Case 30 Answer 2
C - Suspicious, recommend needle biopsy, is the best answer. Answers D and E can also be correct. A core biopsy can provide a diagnosis to assist with treatment planning if cancer is present. Studies show that patients who have needle biopsies will undergo fewer expensive surgeries for definitive therapy. Some institutions will recommend excision of this lesion immediately because regardless of the core needle biopsy result the lesion needs to be removed. Radial scars have an association with tubular carcinomas about 20% of the time. They are also notoriously difficult to diagnose from a needle biopsy (just ask your local pathologist!) This did turn out to be a radial scar, in case you're keeping track.
Our surgeons at UW prefer that we attempt a core biopsy prior to excision (a cancer diagnosis prior to surgery will change surgical management-- the surgeon will attempt to get clean margins and will perform a sentinel node biopsy).
As I have mentioned before (see Case 2) some mammographers prefer to call these lesions BI-RADS 5, to be sure to convey the need for excision. Since I know I'd be eating my hat over these most of the time, I prefer to call it BI-RADS 4. As long as you communicate your recommendations clearly, this should not be a problem.