South Australian Pathology, Royal Adelaide Hospital, Adelaide, SA, Australia.
BreastScreen South Australia, Flinders Street, Adelaide, SA, Australia.
Breast Cancer Res Treat. 2019 Feb;174(1):165-177. doi: 10.1007/s10549-018-5040-3. Epub 2018 Nov 20.
Since concurrent malignancy may be associated with radial scars (RS) in up to 45% of RS diagnosed on core biopsy, surgical excision is usually advised. Recent very low upgrade rates have caused a re-evaluation of the need for routine surgery. We aimed to find subsets of RS at such low risk of upgrade, as to render imaging surveillance a plausible alternative to surgery.
We performed a systematic review of the Pubmed, Cochrane and Embase databases, focusing on the following eligibility criteria: full papers, published after 1998, in English, included at least 5 RS, provided information on needle biopsy gauge and upgrade rates based on the excised lesion. For the meta-analysis, studies were grouped by the presence of histologic atypia and the core needle gauge. Study-specific and pooled upgrade rates were calculated for each subgroup.
49 studies that included 3163 RS with surgical outcomes are included. There were 217 upgrades to malignancies, 71 (32.7%) invasive and 144 (66.4%) DCIS. The random-effects pooled estimate was 7% (95% CI 5, 9%). Among the pre-planned subgroups, in RS assessed by 14G NCB the upgrade rates were: without atypia - 5% (95% CI 3, 8%), mixed or presence of atypia not specified - 15% (95% CI 10, 20%), with atypia - 29% (95% CI 20, 38%). For RS assessed by a mix of 8-16G cores the respective upgrade rates were 2% (95% CI 1, 4%), 12% (95% CI 6, 18%) and 11% (95% CI 3, 23%) and for RS assessed by 8-11 vacuum assisted biopsies 1% (95% CI 0, 4%), 5% (95% CI 0, 11%) and 18% for the one study of RS with atypia assessed by VAB. Surgery after VAB excision showed no upgrades. The difference across all subgroups was statistically significant.
When stratified by atypia and biopsy gauge, upgrade rates in RS are consistent and predictable. RS assessed by VABs and lacking atypia have a 1% (95% CI 0, 4%) upgrade rate to DCIS. Other groups have upgrade rates of 2-28%. This risk may be reduced by VAB excision. The results of this meta-analysis provide a decision aid and evidence-based selection criteria for surgery after a needle biopsy diagnosis of RS.
由于在经核心活检诊断的 RS 中，多达 45%的 RS 可能并发恶性肿瘤，因此通常建议进行手术切除。最近极低的升级率导致人们重新评估常规手术的必要性。我们旨在发现 RS 的亚组，其升级风险如此之低，以至于影像学监测成为手术的一种合理替代方案。
我们对 Pubmed、Cochrane 和 Embase 数据库进行了系统回顾，重点关注以下纳入标准：全文、1998 年后发表的英文文章、至少包含 5 个 RS、提供基于切除病变的活检针规格和升级率信息。对于荟萃分析，根据组织学异型性和核心针规格将研究分组。为每个亚组计算了研究特异性和汇总升级率。
纳入了 49 项包含 3163 例手术结果的 RS 研究。有 217 例升级为恶性肿瘤，71 例（32.7%）为浸润性癌，144 例（66.4%）为 DCIS。随机效应汇总估计值为 7%（95%CI5%，9%）。在预先计划的亚组中，在 14G NCB 评估的 RS 中，升级率为：无异型性-5%（95%CI3%，8%）、混合或未明确异型性-15%（95%CI10%，20%）、异型性-29%（95%CI20%，38%）。在 8-16G 核心混合评估的 RS 中，相应的升级率分别为 2%（95%CI1%，4%）、12%（95%CI6%，18%）和 11%（95%CI3%，23%），在 8-11 真空辅助活检评估的 RS 中为 1%（95%CI0%，4%）、5%（95%CI0%，11%），在一项仅评估 VAB 评估的 RS 异型性的研究中为 18%。VAB 切除后的手术未见升级。所有亚组之间的差异均具有统计学意义。
当按异型性和活检规格分层时，RS 的升级率是一致且可预测的。VAB 评估且无异型性的 RS 升级为 DCIS 的几率为 1%（95%CI0%，4%）。其他组的升级率为 2%-28%。VAB 切除可能会降低这种风险。本荟萃分析的结果为经针活检诊断为 RS 后的手术提供了决策辅助和基于证据的选择标准。
