Importance of parental anxiety in management of developmental breast conditions in children: A study with a prospective hierarchical regression model

The parent is the most critical link and decision-maker between the patient and the healthcare provider in treating many pediatric diseases. This entity is essential for the management of pediatric breast diseases for which the rate of surgical intervention is known to be very low. Although previous publications have emphasized that pediatric breast diseases may cause alarming anxiety in parents, the demographic factors that influence this anxiety have not been investigated. Even if practitioners complete patient management with appropriate procedures, treatment is incomplete if the questions remain unanswered. In this observational prospective study, we investigated the demographic factors that affect parental anxiety, which should be prioritized to prevent incomplete management. The Beck Anxiety Inventory score (BAS) created by the parents of 409 boys and girls aged 0 to 17 with breast conditions was recorded at the diagnosis, termination of treatment, and final control stages. A 2-stage hierarchical logistic regression model was applied to show how strongly the demographic characteristics of parents and their children predicted the parental BAS. Of the demographic characteristics, there was a significant correlation (P < .05) between the patient's sex, age, developmental period, Tanner stage, referral status, management method, family's place of residence, economic distress, and BAS. However, according to the 2-stage hierarchical regression model, only 3 demographic characteristics, the patient's gender, place of residence, and method used in patient management, significantly predicted BAS (P < .05, ΔR2 = .35). Among the many factors that affect anxiety experienced by parents whose son or daughter has breast problems, the gender of the child, place of residence of the family, and management methods used by the practitioner are demographic characteristics that should be taken into consideration.

Paediatric and Adolescent Breast Cancer: A Narrative Review

Breast cancer is the most prevalent form of cancer worldwide. Every year, it affects a significant number of women in the UK and is considered one of the leading causes of cancer-related deaths globally. While breast cancer is primarily linked to adult women, its occurrence in children and adolescents is exceedingly rare. This study conducted a narrative review spanning from 1999 to 2023, examining 32 case reports to investigate the characteristics of breast cancer in the paediatric age group. These reports focused on patients under 18 years old who were diagnosed with primary glandular breast cancer, excluding cases originating from other tissues like angiosarcoma, leukaemia, and metastatic cancer. The data analysis encompassed various parameters, including gender, age, histology, receptor status, lymph node involvement, treatment methods, and genetic characteristics. From the published case reports, it was concluded that the most common type of breast cancer affecting children and adolescents is secretory breast carcinoma and predominantly occurs in females. It is typically hormone receptors negative, and the preferred treatment approach involves mastectomy as breast conservation surgery to preserve the developing breast tissue is a real challenge due to limited breast tissue volume in this age group.

A Retrospective Study of the Epidemiology, Histomorphological Features, Hormonal Status, and Radiological Features of Breast Cancer Diagnosed on Biopsies in Women in Bahrain Up to the Age of 40: A Single-Center Study

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women worldwide. There are many risk factors that contribute to breast cancer which involve modifiable and non-modifiable factors. Most of the patients diagnosed with breast cancer are over 50 years of age, with breast cancer in women less than 40 years of age being relatively rare and typically more aggressive variants. Moreover, radiological examination is essential for diagnosis and triaging patients for further diagnostic procedures including tissue biopsy sampling. Despite the rarity of malignancy among the younger age group, all of their breast lesions are usually biopsied. Hence, this paper outlines the percentage of benign and malignant breast lesions detected on biopsies obtained from female patients who presented to our hospital before or at the age of 40.

METHODS

 We conducted a single institution retrospective study on 267 breast biopsies done for female patients before or at the age of 40 in the period from January 2020 to January 2023. The data was obtained from the National Health Information System at Salmaniya Medical Complex. The data collected included clinical history, histological, and radiological findings. Data on prognostic markers (estrogen receptor (ER)/progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status) were also included. The distribution of samples was established according to age ranges, pathological diagnostic categories (B1-5), and prognostic marker interpretation. Further subdivision was performed on cases with malignancy according to tumor grade. The frequency distribution was obtained for ER, PR, and HER status jointly. The association between age and grade, as well as age and categories, was also determined. All the analyses were performed using SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp), and the statistical significance was tested at a 5% level.

