advanced health assessment

Assignment: Lab Assignment: Assessing the Genitalia and Rectum

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ASSIGNMENT

GENITALIA ASSESSMENT

Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”

• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no

dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

• PMH: Asthma

• Medications: Symbicort 160/4.5mcg

• Allergies: NKDA

• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia

• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney

Diagnostics: HSV specimen obtained

Assessment: Chancre

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

· Analyze the subjective portion of the note. List additional information that should be included in the documentation.

· Analyze the objective portion of the note. List additional information that should be included in the documentation.

· Is the assessment supported by the subjective and objective information? Why or why not?

· Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

· Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Please do not write the paper in soap note format. PLEASE ANSWER ONLY THE QUESTIONS. DO NOT REWRITE THE CASE STUDY. Title page and Reference page required ( APA format ).

Health Assessment

Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

· Based on the Episodic note case study:

· Review this week’s Learning Resources, and consider the insights they provide about the case study.

· Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

· Consider what history would be necessary to collect from the patient in the case study.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

· Analyze the subjective portion of the note. List additional information that should be included in the documentation.

· Analyze the objective portion of the note. List additional information that should be included in the documentation.

· Is the assessment supported by the subjective and objective information? Why or why not?

· Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

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Digestive and Liver Disease 46 (2014) 1082–1085

Contents lists available at ScienceDirect

Digestive and Liver Disease

journa l h om epage: www.elsev ier .com/ locate /d ld

limentary Tract

hat is the best position for analyzing the lower and middle rectum
nd sphincter function in a digital rectal examination? A randomized,
ontrolled study in men

harles Sabbagha,b,c, Franç ois Mauvaisd, Amaury Vectena, Najib Ainsebad,
yril Cossea,b,c, Momar Dioufe, Jean-Marc Regimbeaua,b,∗

Department of Digestive and Oncological Surgery, Amiens University Hospital, Amiens, France
Jules Verne University of Picardie, Amiens, France
INSERM U1088, Amiens, France
Department of Digestive Surgery, Beauvais General Hospital, Beauvais, France
Clinical Research Directorate, Jules Verne University of Picardie, Amiens, France

r t i c l e i n f o

rticle history:
eceived 28 April 201

ccepted 25 August 2014
vailable online 22 September 2014

eywords:
igital rectal examination
osition
andomized controlled trial
ectum

a b s t r a c t

Background: Digital rectal examination is an essential tool in the evaluation of the rectum. The aim of this
trial was to determine the best position for performing a digital rectal examination.
Methods: A total of 321 patients were randomized into “dorsal” or “lateral” groups in this multicentre
randomized controlled trial performed in an outpatient setting. The primary endpoint was the proportion
of patients with a complete digital rectal examination, defined as the examination of the rectum (upper
border of the prostate), the entire circumference, and the assessment of the sphincter tone.
Results: The dorsal group included a total of 161 patients (mean age: 62.3 ± 13.04 years), while the lateral
group included 160 patients (mean age: 62.7 ± 14.4 years). The proportion of patients with a complete
digital rectal examination was 44% (n = 71) in the dorsal group and 49% (n = 79) in the lateral group (p = 0.3).

The entire circumference of the rectum could be examined in 66% of the patients (n = 106) in the dorsal
group and in 79.5% of the patients (n = 128) in the lateral group (p = 0.007).
Conclusion: The intergroup difference in terms of digital rectal examination completion rate was not
significant. In the lateral position, however, the entire circumference of the rectum could be examined
more thoroughly.

. Introduction

Digital rectal examination (DRE) is an essential tool for obtain-
ng important information in the diagnosis and management of
ectal cancer and other diseases, such as dyssynergic defecation,
aecal incontinence, anal pain, functional anorectal disorders, and
istal haemorrhage. DRE still has an important role in determin-

ng the application of preoperative treatments, sphincter-saving

rocedures, or a “watch and wait” policy

[

1–3]. The procedure is
erformed by physicians on a daily basis. For the evaluation of rec-
al tumours, DRE can be performed with the patient lying in the

∗ Corresponding author at: Department of Digestive Surgery, Amiens North Hos-
ital, University of Picardy Medical Centre, Place Victor Pauchet, F-80054 Amiens
edex 01, France. Tel.: +33 322 668301; fax: +33 322 668680.

E-mail address: regimbeau.jean-marc@chu-amiens.fr (J.-M. Regimbeau).

ttp://dx.doi.org/10.1016/j.dld.2014.08.045
590-8658/© 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All

lateral or the dorsal position. Despite the DRE’s importance in the
screening of rectal cancer, little is known about the best way to
perform this procedure. Furthermore, the factors that may influ-
ence the ability to perform a complete DRE have been studied for
prostate cancer [4] but not for rectal cancer.

