0.9%, one of 117 [95% CI: 0.02, 4.7]). This lesion cer treated with segmental excision and radiation therapy 7 years
presented as AD at DBT (Fig 2A–2C) with a corresponding mass prior. At excisional biopsy, a 7-mm estrogen receptor–positive,

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 Yan et al

Figure 2: Im-
ages in a 66-year-
old woman with
previous history of
left breast cancer
treated with seg-
mental excision and
radiation therapy 7
years prior. Digital
breast tomosynthesis
(DBT) helped detect
radial sclerosing
lesion (RS) without
atypia in the con-
tralateral (right)
breast, which was
upgraded to inva-
sive carcinoma after
surgical excision. (A) Craniocaudal (CC) digital mammogram and (B) mediolateral oblique (MLO) digital mammogram as well as (C) MLO DBT views. Architectural dis-
tortion with possible associated mass in the upper right breast posteriorly was optimally observed on DBT MLO view (circle). (D, E) Sagittal and biopsy US images show a
subtle 7-mm hypoechoic mass (arrows) corresponding to the DBT finding. (F, G) Postbiopsy mediolateral and laterally exaggerated CC digital mammograms demonstrate
clip placement within the area of architectural distortion. Core biopsy returned radial scar, which was assessed as concordant. Surgical excision was recommended. Final
surgical excisional pathologic analysis demonstrated a 7-mm estrogen receptor–positive, progesterone receptor–positive, human epidermal growth factor receptor 2–neg-
ative, invasive tubular carcinoma Nottingham grade I of III with no lymphovascular invasion, which was identified adjacent to, but distinct from, the biopsy needle track.

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Malignancy Upgrade Rates of Radial Sclerosing Lesions at Breast Cancer Screening