RESULTS

Out of 267 samples, the majority (62.9%) were in patients with a range of age between 30 and 40. There were 68.5% of samples with the B2 (benign) category, followed by 20.2% with the B5b (malignant-invasive carcinoma) category. Out of 61 malignant samples, there were 17 (6.4%) samples positive on ER and PR but negative on HER2, 16 (6.0%) samples negative on ER, PR, and HER2, eight (3.0%) samples negative on ER and PR negative but positive on HER2, and five (8.2%) samples positive on ER, PR, and HER2. The majority of malignant cases were of grade II which accounted for 29 (10.9%) samples, followed by 23 (8.6%) with grade III. The association between age and grade was statistically not significant (p=0.113). However, the association between age and B categories was statistically significant with a p-value of 0.0002. A significantly higher proportion of cases with B5a (malignant-in situ carcinoma) or B5b (malignant-invasive carcinoma) categories were in the age range of 31-35 years and 36-40 years.

CONCLUSION

Breast cancer is rare among younger women. It mostly occurs in women over the age of 40 years. In women under the age of 40, it usually presents as a self-detected palpable mass and can show various radiological findings in accordance with the histological grade. Ultrasonography is the main method for the diagnosis of breast cancer especially in younger women, whereas mammography and MRI can contribute to both diagnosis and assessment of the extent of the disease.

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.

Cysticercosis Mimicking Fibroadenoma of the Breast in a Young Female: A Case Report From North Central Nigeria

The parasitic infestation, cysticercosis, arises when humans are infested with the larvae (cysticerci) of the pork tapeworm, Taenia solium (T. solium). Epidemiologically, cysticercosis presents a worldwide distribution due in part to endemicity in developing countries in Latin America, Asia, and sub-Saharan Africa, and increased migration from these countries to more developed countries in Europe and North America. Cysticercosis may be asymptomatic or may manifest clinical symptoms and signs depending on which part of the body cysticerci are found, including skeletal and heart muscle, skin, subcutaneous tissues, the lungs, liver, the central nervous system (CNS), and less commonly, the oral mucosa and breast. We report a case of a mass in the left breast in an 11-year-old Nigerian girl, which was diagnosed clinically and on ultrasonography as fibroadenoma but was confirmed on histology to be cysticercosis. Cysticercosis should be included in the differential diagnoses of breast lumps in persons of all ages and sex, especially in endemic areas and in places with significant immigration from endemic areas.

Comparison of emergency pediatric breast ultrasound interpretations and management recommendations between pediatric radiologists and breast imaging radiologists

PURPOSE

Pediatric patients with breast-related symptoms often initially present to the emergency department for evaluation. While pediatric radiologists are accustomed to evaluating acute infectious and traumatic etiologies, they may be less familiar with breast-specific findings. This study compares management recommendations of pediatric breast ultrasounds performed in the emergency setting between pediatric and breast imaging radiologists.

METHODS

This retrospective cohort study reviewed data from all pediatric breast ultrasounds performed in the emergency setting from a single academic institution from 1/1/14 to 12/31/19. During the study period, 12 pediatric radiologists with experience ranging from 1 to 33 years interpreted pediatric breast ultrasounds. Three breast imaging radiologists (with 3, 8, and 25 years of experience) retrospectively reviewed each case and recorded whether further management was recommended. Differences in recommendations were compared using Fisher's exact test. Cohen's kappa was used to assess agreement between subspecialty radiologists.

RESULTS

This study included 75 pediatric patients, with mean age 13 ± 5.6 years and malignancy rate of 1.3% (1/75). Pediatric radiologists and the most experienced breast imaging radiologist had moderate agreement in management recommendations (k = 0.54). There was no significant difference in recommendations for further management between pediatric radiologists (22/75 [29.3%]) and the most experienced breast imaging radiologist (15/75 [20.0%]), p = 0.26.

CONCLUSION

Recommendations for pediatric breast complaints in the emergency setting are comparable between subspecialties.

The prevalence of incidental finding of gynecomastia on thoracic computed tomography in the pediatric age group

OBJECTIVES

This study aimed to determine the prevalence rate of gynecomastia, determine mean glandular breast tissue sizes, and evaluate whether there is any difference in the prevalence rate of gynecomastia according to age using three different reference values of glandular breast tissue size (≥5, ≥10, ≥20 mm) in the pediatric age group.

METHODS

Glandular breast tissue sizes were measured retrospectively from thoracic computed tomography (CT) images taken for other reasons in 961 boys aged 1-18 years.

RESULTS

When each breast was evaluated separately (1,922 breasts), gynecomastia was observed in 1,001 (52.1%), 719 (37.4%), and 216 (11.2%) breasts with ≥5, ≥10, and ≥20 mm considered as reference values, respectively. A significant difference was found in terms of gynecomastia (p<0.001) and mean glandular breast tissue size (p<0.001) with respect to age.

CONCLUSIONS

New studies are currently needed to determine the glandular breast tissue size and the prevalence rate of gynecomastia in boys, and thoracic CT images can be used for this purpose.

