What is the management approach for sclerosis adenosis identified on a mammogram?

Management of Sclerosing Adenosis Identified on Mammogram

Sclerosing adenosis identified on mammogram requires tissue diagnosis through core needle biopsy (preferred) or excisional biopsy to rule out malignancy, followed by appropriate surveillance based on pathology results. 1

Understanding Sclerosing Adenosis

Sclerosing adenosis is a benign proliferative breast condition that:

• Can mimic malignancy on imaging studies 2, 3
• Has no distinctive radiological features 3
• May present as:
  • Mass lesions (44%)
  • Microcalcification clusters (39%)
  • Architectural distortion (7%)
  • Asymmetrical opacity (5%)
  • Focal acoustic shadowing (5%) 2
• Is associated with a slightly increased risk of developing breast cancer 3

Diagnostic Approach

Initial Assessment

1. Categorize according to BI-RADS classification:

   • For BI-RADS 1-3: If clinically concordant, physical examination with or without imaging every 6 months for 1-2 years 1
   • For BI-RADS 4-5: Proceed to tissue sampling 1, 4

2. Imaging evaluation:

   • For women ≥30 years: Diagnostic mammogram with ultrasound 1, 4
   • For women <30 years: Ultrasound as initial imaging modality 4

Tissue Diagnosis

• Core needle biopsy (CNB) is preferred over fine needle aspiration (FNA) 1, 4
• Ensure concordance between pathology report and imaging findings 1
• If pathology and imaging are discordant, repeat breast imaging and obtain additional tissue samples 1

Management Based on Biopsy Results

Benign Results with Imaging-Pathology Concordance

• Follow-up with mammography every 6-12 months for 1-2 years 1
• After 1-2 years of stability, return to routine screening 1

Atypical Findings

• Surgical excision is recommended for:
  • Atypical ductal hyperplasia
  • Lobular carcinoma in situ (LCIS)
  • Other potentially pathologic conditions 1, 4

Malignant Findings

• Manage according to breast cancer treatment guidelines 1

Special Considerations

Radiological Pitfalls

• Sclerosing adenosis can mimic malignancy on imaging 2, 3, 5
• On mammography, it may appear as architectural distortion (30.8%), calcifications (23.1%), mass/nodular lesions (17.9%), or asymmetric density (12.8%) 5
• On ultrasound, it typically presents as regular-shaped (57.1%), well-defined (60%), heterogeneous low-echo nodules (71.4%) 5

Diagnostic Challenges

• Core biopsy accuracy is high (96% in one study) but not perfect 6
• Sclerosing adenosis can coexist with malignancy, particularly DCIS 6
• Radial sclerosing lesions may be difficult to recognize and may warrant excision 6

Follow-up Protocol

• For benign concordant findings: Imaging follow-up at 6-12 months intervals for 1-2 years 1
• If the lesion remains stable or resolves, resume routine screening 1
• If any interval mammograms show increased size or changed characteristics, perform biopsy 1

Exceptions to Standard Protocol

• Consider initial biopsy with histologic sampling when:
  • Return visit is uncertain
  • Patient is highly anxious
  • Patient has strong family history of breast cancer 1

By following this systematic approach to sclerosing adenosis identified on mammogram, clinicians can ensure accurate diagnosis while minimizing unnecessary procedures and patient anxiety.