Korean J Radiol.  2018 Oct;19(5):978-991. 10.3348/kjr.2018.19.5.978.

Breast Lesions in Children and Adolescents: Diagnosis and Management

• Lee EJ
• Chang YW
• Oh JH
• Hwang J
• Hong SS
• Kim HJ

• KMID: 2418562
• DOI: http://doi.org/10.3348/kjr.2018.19.5.978

Abstract

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.

Keyword

Pediatric breast; Child; Adolescence; Normal development; Fibroadenoma; Gynecomastia; Cyst; Phyllodes tumor; Sonography

MeSH Terms

Acoustics
Adolescent*
Adult
Biopsy
Biopsy, Large-Core Needle
Breast Diseases
Breast Neoplasms
Breast*
Child*
Diagnosis*
Fibroadenoma
Gynecomastia
Humans
Male
Phyllodes Tumor
Risk Factors
Shadowing (Histology)
Thorax
Ultrasonography

Figure

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  Fig. 1 3-year-old girl with palpable lesion in left breast. A. On ultrasonographic image, normal chostochondral junction is seen in scan of palpable area. Note that rib is located posterior to pectoralis muscle (arrow), showing posterior acoustic shadowing (arrowhead). No abnormality is noted in breast parenchyma. B. Plain chest radiograph showing cleavage of left fifth rib at costochondral junction, suggestive of bifid rib (arrow).

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  Fig. 2 15-year-old girl undergoing CT for evaluation of trauma. A. CT scan reveals enhancing mass in left breast (arrow). B. Ultrasonographic image shows probably benign mass in left breast that correlates with CT findings. This patient was followed up without pathologic confirmation of probably benign mass. CT = computed tomography

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  Fig. 3 Findings in 1-day-old boy who had palpable mass in right lateral portion of chest wall. A. Ultrasonographic image revealed thin septate cyst suggesting lymphangioma. B. Fat suppressed T2-weighted MR image showing thin septate high-signal intensity lymphangioma. C. T1-weighted MR image showing proliferation of glandular tissue in subareolar area bilaterally and attributable to physiologically enlarged glandular tissue under influence of maternal hormones. MR = magnetic resonance

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  Fig. 4 Ultrasonographic images for 18-year-old girl with corpus callosum agenesis. A. US of breast showing hypogenesis of fibroglandular tissue bilaterally. B. US of pelvis reveals immature uterus, suggestive of sexual immaturity. US = ultrasonography

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  Fig. 5 Ultrasonographic image for 1-year-old girl who had palpable masses in both breasts. Image reveals proliferation of glandular tissue in subareolar area bilaterally with no other signs of precocious puberty. Clinical follow-up was sufficient and no further imaging or intervention was needed.

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  Fig. 6 Ultrasonographic images for 9-year-old girl who had been diagnosed to have lump in each breast 6 months earlier. A. Ultrasonographic image of breast showing hypoechoic linear projection of glandular tissue in subareolar area (Tanner stage 3). B. Ultrasonographic image of pelvis showing enlarged uterus with ovaries that had normal volume range (not shown).

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  Fig. 7 Ultrasonographic comparison of Tanner stages. A. Tanner stage 1. Clinical elevation of papilla is seen. US shows small foci echogenic tissue in subareolar area. B. Tanner stage 2. Clinical elevation of both breast and papilla is seen with small amount of enlargement in areolar diameter. US shows hypoechoic subareolar breast bud with hyperechoic breast parenchyma composed of adipose tissue and loose connective tissue. C. Tanner stage 3. Clinically palpable subareolar nodule with further enlargement of breast and areola are noted without separation of their contours. US shows extension of hyperechoic fibroglandular tissue with central spider-like and hypoechoic linear projections away from retroareolar region, reflecting elongated ducts. D. Tanner stage 4. Clinical projection of areola and papilla forms secondary mound above breast with separation of their contour. US shows more widely elongated hypoechoic breast bud and loss of rounded appearance. Subcutaneous fat may be present. E. Tanner stage 5. Clinical projection of papilla only with recession of areola to general contour of breast. US shows mature breast appearance, heterogeneous echogenicity of breast parenchyma intermixed with echogenic glandular and stromal tissue, and increased amount of subcutaneous fat.

