Journal of Cytology
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 Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 30  |  Issue : 1  |  Page : 49-51
Nodular sclerosing adenosis of breast: A diagnostic pitfall in fine needle aspiration cytology


1 Department of Cytology and Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication21-Feb-2013
 

   Abstract 

Fine needle aspiration cytology was performed in a 46-year-old female presenting with a breast lump and mammography suggesting a malignancy. The smears were cellular with cohesive clusters and scattered epithelial cells showing moderate nuclear pleomorphism and focal acinar formation. Stromal fragments, benign epithelial cell clusters and a few naked nuclei were noted in the background. Considering the clinical features, mammography findings as well as cytological features, a diagnosis of ductal carcinoma was suggested. Subsequent histopathological examination revealed it to be nodular sclerosing adenosis. The cytohistological correlation of this uncommon lesion, a potential pitfall in breast fine needle aspiration diagnosis which may lead to a false-positive diagnosis is discussed.

Keywords: Breast fine needle aspiration; ductal carcinoma, false-positive diagnosis; fine needle aspiration cytology; nodular sclerosing adenosis; proliferative breast disease

How to cite this article:
Sreedharanunni S, Das A, Veenu S, Srinivasan R, Singh G. Nodular sclerosing adenosis of breast: A diagnostic pitfall in fine needle aspiration cytology. J Cytol 2013;30:49-51

How to cite this URL:
Sreedharanunni S, Das A, Veenu S, Srinivasan R, Singh G. Nodular sclerosing adenosis of breast: A diagnostic pitfall in fine needle aspiration cytology. J Cytol [serial online] 2013 [cited 2020 Jun 4];30:49-51. Available from: http://www.jcytol.org/text.asp?2013/30/1/49/107514



   Introduction Top


Sclerosing adenosis is a form of adenosis in which there is an expansion of terminal duct lobular units (TDLU) due to proliferation of glandular components, accompanied by stromal proliferation which is usually dense and hyalinized with resultant compression and distortion of glands. [1],[2] Though it is often found as a microscopic lesion accompanying fibrocystic diseases, it rarely presents as a palpable mass when it is also called adenosis tumor or better designated as nodular sclerosing adenosis mimicking carcinoma clinically and mammography. [3] Since the mammographic appearance is often indistinguishable from malignancy, fine needle aspiration cytology (FNAC), with or without a core biopsy is mandatory to rule out breast cancer. [4] We discuss a case of nodular sclerosing adenosis misdiagnosed as ductal carcinoma in FNAC. We discuss this case due to the relative paucity of literature regarding the cytology of sclerosing adenosis and its potentiality to be misdiagnosed as carcinoma.


   Case Report Top


A 46-year-old lady complained of awareness of breast mass. The mass was present for around 12 years and she was taking homeopathic medicines on and off for the same. There was history of waxing and waning in the size of the mass. There was a recent increase in the size of the mass and the surgeon referred the patient for a mammogram and FNA. On examination, the lump measured 3.5 cm, which was very firm to hard in consistency and had restricted mobility. The nipple was mildly retracted. No lymph nodes were palpable in the axilla. Mammography of left breast showed a high-density mass in the central region suspicious of malignancy; however, there was no evidence of microcalcifications. The lesion was classified as BI-RADS 4.

