Pediatric Breast Mass Corey Johnson, MD R2 Seattle Children’s Hospital Pediatric Surgery Case Presentation
JG 11 year old girl with Left breast mass PMH Exam Ultrasound increasing in size inflamed appearance no discharge beginning to have pain PMH pre-menarche no medications no significant personal or family medical history Exam Ultrasound
JG DDx of pediatric breast mass Hypertrophy Thelarche or premature thelarche Fibrocystic change Fibroadenoma Giant fibroadenoma Phyllodes tumor Lipoma Hemangioma PASH Intraductal papilloma Duct ectasia Montgomery tubercles Infection Trauma Neoplasm Primary (secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, lymphoma) Metastasis (lymphoma, neuroblastoma, hepatocellular carcinoma, rhabdomyosarcoma) Secondary (history of chest radiation therapy)
JG DDx of pediatric breast mass Hypertrophy Thelarche or premature thelarche Fibrocystic change Fibroadenoma Giant fibroadenoma Phyllodes tumor Lipoma Hemangioma PASH Intraductal papilloma Duct ectasia Montgomery tubercles Infection Trauma Neoplasm Primary (secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, lymphoma) Metastasis (lymphoma, neuroblastoma, hepatocellular carcinoma, rhabdomyosarcoma) Secondary (history of chest radiation therapy)
JG Image courtesy of Dr. Kenneth Gow
JG Image courtesy of Dr. Kenneth Gow
Fibroadenoma Most common breast lesion in adolescents 91% (44/49) of solid breast masses on ultrasound Clinical Dx: 2-3 cm rubbery, well-circumscribed mass in upper outer quadrant Ultrasound shows a well-circumscribed, solid, homogeneous mass, posterior enhancement Bimodal age distribution Recurrent or multiple in 10-25% of patients
Fibroadenoma Approximately 50% resolve in 5 years Malignancy within a fibroadenoma is extremely rare 1.3 to 2.1 relative risk increase for breast cancer Indications for biopsy rapid growth lesion >5cm persistence into adulthood
Giant Fibroadenoma >5cm or >500g Rapid growth Association with pregnancy and lactation May be lobulated on ultrasound FNA and core needle biopsy cannot differentiate from phyllodes Excisional biopsy
Giant Fibroadenoma Adult type Juvenile type 4% of fibroadenomas Hypocellular to variably cellular stroma Juvenile type 0.5-2% of fibroadenomas Mean age 15, range 10-39 Uniformly hypercellular stroma No leaf-like architecture, periductal stromal condensation or infiltration of surrounding tissue No stromal atypia, mitotic rate <3/hpf, no stromal overgrowth
Phyllodes Reported in girl as young as 10 years of age 0.3-0.5% of all breast masses Large breast mass, usually painless Bloody discharge if nipple involved Ultrasound shows heterogeneous mass with lobulations Benign, borderline or malignant based on histology Borderline and malignant have potential for mets Review of 173 patients with 179 tumors 101 (56.4%) benign, 50 (27.9%) borderline, 28 (15.6%) malignant Malignant associated with older patients and larger tumor size
Resources Morris A, Shaffer K. Recurrent bilateral giant fibroadenomas of the breasts. Radiology Case Reports. [Online] 2007;2:96. Sanchez R, Ladino-Torres MF, Bernat JA, Joe A, DiPietro MA. Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings. Pediatric Radiology. 2010 Oct;40(10):1681-9. Kempson RL, Rouse RV. Juvenile fibroadenoma of the breast. Surgical Pathology Criteria. Stanford School of Medicine. http://surgpathcriteria.stanford.edu/breast/juvfibroadenoma/printable.html Tse GMK, Putti TC, Lui P, Lo A, Scoyler R, Law B, Karim R, Soon Lee C. Modern Pathology (2004) 17, 827–831. Greenburg R, Skornick Y, Kaplan O. Management of breast fibroadenomas. J Gen Intern Med. 1998 September; 13(9): 640–645. Karl SR, Ballantine TV, Zaino R. Juvenile secretory carcinoma of the breast. J Pediatr Surg. 1985 August;20(4):368-71. Louvet C, Brunel P, Espie M, de Rocquancourt A, Schaisn G, Extra JM, Marty M. Breast cancer in patients under 18 years. Report of an inflammatory case and review of the literature. Breast. 1998 August;5(4):277-281. Ashikari H, Jun MY, Farrow JH, Rosen PP, Johnston SF. Breast carcinoma in children and adolescents. Clin Bull. 1977;7(2):55-62