The patient’s position for a DRE appears to depend mainly on
the physician’s usual practice, however this parameter has not been
studied in a clinical trial.

To determine the best position for DRE, we chose the prostate
as a single landmark for an objective and reproducible reference
feature. Hence, to allow for the best possible rectal examination,
we only included men who had not undergone prostatectomy and
who were free of rectal disease.

The objective of the present randomized, controlled trial in
tumour-free subjects was to evaluate the best position for per-
forming a thorough examination of the distal part of the rectal
tube.

rights reserved.

dx.doi.org/10.1016/j.dld.2014.08.045

http://www.sciencedirect.com/science/journal/15908658

http://www.elsevier.com/locate/dld

http://crossmark.crossref.org/dialog/?doi=10.1016/j.dld.2014.08.045&domain=pdf

mailto:regimbeau.jean-marc@chu-amiens.fr

dx.doi.org/10.1016/j.dld.2014.08.045

Liver

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C. Sabbagh et al. / Digestive and

. Patients and methods

.1. Study overview

Patients were enrolled in two centres in France (Amiens and
eauvais). The study was coordinated by the Department of Diges-
ive and Oncologic Surgery at the Amiens University Hospital. The
tudy protocol has been approved by the French National Com-
ittee for Data Protection in Medical Research (Comité Consultatif

ur le Traitement de l’Information en Matière de Recherche dans le
omaine de la Santé, Paris, France; reference 12.155) and the local

ndependent ethics committee (Comité de Protection des Person-
es Nord-Ouest II, Amiens, France; reference CPP-SC-2011/06).

The above committees decided that the present non-
nterventional study did not require written informed consent from
he participants. All patients were provided with verbal informa-
ion on the study’s protocol and the objectives. This study was
egistered on ClinicalTrials.gov (reference: NCT01727388) after
pproval of the protocol by the ethics committees, but before inclu-
ion of the first patient.

.2. Patients

The main inclusion criteria were the following: male patients
ged 18 years or more and requiring a DRE during an outpatient
xamination for colon or upper rectal cancer, colon surgery for

benign disease, hernia surgery, or blood in the stools. Patients
ho had undergone surgery or were scheduled for surgery were

ncluded. The main exclusion criteria were the following: a history
f diseases that could interfere with the interpretation of the DRE
esults (middle and lower rectal cancer, or other anal diseases).

omen were excluded as the prostate was used to evaluate the
eight of the examination. Patients with restricted mobility or with
revious prostatectomy were also excluded (Fig. 1).

.3. Study procedures

The study was performed at each hospital’s outpatient clinic. At
ach centre, two rooms were available and each room had a net-
orked computer and an examination table. The table was disposed

Fig. 1. Flowchart. Distribution

Disease 46 (2014) 1082–1085 108

such that both left-handed and right-handed examiners were able
to perform a complete examination (four examiners were involved,
of whom one was left-handed, and all were consultants, i.e. experts
in rectal examination).

The investigating examiner accessed an online data collection
software package and randomized the patients to the dorsal group
or the lateral group. The examiner then asked the patient to adopt
the position that had been randomly assigned. If the investigator
felt that the information obtained during the examination was not
enough, the patient could be asked to switch to the other posi-
tion. The examination was always performed with latex gloves and
Vaseline.

2.4. Data collection

After the DRE, the examiner (i) entered all the study data online,
and (ii) showed the patient schematic pictures of the two different
positions and asked him in which position he thought he would feel
most uncomfortable (“Which of these two positions do you think
is the most uncomfortable?”).

2.5. Primary and secondary endpoints

The primary endpoint was the proportion of complete DREs in
each group. A complete DRE was defined by three criteria, i.e. it had
to be possible to: (i) examine the rectum as far as the upper border
of the prostate, (ii) examine the entire circumference of the rectum,
and (iii) assess anal sphincter tone according to the Digital Rectal
Examination Scoring System [5]. When any one of these criteria
was not met, the DRE was considered to be incomplete.

The secondary end points were: (i) the patient’s own evaluation
of the DRE position; (ii) each of the three items defining a complete
DRE (in order to determine which item was associated with the
highest proportion of missing data and whether there were inter-
group differences in these items); (iii) the proportion of complete

DREs, as a score in which each of the three items was scored as one
point if achieved and zero if not (i.e. ranging from zero to three);
(iv) risk factors for DRE failure (body mass index (BMI), height, indi-
cation for DRE, and the examiner); (v) the rate of conversion to the

of the study population.

1084 C. Sabbagh et al. / Digestive and Liver Disease 46 (2014) 1082–1085

Table 1
Characteristics of the study groups.

