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Management for these lesions (surgical excision vs surveillance with radiological follow-up) remains controversial. Current guidelines increasingly favor surveillance if the lesion is small and radiological findings are completely removed by CNB or VAB [5]. |
According to AGO (German Gynecological Oncology Group) guidelines, when FEA is found at CNB or VAB, surgery can be avoided in the following situations: small lesion (< 2 TDLU involved at VAB) and/or partial or complete resolution at imaging [14]. On the contrary, surgical intervention is mandatory if the lesion is dete... |
## Radial scar and complex sclerosing lesion |
Radial scar (RS) is a breast lesion that may mimic invasive carcinoma because of its stellate configuration. RS is a focus smaller than 10 mm while complex sclerosing lesion (CSL) refers to a lesion which is larger than 10 mm and which has more complex features [14, 18, 78]. RS and CSL are classically non-palpable. [79... |
### Histopathology |
RS and CSL are characterized by a central fibroelastic core, which is surrounded by elastic fibers and which contain one to several ducts showing obliterated mastopathy (Fig. 5a). In addition, other ducts converge into the scar-like area in a stellate fashion. The epithelium lining the latter ducts may show a great var... |
### Prognosis |
RS and CSL are proliferative lesions which are frequently associated with other high-risk lesions and proliferative lesions such as atypia, and which may themselves contribute to the high frequency of associated cancers and to the upgrade rate to malignancy at excision. The prognosis of RS/CSL depends on the presence o... |
### Diagnosis |
The mammographic appearance of a RS/CSL typically consists of a radiolucent star-shaped lesion, which can be confused with a form of presentation of invasive carcinoma. Over the years, authors have reported certain findings that may be helpful in detecting RS/CSL at mammography, including the presence of radiolucent li... |
Nowadays, the use of recently developed digital breast tomosynthesis techniques has gained momentum, due to their more accurate visualization, characterization, and identification of architectural distortion [88–91]. Architectural distortion on diagnostic digital breast tomosynthesis has been reported to demonstrate ma... |
With the increasing use of ultrasound in both screening and diagnostic settings, an increasing number of mammographically occult RS/CSLs have been detected at ultrasound and diagnosed at subsequent ultrasound-guided CNB, ranging from approximately 15.7 to 39% among radial scars without atypia diagnosed at percutaneous ... |
The MRI appearance of RS/CSL is similarly variable. In Ha et al.’s study involving 13 radial scars that were imaged with MRI, six lesions were not detected, six appeared as a mass (three with irregular margins, four with a homogenous enhancement pattern, and five with a Type 3 enhancement kinetic curve), and one appear... |
### Management |
RS/CSLs are only rarely associated with atypia or DCIS. Therefore, RS lesions are most often benign lesions, and recent studies with careful radiological correlation have indicated that open surgical excision may not be necessary for small lesions and complete removal of the imaging abnormality. The current recommendat... |
## Papillary lesions |
Papillary lesions include a large number of rare lesions, accounting for approximately 3% of all breast malignancies [59]. They are seen most frequently in women aged 30–50 years old; by contrast, they are rarely reported in adolescents [18]. Papillary lesions may be classified as solitary intraductal papillomas, multi... |
### Histopathology |
Papillary lesions are composed of papillary fronds which are attached to the inner mammary ductal wall through a fibrovascular core and which extend into the lumen of the duct (Fig. 5b). Ductal epithelial and myoepithelial cells line the fibrovascular core, and it is these epithelial cells that can undergo degrees of a... |
Usually, papillary lesions can be divided according to their localization into two main groups: central (generally isolated), i.e., arising from the ducts of the sub-areolar region sparing TDLU; and peripheral (generally multiple), i.e., originating from TDLU following the involvement of galactophorous ducts [99]. |
### Prognosis |
The risk of an invasive cancer onset is two times that of the normal population for the central form and three times for the peripheral form, with a higher risk of invasive cancer onset of up to 7.5% in the case of papilloma with atypia [18]. The diagnosis of multiple peripheral papillomas (so-called “papillomatosis”) ... |
It is important to note that the upgrade rates for papillary lesions vary widely in the literature and may be as low as 3.1% for solitary papillomas [100]. Several studies have attempted to identify which patients among those with papillary lesions are suitable for surgery, focusing on clinical, radiological, and histo... |
### Diagnosis |
Papillomas can be asymptomatic and detected at routine breast screening. However, when symptomatic, they can be present as a palpable mass near the nipple or with bloody nipple discharge, in up to 20–50% of cases, due to pedicle torsion [34, 91]. Mammography is limited with poor sensitivity and specificity; when visibl... |
Breast ultrasound is of great value in the diagnosis of papillomas, whether conventional ultrasound, Doppler ultrasound, or elastography [112]. Ultrasound may demonstrate a solid, round mass; a mass with well-defined borders; an intra-cystic mass; or a hypo-echoic, well-defined mass in a dilated duct. The fibrovascular... |
