Clinical breast concerns in low-risk pediatric patients: practice review with proposed recommendations

Breast development and disorders in children and adolescents

Breast masses are infrequently encountered in pediatric and adolescent populations. Most breast masses in children are benign entities arising from embryological defects which can be managed once breast development is complete. Diagnostic and management dilemmas arise when fibroepithelial lesions of the breast are seen in clinical practice. Differentiation between a fibroadenoma and a phyllodes tumor is important to guide management. Breast cancer in children under 18 years of age is extremely rare and invasive diagnostic testing and aggressive management is only recommended when clinical suspicion of malignancy is very high. Patient and caregiver counseling plays an important role in the management of these diseases. While adult-onset breast diseases have been studied very closely, there is a dearth of literature on pediatric breast anomalies. This review aims to provide a scoping overview of the available literature on benign, fibroepithelial, and malignant lesions of the breast in pediatric and adolescent populations to help guide physicians and surgeons with decision-making regarding the diagnosis and management of pediatric breast diseases.

Bloody nipple discharge due to intraductal papilloma in an adolescent girl

An early adolescent girl was referred to our breast surgery clinic with multiple right-sided breast masses and several months of unilateral bloody nipple discharge. MRI demonstrated multiple enhancing masses in the right breast with intrinsic hypertensive T1 signal of the ducts extending to the nipple. A biopsy showed partially sclerosed intraductal papillomas without atypia or malignancy. Following extensive counselling with the patient and her family, two palpable breast masses and a single central breast duct responsible for bloody nipple discharge were fully excised. Histopathological analysis showed unique overlapping features of resembling intraductal papilloma, nipple adenoma and fibroadenomas. The patient has had resolution of her bloody nipple discharge and excellent cosmetic outcomes post-surgery. Intraductal papilloma is rare in the adolescent population and the risk of concurrent and future malignancy is not well established. Thus, a tailored approach to the work-up and management of paediatric breast masses is essential.

Use of Diagnostic Imaging Modalities in Modern Screening, Diagnostics and Management of Breast Tumours 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

Breast radiologists and nuclear medicine specialists updated their previous recommendation/guidance at the 4th Hungarian Breast Cancer Consensus Conference in Kecskemét. A recommendation is hereby made that breast tumours should be screened, diagnosed and treated according to these guidelines. These professional guidelines include the latest technical developments and research findings, including the role of imaging methods in therapy and follow-up. It includes details on domestic development proposals and also addresses related areas (forensic medicine, media, regulations, reimbursement). The entire material has been agreed with the related medical disciplines.

Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study

BACKGROUND

The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention.

MATERIALS AND METHODS

A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized.

RESULTS

Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors.

CONCLUSIONS

Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

Breast complaints in children and the effect of family history

BACKGROUND

To evaluate the correlation of physical examination, and radiological and pathological findings of children and adolescents with breast-related complaints.

METHODS

Children and adolescents with breast complaints between January 2016 and December 2019 were analyzed retrospectively.

RESULTS

A total of 118 children and adolescent patients were included. Their ages ranged from 12 to 18 years (median, 16 years). Twenty-one patients had a family history of breast cancer (17.8%). The most common complaints were pain, mass, and nipple discharge. Physical examination revealed mass (41.5%), tenderness (11%), and fullness (8.5%). Thirty-nine patients were classified ultrasonographically with Breast Imaging Reporting and Data System (BIRADS) 3 (39.4%) and four patients were BIRADS 4 (4%). Excision was applied to all patients with BIRADS 4, and 13 of 39 patients with BIRADS 3. Pathological diagnoses of the patients with BIRADS 3 were fibroadenoma (n: 12, 92.3%) and benign phyllodes tumor (n: 1, 7.7%). In patients with BIRADS 4, three patients had fiboradenomas and one patient had a benign phyllodes tumor. No recurrence was observed in any patients who had an excision. Only six of the patients with positive family history had BIRADS 3 lesions, and the others were BIRADS 1. Excision was recommended in two patients and the pathological diagnoses were fibroadenoma.

CONCLUSION

In this age group, the most common complaints were pain and mass, while physical examination was normal in nearly half of the patients. All of the pathological diagnoses were benign. While evaluating the patients in this age range, the experience of the clinician and radiologist is important and we think that it is necessary to increase the awareness of the patient and family about physiological breast development and self-breast examination.

The limited role of ultrasound in the surgical assessment of solid pediatric breast lesions

INTRODUCTION

Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P).

METHODS

A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS.

RESULTS

88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPØ) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPØ 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPØ 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPØ 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing.

CONCLUSION

US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE.

