Cytology report: Moderately cellular smears with large, solid, cohesive sheets of epithelial cells with a low degree of overlapping. Clean, hemorragic background. Small, regular, round-oval nuclei with small nucleoli. The aspirate was reported in category C2.

Needle core biopsy report: Hypertrophic lobules some lined with hyperplastic ductal epithelium. Presence of peri-lobular benign stromal proliferation. The NCB was reported in category B2.

Triple assessment:

1. Clinic: negative.
2. Mammography: negative.
3. Ultrasound: suspicious abnormality.
4. Cytology: representative, adequate sample, benign.
5. NCB: representative (?), adequate sample, benign.

Histology report: Pseudo-tumoral adenosis focus 1.5 cm, totally removed.

Further treatment: nihil.