Definition
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• Benign lesion with stellate architecture, prominent fibroelastosis and epithelial hyperplasia
• Initially described in 1977 (Am J Surg Pathol 1977;1:155)

Terminology
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• Also called complex sclerosing lesion (CSL, larger lesions), sclerosing ductal lesion, sclerosing adenosis with pseudoinfiltration, radial sclerosing lesion
• Recommended to not use the term infiltrative epitheliosis (Semin Diagn Pathol 2010;27:5)

Epidemiology
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• Common; incidence has increased with mammography (J Clin Pathol 2003;56:721)

Clinical features
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• If large, may present as a mass
• May be associated with 2x increased risk of breast cancer, which may be due to coexisting proliferative disease (Cancer 2006;106:1453, Breast Cancer Res Treat 2008;108:167, but see Cancer Causes Control 2010;21:821-no increased risk)
• May be associated with metaplastic carcinoma (Mod Pathol 2003;16:893)

Case reports
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• 40 year old woman with secretory carcinoma arising in radial scar (Indian J Pathol Microbiol 2009;52:83)
• 57 year old woman with coexisting DCIS and invasive carcinoma (Breast Cancer 2006;13:107)

Treatment
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• Local excision and follow up or possibly vacuum assisted excision (Breast 2008;17:546)
• Core biopsy: Excision recommended since associated carcinoma is relatively common (Am J Surg Pathol 2004;28:1626, Am J Surg Pathol 2002;26:1095, Breast Cancer Res Treat 2008;107:371)

Xray description
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• Stellate abnormalities ("black star") may resemble invasive ductal carcinoma or tubular carcinoma
• Often bilateral

Xray images
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Characteristic findings

Mammogram, spot film, courtesy of Dr. Mark R. Wick

Gross description
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• Stellate with central sclerosis and elastosis, resembles invasive ductal carcinoma, usually 1 cm or less
• May be firm, irregular, with yellow streaks and flecks (due to elastotic stroma)

Gross images
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Central sclerosis and elastosis resembling carcinoma

 

Subgross images

Micro description
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• "Flower head" pattern on low power
• High power shows central fibroelastotic zone of basophilic elastic material in walls of obliterated ducts and elsewhere, with radiation of compressed tubular structures with 2 cell layers (including myoepithelium) and hyalinized stroma
• Variable amounts of epithelial hyperplasia, adenosis and cysts
• Perineural invasion occasionally noted

Micro images
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Courtesy of Dr. Mark R. Wick

Small size, stellate shape, central fibrosis

Densely fibrotic

Ductal hyperplasia

Radiating patter of the ducts

Central fibroelastotic core

 

Central fibrosis and elastosis with radiating fibrous bands and dilated ducts

Fibrosis, elastosis and ductal hyperplasia

 

Various images

Adenosis surrounds
central area of
fibrosis and elastosis
with entrapped ducts;
cysts are commonly
present at periphery

Squamous metaplasia

Central angular glands
are suggestive of tubular
carcinoma, but peripheral
duct hyperplasia and cysts
are not typical

Elastic stain highlights central elastosis

With tubulolobular carcinoma

Cytology description
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• Fine needle aspiration often inadequate (J BUON 2002;7:137)
• Bland epithelial clusters and bipolar naked nuclei
• Also frequent apocrine cells, papillary clusters, foam cells and fibrillary elastoid material
• Features are nonspecific, but suggest benign diagnosis (Diagn Cytopathol 1997;17:353)
• May also be atypical / malignant features if additional lesions present

Positive stains
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• Elastic stains (von Gieson)
• Myoepithelial cells: p63, CD10 (Appl Immunohistochem Mol Morphol 2006;14:71)

Differential diagnosis
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• Invasive ductal carcinoma: lacks typical architecture of radial scar, lacks myoepithelial cells
• Tubular carcinoma: atypia present; no peripheral duct hyperplasia and cysts, negative for myoepithelial markers

Additional references
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• Stanford University

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