Breast Disorders in Adolescence: A Review of the Literature

Background

Adolescence is accompanied by a variety of changes in young breast development, which greatly affects the adolescent's psychology and socialization.

Summary

PubMed, EMBASE, and the Cochrane Library were searched for studies relative to epidemiology, clinical characteristics, diagnosis, and management of all breast disorders in adolescence and their consequences. Development disorders are breast asymmetry, breast atrophy, breast hypoplasia, hypomastia, juvenile breast hypertrophy, and tuberous breast. Breast congenital abnormalities include athelia, amastia, accessory breast tissue, polymastia, polythelia, and congenital disorders of nipples. Breast infections are commonly caused from Gram-positive coccus rather than Gram-negative bacteria. Breast abscess occurs when breast infections are not promptly treated. Nipple discharge is caused by a variety of conditions and should be managed carefully. Fibrocystic changes, cysts, and fibroadenomas are the most common benign masses in adolescence. Primary, secondary, or metastatic breast cancer is extremely rare in adolescence. However, clinicians should include breast cancer in the differential diagnosis of a breast mass in adolescence.

Key Messages

Clinicians should be aware of all breast disorders that may occur in adolescence. Early diagnosis and treatment will result in the reassurance of adolescents and their families without any detrimental effect on their psychology, sexual behavior, and socialization. Adolescents with breast disorders may require a multidisciplinary approach by a pediatrician, a gynecologist specializing in pediatric-adolescent gynecology, a plastic surgeon, and a psychologist for the best management of breast disorders.

Langerhans cell histiocytosis of an intra-mammary lymph node in an 18-year-old woman

We describe an 18-year-old woman with several month's history of a 12 x 7 mm palpable mammary nodule, that was hypoechoic, with regular margins and vascularization areas by ultrasound. A fibroadenoma was hypothesized (American College of Radiology BI-RADS 3). A 14 G needle biopsy was performed, showing a LC proliferation suspected for LCH of a lymph node, with florid dermatopathic lymphadenopathy in differential diagnosis. The multidisciplinary team of the breast clinic decided to perform a lumpectomy and a diagnosis of LCH involving an intra-mammary lymph node was made. Langerhans cells (LC) are dendritic cells characterized by grooved nuclei, irregular nuclear contours, and abundant cytoplasm, that normally reside in the skin and mucosal surfaces. They were positive for CD1a, langerin/CD207, and S100 by immunohistochemistry. Langerhans cell histiocytosis (LCH) is a clonal proliferation of histiocytes that is thought to be neoplastic in most cases. Reactive LC can be distinguished from LCH by cyclin D1 immunostaining, which is positive only in LCH. About 50% of cases have BRAF V600E mutations. The revised classification of histiocytes divides LCH in subtypes: LCH SS (single system), LCH lung positive, LCH Multiple System/Risk Organ negative and LCH Multiple System/Risk Organ positive. Localized disease can progress to multisystem involvement. The diagnosis of LCH is based on clinical and radiological findings in combination with histopathological, immunophenotypic or ultrastructural analyses identifying tissue infiltration by LC. It is recommended that biopsy confirmation of suspected LCH be performed in all cases. Lymph nodes may be the only site of disease or a part of multisystem involvement by LCH. The histologic differential diagnosis is discussed.

Pediatric and Adolescent Surgical Breast Clinic: Preliminary Experience

STUDY OBJECTIVE

The diagnostic and treatment tools used in breast centers are largely geared to adults, and there is little consideration of the unique characteristics of breast diseases in younger age groups. Herein we report on the preliminary experience of a specialized breast clinic for children and adolescents.

DESIGN

Retrospective, observational.

SETTING

Pediatric Surgical Breast Clinic of Schneider Children's Medical Center of Israel.

PARTICIPANTS

Patients referred to the clinic during the first 18 months of its establishment.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Rate of breast masses, rate of malignancy, and types of evaluation and treatment.

RESULTS

Forty-seven patients aged 0-19 years were referred. Breast masses were suspected in 23/47 (48.9%) and confirmed using ultrasound in 14/47 (29.7%; mean age, 16.4 years), followed by needle core biopsy in 7. Seven patients had multiple masses. Breast Imaging and Reporting Data System scores ranged from 3 to 4b. All cases were treated as fibroadenomas. Four patients underwent surgery because of a large mass (>5 cm; n = 3) or patient's preference to remove the lump rather than follow-up (n = 1). There were no malignancies. The median time from patient identification of the mass until seeking medical help was 5 months.

