Pathologic breast conditions in childhood and adolescence: evaluation by sonographic diagnosis

Early breast development in girls: the power of greyscale sonography and sonoelastography

OBJECTIVE

Accurate distinction between central pubertal precociousness (PP) and premature thelarche (PT) is important to guide treatment. Both greyscale ultrasonography (US) and sonoelastography can be used to examine breast tissue. The aim of this study is to investigate the performance of breast US and strain elastographic (SE) in the diagnosis of increased breast volume in girls.

METHODS

Sixty-three girls with breast development up to 8 years of age and diagnosed with PP and PT were included in the prospective study. Basal luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol (E2) values were obtained. Each bud was considered as a unit in US. Mediolateral (ML) and anteroposterior diameters (AP) were measured, and US grading was performed. Breast SE was examined, and strain index (SI) was calculated. US and laboratory findings were compared.

RESULTS

Of the 121 buds examined, 39 (32.2%) were with PP (6.97 ± 2.44 years) and 82 (67.8%) were with PT (6.51 ± 2.52 years). Diameters were correlated with bone age, LH, FSH, and US grade. The mean AP showed a moderate difference in favour of PP between the groups (P < .06). The mean ML was higher in PP (P < .01). There was a difference in mean SI values (P < .004). Sensitivity and specificity were 71% and 61% for ML and 72% and 56% for SI, respectively.

CONCLUSION

Both ML and US grading may help discriminate PP from PT. The role of sonoelastography requires further investigation.

ADVANCES IN KNOWLEDGE

Ultrasound and SE show significant differences between PP and PT, but these are not sufficiently reliable to be of clinical use. The contribution of sonoelastography requires further study before it can be recommended. However, SI of breast tissue can be helpful in distinguishing PP and PT from other causes of early increase in breast volume.

Mammary Fibrocystic Change in a Pre-Pubertal child- A Case Report with a Histopathological Perspective

Fibrocystic change in the breast is one of the entities under the spectrum of benign breast disease. It occurs primarily in females of the reproductive age group. Though the exact etiology is unknown, estrogen-progesterone imbalance is possibly one of the causative factors. Its occurrence in the pediatric age group is infrequent and is hitherto unreported in the pre-pubertal age group. Case report: We present the case of a 2-year-old female presenting with an ill -defined lump approximately 4 cm in diameter, with an unremarkable hormonal status for the age. Histopathology revealed fibrocystic change in the resected tissue. Conclusion: Fibrocystic breast change in children may represent an exaggeration of the normal developmental involution process.

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.

Age distribution and types of breast lesions among Afghan women diagnosed by fine needle aspiration cytology (FNAC) at a tertiary care centre in Afghanistan: a descriptive cross-sectional study

OBJECTIVES

In Afghanistan, breast diseases are a common reason for women to visit hospitals. This is the first study in Afghanistan aimed to describe the age distribution and types of breast diseases among patients diagnosed by fine needle aspiration cytology.

DESIGN

Descriptive cross-sectional study.

SETTING

French Medical Institute for Mothers and Children, Kabul, Afghanistan.

PARTICIPANTS

The study included 650 patients with breast lesions between 1 April 2015 and 1 April 2019.

RESULTS

The mean age of diagnosis was 35.38 (SD ±13.11) years, ranging from 15 to 75 years. The most common diagnosis was cancer (24% of all cases). The second most common diagnosed lesion was fibroadenoma, constituting 22.4%, and the third most common lesion was fibrocystic changes, with 15.4% of cases. Inflammatory conditions were diagnosed in 9.7% of cases, granulomatous inflammation in 9.1%, lesions only suspicious for malignancy in 5.5%, lipoma in 2.8% and miscellaneous benign lesions in 11.1%. Cancer was diagnosed at the youngest age of 20 years. Cancer was more common on the left side (62%), and only one case (0.9%) was bilateral.

CONCLUSION

Our study showed that cancer was the most commonly diagnosed lesion and was reported at younger ages too. This suggests that physicians should not ignore any breast lump in younger patients and that the possibility of cancer must be considered. Further country-wide studies are suggested to assess breast cancer and associated risk factors.

