AJR 2000; 174:1075-1078
© American Roentgen Ray Society
Role of Sonography in Evaluation of Radial Scars of the Breast
Michael A. Cohen1 and
Steven J. Sferlazza
1
Both authors: Memorial Sloan-Kettering Guttman Diagnostic Center, 12th Fl., 55
Fifth Ave., New York, NY 10003.
Received June 30, 1999;
accepted after revision September 8, 1999.
Address correspondence to M. A. Cohen.
Abstract
OBJECTIVE. We investigated the usefulness of sonography in revealing
radial scars suspected on mammography.
CONCLUSION. Many radial scars are visible on sonography and, when
visible, may present features virtually identical to those of carcinoma of the
breast. Findings indicative of a radial scar are often more conspicuous on
sonography than on mammography; thus, sonography may have a definitive role
when evaluating subtle findings suggestive of a radial scar or when features
of a radial scar are evident on only one mammographic view and cannot be
localized with certainty.
Introduction
Though the mammographic features of a radial scar have been well described
in the literature
[1,2,3,4,5],
detecting a radial scar may be difficult. Because breast lesion features may
be indistinguishable from breast carcinoma, a biopsy is necessary. Less often,
tubular carcinoma or ductal carcinoma in situ may coexist with radial scars,
providing more reason to excise lesions with imaging characteristics of a
radial scar to unmask the cohabiting carcinoma. Additionally, it has been
reported that the risk of developing breast cancer is almost twice as high for
women with radial scars than for women without radial scars
[6]. These lesions rarely
present with clinical findings and may be extraordinarily subtle on
mammography. We have found sonography quite helpful in evaluating subtle and
even equivocal mammographic findings of a radial scar by clearly confirming
the presence and location of a suspicious lesion, thus leading to a firm
recommendation for biopsy. We will show the value of sonography in examining
radial scars and describe the sonographic features of these lesions.
Materials and Methods
The pathology database for all lesions reported on the Breast Imaging
Reporting and Data System (BI-RADS)
[7] as final assessment
category 4 (suspicious abnormality) or 5 (highly suggestive of malignancy)
during the period of January 1997 through December 1998 was reviewed for
lesions surgically determined to represent radial scars. The pathology
database lists the histologic diagnosis for the specific lesion with the
suspicious imaging features on which the biopsy recommendation was based.
Twelve radial scars in 12 women were identified in the pathology database and
form the basis for this report. In all 12 women, both mammography (Lorad MIII
and IV; Lorad, Danbury, CT) and sonography (Acoustic Imaging 5200S with
7.5-MHz transducer; Acoustic Imaging Technologies, Phoenix, AZ) were
performed. These images were retrospectively reviewed and the salient features
were tabulated. The two imaging techniques were also retrospectively judged by
the authors as equal in lesion conspicuity, mammographic lesion more
conspicuous than sonographic lesion, or sonographic lesion more conspicuous
than mammographic lesion.
Results
Twelve radial scars were diagnosed in 12 women over a 2-year interval that
included a total of 38,227 screening mammograms. Five radial scars occurred in
the right breast, seven in the left. Age at diagnosis ranged from 47 to 80
years (mean, 61 years). None of the radial scars was palpable or otherwise
clinically apparent. At histology, none of the radial scars was associated
with a malignant lesion. All lesions were first revealed on routine screening
mammography as a region of stromal distortion. These patients were recalled
for further diagnostic evaluation. Additional views confirmed the presence of
focal stromal distortion manifested as an array of radially oriented thin
linear strands. Centrally, no definite focal soft-tissue mass was identified
in nine of the 12 patients (Fig.
1A,1B,1C,1D,1E,1F).
In the other three patients, the radial array converged on a soft-tissue
density masslike opacity (Fig.
2A,2B,2C,2D,2E).