Child gigantomastia revealing juvenile giant fibroadenomas

Breast masses in children and adolescents are uncommon. They can be caused by tumors such as fibroadenomas and phyllode tumors. These masses can cause gigantomastia, due to their rapidly increasing size. We report the case of a 12- year-old patient admitted in our department for a rapidly growing gigantomastia evolving in a matter of 8 months. Imaging features were in favor of juvenile giant fibroadenomas and diagnosis was confirmed by biopsy. Juvenile giant fibroadenomas are rare and represent 0.5–2% of all fibroadenomas, their exact etiology is unknown. They affect children and adolescents, with a predominance in African-American females. They may cause breast enlargement and asymmetry. The rapid growth causes anxiety and is the main cause of consultation. These tumors although benign, have to be treated rapidly because they can destruct up to 80% of the surrounding normal breast tissue, and conservatory treatment cannot be done.

Longitudinal evaluation of breast tissue in healthy infants: Prevalence and relation to reproductive hormones and growth factors

INTRODUCTION

Breast tissue in infancy is a rather undescribed phenomenon. We aimed to describe the prevalence and progression of palpable breast tissue in healthy boys and girls aged 0-1 years and to evaluate clinical markers, individual serum hormone concentrations as well as combined hormone profiles as determinants of the persistence of breast tissue.

METHODS

In total, 233 term infants (119 boys, 114 girls) were included and followed from birth until 1 year of age in The COPENHAGEN Minipuberty Study (ClinicalTrials.gov #NTC02784184). Infants were followed up to six times with a clinical examination and serum sampling. Principal component analyses (PCAs) produced combined hormone profiles.

RESULTS

A total of 98% of all infants aged 0-1 year exhibited breast tissue at some point. 50% still had breast tissue present at 0.5-0.6 years in girls and 0.3-0.4 years in boys ('persistent'). At one year, more girls than boys had breast tissue present (p=0.010). Most clinical and hormonal markers did not differ in infants with/without persistent breast tissue. However, in those with persistent breast tissue, estradiol (first visit, girls, p=0.034), androstenedione, corticosterone, cortisol (first visit, boys, all p<0.050), length (first visit, boys, p=0.030), and testicular volume (0.3-0.4 years, p=0.040) were higher, while IGF-I (0.3-0.4, boys, p=0.033) was lower. In boys, a combined, PCA-derived hormone profile (first visit) was able to predict the persistence of breast tissue (area under the curve=83%) better than any single marker.

DISCUSSION

Palpable breast tissue in infancy is common in both sexes although it persists in significantly more girls than boys at one year of age. Data supports both the early origin of breast tissue (in utero- and early postnatal) as well as a role of endogenous hormone production in later development and maintenance.

Breast development in pediatric patients from birth to puberty: physiology, pathology and imaging correlation

Breast tissue undergoes a series of changes from birth to puberty. The majority of the changes are transient, related to physiological hormonal changes. Although the breast is identical in both sexes at birth, its histology and development will eventually differ. It is important for radiologists to have a basic understanding of endocrinological changes and appearance on imaging to avoid potential pitfalls, particularly on ultrasound, which is the primary modality used to evaluate the breast.

Prepubertal retroareolar cysts

Bluish nodular mammary lesions in prepubertal girls are a challenging diagnosis. Retroareolar cysts are rare in this population, but relatively common among adolescent women. This diagnosis can be suspected clinically and ultimately confirmed by cutaneous ultrasonography, avoiding unnecessary biopsies or complex radiologic studies.

Ultra-high-frequency ultrasound of superficial and musculoskeletal structures in the pediatric population

Because of its relatively low cost, lack of ionizing radiation and great versatility, US is considered the imaging modality of choice to evaluate a large variety of pediatric conditions. Imaging of superficial structures and small anatomical parts can be at times limited with standard US. Recent advances in technology yielded ultra-high-frequency US systems that are capable of scanning with frequencies as high as 70 MHz and resolutions of 30 μm. This technology, approved by the United States Food and Drug Administration, has not been widely used in the clinical setting. It has the potential to become a powerful diagnostic tool in clinical practice, especially in the evaluation of infants, given their inherent body habitus. Our main objective is to discuss the use of ultra-high-frequency US at a tertiary care center. This pictorial essay presents a gamut of pediatric pathologies pertaining to imaging of the soft tissues and the superficial and musculoskeletal structures. Our aim in this pictorial essay is to highlight and illustrate the role of ultra-high-frequency US in improving the depiction of common and less common pathologies. We think it also helps to gain a new understanding of the normal anatomy in the pediatric population and to display specific features not shown by standard US and, in certain cases, ones that lead to a change in diagnosis.

