Thursday, July 24, 2008

Breast Masses in Adolescent Girls

Breast masses in adolescent girls are usually benign.

Fibroadenoma

  • is the most common discrete breast mass in the adolescent female (70%).
  • As many as 15% of patients may have multiple fibroadenomas.
  • On examination, these masses are smooth, mobile, and round.
  • They may occasionally become larger just before the patient's menstrual period.
  • They are well-circumscribed lesions that can be enucleated from the surrounding tissue at surgery. A true capsule is not typically present.
  • If the mass has the characteristics of a fibroadenoma, then it may be monitored with repeated careful physical examination every 1-3 months. Alternatively, an excisional biopsy may be performed if the patient and family request it.

Juvenile, or giant, Fibroadenomas

  • are unusually large (>5 cm) and are termed giant when greater than 8 cm.
  • The rapid increase in size is what usually brings the patient in to be seen.
  • They are benign, do not appear to become malignant or to be familial.
  • Management consists of surgery. Histologically, juvenile fibroadenomas have more cellularity than typical fibroadenomas. They should be differentiated from cystosarcoma phyllodes.

Cystosarcoma phyllodes tumors

  • manifest as a painless breast mass. Most occur later in life (the third or fourth decade).
  • Often the patient will have a history of sudden enlargement of a previously stable mass. The mass may be dramatically large; thinning of overlying skin and increased vascularity of the area may be present.
  • Ultrasonography cannot usually be used to distinguish between a fibroadenoma and a phyllodes tumor. That differentiation lies in histologic examination. Phyllodes tumors have a more cellular stroma with nuclear atypia and mitotic figures.
  • Usually quoted as 90% benign and 10% malignant. There are reports that state as many as 25% of phyllodes tumors may be considered malignant.
  • The management for either benign or malignant phyllodes tumor is wide excision with a margin of normal breast tissue. Malignant phyllodes tumors rarely metastasize to the axilla. Axillary dissections are indicated for patients with palpable lymph nodes.

Pseudoangiomatous Stromal Hyperplasia (PASH)

  • is a rare type of benign mesenchymal proliferative disease of the breast.
  • Histologically, it is composed of a proliferation of spindle cells with inter-anastomosing vascular-like arrangement in the interlobular or interductal stroma.
  • Clinically, PASH is usually found in premenopausal women as a discrete, painless mass, which is firm and movable.

Trauma to the breast, iatrogenic or blunt, may result in a palpable mass.

  • The trauma can cause fat necrosis, or breakdown of the adipose tissue. This can lead to a "mass" of scar tissue.
  • To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event.
  • Upon physical examination, the mass is sometimes indistinguishable from a cancer. Ultrasonography, mammography, and even MRI of the breast may not be able to discern the difference, leading to biopsies in concerning masses.
  • Key radiologic features (thought of as pathognomonic for) of fat necrosis include peripheral calcifications, fibrotic scar, and echogenic internal bands. However, these may also be consistent with breast cancer. Findings of lipid cysts or ultrasonographic evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy.

Fibrocystic changes of the breast

  • are very common in the adolescent population. Physical examination findings may reveal discrete breast cysts or diffuse small lumps throughout.
  • Breast tenderness and heaviness may be experienced by the patient, especially before her menstrual period.
  • The patient is advised to avoid caffeine. Evening primrose oil (1 tablespoon at bedtime) may be used to alleviate breast pain associated with fibrocystic changes of the breast.
  • A single dominant lump that is present for several months likely requires excisional biopsy.
  • Single dominant cysts may be aspirated in an outpatient setting. Cytopathologic examination should be conducted if the fluid is bloody.
  • 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.
  • There is no specific data available in adolescents that would describe their risk of developing breast cancer. It is well described in adults.
  1. There is a 1.5-2 fold increase in women with proliferative fibrocystic disease (described histologically as moderate or florid hyperplasia, sclerosing adenosis, or papilloma with a fibrovascular core).
  2. There is a 4.4 fold increase in patients with atypical or lobular hyperplasia. This risk increase to 9 fold with a positive family history.
  3. Screening guidelines for patients with a history of atypia on breast biopsy findings are still evolving. In adults, current recommendations include yearly physician examinations and yearly mammography.

Malignant breast disease is uncommon in children and in adolescents. Risk factors for breast malignancies include history of familial breast cancer, previous benign disease associated with malignancy (ie, fibrocystic changes with atypia), other malignancies, or irradiation to the neck and chest areas. The most common malignant mass in the breast of a child or adolescent is a metastatic lesion.

Cautionary Note: In very young and preadolescent children, a biopsy should be considered with extreme caution because the developing breast bud may be irreparably harmed, even with a needle aspirate. That said, discrete masses should almost always be removed regardless of age.

REFERENCES

Disorders of the Breast; eMedicine Article, Jan 24, 2008; Margorie J Arca, MD and Denise B Klinkner MD

What is this Girl's Rapidly Enlarging Breast Mass? How we diagnosed and treated a juvenile fibroadenoma; Contemporary Surgery Vol 64, No 7, pp 328-331; Sheetal M Patel MD and Matthew J Hyser MD

Pseudoangiomatous Stromal Hyperplasia of the Breast in Two Adolescent Females; Am Surg 2004; 70(7):605-8; Gow KW, Mayfield JK, Lloyd D, Shehata BM (abstract)

Breast, Fibroadenoma; eMedicine Article, Feb 16, 2007; Marilyn A Roubidoux MD

Cystosarcoma Phyllodes; eMedicine Article, June 12, 2006; Donald R Lannin MD and Anastasios K Konstantakoes MD, John H Raaf MD

Pseudoangiomatous Stromal Hyperplasia Tumor: a Clinical, Radiologic, and Pathologic Study of 26 Cases; Mod Pathol 2008; 21(2):201-7; Ferreira M; Albarracin CT (abstract)

Fast-growing Pseudoangiomatous Stromal Hyperplasia of the Breast: Report of a Case; Surg Today 2007; 37(11): 967-70; Yoo K; Woo OH; Yong HS; Kim A; Ryu WS; Koo BH; Kang EY (abstract)

3 comments:

TBTAM said...

Great summary.

Most of what I se are fibroadenomas.

Jessica Bond said...

Very informative blog. I assume that these young patients will continue to have similar problems throughout adulthood?

rlbates said...

Jessica, not necessarily. It will depend on the type of mass. Most of the benign ones do not cause long term issues.