Breast Masses in Children and Adolescents

1. Breast Masses in Children and Adolescents

2. The spectrum of breast lesions in children and adolescents varies markedly from that for adults, with the former lesions being overwhelmingly benign • may arise from normal and abnormal breast development.. • After onset of puberty, most cases of breast enlargement arise from benign fibroadenoma in girls and gynecomastia in boys`

3. Evaluation of the Pediatric Breast. • the initial breast imaging is sonography, whereas mammography is reserved for selected cases. • CT is usually not used • MR imaging may be valuable for those patients with breast masses that involve deeper structures, such as vascular malformations or chest wall lesions. . • The prevalence of breast cancer is extremely low compared with that in the adult population , • whereas the risk of intervention is much greater than that to the mature breast . • Consequently, a conservative approach of clinical and sonographic follow-up is more commonly adopted in children.

4. Normal Breast Development • In the 5th–6th week of fetal life, breast development begins when epidermal cells invaginate toward the deeper mesenchyme and form the primary mammary ridges or milk lines. • These ridges extend from the axilla to the groin, but, normally, the cranial and caudal portions involute, which leaves only the portion at the fourth intercostal space to develop into the breast .

5. ducts are often enlarged at birth in full-term infants because of the effects of maternal hormones. • Bilateral subareolar palpable nodules are common and may persist for the first 6–12 months of life . • In girls, a second phase of breast development begins at puberty. • The onset of pubertal breast development is called thelarche, which normally occurs after age 8–9 years and before 13 years of age , the ducts begin to elongate and branch, leading to lobular differentiation and the development of terminal duct-lobular units . • Pubertal breast development is divided into five phases called Tanner stages .

6. Pubertal breast development is divided into five phases called Tanner stages .

7. In Tanner stage 1 ( before thelarche): • sonography of the breast demonstrates mildly heterogeneous retroareolar subcutaneous tissue anterior to the pectoralis muscle .

8. In Tanner stage 2,: • the classic breast bud forms as a subareolar disk . Sonography at this stage reveals a hyperechoic nodule with central, linear or stellate, hypoechoic areas that represent ducts

9. Tanner stages 3 and 4,: the hyperechoicfibroglandular tissue extends away from the areola, and the central, hypoechoicretroareolar region becomes spider-shaped and then nodular

10. At Tanner stage 5,: • the breast is mature and sonographically manifests as echogenic fibroglandular tissue without the central hypoechoic region seen in earlier stages . • Hypoechoic fat is seen anteriorly, and pectoralis muscle posteriorly

11. Congenital and Developmental Abnormalities • Anomalous Nipple and Breast Development • Polythelia, or supernumerary nipple, / 1%–2% of the population/ usually unilateral /, 95% are found along the milk line . • Polymastiathe presence of more than two breasts occurs less frequently than polythelia. • Accessory breast tissue is most often found in the axilla • Amastia(absence of the breast) is rare and may be associated with the Poland syndrome of unilateral pectoral muscle aplasia

12. Premature Thelarche • onset of female breast development before age 7–8 years., • may be asymmetric or unilateral, • At sonography, appears as normal developing breast tissue without a discrete lesion . • may occur as an isolated event or as part of precocious puberty. • Isolated premature thelarche : • generally occurs in girls aged 1–3 years and is nonprogressive. Reassurance is all that is required. • However, if the patient has clinical evidence of other forms of sexual maturation, a work-up for precocious puberty should be pursued.

13. Radiologic evaluation for suspected precocious puberty include: • a bone age assessment • and abdominal and tranvesicle pelvic sonography to look for evidence of • maturation of the uterus and ovaries. • ovaries and adrenal glands should be evaluated for estrogen-producing lesions,: • including functioning ovarian cysts, juvenile granulosacell tumors of the ovary, and rare feminizing adrenal cortical tumors.

14. Gynecomastia • excessive development of the male breast and clinically manifests as tender, firm subareolar nodules. • often occurs during the neonatal period and puberty. • common bilateral enlargment in neonates because of the influence of maternal hormones. • At puberty, two-thirds to three-fourths of boys have some degree of breast enlargement, which peaks at age 13–14 years and usually resolves within 2 years. The condition is usually bilateral but may be unilateral, and it may be familial. • The etiology is thought to be a decrease in the ratio of testosterone to estrogen. • Excessive body fat may lead to increased conversion of testosterone to estrogen. .