progesterone receptor–positive, human epidermal growth fac- the majority of RS were detected with DBT, and the majority of
tor receptor 2–negative, invasive tubular carcinoma Nottingham biopsies were obtained with DBT guidance. This is not surpris-
grade I of III with no lymphovascular invasion was identified adja- ing, as DBT has been shown to help detect more AD and RS
cent to, but distinct from, the biopsy needle track. Sampling error (4,6,11–13).
likely contributed to this upgrade. As Cohen et al postulated, biopsy sampling error may con-
tribute to radiologic-histopathologic discordance and to false-
Discussion negative findings (31,32,36). Our single upgraded RS without
Conventional two-dimensional mammography has been a stal- atypia was 7 mm in size and had three samples taken with a
wart of breast radiology practice. With the advent of DBT, this 12-gauge needle. Excisional histopathologic analysis demon-
new technology is now the predominant form of screening in strated the biopsy needle tracked adjacent to, but not involving,
41.8% of hospital referral regions in the United States and has the invasive carcinoma. In addition, US images from the bi-
improved the sensitivity of screening mammography and our opsy show the needle was likely superficial to the targeted mass,
ability to characterize lesions (5–9,28). As widespread clinical thus sampling error likely contributed to this upgrade. While
use of DBT has identified more RS (4,6,11–13), appropriate some studies have shown that taking more than 12 samples at
management of newly detected RS remains unclear. The pur- biopsy (19,37) reduces the likelihood of missed associated car-
pose of this study was to determine the rate of upgrade to ma- cinoma, AD poses a challenge with regard to sampling error, as
lignancy in RS without atypia and with atypia during a study the spiculations and distortion can extend over a fairly substan-
period when all mammography was performed with DBT. tial distance. Another study demonstrated that a majority of RS
We found that the majority (80.1%, 117 of 146) of RS were upgrades had a needle track that missed the nearby malignancy
without concurrent atypia or malignancy and that the rate of by 6 mm or less (37). The single upgraded lesion in this study
malignancy upgrade among those lesions was minimal (0.9%, likely falls into this category. Precise needle targeting is critical to
one of 117). In contrast, the rate of upgrade was 14% (four decreasing false-negative biopsy results.
of 29) for RS with associated atypia. The proportion of RS In our study, 30 RS lesions without atypia did not undergo
without atypia or malignancy that we found (80.1%) is com- surgical excision; all had stable, benign imaging findings for a
parable to other studies (reported at 75% [91 of 157], 81% median duration of 3 years following biopsy, strongly supporting
[77 of 95], and 87% [76 of 88]) (or 80.1% [95% CI: 62.3, benignity. Another study demonstrating similar results is Kraft et
90.8] vs pooled: 71.8% [95% CI: 60.2, 81.0]; P = .19) (29–31, al, where 50 of 50 patients undergoing active surveillance instead
respectively). The proportion of RS with associated atypia we of excision did not progress on follow-up imaging (35). This is
found (19.9%, 29 of 146) was also comparable to other studies a larger cohort than in previous studies followed with imaging
reporting 25% (66 of 157), 19% (18 of 95), and 13% (12 of alone rather than surgical excision (23,33, 34, 38). For example,
88) (or 19.9% [95% CI: 9.2, 37.7] vs pooled: 28.2% [95% in Martaindale et al, 13 lesions were followed successfully for a
CI: 19.0, 39.8]; P = .19) (29–31, respectively). median of 18 months with benign findings (33). The major-
The upgrade rate for RS associated with atypia in this study ity (66.7%, 78 of 117) of RS without atypia in our study were
was 14%, which is within the range of upgrade rates reported surgically excised. Replacing surgical excisions with follow-up
previously (upgrade rate of 35% [38 of 108] for RS with atypical imaging could have positive mental, emotional, and cosmetic
ductal hyperplasia [32] and upgrade rates of 17% [one of six] outcomes for patients, with minimal risk of a missed cancer. No-
and 10% for RS with atypia [five of 49] [33,34]). These upgrade tably, we had nine patients who were lost to follow-up. This em-
rates support surgical excision as an optimal management deci- phasizes the need to recommend follow-up with imaging care-
sion for patients with RS with atypia at biopsy. fully; establishing benignity in vulnerable populations who may
Our very low upgrade rate of 0.9% (one of 117) for RS with- have sporadic health care access necessitates a shared discussion
out atypia at biopsy strongly supports imaging follow-up over of the feasibility of imaging follow-up. Increasing data regarding
surgical excision as the best treatment for these patients. Similar the minimal upgrade rates of RS without atypia in the DBT era
upgrade rates have been reported in other studies (0% [zero of may help inform management recommendations, potentially al-
92], 0.9% [one of 107], 1.9% [two of 105] 1% [one of 97]) for lowing more lesions to safely be followed with imaging rather
RS without atypia or malignancy at biopsy (26,32,33,35, respec- than undergoing surgical excision.
tively). In one study of DBT-biopsied RS by Martaindale et al, a This study was limited in its ability to recommend manage-
similar upgrade rate of 2.8% (one of 36) was reported for cases ment practice given the small sample size. These are inherent
without atypia at biopsy (33). Interestingly, Rakha et al demon- limitations when studying an uncommon pathologic state at a
strated that the upgrade rate for RS and concurrent atypical duc- small number of centers, though it does examine a larger cohort
tal hyperplasia was similar to the upgrade rate of atypical ductal than some previous studies (33,35,39). In addition, nine patients
hyperplasia alone (32), supporting the hypothesis that atypical were lost to follow-up; the upgrade rate could thus potentially be
ductal hyperplasia is likely the main contributor to malignant higher than the one reported. The radiologists interpreting imag-
potential. ing and performing needle biopsies were all fellowship-trained
An earlier study from our center (23) identified 100 RS with- breast radiologists; thus, the results may not generalize to a gen-
out atypia before the widespread use of DBT; 0% (zero of 100) eral radiology practice. Additionally, we did not consider how
of these were upgraded to malignancy, though only 41 under- other factors, such as the presence of multiple radial scars, dis-
went surgical excisional biopsy. In contrast, in this current study, tantly located concurrent cancer, or the unique breast cancer risk

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 Yan et al

of the individual, may affect outcomes. With the small numbers 16. American College of Radiology. ACR BI-RADS Atlas: Breast Imaging
Reporting and Data System. Reston, Va: American College of Radiology,
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News editorial board member. G.L.B. No relevant relationships. A.P.L. No relevant 24. Leong RY, Kohli MK, Zeizafoun N, Liang A, Tartter PI. Radial scar at
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