Dorsal group Lateral group p

Number of patients 161 160
Mean age (years) 62.3 ± 13.04 62.7 ± 14.4 0.9
Mean BMIa (kg/m2) 26.2 ± 4.8 27.3 ± 4.2 0.8
Height 172.9 171.9 0.4
Height >180 cm 47.2 52.8 0.5
Examiner % (n) 0.0001

1 27.3 (9) 18.2 (6)
2 80.9 (38) 72.9 (35)
3 27.8 (10) 27.3 (9)
4 32.6 (14) 62.2 (28)

Indications (n) 0.6
Hernia 56 73
Colon 85 68

– Diverticulitis 20 15
– Colon cancer 65 53

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Table 3
Logistic regression assessment of the risk factors for the failure of digital rectal
examination.

Variable p Odds ratio 95% confidence interval

BMI > 30 kg/m2 0.5 0.8 0.46–1.51
Height > 180 cm 0.1 0.6 0.39–1.15
Indication for DRE 0.6 0.9 0.66–1.27
DRE position 0.3 1.25 0.80–1.95
Investigator 0.0001 0.3 0.2–0.95

Other 19 20

a BMI: body mass index.

ther position; and (vi) the impact of the investigator’s habits on
he proportion of complete DREs.

.6. Statistical analysis

We performed a multicentre, randomized, controlled, one-
ided superiority trial with stratification for the examiner and the
atient’s BMI. A total of 320 patients (160 per study group) were
equired to detect a 15% intergroup difference in the proportion
f complete DREs, with a power of 80% and type I error of 5%. We
ypothesized that a complete DRE was possible in 70% of cases in
he lateral group and in 55% in the dorsal group. The analysis was
n intention-to-treat analysis.

Intergroup comparisons were performed with a chi-square test
r Fisher’s exact test (for categorical variables) and a t-test (for
ontinuous variables).

No interim analyses were planned. All statistical analyses were
erformed with SAS software (SAS Institute Inc., Cary, NC, USA).

. Results

Over a 7-month period (between November 2012 and May
013), a total of 321 patients were included in the study (among
60 screened patients) (Fig. 1). No patients refused to enter the
tudy. The two groups were well balanced in terms of their baseline
emographic and clinical characteristics (Table 1).

.1. Primary endpoint

The proportion of complete DREs was 44% (n = 71) in the dorsal
roup and 49% (n = 79) in the lateral group (p = 0.3) (Table 2).

able 2
he proportion of complete digital rectal examinations and the conversion rate.

Dorsal group Lateral group p

Number of patients 161 160
Complete DREa % (n) 44(71) 49 (79) 0.3
Score 0.02

0 0 2
1 47 27
2 43 50
3 71 79

Conversion rate % (n) 10 (16) 12.5 (20) 0.4

a DRE: digital rectal examination.

OR: odds ratio; CI: confidence interval; BMI: body mass index; DRE: digital rectal
examination.

3.2. Secondary endpoints

3.2.1. Patient’s comfort
In the dorsal group, 28.5% of the patients (n = 46) stated that

they would have preferred to change to the lateral position. In the
lateral group, only 4% (n = 6) stated that they would have preferred
to change to the dorsal position (p < 0.0001).

3.2.2. Depth of the DRE
The upper border of the prostate had been identified in 55% of

the patients (n = 89) in the dorsal group and 56% of the patients
(n = 89) in the lateral group (p = 0.9).

3.2.3. Rectal circumference
The entire circumference of the rectum could be studied in 66%

of the patients (n = 106) in the dorsal group and in 80% of the
patients (n = 128) in the lateral group (p = 0.007).

3.2.4. Evaluation of sphincter tone
Sphincter tone could be evaluated in 100% of the patients

(n = 161) in the dorsal group and in 99% of the patients (n = 158)
in the lateral group (p = 0.08).

3.2.5. The “complete DRE” score
There was one significant intergroup difference in terms of

score: more patients had a score of 1 in the dorsal group (29%)
than in the lateral group (17%) (p = 0.02) (Table 2).

3.2.6. Risk factors for DRE failure
Only the identity of the examiner was found to be a risk factor

for DRE failure (odds ratio [95% confidence interval]: 0.3 [0.2–0.95];
Table 3). Also, it should be noted that the investigator with the
longer finger did not have the highest rate of DRE.

3.2.7. Conversion rate
The extent of conversion from one position to the other did not

differ significantly between the two groups. In the dorsal group 10%
of the patients (n = 16) converted to the lateral position to com-
plete the rectal examination, while in the lateral group 12.5% of the
patients (n = 20) converted to the dorsal position (p = 0.4) (Table 2).
No anomalies were found during rectal examination.