15. Uncommon causes of gynecomastiainclude: • estrogen-producing tumors of the testis, such as Sertoli or Leydig cell tumors; rare, • feminizing adrenal cortical tumors • gonadotropin-secreting tumors: such as hepatoblastoma and fibrolamellar carcinoma or choriocarcinoma; prolactinomas; • liver disease; • Klinefelter syndrome; • testicular feminization syndrome; • neurofibromatosis type 1. • use of drugs such as marijuana, anabolic steroids, corticosteroids, cimetidine, digitalis, and tricyclic antidepressants can cause male breast development

16. At sonography: • , increased subareolar tissue similar to the appearance of early breast development is seen, usually without a discrete mass . • At CT,: dense fibroglandular tissue is noted

17. Unilateral gynecomastia proved after excisional biopsy in a 17-year-old adolescent who admitted frequent use of marijuana. Sonogram shows a biconvex focus of decreased echogenicity (arrow) compared with adjacent subcutaneous fat, deep to which is the pectoralis muscle with hypoechoic muscle bundles separated by linear echogenic fascial bands (arrowhead).

18. Axial CT image of the chest obtained after intravenous administration of iodinated contrast material shows bilateral, triangular areas of soft tissue in the subcutaneous fat in the expected location of the nipple.

19. CT image obtained at a lower level than a shows a large mass in the liver that enhances less than the normal parenchyma.

20. Juvenile Hypertrophy • known as virginal hypertrophy or macromastia, • excessive female breast enlargement that occurs in a relatively short period of weeks to months. • often begins shortly after menarche but may occur during pregnancy. • Usually both breasts are symmetrically, diffusely enlarged, but the condition may be asymmetric or even unilateral. • The pathologic appearance shares features with gynecomastia..

21. Patients are often very symptomatic, • should be avoided surgery in girls with ongoing breast growth. • generally treated with anti-estrogen agents, such as tamoxifen. • After growth has stabilized, surgical options include reduction mammoplasty and mastectomy with reconstruction

22. Cystic lesions • Mammary Duct Ectasia • Galactocele • Retroareolar(Montgomery) Cysts • Abscess and Mastitis • Hematoma • Fibrocystic change

23. Mammary Duct Ectasia • develops in infants or young children in rare cases. • Most often, the retroareolar ducts are involved and the patient presents with bloody nipple discharge . • Less frequently, present with tender or nontender palpable masses caused by secondary inflammation . • Stasis of secretions can lead to bacterial infection with Staphylococcus aureus or Bacteroides species . • At sonography: subareolar, anechoic tubular structures , which may contain debris . • Ectatic mammary ducts may resolve with cessation of breast feeding or with antibiotic therapy. • Surgical excision may be required in patients with persistent or recurrent drainage .

24. Retroareolar duct ectasia in a young pregnant woman. Sonogram demonstrates dilated anechoic ducts (arrow) seen in cross section deep to the areola.

25. Galactoceles • usually develop in lactating women, but they may occur in infants of either gender or in older boys in the absence of endocrinopathy. • typically appear as enlarging painless masses. They may be unilateral or bilateral., • At sonography, depends on the relative proportions of fat and water content of the fluid. Hypoechoic/, hyperechoic; thus, the resulting appearance may be that of a complex cyst . • MR images, show enhancement of only the wall and septations. • A fat-fluid level may be seen on a true lateral mammogram and is a specific finding of galactoceles. • A patient’s clinical history may suggest the diagnosis, but cyst aspiration that yields a milky substance may be required for definitive diagnosis. Aspiration is also therapeutic .

26. Galactocele in a 15-year-old girl that was confirmed by aspiration of milky fluid. • Color Doppler sonogram reveals a well-circumscribed, round cystic structure with homogeneous internal echogenicity, posterior acoustic enhancement, and flow to the cyst wall only. • True lateral mammogram of another patient shows the fat-fluid level (arrowhead), which is a specific finding for galactocele.

27. Retroareolar (Montgomery) Cysts • In adolescent girls, the glands of Montgomery at the edge of the areola may become obstructed. • Clinical symptoms of local inflammation are noted in about two-thirds of patients, whereas another -third present with a painless mass . • The diagnosis is usually made on clinical grounds, but it may be confirmed at sonography, which generally shows single or multiple, retroareolar, thin-walled, unilocular cysts that may contain some echogenic debris. • The cysts measure 2 cm or less in diameter and are frequently bilateral . • Most retroareolar cysts resolve completely or partially with conservative management

28. Abscess and Mastitis • Mastitis most commonly affects lactating women, but it also occurs in young infants and adolescents of both sexes. • The underlying cause may be mammary duct obstruction or ectasia, cellulitis, an immunocompromised state, or nipple injury . • Patients with a suppurative infection present with a tender, indurated, erythematous breast and possibly with fever . • At sonography, a hypoechoic complex mass, often with a thick wall and color Doppler flow at only the periphery, is seen . Sonography may be used to guide needle aspiration of the abscess

29. Hematomas • most commonly result from sports or iatrogenic trauma. • At sonography, appear as complex cystic masses, with the internal echotexture varying with the age of the hematoma. • Acute hematomas are hyperechoic and become progressively more anechoic as they resolve . • Mammography demonstrates a mass with architectural distortion . • At CT, acute hematomas appear hyperattenuating, and the margins may be ill-defined. Reactive changes of healing may produce a spiculatedmargin.