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.

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.

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 pathology in adolescence

OBJECTIVE

Description of breast pathology in adolescents.

METHODS

A retrospective descriptive study of adolescents who were referred to the Gynecology consultation of a tertiary pediatric hospital for suspected breast pathology, in the period from the 1st June 2011 to the 30th December 2018.

RESULTS

One hundred and two female adolescents (11 to 18 years old) with suspected breast pathology were referred (6% of the motives for consultation), with confirmation in 58 (56.9%), who were included in the study. The reasons for referral were breast masses (66%), anomalies in breast size or symmetry (29%) and infection (5%). Of breast masses, the most frequent diagnosis was fibroadenoma (76%), followed by fibro-cystic pathology (18%). In most cases, a conservative approach was chosen, with clinical and imaging surveillance. Surgery was required in 29% of these cases. Anomalies in breast size and symmetry were observed in 17 adolescents. Two adolescents were submitted to symmetrization, after 18 years of age. Infectious and inflammatory pathology occurred in three cases: two mastitis and one retroareolar cyst. The approach consisted mainly of antibiotherapy. There were no cases of malignant breast disease.

CONCLUSION

Lumps or breast masses are the most frequent breast pathology in adolescence, and in the majority of cases surveillance was recommended, as they are a mere sign of hormonal oscillations at this age. Objective examination and/or breast ultrasound are usually enough to make the diagnosis. The approach must be mainly conservative, since malignancy is extremely rare in this age group.

A harmless evil: Giant fungating benign breast mass in an adolescent mimicking malignancy - Case report

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Fungating, ulcerating giant fibroadenomas in adolescents are rare.

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When breast conserving methods are impossible, breast reconstruction should be the focus.

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Management of these cases should be tailored to each patient.

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Awareness on negative effects of traditional medicine should be raised.

Introduction

Juvenile giant fibroadenoma is a rare type of fibroadenoma characterized by rapid growth of a breast tumor in an adolescent. Benign in nature, they rarely present as fungating and ulcerating tumors. Benign tumors masquerading as malignancies are surgical conundrums. No co nsensus exists yet on the management of these cases. We aim to discuss the dilemma in managing a bleeding, fungating giant fibroadenoma in an adolescent female and highlight risks of alternative therapies.

Presentation of case

A 19-year-old lady presented with a bleeding, fungating breast mass worsened with topical herbal concoction. Examination revealed a 10 × 15 cm fungating breast mass that obliterated her nipple- areolar complex (NAC). Computed Tomography (CT) scan reported a huge heterogeneously enhancing mass 10.6 × 14.5 × 15.1 cm with loss of normal fat plane with the overlying skin but a clear fat plane with the pectoralis muscle posteriorly.

Discussion

Giant breast masses that fungate and ulcerate usually indicate a sinister pathology. Traditional remedies have been reported to exacerbate growth. In cases where most of the breast parenchyma and NAC has been destroyed, it is no longer possible to proceed with breast conserving techniques. Breast reconstruction is crucial in adolescents and should be tailored to the patient’s existing breast size as well as body habitus.

Conclusion

In juvenile giant fibroadenomas where breast parenchyma and NAC has been destroyed, breast reconstruction is the goal. The lack of consensus in both diagnosis and management further compounds the difficulty in dealing with this sensitive population. Awareness needs to be raised regarding negative effects related to traditional medicine.

Characterizing excised breast masses in children and adolescents-Can a more aggressive pathology be predicted?

PURPOSE

Our aim was to characterize excised breast masses in children and adolescent and to identify factors associated with a more aggressive pathology.

METHODS

Retrospective review of all female patients <19 who underwent excision of breast masses at our institution between 1999 and 2018. Demographic, clinical, imaging, pathological and management data were collected. We assessed possible association of any of the variables with a more aggressive pathology (phyllodes tumor and malignancy). Correlation between core needle biopsy results and final pathology results was also calculated.

RESULTS

70 patients were included. Median age was 17 years (range: 11-19). Resected mass size was 4 cm (range: 2-16). Final pathology results were: fibroadenoma (49), juvenile fibroadenoma (7), hamartoma (5), benign phyllodes (7), malignant phyllodes (1) and sarcoma (1). Pathology was benign in 61 (87%) patients and more aggressive (phyllodes and sarcoma) in 9 (13%). None of the tested variables was associated with a more aggressive pathology. Presurgical core biopsy results matched final pathology in only 63.6%.

