Case 8310

Sclerosing adenosis mimicking

breast carcinoma
Published on 21.04.2010

DOI: 10.1594/EURORAD/CASE.8310
ISSN: 1563-4086
Section: Breast imaging
Case Type: Clinical Cases
Authors: Battaglia V, Brunu M, Zingoni G, Signorini F,
Bonechi C, Nardini L, Ghelarducci G, Bartolozzi C
Patient: 28 years, female

Clinical History:

The patient presented because of a recently found palpable thickness of the upper quadrant of the right breast
without skin retraction or reddish coloration.
She reported a family history positive for breast carcinoma (mother at 50 years).
Imaging Findings:

The patient underwent ultrasound (US) examination, which showed the presence of a solid, hypoechoic mass in the
upper external quadrant of the right breast, measuring 15x12 mm. Moreover, at US it was possible to identify a
shadow beyond the mass, as well as the presence of infiltration of surrounding tissues (Fig. 1). According to all US
findings, the lesion was classified as BI-RADS US5 and a mammography was performed.
Mammography examination confirmed the presence of a spiculated, large mass, showing micro-calcifications at the
periphery (Fig. 2). Because of these suspicious findings, the lesion was classified as BI-RADS M4. In order to check
for a bilateral involvement and because of the young age of the patient, a Magnetic Resonance (MR) examination
was performed.
Coronal T2 w.i showed the presence of a slightly hyperintense area within the upper external quadrant of the right
breast (Fig. 3). After contrast agent administration, subtracted images were obtained, that confirmed the presence of
an enhancing lesion, which showed an enhancing curve of type III (Fig. 4, 5). MR examination was thus classified as
MR4.
Because of the young age of the patient and the lack of familiarity for breast carcinoma, a tru-cut biopsy (18G
needle, 3 specimens) was performed. Histology revealed fibrosis, micro-cysts and areas of adenosis (B3).
Because of the mismatch between imaging findings (US5, M4, MR4) and histological examination, a surgical
exeresis of the upper external quadrant of the right breast was performed (Fig. 6).
Definitive histological diagnosis was sclerosing adenosis (Fig. 7).
Discussion:

Borderline breast disease (BBD) is a heterogeneous condition consisting of many histological entities including
ductal and lobular atypical hyperplasia, lobular intraepithelial neoplasia (LIN III), radial scar and sclerosing adenosis.
These lesions are thought to represent progressive changes in the progression sequence of histological changes
leading to the development of breast cancer, with an increased risk of 1,7-3,7% [1]. It has been hypothesised that
non-atypical proliferative forms of BBD, proliferative disease with atypia, and in situ cancer represent subsequent
steps preceding the development of invasive breast carcinoma.
Particularly, sclerosing adenosis is a form of fibrocystic change, and is a combination of adenosis and stromal
sclerosis. Adenosis refers to epithelial and myoepithelial proliferation of the lobules. As a result of sclerosis, which
develops together with adenosis, the lobules become irregular and distorted. It generally arises in the peri-
menopausal period. Sclerosing adenosis can appear as focal or diffuse and clinically it is not palpable in 80% of the
cases, while in some cases, it might determine skin retraction [2].
Both at US and mammography, sclerosing adenosis may show a great variability of appearance, depending on the
most represented tissue components within the lesion.
On US, it may in fact appear as a focal acoustic shadowing without a mass configuration, or a well-circumscribed
area, or a mass with lobulated contour, or an irregular mass with posterior acoustic shadowing.
Also at mammography, sclerosing adenosis may show multiple presentations, such as the presence of
microcalcifications, a circumscribed mass or a discrete mass with ill-defined margins, a spiculated mass or an
asymmetrical focal density, or a focal architectural distortion.
Radiological findings do not allow the differentiation with carcinoma, and biopsy is mandatory.
Differential diagnosis of sclerosing adenosis must be posed with ductal and lobular infiltrating carcinomas, ductal
carcinoma in situ (especially in cases of negative US and microcalcifications at mammography), and with benign
diseases such as radial scar and post-surgical scar.
Infiltrating ductal carcinomas are characterised by the formation of tubules, or ducts that infiltrate throughout the
supporting breast parenchyma. Despite a clinical differential diagnosis with sclerosing adenosis might be very hard
(both pathologies can determine skin retraction), a clue that suggests the diagnosis of carcinoma at mammography
is its more hyperdense central area than that of sclerosing adenosis (Fig. 8). Differential diagnosis may however be
very difficult also because of the presence of microcalcifications and spicules and sometimes histology can not
differentiate them either.
Radial scar (RS) is a benign lesion that is often mistaken for sclerosing adenosis, especially at mammography,
because of its spiculated appearance. At mammography, RS may show variable appearances in different
projections, long thin, radiating spicules against a background of a radiolucent centre, that creates a ‘black star
appearance’, microcalcifications.
No mass is usually palpable, nor skin changes are present.
Despite some few, peculiar characteristics at imaging, either for sclerosing adenosis and RS, imaging may be
unreliable in differentiating these two benignant lesions from carcinomas and often excisional biopsy of the entire
lesion is preferable to FNAB or core needle biopsy [3].
Differential Diagnosis List: Sclerosing adenosis

Final Diagnosis: Sclerosing adenosis

References:

Silvera SA, Rohan TE (2008) Benign proliferative epithelial disorders of the breast: a review of the epidemiologic
evidence. Breast Cancer Res Treat 110:397-409 (PMID: 17849184)
Günhan-Bilgen I, Memi? A, Ustün EE, Ozdemir N, Erhan Y (2002) Sclerosing adenosis: mammographic and
ultrasonographic findings with clinical and histopathological correlation. Eur J Radiol 44:232-8 (PMID: 12468074)
Pediconi F, Occhiato R, Venditti F, et al. (2005) Radial scars of the breast: contrast-enhanced magnetic resonance
mammography appearance. Breast J 11:23-8 (PMID: 15647074)
Figure 1
a

Description: US examination shows the presence of a large, inhomogeneous mass within the upper
external quadrant of the right breast. The lesion appers as hypoechoic, infiltrating the surrounding
tissues. A shadow is present beyond it. Origin:
Figure 2
a

Description: Mammograhy showed the presence of spiculate, sclerosing mass in the upper external
quadrant of the right breast. Millimetric calcifications were detected at the periphery of the lesion (white
circle). Origin:
Figure 3
a

Description: Axial baseline T2w.i at different levels shows a slightly hyperintense area within the upper
external quadrant of the right breast. Origin:
b

Description: The lesion is circumbscribed by the yellow circle in the three subsequent cranio-caudal
acquisitions. Origin:
Figure 4
a

Description: Coronal baseline T1 w.i highlights a parenchymal retraction in the upper external
quadrant of the right breast.
Subtracted post contrast T1w.i shows, at that level, the presence of enhancement.Origin:
Figure 5
a

Description: MR automatic curve, obtained by the software at analysis of all T1 w.i post
contrastographic acquisitions, shows the presence of a lesion`s enhancement pattern of type III. This
finding corroborates the suspicion of malignancy. Origin:
Figure 6
a

Description: RX evaluation of the resected specimen. This kind of examination after exeresis is useful
in order to detect the presence of microcalcifications. Origin:
Figure 7
a

Description: Microscopic evaluation (hematoxylin-eosin stain)shows the presence of abundant stromal

tissue (white) as well as the proliferation of glandular acini (violet). Origin:
Figure 8
a

Description: An example of ductal adenocarcinoma at mammography. The central portion of the lesion
is clearly, markedly hyperdense. Adjacent parenchymal rectraction is also evident.Origin: