sclerosing adenosis of the breast: can we picture it? · combination of fibrotic scarring...

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Sclerosing adenosis of the breast: can we picture it?

Poster No.: C-1992

Congress: ECR 2015

Type: Educational Exhibit

Authors: N. N. Abreu, M. Armas Goncalves, M. A. Serrado, A. F. Capelinha;Funchal/PT

Keywords: Pathology, Cancer, Biopsy, Ultrasound, MR, Mammography,Breast

DOI: 10.1594/ecr2015/C-1992

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Learning objectives

• To be familiarized with the clinical and radiological presentations ofsclerosing adenosis;

• To be aware of sclerosing adenosis as a mimicker of breast malignancy;

• To correlate histopathological features with the imaging findings.

Background

Definition

Sclerosing adenosis (SA) is a benign proliferative disease of the breast that may mimickbreast carcinoma, either with clinical, imaging or histological features, which is the mainreason for its clinical importance. The name itself reflects its histologic appearance as acombination of fibrotic scarring (sclerosis) and glandular hyperplasia (adenosis).

It occurs more frequently in perimenopausal women, many times with a family history ofbreast cancer [1]. Although there are some conflicting data on literature, recent studieshave shown that it is associated with a doubling risk of breast cancer [1].

Histologic features

Breast imaging compels to a formal knowledge of the normal histology of the breast inorder to establish a concordance between the histopathological features and the imagingfindings of lesions. This will be critical in determining the need for further rebiopsy orsurgical resection.

Normal breast is composed of large lactiferous ducts which open through pores in thenipple during lactation. Each lactiferous duct, branches out deep into the breast tissuein a dichotomously fashion, where a single large duct successively branches down to itsmost terminal level - the terminal duct lobular unit (TDLU), the functional and structuralunit of the breast. This is composed of a terminal duct and its respective collection of smallductules/acini (according to their tubular or rounded shape, respectively) which producemilk. The overall branching system of each lactiferous duct constitutes a "lobe" whereasthe duct system (ductules/acini) arising from each terminal duct is called a "lobule". Each

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ductule/acinus is lined by two layers: an outer complete layer of myoepithelial cells (whichhelp discharge milk into the terminal duct by contracting) and an inner layer of cuboidalto columnar epithelial cells, enveloped in a basement membrane and the surroundingstroma containing fibroblasts, lymphocytes and plasma cells.

The main histopathological alterations seen in SA occur at the level of the TDLU. Theyconsist on proliferation of epithelium (duplicated, crowded acini) and myoepitheliumassociated with stromal fibrosis and elastosis. The increase in glandular elements plusstromal proliferation and the proeminence of the myoepithelium distort and compressglands. Florid changes are associated with pregnancy. Despite the pronounceddistortion, lobular architecture is preserved. Rarely, SA may extend into fat or even showperineural invasion [3].

The main diagnosis in the differentiation of SA is low-grade breast carcinoma [6].Demonstration of the integrity of the myoepithelium and the basement membrane iscritical in differentiating SA from a malignant process with which it can sometimes co-exist(both invasive and in situ cancers). In this regard, differentiation from lobular carcinomain situ is particularly problematic.

The wide spectrum of imaging appearances mirrors the broad alterations of breast tissuebed. The relative proportions of the cellular elements of the epithelial and mesenchymalcompartments will determine the extent of SA and its form (ranging from a microscopicfocus to an architectural distortion or a mass). If the lesion presents as a tumoral mass itcan be called "adenosis tumor" or "nodular sclerosing adenosis".

Findings and procedure details

On physical examination SA can manifest as a palpable firm mass or multiple firmpalpable ill-defined masses.

The most frequent imaging findings alternate between masses and microcalcifications inseveral studies. [3],[4],[5].

Mammography may depict mass lesions (varying from well-defined to irregular orspiculated forms), focal architectural distortion or radial sclerosing lesions. Despite itshigh suspicious association with malignancy, contour irregularity in mass lesions mayoccur both in the setting of a benign lesion like SA (by fibrosis and stromal sclerosis)and in the presence of a malignant lesion (as a consequence of desmoplastic reactions,local invasion and periductal fibrosis). Likewise, stellate appearance is not exclusive of

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malignancy and may be seen in SA, fat necrosis, radial scars and surgical scars. Previoussuggestion that in spiculated lesions radiodensity of the center of the lesions could beused to differentiate benign from malignant (radiolucent and radiodense, respectively)proved to be unreliable. The microcalcification pattern described in the literature inassociation with SA depicts benign features, most frequently clustered amorphous orpleomorphic punctate or scattered amorphous punctate [5].

Ultrasonography is of particular value in the diagnosis and description of lesionsin extremely dense breasts (as diagnosis of a mass lesion on mammography isunattainable). Detectable lesions are seen when the diameter of the terminal ductlobular unit (TDLU) exceeds 5mm. Mass lesions can appear microlobulated, angulated orspiculated. Tumoral adenosis will appear either defined or not depending on the characterof the surrounding tissue determining their interfaces: if surrounded by fibrous tissue itwill be undefined whereas it will be apparent if surrounded by hipoechoic fat tissue [5].Focal acoustic shadowing with or without a noticeable lesion can occur with SA.

In MRI, SA may appear as a non-mass lesion with indistinct margins or as a mass lesioneither with regular or spiculated contours. It usually appears as an enhancing lesion dueto the presence of sclerosis and elastosis, with an enhancement pattern (patchy, diffuse)that depends on sclerosing adenosis' histologic pattern. Enhancement kinetics is variableand overlaps considerably with the pattern of malignant lesions. Some suggest assessinglesions' characteristics throughout the different phases of the menstrual cycle and ifthe pattern varies, being less conspicuous in the mid-cycle, the diagnosis of fibrocysticdisease (where SA is included) is likely. Furthermore, SA coexistence with an in situcarcinoma is very difficult to distinguish from an invasive carcinoma. Thus, despite MRI'shigh sensitivity in detecting breast lesions, it still lacks specificity is such cases.

Images for this section:

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Fig. 1: Histologically confirmed sclerosing adenosis. Several mammograms showingdiffuse (a,b) and clustered (c) pleomorphic microcalcifications. a) Top right: excisionalbiopsy radiogram of the microcalcifications.

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Fig. 2: Histologically confirmed sclerosing adenosis. a)mediolateral oblique mammogramof the right breast shows a nodular lesion with irregular margins. This lesion waspredominantly hipoecogenic with poorly defined contours(b).

Fig. 3: Histologically confirmed sclerosing adenosis. a)sonography exhibits mass lesionwith partial irregular contour and heterogeneous internal ecogenicity, with parallelorientation to the skin. b)MRI shows an area with multiple foci of high intensity signal

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in T2 sequency (b) that translates into an heterogeneous enhancing area with multiplehyper-enhancing foci in post-contrast subtraction dynamic study (c).

Fig. 4: Histologically confirmed sclerosing adenosis. a)sonography exhibits an area ofheterogeneous ecogenicity, with indistinct margins and mild focal acoustic shadowing;b)MRI of the lesion described in a) reveals a clustered unmass enhancement onpostcontrast dynamic series.

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Fig. 5: Histologically confirmed sclerosing adenosis. MRI Out Phase Ax T2 FSE-IDEAL(a), shows a retromamilar mass in the left breast, with irregular shape and contour (arrow),with intermediate intensity. In post-contrast subtraction dynamic study (b), it exhibited aslow and progressive enhancement after paramagnetic contrast.

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Fig. 6: Several US presentations of histologically confirmed sclerosing adenosis.a)circumscribed solid nodular mass, with heterogeneous ecogenicity. b)poorlymarginated hypoecogenic area with posterior acoustic shadowing. c)hypoecogenicnodule with partially defined margins. d)grossly nodular lesion with indistinct margins andheterogeneous internal ecogenicity. There is some posterior acoustic shadowing.

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Fig. 7: Sclerosing adenosis of the breast histologically confirmed. US study (a)exhibitsa hipoecogenic nodule with irregular lobulated contours. The corresponding MRI T2-weighted images (b) and eTHRIVE-HR (c), show in the left breast a nodular lesionwith irregular contours and intermediate signal intensity. Subtraction dynamic imagesin early (d) and late (e) series, shows that this lesion has heterogeneous, progressiveenhancement with a corresponding type 2 kinetic curve.

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Conclusion

SA is a benign proliferative lesion that can mimic malignancy either clinically (byproducing a mass), radiographically (by exhibiting features more often associatedwith invasive processes) and even histologically (exaggerated distortion of lobulararchitecture).

The unspecificity of imaging findings demands a core needle biopsy or excisional biopsyto differentiate between a benign and a malignant lesion keeping in mind that SA canco-exist with a carcinoma. Concordance between histopathology and imaging findingsshould always be assessed.

Personal information

References

1. Visscher D, Nassar A, Degnim A, Frost M, Vierkant R, Frank R, Tarabishy Y, RadiskyD, Hartmann L. Sclerosing adenosis and risk of breast cancer. Breast Cancer Res Treat2014; 144:205-212

2. Cho S, Park S. Mimickers of breast malignancy on breast sonography. J UltrasoundMed 2013; 32:2029-2036.

3. Gill H, Ioffe O, Berg W. When is a diagnosis of sclerosing adenosis acceptable at corebiopsy? Radiology 2003 Jul;228(1):50-7

4. Günhan-Bilgen I, Memis A, Üstün EE, Özdemir N, Erhan Y. Sclerosing adenosis:mammographic and ultrasonographic findings with clinical and histopathologicalcorrelation. Eur J Radio 2002; 44:232-238

5. Taskin F, Köseo#lu K, Ünsal A, Erkus M, Özbas S, Karaman C. Sclerosing adenosisof the breast: radiologic appearance and efficiency of core needle biopsy. Diagn IntervRadiol 2011; 17:311-316.

6. Oztekin PS, TuncbilekI, Kosar P, Gültekin S, Oztürk FK. Nodular sclerosing adenosismimicking malignancy in the breast: magnetic resonance imaging findings. Breast J 2011Jan-Feb;17(1):95-7

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7. Kundu UR, Guo M, Lnadon G, Wu y, Sneige N, Gong Y. Fine-needle aspirationcytology of sclerosing adenosis of the breast: a retrospective review of cytologicalfeatures in conjunction with corresponding histologic features and radiologic findings. AmJ Clin Pathol 2012; 138:96-102.

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