CONCLUSIONS

Excised breast masses in children and adolescents are sometimes of a more aggressive pathology, which cannot be predicted by presurgical factors, including a core needle biopsy. Prognosis study LEVEL OF EVIDENCE: III.

Juvenile Fibroadenoma in a Four-Month-Old Male Infant

Teaching point: As juvenile fibroadenoma is radiologically indistinguishable from a (malignant) phyllodes tumor, a core biopsy is decisive for both treatment and follow-up.

Ultrasonographic review of pediatric breast masses among Nigerian children in a tertiary hospital

BACKGROUND

Breast masses occur infrequently in children and adolescents. Most of these masses have proved that benign and conservative approach is the management of choice. Consequently, imaging has become crucial. The knowledge of the ultrasonographic features of childhood and adolescent breast masses is needed for age appropriate medical care.

AIM

The aim of this study was to describe and document the ultrasonographic spectrum of breast masses in children and adolescents (0-19) years seen in the Ahmadu Bello University teaching hospital, Zaria.

MATERIALS AND METHODS

A 2-year retrospective review of breast sonograms of 25 consecutively presenting children and adolescents (3 males and 22 females) who had palpable breast masses. Ultrasound scans were performed with a Mindray Machine DC-8 using the linear transducer at 7.5-12 MHz transducer frequency. Histopathological confirmation of the solid masses was also obtained. The statistical analysis of the data collected was done using the SPSS software version 20 (SPSS Inc., Chicago, IL, USA).

RESULTS

The patients were between 40 days and 19 years old (mean 14.8 years and standard deviation 4.1). The ultrasonographic findings were those of infections, benign tumoral lesions and pubertal endocrine changes. Overall, fibroadenoma was the most common mass, seen in 14 (56%) of the patients. Other findings were simple cysts, non-puerperal and puerperal mastitis, juvenile papillomatosis and normal glandular pubertal breast tissue. The three male patients had gynaecomstia, pseudogynaecomastia and cystic lymphangioma of the chest wall presenting as unilateral breast masses, respectively. There was no malignancy recorded in any of the patients.

CONCLUSION

Ultrasonographically, benign masses predominate which is concordant with surgical findings. Familiarity with these features would obviate the need for unnecessary invasive procedures which should be reserved for only deserving cases.

Primum non nocere: Utility and outcomes of pediatric breast ultrasound

PURPOSE

To assess the use and outcomes of ultrasound for the evaluation of breast signs and symptoms in pediatric females.

METHODS

A retrospective database review identified all patients ≤18-years-old who underwent breast ultrasound at an academic institution over a 20-year period. Each symptomatic site was designated a case and analyses were performed on each case. Imaging findings were obtained from the radiology reports. Clinical and pathology data were obtained from the medical records. Descriptive statistics were performed.

RESULTS

The final cohort comprised 124 cases in 101 patients. Mean age was 15 years (range 1-18). The most common indication for ultrasound was a palpable lump (71%). Thirty-seven cases (30%) demonstrated no sonographic correlate to the symptom; 36 (29%) had a benign correlate. The most common benign correlates were abscess/phlegmon and cyst. All cases of abscess/phlegmon had infectious symptoms. Fifty-one cases (41%) demonstrated a sonographic mass that was not characteristically benign. Of these indeterminate masses, 27 were recommended for biopsy, 13 for short-interval follow-up, and 6 had no recommendation. Of 27 biopsied masses, 63% were fibroadenomas. No symptoms were due to malignancy. Therefore, the NPV of ultrasound was 100% and the PPV 0%.

CONCLUSION

In this cohort of pediatric and adolescent patients, malignancy was never the cause of breast symptoms. Imaging yielded false positives with a biopsy recommendation in 22% of cases. Ultrasound provided value in evaluating infectious symptoms. Given the extreme rarity of breast cancer in this population, surveillance may be a safe alternative for most indeterminate lesions.

Benign phyllodes tumor with hemorrhagic cyst in a 14-year-old girl: A case report

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A rare phyllodes tumor in a 14-year-old girl.

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It increased rapidly due to bleeding and was accompanied by cyst formation.

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Needle biopsy is also important for differential diagnosis.

Introduction

The incidence of mammary phyllodes tumor is less than 0.3–0.5% of all breast tumors. Only a few pediatric cases have been reported. Here we report a benign phyllodes tumor that occurred in a 14-year-old girl.

