Disorders of the breast in children and adolescents, Part 2: breast masses

Management of Pediatric Breast Masses for the Pediatric Surgeon: Expert Consensus Recommendations From the APSA Cancer Committee

BACKGROUND

The pathology and management of breast masses in pediatric patients is markedly different than in adults. The vast majority of lesions in children and adolescents are benign, but the rare malignant breast masses require prompt recognition and treatment. Pediatric surgeons navigating clinical evaluation of these masses must balance preservation of the developing breast with appropriate diagnosis and surgical management.

METHODS

The current English language literature was queried for pediatric and adolescent breast masses. Identified manuscripts were reviewed and classified by level of evidence. Based on these results, as well as expert consensus, an algorithm regarding clinical workup and management was established.

RESULTS

Evaluation of pediatric breast masses begins with a thorough history and physical exam. Palpable masses should then be further characterized using an ultrasound-guided algorithm. In select cases, observation without surgical resection is appropriate. Surgical management of presumed benign lesions, when performed, should prioritize conserving developing breast tissue and the nipple areolar complex. Excisional biopsy is preferable to core needle biopsy when technically feasible. Surgical management of malignant lesions varies depending on the type of malignancy.

CONCLUSION

Pediatric surgeons are often the first point of contact after identification of a breast mass in a pediatric or adolescent patient, and therefore play a critical role in management. Based on literature review and expert consensus, we propose an algorithm to guide pediatric surgeons in the diagnosis and treatment of these predominantly benign lesions. For the rare malignant lesions, a multi-disciplinary team approach is recommended to optimize patient care.

LEVEL OF EVIDENCE: 5

Disparities in the Management of Pediatric Breast Masses

INTRODUCTION

Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass.

METHODS

A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses.

RESULTS

A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis.

CONCLUSIONS

We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Homogeneous blue lumps of the nipple-areola complex in pubertal girls

Retroareolar cysts are benign breast lesions caused by the obstruction and consequent dilatation of Montgomery tubercles. Herein, we report two cases of premenarchal girls who developed retroareolar cysts. Their course and differential diagnosis are discussed.

Use of breast imaging-reporting and data system (BI-RADS) ultrasound classification in pediatric and adolescent patients overestimates likelihood of malignancy

BACKGROUND/PURPOSE

Breast masses in the pediatric population cause patient and family concern, partially driven by public awareness of adult breast cancer. However, the spectrum of breast masses in children differs greatly from that in adults, and malignancy is exceedingly rare. The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) ultrasound-based classification system is the diagnostic standard, yet no study has validated BI-RADS in pediatric patients. This study compares BI-RADS classification with histologic diagnoses to evaluate BI-RADS validity in pediatric patients.

METHODS

Multicenter retrospective evaluation of breast masses in patients under 21 years. Ultrasound reports were compared with histologic diagnoses.

RESULTS

There were 283 patients with breast pathology results after excluding clinical diagnoses of gynecomastia. Mean age was 16.9 (SD 2.3), ranging 10-20 years. 227 had pre-operative ultrasounds, and 84% (191/227) were assigned a BI-RADS category. BI-RADS 4 was the most frequent category (55%, n = 124), by definition predicting 2 - 95% likelihood of malignancy. However, pathology was benign in all patients.

CONCLUSIONS

The current BI-RADS categorization system overestimates cancer risk when applied to pediatric patients. BI-RADS scores should not be assigned to pediatric patients, and BIRADS-defined recommendations for biopsy should be disregarded. A pediatric-specific classification system could be useful.

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.