3.2.8. Influence of the investigator’s habits on the proportion of
complete DREs

Investigators who usually performed a DRE in the lateral posi-
tion examined 157 patients (78 in the lateral position and 79 in
the dorsal position). The proportion of complete DREs was 47.4%
(n = 37) in the lateral group and 30.3% (n = 24) in the dorsal group
(p = 0.02). Investigators who usually performed a DRE in the dor-

sal position examined 164 patients (82 in the lateral position and
82 in the dorsal position). In this case, the proportion of complete
DREs was 51.2% (n = 42) in the lateral group and 57.3% (n = 47) in
the dorsal group (p = 0.4).

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C. Sabbagh et al. / Digestive and

. Discussion

DRE is a routine procedure and is of importance in the man-
gement of colon and rectal tumours, anorectal diseases (anorectal
anifestations of Crohn’s disease, ulcerative colitis, faecal inconti-

ence, constipation, and haemorrhoids), acute situations (such as
bstruction), and urological diseases (prostate cancer and benign
rostatic hyperplasia). However, it has been reported that 4.3% of
atients refuse to undergo a DRE [6].

Despite the importance of DRE in daily practice and in teach-
ng programmes at medical schools, little is known about the best

ay to perform this procedure. Moreover, it has been shown that
he number of DREs performed each year by a given physician
s correlated (r = 0.37, p < 0.01) with the number of years of clini- al experience (ranging from an average of 29 DREs/year among hysicians within 4 years of graduation to 123 DREs/year among hysicians with more than 20 years of practice). The use of DRE also epends in the physician’s speciality [6–9]. In the present study, we pecifically sought to determine the optimal patient’s position for RE. No specific data are available on the proportion of DREs that re completed. Marshall et al. studied the rate of complete exami- ation of the prostate as a function of the BMI. The authors found hat the prostate could be examined completely in 91.7% of patients ith a BMI below 25 kg/m2, and in 14.3% of those with a BMI above

0 kg/m2 [4]. In view of the lack of robust data in this field, we based
ur hypothesis on our own clinical experience. We did not observe

significant intergroup difference in the DRE completion rate (44%
n the dorsal group and 49% in the lateral position; p = 0.3). One
ould suppose that this lack of difference and the low rate of DRE
ompletion are due to the fact that, first, the primary endpoint is
n arbitrary, composite criterion and, second, that three elements
eeded to be present to define a complete DRE. On the basis of the
riteria used here, no specific recommendations on the best way
o perform a DRE can be made. Nevertheless, our results show that
he lateral position better enabled the examination of the entire
ircumference of the rectum (66% in the dorsal group vs. 80% in
he lateral group, p = 0.007), which is a key element in rectal cancer

anagement. Hence, when examination of the entire circumfer-
nce of the rectum is not possible in the dorsal position, a move
o the lateral position may allow the successful completion of this
rocedure.

Interestingly, we found that 28.5% of the patients in the dor-
al group would have preferred the lateral position, whereas only
% of the patients in the lateral group would have preferred the
orsal position. Thus, randomization had an influence on patient’s

[

Disease 46 (2014) 1082–1085 1085

preference, as significantly more patients in the dorsal group would
have preferred to change position.

Patients preferred not to see the examiner during DRE. Hence,
patients’ preference also argues in favour of performing a DRE in
the lateral position.

The main limitation of the present study is that only men were
included. This point was discussed extensively when the proto-
col was being drafted. We chose a male-only design for this initial
study in order to (i) assess a single landmark (the prostate) in a more
homogeneous population, and (ii) limit the influence of potential
anorectal anomalies (rectocele, prolapse, etc.). Investigation of the
influence of pelvic floor anomalies or rectal cancer is probably nec-
essary.

In conclusion, there was no difference between the dorsal group
and the lateral group in terms of the proportion of complete DREs
(according to our composite criteria). Nevertheless, the lateral posi-
tion was associated with better evaluation of the full circumference
of the rectum and less embarrassment for the patient. Therefore, at
present the lateral position may be preferable.

Conflict of interest
None declared.

References

1] Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postopera-
tive chemoradiotherapy for rectal cancer. New England Journal of Medicine
2004;351:1731–40.

2] Rullier E, Zerbib F, Laurent C, et al. Intersphincteric resection with excision of
internal anal sphincter for conservative treatment of very low rectal cancer.
Diseases of the Colon and Rectum 1999;42:1168–75.

3] Habr-Gama A, Perez RO, Nadalin W, et al. Operative versus nonoperative
treatment for stage 0 distal rectal cancer following chemoradiation therapy:
long-term results. Annals of Surgery 2004;240:711–7 [discussion 7-8].

4] Marshall JB. How adequate is digital rectal exam for prostate cancer screening
at colonoscopy? Can adequacy be improved. Digestive Diseases and Sciences
2008;53:719–22.

5] Orkin BA, Sinykin SB, Lloyd PC. The digital rectal examination scoring system
(DRESS). Diseases of the Colon and Rectum 2010;53:1656–60.

