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Breast Imaging in the Pediatric and Adolescent Patient

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Breast Imaging in the Pediatric and Adolescent Patient

Sheila Venkatesh, MD

Donnette Dabydeen, MD

Rochester General Hospital

Department of Radiology

Introduction

  • Clinical indications for breast imaging are painful, palpable mass, unilateral, spontaneous, bloody or clear nipple discharge, and breast infection.
  • Ultrasound is the primary imaging modality in the pediatric and adolescent patient. 
  • Ultrasound has a 99.5% negative predictive value in distinguishing between benign and malignant masses. 
  • Mammography is less sensitive due to increased breast density. 
  • For radiation exposure to be as low as reasonably achievable, mammography is only used only when necessary. Routine screening mammograms are not recommended. 
  • In patients with genetic mutations or strong family history, screening with breast MRI may be indicated.
Benign and Malignant Breast Imaging Findings

Breast cyst

  • Can be single or multiple, simple or complex.
  • Circumscribed margins, posterior acoustic enhancement, and thin walls on ultrasound.
  • In adolescent patients, retroareolar cysts may be seen.
  • Can follow up if needed with ultrasound.

Gynecomastia

  • Benign, excessive subareolar breast tissue.
  • Can be physiologic in neonates and pubertal boys.
  • Can present as tender, mobile mass.
  • Can present as ill-defined hypoechoic region in the retroareolar breast.

Fibroadenoma

  • Commonly seen in pediatric and adolescent patients.
  • Mobile, painless mass.
  • Circumscribed, hypoechoic, wider than tall orientation.
  • Can present as bilateral giant juvenile fibroadenomas.
  • Follow up with ultrasound, biopsy, or surgically excise.

Galactocele

  • Epithelial-lined cyst filled with milk.
  • Can be seen in lactating,  adolescent female patients.
  • On lateral mammogram, a fat-fluid level can be seen.
  • On ultrasound, seen as complex cystic mass.
  • Follow up with ultrasound or ultrasound-guided aspiration.

Breast abscess

  • Can present with erythema, warmth, and tenderness.
  • Hypoechoic, complex fluid collection.
  • Increased peripheral flow on color Doppler.
  • Ultrasound-guided aspiration is diagnostic and therapeutic.

Breast Hematoma

  • Secondary to trauma or iatrogenic injuries.
  • Complex cystic lesion that is initially hyperechoic.
  • Becomes anechoic as the hematoma evolves.
  • Follow up  is recommended to ensure benign evolution.

Phyllodes tumor

  • Orgiginates from specialized lobular connective tissue similar to fibroadenomas.
  • May present as rapidly enlarging breast mass.
  • Can be benign, borderline, or malignant histologically.
  • Most common malignant breast mass in adolescents.
  • Can appear similar to fibroadenomas on ultrasound especially in cases of giant juvenile fibroadenomas.
  • Histologic examination can be used to differentiate between fibroadenoma and phyllodes tumor and to further categorize the phyllodes tumor.
  • Treatment with surgical excision.

Benign:

  • Pseudoangiomatous stromal hyperplasia
    • Benign proliferation of stroma; hypoechoic, well-circumscribed, and wider than tall on ultrasound; biopsy is recommended to ensure benignity.
  • Intraductal papilloma
    • Rare in this population; presents with spontaneous nipple discharge; found in subareolar region.
  • Juvenile papillomatosis
    • Rare, proliferative process; mobile, firm, well-circumscribed mass; surgical excision is recommended.

Malignant:

  • Primary breast cancer
    • Extremely rare and accounts for less than 1% of all childhood cancers.
    • Most commonly reported type is secretory carcinoma.
  • Metastatic disease 
    • Most common primaries are lymphoma, leukemia, and rhabdomyosarcoma.

References:

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 May-Jun;29(3):907-31.

Gao Y, Saksena MA, Brachtel EF, terMeulen DC, Rafferty EA. How to approach breast lesions in children and adolescents. European Journal of Radiology 2015 Jul;84(7):1350-64.

Jones, KN. Imaging of the adolescent breast. Seminars in Plastic Surgery 2013 Feb;27(1):29-35.

Kaneda HJ, Mack J, Kasales CJ, Schetter S. Pediatric and adolescent breast masses: a review of pathophysiology, imaging, diagnosis, and treatment. AJR. American Journal of Roentgenology 2013 Feb;200(2):W204-12.

Welch ST, Babcock DS, Ballard ET. Sonography of pediatric male breast masses: gynecomastia and beyond. Pediatric Radiology 2004 Dec;34(12):952-7.

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