30. Fibrocystic Change • usually physiologic alterations that are very common in the 3rd decade of life, although such changes may be seen to some extent in late adolescence. • In children, solitary cysts are more common than multiple cysts. • . Some pathologic findings in the spectrum of fibrocystic change, such as atypical duct hyperplasia, are considered risk factors for subsequent breast cancer, but these changes are generally confined to the adult population . • The findings of fibrocystic change at sonography are nonspecific and include multiple cysts of varying sizes, dilated ducts, and echogenic foci representing fibrous tissue that may cause posterior sound attenuation .

31. . Fibrocystic changes are histologically classified into 3 categories: nonproliferative changes, proliferative changes without atypia, and proliferative changes with atypia. • Patients with proliferative changes and/or atypia have a higher risk for future malignancies

32. Benign mass • Fibroadenoma • Juvenile or cellular fibroadenoma • Lactating Adenoma • Intraductal Papilloma • Juvenile Papillomatosis • Granular Cell (Myoblastoma)Tumor • PseudoangiomatousStromal Hyperplasia • Benign Vascular Lesions • Intra mammary lymphnode • Truma &fat necrosis

33. Fibroadenoma • the most common breast mass in girls younger than 20 years of age, accounting for well over half of tumors in surgical series . • The mean patient age is 15–17 years . • Most patients present with a slowly enlarging/, painless mass/ that causes breast asymmetry. • it is most often located in the upper outer quadrant . • Fibroadenomas are estrogen-sensitive and may grow faster during pregnancy , although they usually do not vary in size during the menstrual cycle . • Fibroadenomas in males have been reported but are rare because males have no terminal duct-lobular units . or prominent, distended superficial veins may be noted .

34. Juvenile or cellular fibroadenoma • an uncommon histologic variant of fibroadenoma that frequently undergoes markedly rapid growth. • A fibroadenoma over 5–10 cm in diameter is termed a giant fibroadenoma.. • constitute approximately 7%–8% of all fibroadenoma subtypes and most often occur in African American adolescent girls . • Approximately 10%–25% of patients with juvenile fibroadenomas have multiple or bilateral tumors at presentation,

35. Imaging Appearance: • Sonography:is very sensitive . well-circumscribed, round, oval , or macrolobulated mass with fairly uniform hypoechogenicity. • may appear almost anechoic with low-level internal echoes , • fluid-filled clefts may be seen within juvenile fibroadenomas. • In rare cases, reveals a heterogeneous echotexture,( necrosis) or dystrophic calcification, which is more common in older women. • Posterior acoustic transmission is variable and is usually enhanced or intermediate , but posterior shadowing has been described and may be related to infarction . • In ovoid lesions, the growth pattern is horizontal or parallel; • During a color Doppler evaluation, may appear avascular or may demonstrate some central vascularity .

36. mammography: • appears as a well-defined, round or oval, macrolobulated mass . Calcification may be noted as small, peripheral, punctate densities that coalesce into popcornlike calcifications . • CT:typically not used to evaluate breast masses in children, • but fibroadenomas are common and may be found serendipitously on CT scans obtained for other indications. They appear as well-demarcated, round, ovoid, or smoothly lobulated, noncalcified masses .

37. variable appearance at MR imaging: • low in signal intensity on T1-weighted images and hyperintense on T2-weighted images . • T2 hypointensity was observed in the lesions of older patients, associated with more sclerotic stroma at histopathologic analysis. some had internal septations • Most fibroadenomas demonstrated a benign enhancement pattern, with slow initial enhancement and delayed wash out . • fibroadenoma could not be differentiated from phyllodes tumor at MR imaging.

38. Bilateral juvenile fibroadenomas in a 13-year-old girl who presented with left breast enlargement. • (a) Sonogram of the smaller right breast shows a well-circumscribed, homogeneously hypoechoic mass • (b)Mediolateral oblique mammogram of the left breast shows a large mass that occupies much of the breast and dilated veins

39. Juvenile fibroadenoma in a 14-year-old girl.

40. On a sagittal fat-saturation T2-weighted image, the mass appears lobulated and hyperintense with hypointenseseptations (arrow), • Axial T1-weighted image obtained 5 minutes after intravenous administration of gadolinium contrast material demonstrates diffuse intense enhancement of the tumor except for the septations (arrow).