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  Fig. 8 Ultrasonographic image of breast for 12-year-old girl with lump in left axilla. Image shows focal area of heterogeneous fibroglandular tissue in subcutaneous fat layer of left axilla (arrows) similar to that of breast.

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  Fig. 9 Poland syndrome in 13-year-old boy. (A) CT and (B) MIP reconstruction images showing absence of pectoralis muscle in right chest wall (arrow). MIP = maximum intensity projection

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  Fig. 10 Gynecomastia in 18-year-old boy with palpable mass in subareolar region in both breasts. A. Ultrasonographic image showing normal glandular breast tissue in subareolar regions of both breasts, indicating gynecomastia. B. Computed tomographic image showing linear or tubular soft tissue density in subareolar region of both breasts.

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  Fig. 11 Duct ectasia in 3-day-old boy with lump in subareolar region bilaterally. A, B. Ultrasonographic images showing heterogeneous multiseptate cystic mass-like lesion in subareolar region of both breasts as findings of duct ectasia.

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  Fig. 12 Ultrasonographic images for 19-year-old girl with 2-week history of redness and pain in right breast. A. Ultrasonographic image showing heterogeneous echoic mass-like lesion with diffuse fat infiltration in breast tissue, indicating abscess. B. Color Doppler study showing increased vascularity that suggests hypervascularity because of inflammation.

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  Fig. 13 Giant fibroadenoma in 15-year-old girl. Ultrasonographic image shows approximately 6.5-cm circumscribed, oval, parallel isoechoic mass in left breast.

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  Fig. 14 Conventional fibroadenoma in 17-year-old girl. Ultrasonographic images shows circumscribed, oval, parallel, isoechoic mass with posterior enhancement in left breast.

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  Fig. 15 PASH. Ultrasonographic image for 44-year-old woman shows oval, circumscribed, parallel, and hypoechoic mass with posterior acoustic enhancement in right breast. Imaging features are similar to those of fibroadenoma. US-guided core needle biopsy revealed PASH. PASH = pseudoangiomatous stromal hyperplasia

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  Fig. 16 Juvenile papillomatosis in 17-year old girl with nipple discharge. Ultrasonographic image shows Swiss cheese-like cystic duct ectasia in right breast. Surgical excision revealed intraductal papillomatosis.

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  Fig. 17 Phyllodes tumor in 17-year-old girl with palpable mass in left breast. Ultrasonographic image shows 2.5-cm circumscribed, oval, isoechoic parallel mass in left breast. Vacuum-assisted biopsy revealed benign phyllodes tumor.

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  Fig. 18 14-year-old girl with palpable mass in breast. Ultrasonographic image shows right and central portions of huge mass. Huge, circumscribed, round mass with peripheral cystic component (arrows) can be seen. Patient was confirmed to have low-grade malignant phyllodes tumor.

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  Fig. 19 17-year-old girl with non-Hodgkin's lymphoma. A. Ultrasonographic showing multiple circumscribed, oval, hypoechoic masses with posterior enhancement in both breasts. B. Fat suppressed T2-weighted MR image showing multiple, round, inhomogeneous masses with high signal intensity in both breasts. C. Early subtraction T1-weighted MR image after administration of gadolinium contrast showing inhomogeneous enhancing breast masses bilaterally. Core needle biopsy revealed metastatic lymphoblastic B-cell lymphoma of breast.

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  Fig. 20 Primary breast cancer in 23-year-old woman with family history of breast cancer. A. Ultrasonographic image of breast showing irregular, indistinct, hypoechoic mass with posterior shadowing. B. MIP reconstruction-enhanced early subtraction MR image showing rapidly enhancing mass with neoangiogenetic vascular structures. Enlarged enhancing axillary lymph node is also noted in left axilla level I. US-guided core needle biopsy of left breast mass confirmed invasive ductal carcinoma.