The lesions ranged from 10 to 40 mm (mean, 22 mm), including the spicules. No
calcifications were evident in any of the lesions. One lesion was discovered
in BI-RADS [7] breast
composition 1 breasts (fatty), five lesions in BI-RADS category 2 breasts
(scattered fibroglandular densities), four lesions in BI-RADS category 3
breasts (heterogeneously dense), and two lesions in BI-RADS category 4 breasts
(extremely dense). Of the 12 mammographically identified radial scars, eight
were revealed sonographically on diagnostic workup. When the radial scar was
identified on sonography, the lesion appeared as an irregularly shaped
hypoechoic mass with ill-defined borders and diminished posterior acoustic
transmission (shadowing). Central mass echo texture was homogeneous in six
patients and heterogeneous in two patients. The sonographically defined masses
(range, 5-15 mm; mean, 7 mm) were smaller than the mammographic masses in all
patients. In four patients, no correlation between the sonographic and the
mammographic lesion was discernible.
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Fig. 1A. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Screening mammogram, mediolateral oblique
view, shows subtle stromal distortion without central mass
(arrow).
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Fig. 1B. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Screening mammogram, craniocaudal view,
shows corresponding, though less conspicuous, stromal distortion without
central mass (arrow).
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Fig. 1C. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Diagnostic mammogram, mediolateral oblique
coned magnification view, confirms stromal distortion without central mass.
Note predominance of radiating black stripes, "black star"
configuration, suggestive of radial scar (arrows).
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Fig. 1D. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Diagnostic mammogram, craniocaudal coned
magnification view, confirms corresponding region of ill-defined stromal
distortion without discrete central mass (arrows).
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Fig. 1E. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Sagittal (E) and transverse
(F) sonograms confirm the presence of focal hypoechoic irregular mass
with ill-defined borders and posterior acoustic shadowing
(arrows).
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Fig. 1F. —69-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Sagittal (E) and transverse
(F) sonograms confirm the presence of focal hypoechoic irregular mass
with ill-defined borders and posterior acoustic shadowing
(arrows).
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Fig. 2A. —80-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Screening mammograms, mediolateral oblique
(A) and craniocaudal (B) views, show region of stromal
distortion radiating from vague zone of intermixed fat and soft tissue
(arrows).
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Fig. 2B. —80-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Screening mammograms, mediolateral oblique
(A) and craniocaudal (B) views, show region of stromal
distortion radiating from vague zone of intermixed fat and soft tissue
(arrows).
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Fig. 2C. —80-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Diagnostic mammograms, coned magnification
mediolateral oblique (C) and craniocaudal (D) views, reveal long
slender spicules radiating from lowdensity, poorly-defined fat and soft-tissue
masslike opacity (arrows), suggesting presence of radial scar.
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Fig. 2D. —80-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Diagnostic mammograms, coned magnification
mediolateral oblique (C) and craniocaudal (D) views, reveal long
slender spicules radiating from low-density, poorly-defined fat and
soft-tissue masslike opacity (arrows), suggesting presence of radial
scar.
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Fig. 2E. —80-year-old asymptomatic woman who underwent screening mammography.
Radial scar diagnosed at pathology. Transverse sonogram reveals hypoechoic
irregular mass with ill-defined borders and posterior acoustic shadowing
(arrow).
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No identifiable mammographic features were found to predict whether the
radial scar would be visible on sonography. No significant mammographic
differences in breast composition, lesion size, lesion location, or imaging
features were noted between radial scars viewed sonographically and those not
seen on sonography.
In retrospective review of both the mammographic images and the
corresponding sonographic images of the eight lesions visible on both, the
radial scar was equally conspicuous on both techniques in two patients, and
more conspicuous on sonography than on mammography in six patients. In no
patient was the radial scar more conspicuous on mammography than on
sonography.
Discussion
Although most radial scars are detected during histologic examination of
breast tissue for other reasons, the increasing frequency of screening
mammography has led to the discovery of an increasing number of these lesions
on imaging. The mammographic features of a radial scar have been thoroughly
described and are best summarized by Tabar and Dean
[8] as a spiculated mass with
the following characteristics: variable appearance from one projection to
another, the absence of a solid central tumor mass commensurate in size to the
length of the spicules, the presence of long slender spicules that may
aggregate centrally creating a "sheath of wheat" appearance, the
presence of radiolucent linear structures paralleling the spicules that
represent entrapped fat and occasionally dominate the overall appearance
creating a "black star" effect, the absence of overlying skin
thickening or retraction, and the striking differences between the distinct
mammographic appearance and the complete or near complete absence of a
palpable lesion irrespective of size.