6] Wong RK, Drossman DA, Bharucha AE, et al. The digital rectal examination: a
multicenter survey of physicians’ and students’ perceptions and practice pat-
terns. American Journal of Gastroenterology 2012;107:1157–63.

7] Low-Beer N, Kinnison T, Baillie S, et al. Hidden practice revealed: using task
analysis and novel simulator design to evaluate the teaching of digital rectal
examination. American Journal of Surgery 2011;201:46–53.

8] Eziyi AK, Ademuyiwa AO, Eziyi JA, et al. Digital rectal examination for prostate

and rectal tumour: knowledge and experience of final year medical students.
West African Journal of Medicine 2009;28:318–22.

9] Yeung JM, Yeeles H, Tang SW, et al. How good are newly qualified doctors at digi-
tal rectal examination? Colorectal Disease: The Official Journal of the Association
of Coloproctology of Great Britain and Ireland 2011;13:337–40.

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http://refhub.elsevier.com/S1590-8658(14)00669-0/sbref0030

http://refhub.elsevier.com/S1590-8658(14)00669-0/sbref0035

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http://refhub.elsevier.com/S1590-8658(14)00669-0/sbref0045

What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination…

1 Introduction
2 Patients and methods
2.1 Study overview
2.2 Patients
2.3 Study procedures
2.4 Data collection
2.5 Primary and secondary endpoints
2.6 Statistical analysis
3 Results
3.1 Primary endpoint
3.2 Secondary endpoints
3.2.1 Patient’s comfort
3.2.2 Depth of the DRE
3.2.3 Rectal circumference
3.2.4 Evaluation of sphincter tone
3.2.5 The “complete DRE” score
3.2.6 Risk factors for DRE failure
3.2.7 Conversion rate
3.2.8 Influence of the investigator’s habits on the proportion of complete DREs

4 Discussion
Conflict of interest
References

Sclerosing Adenosis of the Breast: Report of Two Cases
and Review of the Literature
Eleonora Cucci1EF, Angela Santoro2E, Cinzia Di Gesù3E, Renato Di Cerce4F,
Giuseppina Sallustio1

1 Department of Radiology, Catholic University of the Sacred Heart-Foundation for Research and Treatment “John Paul II”,

Campobasso, Italy
2 Department of Anatomic Pathology, Catholic University of the Sacred Heart-Foundation for Research and Treatment

“John Paul II”, Campobasso, Italy
3 Department of Radiotherapy, Catholic University of the Sacred Heart-Foundation for Research and Treatment “John Paul II”,

Campobasso, Italy
4 Department of Oncology, Gynaecologic Oncology Unit, Catholic University of the Sacred Heart-Foundation for Research and

Treatment “John Paul II”, Campobasso, Italy

Author’s address: Eleonora Cucci, Department of Radiology, Catholic University of the Sacred Heart-Foundation for Research
and Treatment “John Paul II”, L.go Agostino Gemelli, n°1, 86100, Campobasso, Italy, e-mail: eleonora.cucci@rm.unicatt.it

Summary
Background: Sclerosing adenosis is a benign, usually asymptomatic lobulocentric proliferative process that

involves both the epithelial and the mesenchymal component of the breast. It is commonly an
incidental finding in perimenopausal women undergoing screening mammography.

Case Report: We reported on two patients with sclerosing adenosis assessed with mammography, ultrasound, and
contrast-enhanced magnetic resonance imaging. Case 1 was a 21-year-old woman with a palpable
lesion in her right breast that was depicted as an irregular mass on contrast-enhanced magnetic
resonance imaging. Case 2 was an asymptomatic 42-year-old woman with suspicious ultrasound
findings in her left breast; contrast-enhanced magnetic resonance imaging showed regional non-
mass-like enhancement associated with increased vascularity. Both patients underwent ultrasound-
guided vacuum-assisted biopsy. Sclerosing adenosis does not have distinctive radiological features
and can mimic a malignant growth process, thus requiring a diagnostic biopsy.

Conclusions: SA is a common, benign, generally asymptomatic proliferative lesion of the breast. It is associated
with a doubling of the risk of developing breast carcinoma, even though its role in carcinogenesis
remains to be elucidated. It does not exhibit distinctive MG, US or even MRI features. Since it may
mimic a carcinoma it requires further investigation with a diagnostic biopsy.