MRI is useful for determining the extent of disease in cases when a diagnosis of papilloma has already been established. MRI allows a comprehensive assessment including the identification of connections with the ductal system and a more accurate estimation of disease extent in cases of malignant papillary lesions. The ... |
### Management |
Certain clinical and imaging factors including patient age, lesion multiplicity, and peripheral location are associated with increased breast cancer risk. Overall, management depends on a number of factors, including age at diagnosis, lesion type, and presence of atypia. As previously mentioned, it is well established ... |
## Bland-looking spindle cell lesions |
Bland-looking spindle cell lesions encompass a heterogenous group of tumor-like and tumor entities, ranging from benign reactive to low-grade malignant neoplasms with metastatic potential [116]. The more common spindle cell lesions encountered in the breast are spindle cell metaplastic carcinoma, which is a malignant l... |
## Phyllodes tumor |
Phyllodes tumor of the breast is a rare tumor that accounts for fewer than 1% of all breast tumors and 2–3% of fibroepithelial neoplasms [18, 118]. Although it is often characterized by a large size and/or rapid growth, it can exhibit a slow-growth pattern [97]. Commonly, this tumor occurs in women aged 40–51 years, al... |
### Histopathology |
Phyllodes tumors are rare breast fibroepithelial lesions and are similar to fibroadenomas and hamartomas, and they can range from benign to borderline or clearly malignant forms from the histological point of view (Fig. 5c). In some cases, the distinction between the typical fibroadenoma and phyllodes tumor can be chal... |
Therefore, WHO recommends the diagnosis of fibroepithelial tumors (BI-RADS 3 category) for unclear cases. Briefly, both benign and borderline phyllodes tumors are considered B3 lesions of the breast, histological classification, whereas malignant Phyllodes tumors are included into the B5b category [18]. B3 lesions, esp... |
### Prognosis |
The majority of phyllodes tumors have a benign behavior, with a risk of recurrence of approximately 10–20% for benign lesions, and up to 30% for borderline or malignant lesions. Metastatic capacity depends on histology, with 15–20% for malignant phyllodes tumors [5, 120, 121]. Several studies also confirmed that involv... |
### Diagnosis |
The typical appearance of a phyllodes tumor is a unilateral mass that is frequently symptomatic (palpable) and mobile (not fixed to deep tissues); as a large palpable tumor, it stretches the skin with distension of superficial vein, with a size that ranges from 2 to 5 cm [18, 124]. Imaging features of phyllodes tumors ... |
At mammography, phyllodes tumors appear as a big ovoid high-opacity mass with irregular edges and usually lobulated [125]; coarse calcifications can be detected only rarely due to their fast growth, whereas it is possible to find fat content as a lucent halo of the margins. Therefore, digital breast tomosynthesis can b... |
Ultrasound findings of phyllodes are variable. Several reviews report that these lesions can have either circumscribed as well as non-circumscribed borders [125, 126]; the most common characteristics are mildly hypoechoic internal echoes, a heterogeneous internal echo pattern, and a posterior acoustic shadow [126, 127]... |
There is lack of data regarding the assessment of phyllodes using MRI. Several authors focused on identifying signal features that may predict benignity or malignancy. Farria et al. reported that rapid enhancement after gadolinium injection is associated with benign phyllodes tumor [129]; in addition, Kinoshita et al. ... |
### Management |
Available data suggest that the most common management for phyllodes tumor is surgical excision [5, 132]. The possibility of phyllodes underestimation diagnosed at CNB is approximately 20%, whereas it is lower at 8% when diagnosed at VAB [133]. Based on the current evidence, the second International Consensus Conferenc... |
## Conclusion |
Diagnosis of high-risk lesions occurs frequently and incidentally at percutaneous biopsy, following suspicious imaging findings such as distortion, a group of microcalcifications, or even a mass. Traditionally, high-risk lesions are managed with surgical excision because of their low but latent potential of upgrade to ... |
## Acknowledgements |
Joanne Chin, MFA, ELS, provided assistance with manuscript editing. |
## Abbreviations |
## Authors' contributions |
FC, GC, DA, CS, and EVR performed the literature review and contributed to the writing of the manuscript. GA, MGM, KP, and MAM revised and finalized the manuscript. MAM, DA, and KP were involved in creating the concept of the manuscript. All authors read and approved the final manuscript. |
## Funding |
KPD was partially supported by the NIH/NCI Cancer Center Support Grant P30 CA008748. |
## Availability of data and material |
Not applicable. |
## Ethics approval and consent to participate |
Not applicable. |
## Consent for publication |
Not applicable. |
## Competing interests |
KPD received payment for activities not related to the present article including lectures including service on speakers bureaus and for travel/accommodation/meeting expenses unrelated to activities listed from the European Society of Breast Imaging (MRI educational course, annual scientific meeting). KPD is currently o... |
## Footnotes |
## References |
## Associated Data |
### Data Availability Statement |
Not applicable. |
3561117ecf186d48f66f5d48747387a04158f739b7a13765c3d018434f9bc658 pmc8155169.txt |
PMCID: PMC8833401 |
TITLE: Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions |
LICENSE: Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). |
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