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  Fig. 21 Summary of management for pediatric breast diseases.

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  Fig. 22 Algorithm for sonographic assessment and management of pediatric breast lesions. *BI-RADS assessment category 2: simple cyst. Oval, round, circumscribed, anechoic mass with posterior acoustic enhancement. **BI-RADS assessment category 3: oval, circumscribed, hypo-/iso-/hyperechogenic mass with various vascularity. ***BI-RADS assessment category 4 or 5: masses with suspicious features; irregular margin, nonparallel orientation, non-circumscribed margin, increased vascularity, heterogeneous echo pattern (including complex cystic and solid), associated features. BI-RADS = Breast Imaging Reporting and Data System, MRI = magnetic resonance imaging, Sx/sign = symptom/sign

Reference

1. Valeur NS, Rahbar H, Chapman T. Ultrasound of pediatric breast masses: what to do with lumps and bumps. Pediatr Radiol. 2015; 45:1584–1599. quiz 1581-1583.

2. Chung EM, Cube R, Hall GJ, González C, Stocker JT, Glassman LM. From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation. Radiographics. 2009; 29:907–931.

3. García CJ, Espinoza A, Dinamarca V, Navarro O, Daneman A, García H, et al. Breast US in children and adolescents. Radiographics. 2000; 20:1605–1612.

4. Kronemer KA, Rhee K, Siegel MJ, Sievert L, Hildebolt CF. Gray scale sonography of breast masses in adolescent girls. J Ultrasound Med. 2001; 20:491–496. quiz 498.

5. Sanchez R, Ladino-Torres MF, Bernat JA, Joe A, DiPietro MA. Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings. Pediatr Radiol. 2010; 40:1681–1689.

6. Gutierrez JC, Housri N, Koniaris LG, Fischer AC, Sola JE. Malignant breast cancer in children: a review of 75 patients. J Surg Res. 2008; 147:182–188.

7. Kaneda HJ, Mack J, Kasales CJ, Schetter S. Pediatric and adolescent breast masses: a review of pathophysiology, imaging, diagnosis, and treatment. AJR Am J Roentgenol. 2013; 200:W204–W212.

8. Gao Y, Saksena MA, Brachtel EF, terMeulen DC, Rafferty EA. How to approach breast lesions in children and adolescents. Eur J Radiol. 2015; 84:1350–1364.

9. Baker JA, Soo MS, Rosen EL. Artifacts and pitfalls in sonographic imaging of the breast. AJR Am J Roentgenol. 2001; 176:1261–1266.

10. Durmaz E, Öztek MA, Arıöz Habibi H, Kesimal U, Sindel HT. Breast diseases in children: the spectrum of radiologic findings in a cohort study. Diagn Interv Radiol. 2017; 23:407–413.

11. Bock K, Duda VF, Hadji P, Ramaswamy A, Schulz-Wendtland R, Klose KJ, et al. Pathologic breast conditions in childhood and adolescence: evaluation by sonographic diagnosis. J Ultrasound Med. 2005; 24:1347–1354. quiz 1356-1357.

12. Youn I, Park SH, Lim IS, Kim SJ. Ultrasound assessment of breast development: distinction between premature thelarche and precocious puberty. AJR Am J Roentgenol. 2015; 204:620–624.

13. Adler DD, Rebner M, Pennes DR. Accessory breast tissue in the axilla: mammographic appearance. Radiology. 1987; 163:709–711.

14. Mojallal A, La Marca S, Shipkov C, Sinna R, Braye F. Poland syndrome and breast tumor: a case report and review of the literature. Aesthet Surg J. 2012; 32:77–83.

15. Zhang F, Qi X, Xu Y, Zhou Y, Zhang Y, Fan L, et al. Breast cancer and Poland's syndrome: a case report and literature review. Breast J. 2011; 17:196–200.