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.

Ultrasound assessment of pubertal breast development in girls: intra- and interobserver agreement

BACKGROUND

Clinical assessment of pubertal breast development using Tanner staging is subjective. This has led to the introduction of ultrasound (US), aiming for a more objective analysis. However, information regarding its reliability is lacking.

OBJECTIVE

To examine intra- and interobserver agreement of breast maturity staging using US and to examine the precision of direct measurements of the gland.

MATERIALS AND METHODS

Fifty-seven healthy girls (mean age: 10.9 years, range: 6.1 to 15.9 years) were examined independently by two observers using US of the left breast to score the glandular maturity stage on a 0-5 scale, and to measure the depth and diameter. One observer repeated the examination after 20 to 35 min to assess intra-observer agreement. Cohen's kappa with linear weights was used to examine intra- and interobserver agreement of the US staging, while the measurement precision was analyzed using Bland-Altman plots and 95% limits of agreement.

RESULTS

The agreement of US staging on a 0-5 scale was very good (kappa 0.84; 95% confidence interval [CI] 0.78-0.91) for intra-observer observation and good (kappa 0.71; 95% CI 0.62-0.80) for interobserver observation. Measurements of glandular depth and diameter were unbiased for a single observer, but the variances were large both within and between observers.

CONCLUSION

US using a scale from 0 to 5 is a reliable method to stage the development of glandular breast tissue during puberty in healthy girls. Measurements of glandular depth and diameter were found to be imprecise.

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.

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.

Profile of Non-Hematological Pediatric Tumors: A Clinicopathological Study at a Tertiary Health Care Centre

BACKGROUND

Tumors in pediatric age group are biologically different from tumors in adults and emerging as a significant contributor to morbidity/mortality in children.

OBJECTIVES

This study evaluated the epidemiological profile of pediatric solid tumors in 0-18 years of age over a period of 5 years in a general hospital in India.

RESULTS

A total of 510 cases of tumors were included, which accounted for 5.1% of the total tumor burden of the hospital. Benign tumors were more common than malignant tumors. Most common age group affected was 14-18 years. Among benign tumors, vascular tumors were the most common, while malignant bone tumors outnumbered all other malignant tumors. Neuroblastomas comprised only 0.9% of our malignancies.

CONCLUSION

Our study provides an insight into the patterns of childhood tumors for which exists little literature in India. With lack of a dedicated pediatric cancer registry from India, tracking of the diverse histological spectrum of tumors is difficult.

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.

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.

Pathological profile of patients with breast diseases in Shiraz

BACKGROUND

Around 200,000 breast disorders are annually diagnosed all over the world. Fibrocystic changes are the most common breast disorder and fibroadenoma is the most prevalent benign breast tumor. The present study aimed to determine the spectrum, type and prevalence of breast masses in women referred to Shiraz University of Medical Sciences between 2004 and 2012 .

MATERIALS AND METHODS

A cross-sectional study was conducted on the diagnostic reports data.

RESULTS

A total of 640 samples were studied. Most 57.3% of masses were detected in the left breast, 65%, 28.2% and 6.1% of cases presenting with benign, malignant, and inflammatory lesions, respectively. Among all the samples the most prevalent diagnosis (37.7%) was fibroadenoma and fibrocystic lesions (17%). 174 samples (96% of the malignant cases) were invasive. 6.5% of the benign, and 37% of the malignant cases occurred in post menopause women and the differences were statistically significant. Among those with malignant tumors lymph nodes were involved in 25.6% of menopausal women and 44.2% of non-menopausal ones, and the difference was statistically significant.

CONCLUSIONS

Regular clinical breast examination beside mammographic follow-ups, especially during menopause, should be carried out as a priority and a national organized program should be designed for screening breast disorders.