Presentation of case

A left breast mass with a bleeding cyst of about 9 cm was resected after the tumor had rapidly increased in size over the course of 2 months. Imaging examinations suggested an intracystic tumor. Histopathological examination, however, revealed a benign phyllodes tumor without cytomorphism or mitotic figures. The tumor was accompanied by partial bleeding, which was considered to be the cause of the rapid increase in size of the hemorrhagic cyst. The patient remains under observation, and local recurrence has not occurred as of 3 years after surgery.

Conclusion

Due to the rarity of the condition in children and adolescents, an individualized, case-based approach is recommended.

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.

A rare cause of unilateral breast swelling in a male infant caused by fibrous hamartoma of infancy combined with pseudoangiomatous stromal hyperplasia

We report a case of a male infant who underwent resection of a unilateral breast mass with a histopathological diagnosis of a fibrous hamartoma of infancy (FHI) combined with a pseudoangiomatous stromal hyperplasia (PASH). Breast lumps are uncommon in infants and children, especially in boys. FHI and PASH are very rare causes of breast lumps, especially in infants. To our knowledge, this is the first report of a combination of both pathologies in 1 lesion in the breast of an infant.

Juvenile Fibroadenoma at Menarche: A Case Series

Juvenile fibroadenomas of the breast are benign neoplasms. They present during the development phase of the breast. They are poorly understood because of their rarity and unpredictable behavior. In this article, a series of three different sonographic breast cases are provided of adolescent girls, who were brought for medical evaluation of a large breast lump, which had presented just after menarche. The results of evaluating these cases revealed that sonography of the breast was helpful in characterizing and delineating the extent of the lump. In conclusion, giant fibroadenomas of the breast, at menarche, are also known as juvenile fibroadenomas. They are a dilemma for the clinician, radiologist, and pathologist alike. The use of ultrasound can assist with characterizing these lesions, as an incorrect diagnosis could lead to a disfiguring surgery, for a young girl.

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.

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.

A Prospective Observational Study of Breast Lumps in Adolescent Girls: Tertiary Care South Indian Teaching Hospital Experience

The aim of the current study was to assess the incidence and varying clinical presentations of benign breast lumps in adolescent age group in a Tertiary care Medical College Hospital. This was a prospective, observational study of 6-year duration (2011 to 2017) conducted in a Medical College, South India. All adolescent age group patients visiting the outpatient department (OPD) with complaints of breast lump were enrolled into the study. Triple assessment comprising of clinical examination, imaging, and core biopsy was used for diagnosis and identification of type of tumor. Management of tumors was based on pathology of core biopsy. During the study duration (2011 to 2017), a total of 15 pediatric patients of age between 11 to 14 years, presented with complaints of breast lumps. The most common symptom included painless lump in breast in 11 patients (73.34%). The histopathological examination (HPE) reported 12 cases (80%) as fibroadenomas and only 3 cases (20%) were phyllodes tumors. Based on the results of HPE, majority of the patients (53.34%) underwent circumareolar cosmetic incision. The most common lesions in pediatric age group are benign fibroadenomas; however, phyllodes are also not rare, and to manage them appropriately, they should be diagnosed preoperatively with core biopsy. Cases of malignancy, including phyllodes tumors, ductal adenocarcinomas, and metastatic lesions, have been documented in children and adolescents. Therefore, malignancy should be considered in the diagnosis of a pediatric and adolescent breast mass until formally ruled out.

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.

Breast diseases in children: the spectrum of radiologic findings in a cohort study

PURPOSE

We aimed to investigate the spectrum of radiologic findings and referral reasons for breast diseases in children considering age-appropriate presentation.

METHODS

Our retrospective cohort study included 348 consecutive pediatric patients aged <19 years (median, 13 years) referred to radiology with a clinical presentation between 2005 and 2016. Radiologic findings were reviewed in four age ranges (0-2 years, 2-8 years, 8-15 years, >15 years).

RESULTS

Of 348 patients, 257 had a referral reason. The most frequent referral reason was a palpable mass (35%). Developmental abnormalities accounted for 48% of all radiologic findings in 348 patients. We did not detect any breast malignancy. According to age groups, the most common radiologic findings were neonatal hypertrophy (0-2 years), early breast development (2-8 years), developmental abnormalities by a majority of gynecomastia (8-15 years), and normal findings or developmental abnormalities (>15 years). Interestingly, the frequency of gynecomastia was only 4% in neonatal period or early childhood. Fibroadenomas and fibroadenoma-like solid masses were seen after 8 years and constituted the majority of solid masses (65%). Cysts were seen at a rate of 7% and majority of them were of simple type, which tends to resolve in time.

CONCLUSION

In our study, the most common referral reason to radiology was a palpable breast mass. Neonatal hypertrophy and early breast development in younger children, and developmental abnormalities in older children may be kept in mind as the most common radiologic findings. Our study confirms the substantial absence of malignancies in children as well as a widely different disease spectrum in comparison with the adult population.