CONCLUSION

Several findings distinct to this age group were highlighted: high rate of multiple masses, lack of malignancy, and high risk of delayed diagnosis. Care should be taken when using Breast Imaging and Reporting Data System categorization because it was formulated for adults and might be very limited in the adolescent population. Longer-term studies of larger cohorts are planned.

Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease

PURPOSE

Breast masses in pediatric patients are often managed similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients.

METHODS

A multi-institutional retrospective cohort study was completed between 1995 and 2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions.

RESULTS

A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p < 0.25) for decisions made on clinical suspicion alone.

CONCLUSION

Despite literature supporting an observation period for pediatric breast masses, half of patients had an intervention within three months with one out of ten patients undergoing an invasive procedure within this time frame. Furthermore, 81.1% of invasive interventions were unnecessary based on final pathologic findings. A formal consensus clinical guideline for the management of pediatric benign breast disease including a standardized clinical observation period is needed to decrease unnecessary procedures in pediatric patients with breast masses.

Clinicoradiologicial aspects of secretory carcinoma breast: A rare pediatric breast malignancy

Secretory carcinoma (juvenile carcinoma) is one of the very rare breast malignancy reported to be prevalent in pediatric age group. We report imaging and clinicopathological features of secretory carcinoma breast with distant and axillary metastasis, in an 11-year-old girl, who presented with a painful lump in right breast. Ultrasound revealed a well-defined, partially microlobulated hypoechoic mass with skin and pectoralis muscle involvement and a suspicious morphology right axillary lymph node. Color Doppler revealed increased vascularity in both the breast mass and suspicious axillary node. Magnetic resonance imaging helped in better evaluation of pectoralis muscle involvement. Computed tomography (CT) neck, chest, and abdomen revealed multiple fibronodular opacities in bilateral lung fields. 18 Flouro-Deoxy-Glucose Positron Emission Tomography (FDG PET-CT) showed a hypermetabolic retroareolar breast mass with multiple hypermetabolic bilateral lung nodules suggesting lung metastasis. The histopathology confirmed the diagnosis of secretory carcinoma. The patient was offered chemotherapy for 2 years and put on follow-up since then.

A population-based analysis of pediatric breast cancer

PURPOSE

The purpose of this study was to evaluate trends in demographics and outcomes of pediatric breast cancer in a United States population-based cohort.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify all pediatric patients with malignant breast tumors between 1973 and 2014. Analysis was performed using Stata Statistical Software version 13.1. Associations between categorical variables were made using X2 test. Log-rank test was used for univariate survival analysis. Kaplan-Meier analysis investigated five-year survival rates across several variables. Adjusted analysis was performed using a Cox Proportional-Hazards regression.

RESULTS

134 patients with breast malignancies were identified. Carcinoma was the most prevalent histology (48.5%), followed by fibroepithelial tumors (FETs) (35.1%), and sarcoma (14.2%). FETs were twice as common in black compared to nonblack patients (56.3% vs. 29.0%, p < 0.01). Analyzing histology by stage revealed that 100% of FETs were early stage disease (p < 0.0001). 46.7% of the tumors tested were ER/PR negative, more than twice as many compared to the published adult estimate of 20.0%. Unadjusted survival analysis revealed worse survival for patients with adenocarcinoma/sarcomas, advanced stage, and high grade disease, without a survival difference between races.

CONCLUSION

Breast cancer remains a rare malignancy among pediatric patients. Although black patients were found to have more noncarcinomatous tumors with less advanced disease, this did not confer a survival advantage.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

Breast Lesions in Children and Adolescents: Diagnosis and Management

Pediatric breast disease is uncommon, and primary breast carcinoma in children is extremely rare. Therefore, the approach used to address breast lesions in pediatric patients differs from that in adults in many ways. Knowledge of the normal imaging features at various stages of development and the characteristics of breast disease in the pediatric population can help the radiologist to make confident diagnoses and manage patients appropriately. Most breast diseases in children are benign or associated with breast development, suggesting a need for conservative treatment. Interventional procedures might affect the developing breast and are only indicated in a limited number of cases. Histologic examination should be performed in pediatric patients, taking into account the size of the lesion and clinical history together with the imaging findings. A core needle biopsy is useful for accurate diagnosis and avoidance of irreparable damage in pediatric patients. Biopsy should be considered in the event of abnormal imaging findings, such as non-circumscribed margins, complex solid and cystic components, posterior acoustic shadowing, size above 3 cm, or an increase in mass size. A clinical history that includes a risk factor for malignancy, such as prior chest irradiation, known concurrent cancer not involving the breast, or family history of breast cancer, should prompt consideration of biopsy even if the lesion has a probably benign appearance on ultrasonography.