Ultrasound assessment of breast development: distinction between premature thelarche and precocious puberty

OBJECTIVE. We analyzed the correlation between breast development and ultrasound-measured breast bud diameter. We also evaluated different breast ultrasound findings in pediatric subjects with precocious puberty and premature thelarche while comparing bone age and hormone levels. MATERIALS AND METHODS. We performed a retrospective study with a sample of 90 girls (mean age, 7.8 years) who underwent breast ultrasound for evaluation of early breast development between March 2011 and February 2013. We evaluated breast ultrasound grade, bud diameter, and clinical characteristics including bone age and hormone levels. Among the 90 girls, 69 were up to 8 years old (mean age, 7.3 years). We divided them into healthy, precocious puberty, and premature thelarche groups and evaluated the clinicoradiologic findings for each group. RESULTS. Breast ultrasound grade was correlated with age, bone age, bud diameter, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol (E2). Bud diameter was correlated with age, bone age, LH, FSH, and E2. However, the difference between bone age and chronological age was not correlated with ultrasound grade or bud diameter. Among 69 girls up to 8 years old, including 11 healthy girls (15.9%), 26 girls with precocious puberty (37.7%) (mean [SD] age, 7.3 years), and 32 girls with premature thelarche (46.4%) (mean age, 7.2 years), there were no significant differences in other variables except values for bone age (p = 0.001) and difference between bone age and chronological age (p < 0.001). CONCLUSION. Breast ultrasound might be useful for evaluating sexual development with respect to bud diameter or ultrasound grade. However, its ability to distinguish precocious puberty from premature thelarche is limited.

Spectrum of nonhematological pediatric tumors: A clinicopathologic study of 385 cases

Background:

The aim of this study is to understand the epidemiology of tumors in children in our region due to a paucity of studies on the histologic review of the childhood tumors in general and benign tumors in particular.

Materials and Methods:

The records of all the tumors diagnosed histopathologically in children <14 years of age during a period of 8-year (2005-2012) were reviewed.

Results:

A total of 385 tumors were seen in the age range of 1 month-14 years with 231 (60%) in boys and 154 (40%) in girls. Highest number of cases, 224 (58.18%) were in the age group of 10-14 years. Benign tumors comprised 275 (71.43%) cases while the malignant tumors accounted for 110 (28.57%) cases. In benign tumors, vascular tumors were in majority with 68 cases, while in malignant category bone tumors were most common with 36 cases.

Conclusions:

Although the exact incidence rate cannot be provided by this hospital-based study, the information is useful in showing patterns of childhood tumors. We included both benign and malignant tumors, while most of the studies in the past have focused mainly on malignant tumors in children.

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.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings

BACKGROUND

Sonography is usually requested to evaluate palpable pediatric breast lumps, and solid masses are almost always fibroadenomas. Lack of familiarity with the findings of fibroadenomas can lead to diagnostic uncertainty and sometimes unnecessary biopsy and excision. We sought to review the spectrum of sonographic findings in our cases of pathology proven pediatric fibroadenomas.

OBJECTIVE

The purpose of this retrospective study was to describe the sonographic appearances of pathologically proven pediatric breast fibroadenomas.

MATERIALS AND METHODS

A query of the Department of Radiology database at our institution was performed for all patients younger than 19 years who underwent breast US from January 2001 to June 2009. A total of 332 patients were identified: 282 girls (85%) and 50 boys (15%). Ninety-one girls and no boys had a solid breast mass based on US findings. Forty-three children had a total of 49 pathologically proven breast masses with the diagnoses of fibroadenoma (44), hamartoma (1), non-Hodgkin lymphoma (1), tubular adenoma (1), pseudoangiomatous stromal hyperplasia (1) and lactation changes (1). Reviews of medical records, histological results and sonographic examinations of all pathology-proven fibroadenomas were performed. US findings were characterized according to location, multiplicity, size, shape, echogenicity and homogeneity, definition of margins, posterior acoustic features and Doppler vascularity.