Inflamed Phylloides Tumour in a Girl: A Challenging Diagnosis in Paediatric Breast Lesions

Introduction: Phylloides tumours (PTs) are rare fibroepithelial neoplasms that account for 0.3⁻0.9% of all breast tumours. These tumours typically occur in women aged 30⁻70 years. The occurrence of these tumours in older children and adolescents poses particular diagnostic and therapeutic problems. However, early diagnosis is mandatory because although most of the cases of PTs in children are benign, the borderline and malignant cases with potential negative outcomes cannot be excluded. Case presentation: A 12-year-old girl presented at the Paediatric Emergency Department for hyperaemia and warmth of the left breast that occurred a few days prior without fever. The girl experienced menarche 8 months previously. She experienced no previous trauma and she had no family history of breast cancer. On physical examination, the left breast was painful, enlarged and tender. The overlying skin was erythematous and warm. A breast ultrasonography (US) revealed a large mass with features of an abscess, including a hyperechoic wall, scattered internal echoes and hypoechoic peripheral lacunae of apparent colliquative nature. After 4 days of unsuccessful antibiotic therapy, surgical drainage was performed due to the suspicion of a mammary abscess. At the surgical incision site, the lesion was not-well circumscribed and lacked a capsule. In addition, purulent material was not detected. Histological examination revealed that the tissue alterations were compatible with benign PT. With this diagnosis, the girl underwent definitive surgical removal of the lesion. The postoperative period passed without negative events. An US performed 6 months later revealed that no new mass was present at this time, suggesting no recurrence of the tumour. Conclusion: This case shows that in the presence of a clinical picture suggesting the inflammation of the breast in adolescent females, PT should be considered as a possible diagnosis and US-guided core biopsy should be considered to confirm this suspicion. Thereafter, when surgical excision is performed, particular attention must be paid to both the preservation of all the normal breast parenchyma and future aesthetic problems.

Clinical and ultrasonographic features of male breast tumors: A retrospective analysis

Objective

The purpose of this study was to determine clinical and ultrasonographic characteristics of male breast tumors.

Methods

The medical records of male patients with breast lesions were retrieved from an electronic medical record database and a pathology database and retrospectively reviewed. A total of 112 men (125 breast masses) with preoperative breast ultrasonography (US) were included (median age, 59.50 years; age range, 15–96 years). Data extracted included patient age, if the lesions were bilateral, palpable, and tender, and the presence of nipple discharge. Breast lesion features on static US images were reviewed by three experienced radiologists without knowledge of physical examination or pathology results, original breast US image interpretations, or surgical outcomes. The US features were documented according to the BI-RADS (Breast Imaging-Reporting and Data System) US lexicons. A forth radiologist compiled the data for analysis.

Results

Of the 125 breast masses, palpable tender lumps and bilateral synchronous masses were more likely to be benign than malignant (both, 100% vs 0%, P < 0.05). Advanced age and bloody discharge from nipples were common in malignant lesions (P <0.05). A mass eccentric to a nipple, irregular shape, the presence of an echogenic halo, predominantly internal vascularity, and rich color flow signal on color Doppler ultrasound were significantly related to malignancy (all, P < 0.05). An echogenic halo and the presence of rich color flow signal were independent predictors of malignancy.

Conclusion

Specific clinical and US characteristics of male breast tumors may help guide treatment, and determine if surgery or conservative treatment is preferable.

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

BACKGROUND

Fibroadenoma is overwhelmingly the most common pediatric breast lesion. Breast malignancy is quite uncommon in children, most frequently metastatic or hematological malignancy. Core biopsy has largely replaced excision for diagnosis of breast masses in adults.

OBJECTIVE

The purpose of this study is two-fold: (1) compare utilization at our institution of interventional procedures vs. surgery for breast mass diagnosis in patients ≤18 years and (2) propose guidelines for breast imaging and biopsy in this population.

MATERIALS AND METHODS

We extracted data for all patients ≤18 who, between 2004 and 2016, underwent either (a) imaging and/or intervention procedure, or (b) breast surgery, from the Radiology Information System and Pathology Data System, respectively. We recorded age, gender, imaging, procedure, lesion size and histopathology.