FNAC was performed using a 23-gauge needle and smears were air-dried and stained using May Grünwald-Giemsa method as well as fixed in 95% ethanol and stained with hematoxylin and eosin. Lump was gritty on FNA and yielded particulate material. The smears were highly cellular and showed predominantly three-dimensional cohesive clusters and few scattered cells [Figure 1]a and b. At places, the clusters showed acinar formation [Figure 1]c. Occasional clusters of apocrine cells and singly scattered large cells with moderate nuclear pleomorphism and conspicuous nucleolus were also found [Figure 1]d. Admixed benign cell clusters, few bipolar cells and hyalinized eosinophilic stroma were found in the background [Figure 1]b. Considering the overall picture, a cytological diagnosis of ductal carcinoma was made, and she was advised surgical excision and histopathological examination to rule out invasion. Lumpectomy was performed, and the histopathological examination of the specimen showed a nodular lesion with expanded lobular units which showed extensive adenosis with marked sclerosis of intervening stroma. The proliferating glands were distorted in many areas and showed apocrine metaplasia at places. The lining cells showed moderate nuclear pleomorphism and atypia [Figure 1]e. The individual glands were surrounded by myoepithelial cells which were confirmed by immunohistochemistry for smooth muscle actin (SMA) [Figure 1]f. There was no evidence of any associated lobular or ductal intraepithelial neoplasia. The surrounding area showed features of fibrocystic disease. There was no evidence of an in situ or invasive malignancy. Based on these features, a diagnosis of nodular sclerosing adenosis was made.
Figure 1: Nodular sclerosing adenosis: Cytomorphological and corresponding histological features. (a) Irregular cohesive clusters of cells along with naked nuclei and bipolar cells in the background; (b) Hyalinized eosinophilic stromal fragments; (c) Acinar formation; (d) Moderate nuclear pleomorphism and nucleoli; (e) Histological section showing tubular arrangement showing atypia, compressed by stroma; (f) Immunohistochemistry showing SMA positivity (a, c, d, e, H and E ; b, MGG ; f, immunoperoxidase; original magnification: a, b, ×200; c-f, ×400)

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   Discussion Top


Nodular sclerosing adenosis or adenosis tumor is an unusual presentation of sclerosing adenosis as a palpable mass, and may clinically, radiologically and pathologically simulate breast malignancy. It usually presents in the perimenopausal age group. [5] It poses a diagnostic confusion with infiltrating lobular carcinomas and tubular carcinomas even in histological sections, but is identified by the relative preservation of overall lobular architecture, the compressed glands, lack of atypia, the retention of two cell layers, and the confirmation of the presence of myoepithelial cells by immunohistochemistry. [2] It could be associated with microcysts, apocrine metaplasia, luminal histiocytes and pseudopapillomas, called glomeruloid structures. [6] The presence of microcalcifications in mammography, the pseudoinvasive growth pattern resulting from compression of glands, rare but actual invasion of nerves and apocrine metaplasia add to the diagnostic confusion in many cases. [2] However, in tissue sections, especially core biopsies, the identification of myoepithelial cells and basement membrane by immunohistochemistry is really useful in difficult cases. Although core needle biopsy provides a definite diagnosis in most cases, a coexisting cancer may be missed due to sampling error. [7] There is a case report of sclerosing adenosis occurring within the lymph node, also mimicking metastatic cancer. [8] It is important to distinguish sclerosing adenosis from other benign lesions due to the fact that it is associated with small but definite risk of invasive carcinoma and the risk increases if it is associated with atypical hyperplasia. [9] Sclerosing adenosis may also be associated with collagenous spherulosis; in a case report from India, the lesion was diagnosed on FNA as benign epithelial hyperplasia with collagenous spherulosis. [10]

Cytological features of sclerosing adenosis have been described by only a few authors [4],[7] and include cellular smears with small groups of uniform benign ductal cells, acinar sheets, scattered individual epithelial cells, apocrine metaplasia, foam cells, hyalinized stromal fragments and small number of stripped bipolar nuclei; however, hyperchromasia, prominent nucleoli, hypercellular stroma and calcification were not seen in any one of these studies. FNAC of sclerosing adenosis may be difficult to distinguish from benign lesions like fibroadenoma, adenomyoepithelioma and proliferative breast diseases. [11] Distinction from fibroadenoma is not difficult as sclerosing adenosis has more abundant cellularity, acinar arrangement, single epithelial cells and hyalinized stroma. Fibroadenomas, in comparison, display more of a branching pattern of larger epithelial sheets, bipolar/oval, naked nuclei, and large, hypocellular, fibromyxoid stroma.