MeSH Keywords: Breast • Fibrocystic Breast Disease • Magnetic Resonance Imaging • Mammography

PDF fi le: http://www.polradiol.com/abstract/index/idArt/892706

Received: 2014.10.10
Accepted: 2014.11.18
Published: 2015.03.07

Background

Sclerosing adenosis (SA) is a benign lobulocentric prolifera-
tive process of the breast that is associated with a doubling
of the risk of developing breast carcinoma [1]. It may be a
component of other benign or malignant proliferative pro-
cesses [2]. It is commonly asymptomatic and is generally
an incidental finding in perimenopausal women undergo-
ing screening mammography (MG), where it can present
as opacity, focal asymmetry, architectural distortion, or

microcalcifications, mimicking a carcinoma [3]. Ultrasound
(US) usually demonstrates no focal abnormality, or it may
show a mass or focal acoustic shadowing without a mass
[4]. On histopathology, its infiltrating-like appearance and
dilated ducts, due to sclerosis, may mimic a carcinoma.

We report on two patients with SA that were assessed with
MG, US, and contrast-enhanced magnetic resonance imag-
ing (CE-MRI).

Authors’ Contribution:
A Study Design
B Data Collection
C Statistical Analysis
D Data Interpretation
E Manuscript Preparation
F Literature Search
G Funds Collection

122

C A S E R E P O R T

Signature:

127

DOI: 10.12659/PJR.892706

Case Report

Case 1

A 21-year-old woman with a family history of breast car-
cinoma underwent lumpectomy for tubular adenoma
(maximum lesion size, 30 mm) in her left breast in 2012.
In October 2013, a self-examination revealed a nodule in
the right breast. US scanning performed at another insti-
tution depicted a hypoechoic area with ill-defined mar-
gins between the upper quadrants of the right breast,
whose maximum size was 40 mm (image not available).
She underwent CE-MRI examination at our institution
with a 1.5 T scanner (Signa Excite HD; GE Healthcare,
Milwaukee, WI, USA) and a dedicated breast coil (GE
4-channel breast array coil). MRI examination disclosed
an irregular mass with spiculated borders between the
upper quadrants of the right breast, measuring 23 mm
(antero-posterior diameter) ×20 mm (longitudinal diam-
eter) ×23 mm (transverse diameter). The mass exhibited
rim enhancement and predominant type II curves except
for some SA foci which showed early washout (type III
curve). The mass demonstrated intermediate intensity on
T1-weighted images and inhomogeneous hyperintensity on
T2-weighted images (FSE with fat saturation). Diffusion-
weighted imaging (DWI) showed a hyperintense mass with-
out diffusion restriction (Apparent Diffusion Coefficient
[ADC] mass 1.53×10–3 mm2/s vs. ADC corpus mammae
1.45×10–3 mm2/s). MG examination showed a distortion of
breast parenchyma with inhomogeneous density and star-
like appearance, without a radio-opaque nucleus. The lat-
ter finding was best depicted in the mediolateral oblique
view. Six tissue samples were collected in US-guided vacu-
um-assisted biopsy (Ethicon Endo-Surgery, Hamburg) using
an 11-gauge needle. Histolopathological examination dem-
onstrated fibrocystic breast tissue where an SA lesion was
associated with columnar cell metaplasia/hyperplasia and
subacute-chronic inflammation at both intra- and extra-
ductal sites also involving histiocytes (Figure 1A–1E).

Twelve months after breast biopsy the lesion is clini-
cally and radiologically stable, without signs of malignant
change.

Case 2

In December 2013, a 42-year-old woman with a family his-
tory of breast carcinoma underwent CE-MRI at our insti-
tution to investigate an asymptomatic non-nodular hypo-
echoic area associated with some microcysts found by
US in the superomedial quadrant of the left breast (image
not available) while MG performed at the same time was
negative. CE-MRI examination showed regional clumped
non-mass-like enhancement in the superomedial quad-
rant of the breast (maximum axial diameters, 4×16 mm,
longitudinal diameter, 18 mm) and time-signal intensity
curves type I and II. On T2-weighted images (FSE with
fat saturation), only some microcysts whose maximum
size was 5 mm could be visualized at the site of the non-
mass-like enhancement, whereas DW sequences showed
slight diffusion restriction (ADC lesion 1.32×10–3 mm2/s vs.
ADC corpus mammae 1.78×10–3 mm2/s). Asymmetrically
increased vascularity was also noted in the same area.

Histolopathological examination of 6 tissue samples col-
lected in US-guided vacuum-assisted biopsy (Ethicon Endo-
Surgery) using an 11-gauge needle at our institution dem-
onstrated a complex SA lesion associated with epithelial
proliferation that was reminiscent of usual ductal hyper-
plasia (UDH) including florid and papillary aspects as well
as columnar cell metaplasia/hyperplasia with evidence of
flat epithelial atypia (Figure 2A–2E).

At 9 months, the lesion is sonographically stable and has
not undergone malignant transformation.

Discussion

SA is a benign proliferative lesion of the breast that is
found in 27.8% of benign biopsies and in 3.1% of breasts in
post-mortem studies [1,3].