Cyst of Montgomery: An uncommon adolescent breast lump

Reports of the incidence of the cyst of Montgomery, a rare condition of the breast, affecting mainly adolescent female, are scarce in the literature. This cyst develops from an obstruction of the small papular projections at the edge of the areola called Montgomery tubercles. It could be a simple asymptomatic mass or an inflamed symptomatic mass. We report two cases encountered this year. The first case was a 15-year-old female who complained of bilateral breast pain and a right breast mass. Laboratory tests were unremarkable. A diagnosis of noninflamed Montgomery cyst based on clinical and sonographic examination was made. An antibiotic was recommended. The second case was a 13-year-old female who complained of pain and swelling with redness in the right breast. Laboratory tests were unremarkable. Sonographic examination revealed a right retroareolar cyst containing turbid echogenicity with surrounded hyperemia. A diagnosis of inflamed Montgomery's cyst was made. Medical treatment was successful without any surgical intervention. Both patients had favorable outcomes at follow-up visits. This stresses the importance of a proper recognition of the pathology, incidence, diagnosis and management of the cyst of Montgomery in the pediatric age group.

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.

Analysis of factors predicting surgical intervention and associated costs in pediatric breast masses: a single center study

PURPOSE

Finding a breast mass in a child provokes apprehension in parents, especially in those with a family history of breast cancer. Clinicians must decide between serial imaging or biopsy of the mass. Herein, we identify management differences in those with and without a positive family history, as well as identify cost differences.

METHODS

An institutional retrospective review was performed of patients (2-18 years of age) with a diagnosis of breast mass. Patient demographics, presentation, medical and surgical history, physical exam, imaging, and pathologic diagnosis were collected. Cost data were acquired from the pediatric health information system (PHIS). Costs were compared between patients managed by biopsy versus serial ultrasounds. Bivariate analyses including Pearson's Chi-square, student's t tests, and logistic regression were performed.

RESULTS

The probability of biopsy increases with age (p = 0.0001) and female gender (p = 0.006). Biopsy rate is higher for larger masses (p < 0.0001), growing size (p < 0.0001), and in patients with a positive family history of breast cancer (p < 0.0001). The average cost of care for management with initial excisional biopsy was $4491 versus those with serial ultrasounds ($986) (p < 0.0001).

CONCLUSIONS

In patients with small lesions, even with a family history of breast cancer, non-operative monitoring is a safe and cost-effective alternative to invasive biopsy.

Comparison of the Radiologic and Clinical Findings of Adolescents With Breast Complaints

INTRODUCTION

The American College of Radiology's Breast Imaging Reporting and Data System (BI-RADS) was developed to guide imaging-based surgical treatment in patients with breast cancer. Studies confirming the BI-RADS did not include adolescents. To evaluate the validity of this classification system in adolescents, we aim to investigate the relationship between the BI-RADS and pathology findings in adolescents.

METHODS

The medical data of 67 female adolescent patients, aged 12 to 18, referred to our clinic for breast-related complaints between 2013 and 2016 were reviewed retrospectively for demographic data and the results of radiologic and surgical pathologies.

RESULTS

The main underlying reasons for the visit at the clinic were fullness, tenderness, pain, and palpable masses. Of the 67 patients, 46 were enrolled in the study. After breast ultrasonography, patients whose complaints had diminished were subtracted from the follow-up. The mean age of the patients was 16 years (12 to 18 y). The mean mass diameter size was 3.69 cm (0.9 to 15 cm), and the mean clinical follow-up was 65.3 days (11 to 1095 d). All the patients who were surgically intervened had benign pathology. Of the 21 surgically intervened patients with BI-RADS levels of ≥3, most had fibroadenomas.

CONCLUSIONS

The BI-RADS classification-based treatment algorithm may not be valid in adolescents. In the present study, all patients with lesions with BI-RADS ≥3 levels had revealed benign pathologies. The BI-RADS classification may show an increased risk. However, to determine the need for a biopsy in adolescents, there is a need for larger-scale pediatric and adolescent studies using the BI-RADS classification.

Primary rhabdomyosarcoma of the breast in a 17-year-old girl: Case report

RATIONALE

Primary rhabdomyosarcoma of the breast is very rare disease with poor prognosis and no definitive treatment has yet been established.