The experience regarding the diagnosis of sclerosing adenosis is limited as evident from the relative paucity of literature regarding its cytological features, and it is especially difficult when the diagnosis of individual case is considered. In the present case, the clinical presentation, mammographic findings, the cytological presence of cohesive clusters and scattered large cells with moderate nuclear pleomorphism, conspicuous nucleolus with focal acinar formation and dense stromal fragments led to a diagnosis of ductal carcinoma in the FNAC. Ductal carcinoma, especially of the scirrhous variety, can show fragments of collagenous stroma. The presence of typical benign cell clusters, few bipolar cells and the absence of fat infiltration restricted us from the diagnosis of an infiltrating ductal carcinoma. Markopoulos, et al.,[5] have also reported a similar false-positive case. Even in the study by Cho, et al.,[7] none of the seven cases were originally diagnosed as sclerosing adenosis. On retrospective review, it was clearly evident that the cytology corresponds to histological features. The cohesive clusters at places forming acini correspond to proliferating glands, singly scattered cells possibly resulting from high proliferation, small dense stroma from the sclerotic stroma of the lobules and benign epithelial cells from adjacent normal areas. However, at the time of initial diagnosis, it was almost impossible to consider the diagnosis of sclerosing adenosis as there are no specific features described in the literature which would clinch a specific diagnosis. Probably the features which should have kept us away from the diagnosis of ductal carcinoma are the presence of many benign ductal epithelial cell clusters containing myoepithelial cells and naked ovoid nuclei of the myoepithelial cells in the background. The recognition of myoepithelial cells is crucial to classify this lesion as a benign proliferative lesion. These cells are seen as bipolar naked nuclei morphologically; immunoperoxidase staining for smooth muscle actin can aid in their recognition. [4] Further, awareness of the possible presence of acini formation and singly scattered atypical nuclei in sclerosing adenosis [7] may have averted a diagnosis of malignancy. Thus, this case highlights the problems in FNAC, which can lead to the erroneous diagnosis of malignancy in a case of sclerosing adenosis.

 
   References Top

1.Bussolati G, Tavassoli FA, Nielsen BB, Ellis IO, MacGrogan G. Benign epithelial proliferations. In: Tavassoli FA, Devilee P, editors. World Health Organisation classification of tumours: Pathology and genetics of tumors of the breast and female genital organs. Lyon: IARC Press; 2003. p. 81-5.  Back to cited text no. 1
    
2.Carter D, Schnitt SJ, Millis RR. The Breast. In: Mills SE, Carter D, Greenson JK, Reuter VE, Stoler MH, editors. Sternberg's Diagnostic Surgical Pathology. 5 th ed. Philadelphia: Lippincott Williams and Wilkins; 2010. p. 285-350.  Back to cited text no. 2
    
3.Ellis IO, Pinder SE, Lee AH. Tumors of the breast. In: Fletcher CDM (editor); Diagnostic Histopathology of Tumors. 3 rd ed. USA: Elsevier; 2007. p. 903-69.  Back to cited text no. 3
    
4.Silverman JF, Dabbs DJ, Gilbert CF. Fine needle aspiration cytology of adenosis tumor of the breast with immunocytochemical and ultrastructural observations. Acta Cytol 1989;33:181-7.  Back to cited text no. 4
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5.Markopoulos C, Kouskos E, Phillipidis T, Floros D. Adenosis tumor of the breast. Breast J 2003;9:255-6.  Back to cited text no. 5
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6.Nielsen BB. Adenosis tumour of the breast: A clinicopathological investigation of 27 cases. Histopathology 1987;11:1259-75.  Back to cited text no. 6
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7.Cho EY, Oh YL. Fine needle aspiration cytology of sclerosing adenosis of the breast. Acta Cytol 2001;45:353-9.  Back to cited text no. 7
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8.Chen YB, Magpayo J, Rosen PP. Sclerosing adenosis in sentinel axillary lymph nodes from a patient with invasive ductal carcinoma: An unusual variant of benign glandular inclusions. Arch Pathol Lab Med 2008;132:1439-41.  Back to cited text no. 8
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9.Jensen RA, Page DL, Dupont WD, Rogers LW. Invasive breast cancer risk in women with sclerosing adenosis. Cancer 1989;64:1977-83.  Back to cited text no. 9
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10.Jain M, Niveditha SR, Bajaj P, Rani S. Collagenous spherulosis of breast: Diagnosis by FNAB with review of literature. Indian J Pathol Microbiol 2000;43:131-4.  Back to cited text no. 10
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11.El Aouni N, Balleyguier C, Mansouri D, Mathieu MC, Suciu V, Delaloge S, et al. Adenosis tumor of the breast: Cytological and radiological features of a case confirmed by histology. Diagn Cytopathol 2008;36:496-8.  Back to cited text no. 11
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Correspondence Address:
R Srinivasan
Department of Cytology and Gynecologic Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.107514

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