It is more common in perimenopausal women; in those
with a strong family history (at least one 1st-degree rela-
tive, or 2 or more relatives [with at least one of 1st degree]
developing breast carcinoma by the age 50 years); in those
undergoing postmenopausal hormone therapy, and among
multiparous women [1].

Its causes are unknown. Haagensen defined SA as “a phe-
nomenon of the menstrual phase of life”, suggesting that
oestrogens induce the epithelial proliferation that predis-
poses to the development of adenosis and other epithelial
tumours [3].

SA is frequently asymptomatic and is an incidental finding
on mammographic screening or histopathological examina-
tion performed for other reasons, where it is detected as a
focal or diffuse lesion [3,5].

When it presents as a palpable mass, it is defined as “nod-
ular sclerosing adenosis” or “adenosis tumour”; this vari-
ant is generally found in patients with a broader age range,
where most women are aged 30 to 45 years [3].

Histologically it is a complex lobulocentric lesion charac-
terized by enlarged, distorted lobules containing duplicated
and crowded acini (ductuli) whose luminal epithelial and
myoepithelial components and basal membrane are how-
ever preserved [1]. Stromal fibrosclerosis involves at least
half of the terminal duct lobular unit (TDLU), which is
elongated, distorted and compressed by the sclerosis [6].
Lesion extension ranges from microscopic foci smaller than
a normal lobule to a confluent process where the marked
cellularity and the involvement of both the epithelial and
the mesenchymal compartment mimic a carcinoma on
gross and microscopic examinations. The preserved lobular
architecture that can be appreciated at low magnification
is useful in the differential diagnosis from carcinoma, even
though SA may extend to adipose tissue or even invade per-
ineural structures [2,7]. At high magnification, identifica-
tion of myoepithelial cells and the intact basal membrane
allow confirmation of the non-invasive nature of the pro-
cess. In cases where the extensive sclerosis hampers iden-
tification of the myoepithelial layer, immunohistochemi-
cal assays (p63, calponin, a-SMA, CD10, SMMHC, CK14)
confirm the benign nature of the lesion [7]. SA should also

123

Figure 1. Radiological and histopathological features of case 1, right breast. (A) Right mediolateral oblique view: distortion of breast parenchyma
between the upper quadrants showing inhomogeneous density and star-like appearance, but no radio-opaque nucleus. (B, C) Irregular
mass between the upper quadrants exhibiting heterogeneous hyperintensity in sagittal T2-weighted images (FSE with fat saturation)
(B) and hyperintensity on DW (Diffusion Weighted) sequences (b value 600 s/mm2) without diffusion restriction (C). (D) Irregular mass
with spiculated margins showing rim enhancement and persistent enhancement in the sagittal subtraction images obtained before and
after contrast medium administration. (E) Histopathological examination: fibrocystic breast tissue with a sclerosing adenosis lesion and
columnar cell metaplasia/hyperplasia.

E
Case Report

124

be differentiated histologically from radial scar, which is
characterized by a more extensive sclerosis process and a
fibroelastotic core [6].

Albeit defined as a benign proliferating lesion, SA is a risk
factor for the development of breast carcinoma. In their

A D

B
C
E

Figure 2. Radiological and histopathological features of case 2, left
breast. (A) Regional clumped non-mass-like enhancement
in the superomedial quadrant in the subtraction image
obtained before and after contrast medium administration.
(B) Only a few microcysts are depicted at the site of the
non-mass-like enhancement in the sagittal T2-weighted
image (FSE with fat saturation). (C) At the same site, DW
(Diffusion Weighted) sequences (b value 600 s/mm2) show
an area of inhomogeneous hyperintensity with diffusion
restriction. (D) MIP (maximum intensity projection) image
showing non-mass-like enhancement associated with
asymmetrically increased vascularity. (E) Histopathology:
complex sclerosing adenosis lesion associated with usual
ductal hyperplasia (UDH) and florid UDH.

125

study of the biopsies of 13,434 patients with benign lesions
collected from 1967 to 2001 (follow-up 15.7 years), Visscher
and colleagues [1] found SA in 3,733 patients (27.8%).
They calculated that their standard incidence ratio (SIR)
of developing carcinoma was 2.10 compared with 1.52 in
9,701 women without SA, entailing a double risk of devel-
oping breast carcinoma that was in line with earlier stud-
ies [3,8].

SA may be associated with benign lesions (cystic changes,
apocrine metaplasia, fibroadenoma, intraductal papilloma)
as well as malignant changes (carcinoma in situ, invasive
ductal carcinoma) [5]. It is also commonly found in biopsy
tissue showing columnar cell changes and atypical hyper-
plasia, either ductal or lobular [1].