RESULTS

We found 1,050 pediatric patients ≤18 years who underwent diagnostic breast ultrasound between 2004 and 2016. Of these, 168 patients underwent 199 interventional procedures. One hundred thirty patients underwent 160 core biopsies of solid lesions. Core biopsy pathology diagnosed benign lesions in 99%, of which 84.3% were fibroadenomas (n=135). One malignancy was diagnosed, B cell lymphoma. Two hundred three patients underwent surgical excision for 266 discrete lesions, and 89% were fibroadenomas. Seven benign phyllodes tumors were surgically diagnosed. No malignancies were diagnosed.

CONCLUSION

Core biopsy in patients 18 years and younger is well-tolerated, has few risks, and is preferable to surgery in developing breasts, but the goal is to avoid any breast procedure whenever possible. We propose guidelines for pediatric breast imaging, follow-up, core biopsy and excisions.

Diagnosis and imaging characteristics of a juvenile fibroadenoma in a 2-year-old patient: a case report

Fibroadenomas are abundantly reported in the literature with several papers documenting the natural progression and clinical outcomes of thousands of cases. Juvenile fibroadenomas (also called cellular fibroadenomas) are frequently characterized by rapid growth, often described as 5-10 cm in size. They constitute approximately 7%-8% of fibroadenomas. They often measure greater than 5 cm. Pathologically, they show similar features to fibroadenomas but can resemble phyllodes. There have been few documented cases of breast masses in early childhood. Furthermore, there are scant radiology publications focused on the imaging features of juvenile fibroadenomas in patients younger than 5 years old. Our patient presented at 2 years of age with a unilateral right breast mass. Two ultrasound examinations were completed over a period of 5 months, and a magnetic resonance imaging was performed prior to surgical intervention. Eventual surgical excision yielded a final pathologic diagnosis of juvenile fibroadenoma. In this report, we will discuss the imaging and pathology of juvenile fibroadenomas, and we will address important differential considerations both from a pathologic and radiologic standpoint.

A case report of juvenile giant fibroadenoma of the breast: How common?

Breast lesions are rare prepubescents. The majority of breast lesions in this age group are benign. The most common of these rare lesions is juvenile fibroadenoma, which accounts for only 0.5% of all fibroadenomas. It is uncommon to have a palpable lesion in juveniles as very small lesions show obvious asymmetry. Fibroadenomas can grow to a large size, and surgical intervention is cosmetically challenging, especially in achieving symmetry in a developing breast. A 12-year-old girl presented with right breast swelling associated with tenderness. The mass had initially been small on self-discovery 1 year previously and grew with time. There was no overlying skin changes or any significant risk factors for breast malignancy. Triple assessment showed features of fibroadenoma, but we were unable to rule out a phyllodes tumor. She subsequently underwent excision biopsy of the right breast lesion for symptomatic control and histopathology examination (HPE) of the lesion. The HPE report confirmed the diagnosis of fibroadenoma. The patient recovered well postoperatively with no complications. Juvenile breast lesions are rare, and it is a challenge to provide an adolescent with the best treatment in terms of clinical and psychological care. A surgical approach requires meticulous planning to ensure a fine balance between adequate resection and the best cosmetic outcome for a developing breast.

Galactocele in a Prepubertal Girl

BACKGROUND

Galactoceles have been previously described as an unusual cause of benign breast enlargement in male infants and children.

CASE

A 3-year-old prepubertal girl presented with a right-sided breast mass and was found to have a 4.4-cm hypoechoic cyst on ultrasound imaging with otherwise normal endocrine studies including prolactin levels. She underwent cyst aspiration which revealed milky fluid. Fat globules were identified with microscopic examination, confirming the diagnosis of a galactocele. Aspiration resolved the mass.

SUMMARY AND CONCLUSION

The etiology of galactoceles in nonlactating women is poorly understood. Traditionally, treatment of these benign cysts in male children has been surgical excision. In prepubertal girls, conservative management by surveillance or needle aspiration is warranted to prevent damage to developing breast tissue.

Giant phyllodes tumor of the breast with diffuse myxoid changes in an adolescent girl: a case report

Giant phyllodes tumors (PT) are an uncommon fibroepithelial neoplasm and especially rare in adolescent girls. Diagnosis is difficult not only due to the rarity of PT, but also owing to the resemblance of its clinical and imaging features with fibroadenoma. The author reports a case of a giant PT in a 14-year-old girl. Clinical examination showed a large painful mass in the left breast, and an abscess was initially suspected. But magnetic resonance imaging (MRI) displayed features characteristic of PT. Following complete surgical excision of the mass, histopathology confirmed the diagnosis of a benign PT with diffuse myxoid changes, consistent with the MRI findings. This case emphasizes the importance of breast MRI, both for its ability to aid diagnosis, as well as its benefits in guiding the surgical plan.