41. Differential Diagnosis: • phyllodestumor( a fibroepithelial neoplasm that may be malignant.) that they are indistinguishable at imaging.Thefinding of peripheral cysts at sonography suggests phyllodes tumor but definitive diagnosis requires tissue sampling. • Juvenile hypertrophy and giant fibroadenoma both manifest with rapid breast enlargement, and distinguishing between the two may be difficult, However, juvenile hypertrophy is usually bilateral

42. Treatment and Prognosis • The natural history is one of slow growth and eventual regression . • women with complex fibroadenomas have an increased long-term risk for developing breast cancer . • the potential for iatrogenic injury to the developing breast, many authors advocate that pediatric patients with typical clinical and sonographic findings be managed conservatively with clinical and sonographic follow-up . • Fine-needle aspiration or core needle biopsy may be used for patients for whom confirmation of the diagnosis is desired . • Surgical excision is indicated for symptomatic or rapidly growing masses.

43. Lactating Adenoma • develop in late pregnancy or during lactation . • At sonography, usually have benign features, such as well-defined margins, smooth lobulations, homogeneous echotexture, and posterior acoustic enhancement, with their long axis parallel to the chest wall . • However, some features, including irregular or angulated margins or posterior acoustic shadowing, suggestive of malignancy . Small central hyperechoic foci, which represent fat in the milk produced by the tumor, may be seen . • Lactating adenomas usually resolve at delivery or upon cessation of lactation.

44.  Lactating adenoma. • (a)Mediolateral oblique mammogram of a 17-year-old girl shows a posterior, dense, well-circumscribed mass. • (b) Corresponding sonogram shows a heterogeneously echogenic mass (arrowheads) with posterior shadowing. • (c) Sonogram of another patient shows small hyperechoic foci within a mass, findings that represent the fat in the milk produced by the tumor.

45. Intraductal Papilloma • uncommon in children . • These masses have rarely been reported in boys . • usually solitary, arise in the large subareolarducts • , manifest with serous or serosanguinousnipple discharge. • are bilateral in 25% of cases • are histologically similar to juvenile papillomatosis. • At sonography or MR imaging, they may appear elongated or they may be surrounded by a dilated duct filled with anechoic fluid. • Papillomas are treated with simple surgical excision

46. Juvenile Papillomatosis • is a localized, proliferative disorder of young women and older adolescents. • The mean patient age at diagnosis is 19 years . • Patients present with a firm, well-defined, mobile mass in the periphery of the breast and without nipple discharge . • At gross examination, the resected mass appears well circumscribed and contains multiple small cysts (<2 cm) within a dense fibrous stroma, an appearance that has given rise to the term swiss cheese disease . • Yellowish calcifications are common . • Tumors vary in size

47. The imaging appearance of juvenile papillomatosis: • At sonography,: • appears as an ill-defined mass with multiple small cysts, especially at the periphery, findings that reflect the gross pathologic features . • Microcalcificationsmay be seen at sonography. Although results of mammography are usually negative, occasionally mammograms may reveal microcalcifications or asymmetric density . • At MR imaging:, • has been described as a lobulated mass with small internal cysts, which are seen best with T2-weighted sequences, and that demonstrates marked enhancement with a benign enhancement profile .

48. Juvenile papillomatosis in a 16-year-old girl. • Sonogram shows a slightly hypoechoic mass that contains multiple, small anechoic cysts.

49. Although juvenile papillomatosis is a benign condition, it is considered a marker for familial breast cancer. • Patients with this diagnosis have a high rate of positive family history of breast cancer (33%–58% of cases). About 5%–15% of patients have concurrent breast cancer • Treatment is generally complete surgical excision with negative margins to prevent recurrence. • Patients with bilateral and recurrent disease and a family history of breast cancer are at risk of developing subsequent breast cancer and should be closely monitored

50. Granular Cell (Myoblastoma) Tumor • usually a benign neoplasm that most commonly arises in the skin and tongue but may occur in any site • Approximately 5%–6% of these tumors arise in the breast, • are uncommon in children, accounting for less than 1% of breast lesions in this population. • they are now believed to originate from perineural cells . • manifest clinically as palpable, firm masses. Most are superficial, and skin retraction and fixation may be noted . • a characteristic that simulates the growth pattern of infiltrating carcinoma