Lesions of the Breast in Children and Adolescents

Normal Breast Development - Context

• Sabiston Textbook of Surgery, p. 1372

Classification of Breast Lesions in Children and Adolescents

1. Developmental Anomalies

• Sabiston Textbook of Surgery, p. 1372

2. Aberrations of Normal Development and Involution (ANDI Framework)

• Fibroadenoma - the commonest breast mass
• Juvenile hypertrophy - excessive breast development

• Berek & Novak's Gynecology, p. 979-980

3. Fibroadenoma (Most Common Breast Lesion)

• Firm, smooth, rubbery, freely mobile mass - often described as a "breast mouse"
• No inflammatory reaction, no skin dimpling, no nipple retraction
• Often bilobed (a groove can be palpated)
• Usually 1-3 cm when detected

• Classic imaging appearance in a young patient - does not require biopsy; observe with short-interval ultrasound
• Asymptomatic, stable lesions - conservative observation
• Growing or symptomatic lesions - excision to rule out phyllodes tumor or carcinoma
• Fibroadenoma is not associated with increased breast cancer risk
• Berek & Novak's Gynecology, pp. 984-985; Mulholland & Greenfield's Surgery, p. 3903

Giant Fibroadenoma

• Defined as >10 cm in size
• Surgical excision recommended - difficult to distinguish from phyllodes tumor
• Mulholland & Greenfield's Surgery, p. 3904

Juvenile (Cellular) Fibroadenoma

• Occurs in young women aged 10-18 years
• Can range from 5-20 cm in diameter
• Rapid growth is characteristic
• Surgical excision is recommended - cosmetically distressing and difficult to differentiate from phyllodes tumor
• Important caveat: risk of damage to the prepubertal breast bud is a recognized complication of surgery
• Mulholland & Greenfield's Surgery, p. 3904

Complex Fibroadenoma

• Associated with proliferative changes: sclerosing adenosis, ductal epithelial hyperplasia, epithelial calcification, or papillary apocrine changes
• Surgical excision often recommended to exclude carcinoma

4. Phyllodes Tumor

• Benign: 60%
• Borderline: 20%
• Malignant: 20%

• Berek & Novak's Gynecology, p. 985

5. Juvenile (Virginal) Hypertrophy - Macromastia

• Excessive breast growth during puberty, typically bilateral
• Can cause significant physical symptoms: neck, shoulder, and back pain
• Postural disturbances including forward shoulder posture and compensatory trapezius hypertrophy
• Shoulder grooving from support garments
• Primary therapy: weight management if obesity is a contributing factor
• Definitive treatment: reduction mammoplasty (94% improvement in shoulder grooving, 88% improvement in self-esteem reported postoperatively)
• Berek & Novak's Gynecology, pp. 991-992

6. Inflammatory/Infectious Lesions

Neonatal/Breast Abscess

• Neonatal breast secretion ("witch's milk") occurs in ~90% of newborns due to elevated maternal hormones
• If the secretion sequesters, it can cause a lactocele or mass that usually resolves within 3-4 weeks
• Staphylococcal mastitis or abscess can occur in neonates - requires antibiotics and surgical drainage if fluctuant

Periductal Mastitis

• Can occur in young women and adolescents
• Associated with nipple discharge and subareolar inflammation
• Sabiston Textbook of Surgery, p. 1372

7. Cystic Lesions

• Simple cysts are uncommon in adolescents (more common in mature reproductive-age women)
• Pubertal retroareolar cysts - a distinct entity presenting as bluish subareolar lumps at puberty; recently reviewed in pediatric literature (Guido et al., 2024, PMID: 38712575)
• Fibrocystic change is an ANDI condition of the mature reproductive period and is less relevant in this age group

8. Proliferative Lesions

• Ductal hyperplasia - incidental finding; benign cells with increased numbers; no significant cancer risk; no additional treatment needed
• Intraductal papilloma - presents with pathologic (often bloody) nipple discharge; surgical excision recommended when diagnosed on core needle biopsy due to risk of atypia or DCIS
• Sclerosing adenosis - benign lobular lesion; no further treatment after biopsy
• Mulholland & Greenfield's Surgery, pp. 3902-3903

9. Malignant Breast Lesions

• Invasive diagnostic testing and aggressive management are only recommended when clinical suspicion of malignancy is very high
• A multidisciplinary team approach is essential (pediatric oncologist, surgeon, radiation oncologist, pathologist)
• Prior chest radiation (e.g., for childhood lymphoma) is a known risk factor for subsequent breast cancer
• Sosnowska-Sienkiewicz et al., 2024, PMID: 39507494; Current Surgical Therapy 14e

Diagnostic Approach

History and Examination

• Age, pubertal status, menstrual history
• Duration, rate of growth, associated symptoms (pain, discharge)
• Family history of breast cancer
• Physical examination of breast and axillary lymph nodes

Imaging

• Ultrasound is the first-line and most commonly used imaging modality in this age group (avoids radiation, superior for dense breast tissue)
• Mammography: rarely indicated; used in cases of diagnostic doubt
• MRI: reserved for complex clinical scenarios

Biopsy

• Core needle biopsy (CNB): preferred when tissue diagnosis is needed
• Excisional biopsy: for complex or indeterminate lesions
• Fine needle aspiration cytology (FNAC) has a role but lower diagnostic yield than CNB

Management Summary

Recent Evidence

• Sosnowska-Sienkiewicz P et al. (2024) - Front Pediatr - comprehensive scoping review; fibroadenomas comprise 95% of lesions; recommends conservative approach with periodic ultrasound every 6-12 months; CNB preferred over excisional biopsy in most cases [PMID: 39507494]
• Mubarak F et al. (2023) - Curr Probl Pediatr Adolesc Health Care - emphasizes that differentiation between fibroadenoma and phyllodes tumor guides management; aggressive work-up only when malignancy is strongly suspected [PMID: 37914550]
• Schwartz D et al. (2025) - APSA Cancer Committee expert consensus recommendations for managing pediatric breast masses [PMID: 39384492]