Despite familiarity with these mammographic features, the mammographer
frequently finds subtle manifestations of a radial scar, typically faint
regions of stromal distortion with only minimal convergence of a few spicules
toward a vague central focal point. The absence of central mass density and
the variability on orthogonal views further undermine the conspicuity of the
lesion. Unlike invasive lobular carcinoma, the physical examination is of
little, if any, value in confirming the presence of a true lesion. It is in
this context, subtle distortion, that we have found sonography quite helpful
both in terms of substantiating the existence of a suspicious lesion and in
confirming its precise location in the breast for future biopsy.
In the literature, what little is written on the sonographic diagnosis and
specific sonographic features of radial scars conflicts. Monypenny et al.
[9] stated that "radial
scars are usually invisible or have a non-specific appearance." On the
other hand, Finlay et al. [10]
successfully identified 21 radial scars using sonography and reported that no
sonographically specific feature distinguished radial scars from breast
cancer. Kopans [11] described
one radial scar as "hypoechoic, poorly defined tissue," but
further stated that sonography plays no role in the evaluation of radial scars
because the lesion is suspicious on mammography and thus requires biopsy. Our
data, though limited in numbers, indicate that radial scars are frequently
visible on sonography. On sonography, we were able to identify eight of the 12
radial scars that were diagnosed at this center over a 2-year period. In six
of the eight sonographically apparent radial scars, the sonographic appearance
of the lesion was judged to be more conspicuous than the mammographic
appearance. Unlike Kopans, we have found sonography of radial scars quite
helpful when the mammographic features are subtle and when the lesion is seen
with certainty on one view but vaguely, or not at all, on the other. The
sonographic features of all eight radial scars were remarkably similar:
irregular hypoechoic masses with ill-defined borders and diminished posterior
sound transmission. Two lesions revealed heterogeneous internal echo texture;
the other six were homogeneous. As in the study by Finlay et al., these
lesions were virtually identical to breast cancer in sonographic appearance.
We were unable to define any feature of a radial scar in our study that would
explain why most radial scars are visible and others are not. The underlying
histology of a radial scar, that of a central fibroelastic core with
surrounding proliferative and cystic changes, suggests a lesion of multiple
juxtaposed irregular interfaces of varying acoustic impedance that should
theoretically be amenable to sonographic detection. One hypothesis to explain
the variable sonographic detectability is the propensity of the lesion to grow
in a uniplanar platelike fashion that, if interrogated in a plane parallel
with the plane of the lesion, might produce little tissue area to deflect
sound, similar to imaging a coin on edge. Pathologists are occasionally
confronted with similar difficulty detecting radial scars histologically, if
the plane of section of the breast specimen is not coincident with that of the
lesion.
In conclusion, we have found that radial scars are often readily visualized
on sonography as hypoechoic irregular masses with posterior shadowing
virtually identical to the typical appearance of breast cancer. Furthermore,
the sonographic conspicuity of radial scars is often greater than the
mammographic conspicuity. The use of sonography to better define or confirm
the presence of a radial scar may be helpful in a clinical setting. Finally,
with respect to clinical management, most pathologists prefer excision of the
entire radial scar for accurate diagnosis. This reduces the possibility of the
false-positive diagnosis of tubular carcinoma, which may closely resemble a
radial scar (particularly on core biopsy), and permits complete examination of
the radial scar for associated small carcinomas. For this reason, open
surgical biopsy as opposed to imaging-guided biopsy is recommended if a lesion
presents mammographic characteristics of radial scar, despite sonographic
features that may strongly suggest carcinoma
[12].
Acknowledgments
We thank Rosa Delgado for her editorial assistance in the preparation of
this manuscript.
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Abstract
Introduction