16. Braunstein GD. Gynecomastia. N Engl J Med. 1993; 328:490–495.

17. Weinstein SP, Conant EF, Orel SG, Zuckerman JA, Bellah R. Spectrum of US findings in pediatric and adolescent patients with palpable breast masses. Radiographics. 2000; 20:1613–1621.

18. Huneeus A, Schilling A, Horvath E, Pinochet M, Carrasco O. Retroareolar cysts in the adolescent. J Pediatr Adolesc Gynecol. 2003; 16:45–49.

19. Welch ST, Babcock DS, Ballard ET. Sonography of pediatric male breast masses: gynecomastia and beyond. Pediatr Radiol. 2004; 34:952–957.

20. Soo MS, Kornguth PJ, Hertzberg BS. Fat necrosis in the breast: sonographic features. Radiology. 1998; 206:261–269.

21. Simmons PS. Diagnostic considerations in breast disorders of children and adolescents. Obstet Gynecol Clin North Am. 1992; 19:91–102.

22. Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 1995; 196:123–134.

23. Sanders LM, Sharma P, El Madany M, King AB, Goodman KS, Sanders AE. Clinical breast concerns in low-risk pediatric patients: practice review with proposed recommendations. Pediatr Radiol. 2018; 48:186–195.

24. Patterson SK, Jorns JM. A case of juvenile papillomatosis, aka “Swiss cheese disease”. Breast J. 2013; 19:440–441.

25. Gill J, Greenall M. Juvenile papillomatosis and breast cancer. J Surg Educ. 2007; 64:234–236.

26. Tse GM, Niu Y, Shi HJ. Phyllodes tumor of the breast: an update. Breast Cancer. 2010; 17:29–34.

27. Cecen E, Uysal KM, Harmancioglu O, Balci P, Kupelioglu A, Canda T. Phyllodes tumor of the breast in an adolescent girl. Pediatr Hematol Oncol. 2008; 25:79–82.

28. Yabuuchi H, Soeda H, Matsuo Y, Okafuji T, Eguchi T, Sakai S, et al. Phyllodes tumor of the breast: correlation between MR findings and histologic grade. Radiology. 2006; 241:702–709.

29. Surov A, Holzhausen HJ, Wienke A, Schmidt J, Thomssen C, Arnold D, et al. Primary and secondary breast lymphoma: prevalence, clinical signs and radiological features. Br J Radiol. 2012; 85:e195–e205.

30. Wienbeck S, Meyer HJ, Uhlig J, Herzog A, Nemat S, Teifke A, et al. Radiological imaging characteristics of intramammary hematological malignancies: results from a german multicenter study. Sci Rep. 2017; 7:7435.

31. Kennedy RD, Boughey JC. Management of pediatric and adolescent breast masses. Semin Plast Surg. 2013; 27:19–22.

32. Murphy JJ, Morzaria S, Gow KW, Magee JF. Breast cancer in a 6-year-old child. J Pediatr Surg. 2000; 35:765–767.

33. Horowitz DP, Sharma CS, Connolly E, Gidea-Addeo D, Deutsch I. Secretory carcinoma of the breast: results from the survival, epidemiology and end results database. Breast. 2012; 21:350–353.

34. Ha SM, Chae EY, Cha JH, Kim HH, Shin HJ, Choi WJ. Association of BRCA mutation types, imaging features, and pathologic findings in patients with breast cancer with BRCA1 and BRCA2 mutations. AJR Am J Roentgenol. 2017; 209:920–928.

35. Lee MV, Katabathina VS, Bowerson ML, Mityul MI, Shetty AS, Elsayes KM, et al. BRCA-associated cancers: role of imaging in screening, diagnosis, and management. Radiographics. 2017; 37:1005–1023.

36. Mendelson EB, Böhm-Vélez M, Berg WA, et al. ACR BI-RADS ultrasound. ACR BI-RADS Atlas. Breast imaging reporting and data system. 5th ed. Reston, VA: American College of Radiology;2013. p. 128–130.

37. Gordon PB, Gagnon FA, Lanzkowsky L. Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology. 2003; 229:233–238.