PATIENT CONCERNS

A 17-year-old girl presented with right breast mass without distant metastasis in image study.

DIAGNOSIS

The result of core needle biopsy was intraductal carcinoma; however, histopathologic finding after mastectomy was primary rhabdomyosarcoma of breast.

INTERVENTIONS

Adjuvant chemotherapy was recommended because resection margin was involved by tumor cells, but she did not visit the clinic anymore. Five months later, tumor recurred with local invasion and chemotherapy of vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide (VAC/IE) was done.

OUTCOMES

In the course of chemotherapy and sequential follow-up, there was no tumor growth until now.

LESSONS

Primary breast rhabdomyosarcoma is an uncommon disease, as a result diagnosis is often delayed. For the same reason, there is little information about treatment. This report may be helpful for managing the disease.

A prepubertal giant juvenile fibroadenoma in a 12-year-old girl: Case report and brief literature review

•

Giant juvenile fibroadenomas are very rare and they have very low prevalence in prepubertal period. Although they should not be ruled out in differential diagnosis in premenarchal period.

•

Breast examination in premenarchal girls and adolescents plays a pivotal role in order to prevent these peculiar giant lesions.

•

Another remarkable point is the rapid growth of these breast lesions that should not be ruled out in the diagnostic process of the continuously growth of the adolescent breast.

Introduction

Giant juvenile fibroadenomas represent only the 0.5% of all fibroadenomas, constituting a rare condition in adolescence. In prepuberty, the presence of this condition is extremely rare.

Presentation of case

We describe a rare case of a 12- year-old Caucasian girl who presented to our Hospital complaining of a palpable mass with rapid enlargement in her right breast that she had first noticed 3 months ago. Her menarche hadn’t occurred yet.

Discussion

Physical examination showed a giant mass of 15 × 13 cm in the right breast. The patient was further evaluated via ultrasonography showing a sole large lesion of 13 × 12 cm in the right breast. A surgical procedure under general anesthesia was performed. Histopathological findings after the surgical excision were suggestive of giant juvenile fibroadenoma. The patient has a normal breast development over a period of 9 month follow up.

Conclusion

Giant juvenile fibroadenomas should be included in differential diagnosis of a breast mass in prepubertal girls despite the fact that they are very rare in prepuberty, tend to appear later during adolescence and their prevalence is lower in Caucasians. The remarkable size and the rapid growth of the lesion should not be ruled out in the diagnostic process of an adolescent breast.

A clinical approach to benign breast lesions in female adolescents

The female breast undergoes two phases of growth and differentiation. The first occurs during fetal life and results in the formation of simple branched ducts, which are able to respond to the hormonal stimuli of maternal origin. The second period of growth occurs at puberty, when the ducts elongate, divide, and form terminal duct lobular units. Breast pathology during adolescence is usually benign and therefore management has to be mostly conservative. Familiarity with the spectrum of breast pathology in this age group is essential. Ultrasound is the imaging modality of choice. Open surgical biopsies can damage the developing breast and therefore availability and expertise with fine needle aspiration biopsy can circumvent this problem. (www.actabiomedica.it)

Benign Breast Diseases: Evaluation and Management

Benign breast disease is a spectrum of common disorders. The majority of patients with a clinical breast lesion will have benign process. Management involves symptom control when present, pathologic-based and imaging-based evaluation to distinguish from a malignant process, and counseling for patients that have an increased breast cancer risk due to the benign disorder.