RESULTS

The vast majority of solid breast masses in girls are histologically benign. Fibroadenomas accounted for 91% of the pathologically proven solid breast masses. Common findings on US imaging are an oval shape, hypoechoic echo pattern, posterior acoustic enhancement and internal Doppler signal. Lobulations were found in 57% of the masses. Less common findings are absent internal vascular flow and complex echo pattern, while isoechoic echo pattern, posterior shadowing and angular margins are rare or unusual.

CONCLUSION

Fibroadenomas represent the most common solid mass in the breasts of girls. Sonographic appearances are usually characteristic and do not significantly differ from those found in adults. The radiologist must be aware of common and uncommon sonographic appearances of fibroadenomas in the pediatric age group and should be cautious when recommending histological confirmation based on imaging findings, as breast malignancy is extremely rare.

Panoramic ultrasound to measure in vivo tendo Achilles strain

BACKGROUND

The tendo Achilles (TA) is a tendon very susceptible to injury. Biomechanical methodologies for exploring tendon strain are limited, however, as they are typically performed in vitro or by indirectly measuring the displacement of reference markers. By using panoramic ultrasound, this study reports a novel approach to acquire direct, in vivo tendon extension data.

MATERIALS AND METHODS

Sonographic scans were acquired between two in vivo landmarks following a consistent pathway along the long axis of the distal TA. Ten subjects were scanned with an unloaded tendon and then when resisting a range of loads. Tendon cross-sectional area was measured following coronal scans of the TA in three subjects, allowing for calculation and plotting of stress versus strain. Coefficients of variation were also calculated to measure the reliability and robustness of the protocol.

RESULTS

Data from all ten subjects were found to fit with classic tendon force versus extension trend. The stress versus strain plot indicated that the wavy collagen fibers were fully straightened at 4% to 6% strain, which is comparable to results reported in other studies. The Young's modulus of 0.5 to 2.1 GPa also compared favorably to published data.

CONCLUSION

Coefficients of variation indicated that the protocol was repeatable, although the technique for measuring cross-sectional area could be improved.

CLINICAL RELEVANCE

As the reported data is comparable to previous invasive and in vitro studies, we believe sports medicine specialists and orthopaedic surgeons can utilize panoramic ultrasound to directly measure in vivo tendon strain.

From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation

The spectrum of breast lesions in children and adolescents varies markedly from that for adults, with the former lesions being overwhelmingly benign. A breast mass in a young boy or girl may arise from normal and abnormal breast development. Other causes of masses include infection, trauma, and cyst formation. After onset of puberty, most cases of breast enlargement arise from benign fibroadenoma in girls and gynecomastia in boys. These conditions have specific imaging appearances, although juvenile (often giant) fibroadenoma cannot be distinguished from phyllodes tumor, which can be benign or malignant. In children, both conditions usually appear as well-circumscribed, hypoechoic masses at sonography and show diffuse enhancement except for nonenhancing septations at magnetic resonance imaging. A diagnosis of juvenile papillomatosis (a benign lesion) portends later development of breast cancer, and patients with this condition should be closely monitored. Malignant lesions of the breast in children are rare. The most common malignant lesions are metastases and are usually associated with widespread disease. The most common primary breast malignancy is malignant phyllodes tumor. Primary breast carcinoma is exceedingly rare in the pediatric age group, but its imaging appearance in children is the same as seen in adults and is different from that of almost all benign lesions. In girls, diagnostic interventions may injure the developing breast and cause subsequent disfigurement. Given this risk and the low prevalence of malignant disease in this population, a prudent course should be followed in the diagnosis of breast lesions. Imaging findings are very helpful for selecting patients for further diagnostic procedures. Although malignancy is rare, lesions with suspicious imaging findings or progressive growth should be subjected to cytologic or histologic examination.

Diagnostic Breast Ultrasound: Current Status and Future Directions

This summary of breast ultrasound reviews the current indications for its use, discusses the potential technical and human pitfalls in its performance, and briefly examines possible future applications that currently are works in progress. It also contains an in-depth discussion of the use and interpretation of color Doppler and power Doppler imaging, techniques that do not seem to be understood or used fully in daily practice.