Although according to some studies [1,3] the simultane-
ous presence of SA lesions and other benign prolifera-
tive changes with or without atypia would not affect the
stratification of the risk of developing invasive carcinoma,
Oberman and co-workers found that women in whom SA
was associated with atypical hyperplasia had a 2.1-fold
risk of developing carcinoma compared with a 1.7-fold risk
when women with atypical hyperplasia were excluded [8].
Tavassoli and colleagues examined 82 patients with atypi-
cal ductal hyperplasia and found that 17% of those who had
SA went on to develop invasive carcinoma compared with
4% of those without SA [2].

SA may coexist with a lobular or ductal carcinoma, inva-
sive or in situ. The carcinoma may originate from or close
to the SA focus, resulting in secondary infiltration [9].
According to Ogura and colleagues, ductal carcinoma in
situ arising in the SA area often exhibits bilateral biological
features, is of non-comedo type and HER2-negative [9].

On MG, SA may present as a focal or diffuse lesion with a
variety of patterns that include microcalcifications, opaci-
ties (with well-defined, ill-defined or spiculated margins),
focal asymmetry, and architectural distortion [4].

Gunhan-Bilgen and co-workers assessed the mammograph-
ic and sonographic features of 43 SA and found that 81%
(35/43) were detected on MG as microcalcifications (55.8%),
opacity (11.6%), focal asymmetry (6.9%), and architectural
distortion (6.9%) [3]. Taskin and colleagues [5] examined the
MG features of 41 benign lesions in which SA was the main
diagnosis; 90% were visualized on MG as opacity (39%),
microcalcifications (39%), architectural distortion (7.3%),
and focal asymmetry (4.7%).

SA may be associated with intralobular microcalcifications
– punctate, powdery, amorphous or pleomorphic – that are
more often clustered than diffused [5,10,11].

When it presents as a spiculated opacity, SA enters into
differential diagnosis with other spiculated lesions, either
benign (surgical scar, radial scar, fat necrosis, tuberculosis)
or malignant (ductal carcinoma in situ; tubular carcinoma,
invasive lobular or ductal carcinoma) [6]. Even though car-
cinoma tends to have a more radio-opaque nucleus, it is
not easy to differentiate between the two diseases.

US often fails to depict a focal abnormality, even though in
a few cases it demonstrates a circumscribed mass or focal
acoustic shadowing. In the study by Gunhan-Bilgen and
colleagues, 44.2% of SA lesions were depicted on US: 77.9%
presented as a mass (63.1% with irregular margins; 15.8%
as a well-circumscribed mass) and 21% as focal acoustic
shadowing without a mass [3]. In the study by Taskin and
colleagues, 56.1% of the lesions where SA was the main
component were depicted on US as a mass in 78.3% of cases
(43.5% with well-defined margins; 26.1% with ill-defined
margins; 8.7% with spiculated margins); as acoustic shad-
owing/focal heterogeneity without a mass in 17.4%, and as
a cluster of microcalcifications in 4.3% [5].

SA does not seem to present distinctive features on
CE-MRI. Lesions may be depicted as ductal enhancement
or as a homogeneously-enhancing oval or round mass with
lobulated or angular margins showing rapid early enhance-
ment and delayed persistent or washout kinetics [12].

Oztekin and co-workers described a case of bilateral SA
whose clinical presentation was that of multiple palpable
masses depicted on MRI as round, oval, or lobulated masses
with smooth borders, intermediate signal intensity on T1-
and T2-weighted sequences and type I and III curves [13].

Conclusions

SA is a common, benign, generally asymptomatic prolifera-
tive lesion of the breast. It is associated with a doubling
of the risk of developing breast carcinoma, even though its
role in carcinogenesis remains to be elucidated. It does not
exhibit distinctive MG, US or even MRI features. Since it
may mimic a carcinoma, it requires further investigation
with a diagnostic biopsy.

Conflict of interest

The authors declare that they have no conflict of interest to
the publication of this article.

1. Visscher DW, Nassar A, Degnim AC et al: Sclerosing adenosis and risk
of breast cancer. Breast Cancer Res Treat, 2014; 144: 205–12

2. Gill HK, Ioffe OB, Berg WA: When is a diagnosis of sclerosing
adenosis acceptable at core biopsy? Radiology, 2003; 228: 50–57

3. Gunhan-Bilgen I, Memis A, Ustun EE et al: Sclerosing adenosis:
mammographic and ultrasonographic findings with clinical and
histopathological correlation. Eur J Radiol, 2002; 44: 232–38

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4. Pojchamarnwiputh S, Muttarak M, Na-Chiangmai W, Chaiwun
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5. Taskin F, Koseoglu K, Unsal A et al: Sclerosing adenosis of the breast:
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6. Cyrlak D, Carpenter P, Rawal NB: Breast imaging case of the day.
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Case Report

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7. Lawton TJ: Breast. Cambridge: Cambridge University Press; 2009;
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