Lesions of the Breast in Children and Adolescents

Introduction

• Berek & Novak's Gynecology, p. 978

Classification of Breast Lesions in Children/Adolescents

1. Developmental / Physiological Lesions

a. Premature Thelarche

• Unilateral or bilateral breast tissue development before age 8 in girls
• A subareolar disc of tissue - not a true "lesion" but a frequent clinical referral
• Must be distinguished from a true breast mass
• Biopsy is contraindicated as it risks damage to the breast bud and subsequent hypoplasia/aplasia of the breast

b. Juvenile Hypertrophy (Virginal/Macromastia)

• Excessive, rapid bilateral breast enlargement at puberty
• Results from exaggerated hormonal sensitivity of breast stroma
• Can be physically and psychologically distressing
• Treatment: reduction mammoplasty after growth stabilization

2. Benign Tumors

a. Fibroadenoma (Most Common Breast Lesion in Adolescents)

• Pericanalicular fibroadenoma: Fibrous tissue surrounds tubular glands; smaller, harder; occurs in young girls aged 15-30 years
• Intracanalicular fibroadenoma: Glands stretched into elongated spidery shapes indented by fibrous tissue; larger, softer; more common in middle-aged women 35-50 years

• Most common tumor in females under 30 years; most common breast tumor in adolescents
• Painless lump, often found incidentally
• Smooth, firm, well-defined margin
• Non-tender, no skin fixation, no axillary lymphadenopathy
• Highly mobile - termed "breast mouse" or "floating tumor"
• May fluctuate in size with menstrual cycle
• Can be multiple in 10-15% of cases

• Ultrasound: well-circumscribed, solid mass - modality of choice in young women
• Core needle biopsy (CNB) if diagnosis uncertain

• Reassurance once diagnosis confirmed on imaging ± biopsy
• Surgical excision if: symptomatic, enlarging, >3 cm, suspected phyllodes tumor, or patient preference
• Cancer within fibroadenoma is exceedingly rare (0.2%)
• S. Das Manual on Clinical Surgery, p. 434; Sabiston Textbook of Surgery, p. 1384; Mulholland & Greenfield's Surgery, p. 3903

b. Juvenile (Giant) Fibroadenoma

• A large fibroadenoma occurring in adolescents aged 10-18 years, ranging from 5-20 cm in diameter
• Histologically more cellular than ordinary fibroadenoma
• Grows rapidly and can distort breast contour
• Can be cosmetically distressing
• Surgical excision is recommended as these lesions:
  • Are cosmetically distressing
  • Are difficult to differentiate from a phyllodes tumor
  • Risk to the prepubertal breast bud is a potential complication of excision
• A fibroadenoma >10 cm is termed giant fibroadenoma and excision is also recommended.
• Mulholland & Greenfield's Surgery, p. 3904; Sabiston Textbook of Surgery, p. 1385

c. Phyllodes Tumor (Cystosarcoma Phylloides / Serocystic Disease of Brodie)

• A giant fibroadenoma-like tumor, tends to occur in women >40 years but can occur in adolescents
• Not truly malignant (most cases), but has potential for malignant transformation (~10-15%)
• Clinical features:
  • Huge, rapidly growing breast swelling
  • Overlying skin thinned and tense with prominent subcutaneous veins
  • Not fixed to skin or deeper structures
  • Axillary lymph nodes rarely enlarged
  • Occasionally presents with serous nipple discharge
• Arises from progressive cystic degeneration of a soft fibroadenoma - cystadenoma → cystosarcoma phylloides
• Treatment: Wide local excision or mastectomy depending on size
• S. Das Manual on Clinical Surgery, p. 434

3. Inflammatory Lesions

a. Breast Abscess / Mastitis

• Can occur in adolescents (non-lactational)
• Causative organisms: Staphylococcus aureus, streptococci
• Presents with fever, erythema, swelling, tenderness
• Management: Antibiotics + needle aspiration; surgical incision and drainage if refractory

b. Periductal Mastitis / Duct Ectasia

• Chronic relapsing subareolar infection
• Associated with smoking and diabetes
• Mixed aerobic-anaerobic flora
• Can lead to nipple retraction, subareolar mass, and fistula formation
• Treatment: Antibiotics, abscess drainage; recurrent cases require excision of the entire subareolar duct complex
• Sabiston Textbook of Surgery, p. 1385

4. Fibrocystic Change

• Common in the reproductive period; essentially a spectrum of benign histological changes
• Includes: cysts, adenosis, fibrosis, mild epithelial hyperplasia
• Clinical features: cyclical mastalgia, nodularity, tenderness
• Risk for breast cancer: Fibrocystic change without atypia carries no increased risk; with atypical hyperplasia, risk increases ~5-fold
• Management: Reassurance; caffeine reduction; vitamin E/B6 supplementation (controversial); NSAIDs for pain

5. Gynecomastia (in Adolescent Males)

• Benign enlargement of male breast tissue
• Bimodal distribution: puberty (due to relative estrogen excess during hormonal fluctuation) and older age
• Presents as unilateral or bilateral, painful, firm or rubbery subareolar mass
• Associations: liver cirrhosis, hypogonadism, testicular tumors, obesity, drugs (anabolic steroids, spironolactone, digoxin, marijuana, ketoconazole, phenothiazines)
• In adolescents, physiological gynecomastia usually resolves spontaneously
• Can cause emotional and psychological distress in adolescents
• Investigations: Mammography to confirm diagnosis; rule out testicular tumor
• Management:
  • Identify and remove precipitating cause/drug
  • Tamoxifen may reduce symptoms (especially during anti-androgen therapy)
  • Surgical management (subcutaneous mastectomy) for persistent, distressing cases
• Current Surgical Therapy 14e, p. 762

6. Intraductal Papilloma

• Benign tumor within a major lactiferous duct
• Key feature: Blood-stained or serous nipple discharge - most common cause in young women
• Rarely palpable as a mass
• Investigations: Ultrasound, ductography, nipple discharge cytology
• Treatment: Excision of the involved duct (microdochectomy)

Summary Table

Key Points for SAQ

1. Fibroadenoma is the most common breast lesion in adolescents - it is NOT pre-malignant (cancer risk 0.2%)
2. Juvenile fibroadenoma (10-18 years, 5-20 cm) requires excision due to cosmetic distress and difficulty distinguishing from phyllodes tumor
3. "Breast mouse" = classic description of fibroadenoma's high mobility
4. Biopsy/excision of breast bud should be avoided in prepubertal girls to prevent breast hypoplasia
5. Gynecomastia in puberty is mostly physiological and self-limiting
6. Fibrocystic change only increases cancer risk when atypia is present (5x risk with atypical hyperplasia)
7. Phyllodes tumor is mostly benign but has malignant potential; arises from fibroadenoma degeneration