Know how to appropriately work up a breast mass in adolescent females
Author:
Lindsey Albrecht, MD
What to Do - Gather Appropriate Data
The discovery of a breast mass in an adolescent female understandably awakens concern in both the patient and her family. Fortunately, the majority of
breastmassesinthisage grouparebenign,withfibroadenoma being the most
common lesion identified. However, malignant tumors may occur on rare
occasions, making accurate diagnosis of the newly discovered breast mass
critically important in the adolescent population.
A fibroadenoma is a benign estrogen sensitive tumor that is identified
in 70% to 95% of breast biopsy specimens in adolescent females. Their
peak incidence is in late adolescence until the early 20s, though premenarchal cases have been described. A fibroadenoma usually presents as a
firm rubbery nontender mass, often noted to be slowly enlarging over
weeks to months. At the time of diagnosis, most fibroadenomas are 3 to
4 cm in size. Fibroadenomas are most often found in the upper outer
quadrants of the breast, though they can occur elsewhere. They are not
associated with nipple discharge. Overlying skin changes may be noted
in a minority of cases, usually when the lesions are quite large. Lesions
are typically solitary but may be multiple or bilateral in 10% to 25% of
cases, a condition referred to as fibroadenomatosis. Some fibroadenomas
regress spontaneously, while others remain stable in size or enlarge over
time.
A juvenile or giant fibroadenoma is a fibroadenoma that is >5 cm in size.
These masses are often noted to grow rapidly and sometimes reach sizes of
>15 to 20 cm. The giant variant is less common than the regular form, but
makes up a higher percentage of cases in early adolescence. Because giant
fibroadenomas may compress or replace normal breast tissue, their potential
for leading to a poor cosmetic outcome is greater.
Cystosarcoma phyllodes is a breast tumor with peak incidence in the
fourth decade of life, although it occasionally occurs in adolescence. It is
usually painless and slow growing and is usually larger than a fibroadenoma
when discovered. It may be associated with overlying skin changes, nipple
discharge, and axillary lymphadenopathy (usually due to tumor necrosis
or associated infection). Cystosarcoma phyllodes is most often benign, but
borderline and malignant forms exist.
Other than fibroadenoma and cystosarcoma phyllodes, additional etiologies of a breast mass in the adolescent patient include breast abscess,
fibrocystic change or other varieties of breast cyst, intraductal papilloma,
lipoma, and findings related to fat necrosis. Neurofibromatosis, hemangiomas, hematomas, and other causes have also been reported.
Malignant breast tumors, when they occur in the adolescent female,
typically arise from nonbreast tissue. Lymphomas, leukemias, and sarcomas
are the most common of these tumors. Only about one third of malignant
breast masses arise from primary breast tissue, with highest risk seen in
the older adolescent and in those with a family history of breast cancer or
BRCA-1 or BRCA-2 gene mutations. Adenocarcinoma is usually hard with
indistinctborders,andisusuallyfixedornonmobile.Nippleretractionordischarge, skin edema, lymphadenopathy, and signs or symptoms of metastatic
disease may be present in some cases.
The workup of a newly discovered breast mass may vary depending
on the characteristics of the lesion and the particular patient. Small, slow–
growing, rubbery lesions consistent with a fibroadenoma can be observed
over a period of several months. Imaging by ultrasound may be helpful in
differentiating solid lesions from cystic ones, though it is not usually helpful
in distinguishing amongst solid lesions. Mammography is not encouraged
in the adolescent population, because the density of the breast parenchyma
is high in this age group, which may obscure the lesion. Of course, a tissue
diagnosis is needed for suspicious lesions, such as fixed, irregular-feeling
or rapidly enlarging masses. Tissue has traditionally been obtained through
excisional biopsy or open surgery, though newer evidence has supported
the role of fine-needle aspiration (FNA) as a diagnostic tool in adolescent
girls. FNA may be preferable to other more invasive methods given the
high incidence of benign disease in adolescents, as well as the decreased
likelihood of causing a poor cosmetic result in the developing breast. FNA
can additionally be used to drain cysts, which may be both diagnostic and
therapeutic.
Thus, in most cases, breast masses in the adolescent female are benign.
When they occur, they can usually be managed conservatively. Additional
workup is needed for suspicious or questionable lesions, however, given the
rare possibility of malignant disease in adolescents.
Suggested Readings
Greydanus DE, Matysina L, Gains M. Breast disorders in children and adolescents. Prim Care.
2006;33:455–502.
Pacinda SJ, Ramzy I. Fine-needle aspiration of breast masses. A review of its role in diagnosis
and management of adolescent patients. J Adolesc Health. 1998;23:3–6.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.
More About Causes of Breast lump
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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» Next page: Mediastinal Mass (The 5-Minute Pediatric Consult)
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