Primary Pediatric Breast Lesions: Comparing the Prevalence of Malignancies in the Middle East with North America; Review of 1031 Cases

Benign breast masses are uncommon but are becoming more recognized among the pediatric population. Malignant breast lesions are very rare. The aim of our study was to review and compare the demographics, clinical presentation, treatment, and outcomes of breast lesions, including primary malignancies, and to discuss theories that may explain why there is an increased rate of breast cancers diagnosed at a younger age in the Egyptian population. A total of 1031 cases were reviewed. Comparisons were made between the Egyptian (n = 846) and US (n = 185) cohorts. There were 30 (3.5%) malignant tumors in the Egyptian group with 17 (2%) deaths versus 3 (1.6%) malignant tumors in the US group with 2 (1%) deaths (p = 0.247). The relative risk of breast cancer in the Egyptian group was 2.16 (95% confidence interval (CI): 0.67-7.01) compared with the US group. The trend for increased risk of breast cancer in Egypt may be due to delayed diagnosis because of decreased awareness.

Analysis of surgically excised breast masses in 119 pediatric patients

PURPOSE

Breast masses in children and adolescents are uncommon and the vast majority are benign. There are currently limited analyses of breast masses in this population and clinical management is highly variable between institutions and providers. The purpose of our study is to analyze the demographics, pathology and management of 119 pediatric patients with breast masses; one of the largest studies to date.

METHODS

We performed a retrospective review of patients who underwent excision of a breast mass at a single pediatric center from June 2009 to November 2013. Demographics, imaging, pathology and management were reviewed.

RESULTS

Average patient age was 15.3 years, average mass size was 3.15 cm and 20.3 % had a family history of breast cancer. 68 % of patients had pre-operative ultrasound, and 31.9 % underwent a period of observation. The most common indication for resection was patient and family anxiety. All masses were benign, with fibroadenoma being the most common histopathology (75.2 %).

CONCLUSIONS

In our cohort there were no cases of malignancy. Only 31.9 % of patients underwent some form of observation and patient or family anxiety was the most common indication for proceeding with surgery. This suggests that patient anxiety may result in unnecessary operation. Our data may help reassure patients, families and providers that the risk of malignancy is low and could help develop more optimal management strategies.

Recurrent Bilateral Giant Fibroadenomas of the Breasts

We present a case of an 18-year-old woman with recurrent bilateral giant fibroadenomas that were evaluated by mammography and sonography with color Doppler. Imaging revealed solid lobulated masses with significant internal vascularity occupying most of each breast; this evaluation suggested a differential diagnosis of giant fibroadenoma versus phyllodes tumor. The unusual clinical story of recurrent bilateral lesions as reported by the patient, coupled with the findings on visualization of these lesions by mammography and ultrasound with color Doppler, led to the clinical decision to forego biopsy in favor of immediate bilateral surgical enucleation.

[Exploring a non-inflammatory clinical breast mass: Clinical practice guidelines]

PURPOSE

The aim of the study was to assess the diagnostic value of physical examination, radiologic explorations and percutaneous procedures of the breast in the exploration of a non-inflammatory palpable mass, in order to propose guidelines.

METHOD

A systematic literature review was conducted in the Medline and Cochrane library databases. International guidelines in French and English language were also consulted until April 30th 2015.

RESULTS

Physical examination of a non-inflammatory palpable breast mass is not sufficient to eliminate a breast cancer (LE2). Mammography alone has a sensitivity between 70 and 95% for the diagnosis of breast cancer (LE3). Echography alone has a sensitivity of 98 to 100% for the diagnosis of breast cancer (LE2). The core needle biopsy has a better sensitivity and specificity than the fine-needle aspiration for breast cancer diagnosis (LE2). The association of mammography and 2D echography presents excellent sensitivity and negative predictive value (close to 100 %) to exclude a breast cancer (LE3). A double evaluation using mammography and echography is recommended in the exploration of a non-inflammatory palpable breast mass (grade B).

Breast Imaging-Reporting and Data System (BI-RADS) classification in 51 excised palpable pediatric breast masses

INTRODUCTION

The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) classification was developed to risk stratify breast lesions and guide surgical management based on imaging. Previous studies validating BI-RADS for US do not include pediatric patients. Most pediatric breast masses present as palpable lesions and frequently undergo ultrasound, which is often accompanied with a BI-RADS classification. Our study aimed to correlate BI-RADS with pathology findings to assess applicability of the classification system to pediatric patients.

