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Schwartz D, Tracy ET, Naik-Mathuria B, Glick RD, Polites SF, Mattei P, Rodeberg D, Espinoza AF, Mansfield SA, Lal DR, Kotagal M, Lautz T, Aldrink J, Rich BS. Management of Pediatric Breast Masses for the Pediatric Surgeon: Expert Consensus Recommendations From the APSA Cancer Committee. J Pediatr Surg 2024:161916. [PMID: 39384492 DOI: 10.1016/j.jpedsurg.2024.161916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 08/29/2024] [Accepted: 09/06/2024] [Indexed: 10/11/2024]
Abstract
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
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Affiliation(s)
- Dana Schwartz
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, UNC University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA
| | - Bindi Naik-Mathuria
- Division Chief of Pediatric Surgery, University of Texas Medical Branch, 301 8th St 7th Floor, Galveston, TX, 77555, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Northwell Health, Cohen Children's Medical Center, 1111 Marcus Ave, New Hyde Park, NY, 11042, USA
| | - Stephanie F Polites
- Division of Pediatric Surgery, Mayo Clinic College of Medicine and Science, 200 1st St SW Rochester, MN, 55905, USA
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, USA
| | - David Rodeberg
- Division of Pediatric Surgery, University of Kentucky Medical College, Kentucky Children's Hospital, 800 Rose Stree 4th Floor, Lexington, KY, 40536, USA
| | - Andres F Espinoza
- Baylor College of Medicine, 6501 Fannin St, NB302, Houston, TX, 77030, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Wisconsin, 8915 W Connell Ct, Milwaukee, WI, 53226, USA
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Timothy Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL, 60611, USA
| | - Jennifer Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Barrie S Rich
- Division of Pediatric Surgery, Northwell Health, Cohen Children's Medical Center, 1111 Marcus Ave, New Hyde Park, NY, 11042, USA
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Guirguis MS, Arribas EM, Kapoor MM, Patel MM, Perez F, Nia ES, Ding Q, Moseley TW, Adrada BE. Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex. Radiographics 2024; 44:e230113. [PMID: 38483829 DOI: 10.1148/rg.230113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Mary S Guirguis
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Elsa M Arribas
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Megha M Kapoor
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Miral M Patel
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Frances Perez
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Emily S Nia
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Qingqing Ding
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Tanya W Moseley
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Beatriz E Adrada
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
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Makineli S, Vriens MR, Witkamp AJ, van Diest PJ, Moelans CB. The Diagnostic Value of microRNA Expression Analysis in Detecting Intraductal Papillomas in Patients with Pathological Nipple Discharge. Int J Mol Sci 2024; 25:1812. [PMID: 38339089 PMCID: PMC10855314 DOI: 10.3390/ijms25031812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Patients with pathological nipple discharge (PND) often undergo local surgical procedures because standard radiologic imaging fails to identify the underlying cause. MicroRNA (MiRNA) expression analysis of nipple fluid holds potential for distinguishing between breast diseases. This study aimed to compare miRNA expression levels between nipple fluids from patients with PND to identify possible relevant miRNAs that could differentiate between intraductal papillomas and no abnormalities in the breast tissue. Nipple fluid samples from patients with PND without radiological and pathological suspicion for malignancy who underwent a ductoscopy procedure were analyzed. We used univariate and multivariate regression analyses to identify nipple fluid miRNAs differing between pathologically confirmed papillomas and breast tissue without abnormalities. A total of 27 nipple fluid samples from patients with PND were included for miRNA expression analysis. Out of the 22 miRNAs examined, only miR-145-5p was significantly differentially expressed (upregulated) in nipple fluid from patients with an intraductal papilloma compared to patients showing no breast abnormalities (OR 4.76, p = 0.046), with a diagnostic accuracy of 92%. miR-145-5p expression in nipple fluid differs for intraductal papillomas and breast tissue without abnormalities and, therefore, has potential as a diagnostic marker to signal presence of papillomas in PND patients. However, further refinement and validation in clinical trials are necessary to establish its clinical applicability.
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Affiliation(s)
- Seher Makineli
- Department of Surgical Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (M.R.V.); (A.J.W.)
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Menno R. Vriens
- Department of Surgical Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (M.R.V.); (A.J.W.)
| | - Arjen J. Witkamp
- Department of Surgical Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (M.R.V.); (A.J.W.)
| | - Paul J. van Diest
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Cathy B. Moelans
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
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Alikhassi A, Curpen B. Breast ductography: to do or not to do? A pictorial essay. Insights Imaging 2023; 14:201. [PMID: 37995065 PMCID: PMC10667172 DOI: 10.1186/s13244-023-01547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/21/2023] [Indexed: 11/24/2023] Open
Abstract
Nipple discharge is a frequent breast disease clinical presentation. Although most cases of nipple discharge are physiologic, pathologic nipple discharge is not uncommon. Eight to 15% of pathological nipple discharge is associated with malignancy, requiring investigation. Some specialists believe that ductography is a challenging procedure that is better to be substituted by other methods, such as MRI. However, an experienced physician can perform ductography quickly and easily and still play an essential role in some clinical scenarios. Conventional imaging, such as mammography and sonography, commonly fails to detect the underlying causes of pathological nipple discharge. MRI has limitations of low specificity, cost, lengthy exam duration, accessibility, and patient factors such as claustrophobia. In addition, we can make a specific diagnosis and appropriate treatment by coupling ductography with other methods, such as ultrasound-guided or stereotactic biopsy. This study aims to present the ductography technique, possible findings, and the clinical settings where ductography is useful.Critical relevance statement Although ductography is currently less used in breast imaging, it still plays an essential role in some clinical scenarios. These clinical scenarios include pathological nipple discharge with negative conventional imaging, contraindicated MRI, unavailable MRI, unremarkable MRI results, and multiple MRI findings.Key points• Conventional imaging commonly fails to detect the underlying causes of pathological nipple discharge.• MRI in the setting of nipple discharge has some limitations.• Ductography still plays an essential role in some clinical scenarios.• Coupling ductography with other methods helps make a specific diagnosis.
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Affiliation(s)
- Afsaneh Alikhassi
- Breast Imaging Division, Medical Imaging Department, Sunnybrook Health Sciences Centre, University of Toronto, University of Toronto, 2075 Bayview Avenue, M6, Toronto, ON, M4N 3M5, Canada.
| | - Belinda Curpen
- Breast Imaging Division, Medical Imaging Department, Sunnybrook Health Sciences Centre, University of Toronto, University of Toronto, 2075 Bayview Avenue, M6, Toronto, ON, M4N 3M5, Canada
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