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Case 4 Clinical history A female aged 36 years presented to the Breast Clinic with diffuse lumpiness in the left breast. On examination a dominant mass was found, but considered to be benign. Imaging was not performed. FNAC showed a cellular aspirate of benign cells - C2. Diagnostic excision biopsy was carried out at the request of the patient. Histological appearances - A-C The sections show a nodular area composed of a disorderly arrangement of lobular structures, ie, tubules, myoepithelial cells and stroma. There is focal epithelial hyperplasia, some of which appears to involve lobules. Differential diagnosis Sclerosing adenosis Tubular carcinoma Usual epithelial hyperplasia Lobular neoplasia Ductal carcinoma in situ Although tubular carcinoma should always be considered when making a diagnosis of sclerosing adenosis, the lobulocentric structures and lack of desmoplastic stroma favour the latter. Furthermore, immunostaining for anti-smooth muscle actin shows that all tubular structures have a myoepithelial layer. There are no architectural features to suggest ductal carcinoma in situ, but the monotonous small cell epithelial proliferation within lobular acini is indicative of lobular carcinoma in situ. Final Diagnosis Sclerosing adenosis with associated lobular neoplasia and usual epithelial hyperplasia. Management Because the presence of lobular neoplasia is a risk factor for subsequent invasive carcinoma (either breast) the patient is followed-up in the 'high risk' clinic - annual clinical examination and biennial mammography until age 50, then normal screening cycle. Learning points · Lobular neoplasia is sometimes associated with sclerosing adenosis. · Care must be taken not to overdiagnose invasive carcinoma. · The presence of lobular neoplasia indicates the need for close follow-up. |