METHODS

We performed a retrospective review of all patients who underwent excision of a breast mass at a single center from July 2010 to November 2013. We identified all patients who underwent preoperative ultrasound with BI-RADS classification. Demographic data, imaging results, and surgical pathology were analyzed and correlated.

RESULTS

A total of 119 palpable masses were excised from 105 pediatric patients during the study period. Of 119 masses, 81 had preoperative ultrasound, and BI-RADS categories were given to 51 masses. Of these 51, all patients were female and the average age was 15.9 years. BI-RADS 4 was given to 25 of 51 masses (49%), and 100% of these lesions had benign pathology, the most common being fibroadenoma.

CONCLUSIONS

Treatment algorithm based on BI-RADS classification may not be valid in pediatric patients. In this study, all patients with a BI-RADS 4 lesion had benign pathology. BI-RADS classification may overstate the risk of malignancy or need for biopsy in this population. Further validation of BI-RADS classification with large scale studies is needed in pediatric and adolescent patients.

Management of pediatric and adolescent breast masses

Breast masses in children and adolescents are uncommon and most often benign. Occasionally, however, they require surgical intervention for lifestyle limiting symptoms or malignant potential. These masses are best evaluated with physical exam and ultrasound. Breast masses likely to be encountered by the surgeon in the pediatric and adolescent population include intraductal papillomas, phyllodes tumors, primary breast cancer, and metastatic lesions. Unlike adults, pediatric and adolescent breast cancer tends to be of the secretory variety and typically have less metastatic potential. However, cases of inflammatory and medullary breast cancers have also been reported in girls and appear more aggressive. Radiation exposure during breast development is a risk factor to subsequent development of breast cancer. Surgical objective for a concerning pediatric and adolescent breast mass is complete resection while preserving normal breast development, when appropriate. The need for routine axillary dissection for malignant cases in children appears unnecessary from the limited data available, and the authors favor sentinel lymph node sampling and reserve axillary dissection for positive lymph nodes.

Diagnosis and management of retroareolar cysts in adolescents: a case report

Retroareolar cysts are a rare condition of the adolescent female breast and their reported incidence in the literature is scarce. Arising from obstruction of the terminal channels that drain Montgomery's areolar tubercles retroareolar cysts comprise two different pathological entities; symptomatic and asymptomatic. We report on a case of a symptomatic retroareolar cyst in a 15-year-old girl and review the literature. We highlight the subtle clinical differences from other adolescent breast masses, describe the natural course of the condition and with respect to diagnosis detail the correlation between clinical features and characteristic sonographic findings. Finally, we highlight the importance of preserving the developing breast bud by adopting a conservative approach to the management of retroareolar cysts.

Endoscopic specimen pouch technique for removal of giant fibroadenomas of the breast

Giant (juvenile or cellular) fibroadenoma of the breast is the most common tumor that present in adolescent girls. As benign tumors that can exceed 10 cm in diameter, giant fibroadenomas have historically necessitated large incisions to remove these masses, resulting in large unsightly scars. We describe the novel use of an endoscopic specimen pouch to facilitate the removal of these large tumors through minimal incisions in 3 patients. In follow-up, all 3 patients have had excellent cosmetic outcomes, no recurrences, and no postoperative complications.

Giant fibroadenoma of the breast in adolescents: report of 2 cases

Giant fibroadenoma (GF) is an uncommon variant of fibroadenomas that represent the most frequent breast lesion in adolescents and young women. The authors present 2 cases of GF of the breast in girls aged 12 and 14 years, and the respective diagnostic workup and conservative surgical treatment. Giant fibroadenomas are benign tumors, but their rapid growth and large size together with their rarity may determine difficulties in the clinical approach. Moreover, GF must be excised in all cases to exclude a phyllodes tumor and to prevent later deformity.