- Email: [email protected]
Prevalence and longitudinal study of breast masses in adolescents
JOURNAL OF ADOLESCENTHEALTH 1953;13:277-281
ORIGINAL ARTICLE
LAWRENCE MICHAEL
S. NEINSTEIN, DIAMENT,
M.D.,
JAMES ATKINSON,
M.D.,
XND
34. D.
This study examined the prevalence and outcome of breast masses in adolescent females and comparedthese
teens to those without breast masses. A longitudinal study of adolescents with bwast masses was conducted from October 1964 through January 1990. The prevalence of discrete breast masses in the 13-month study peeiad was 1.3/400(3.25%)among new female patients. The mean length and width of the masses were 2.8 and 1.9 cm; 86% had a solitary mass. Of 61 diagnosed with breast masses, 39 were followed for up to 40 months (mean, 7 months). Teens with a mass were older 06.8 versus 15.1 years, p C 0.001) and had a greaterchance of a family history of breast disease (26%versus 10.5%,p < 0.05) than those without a breast mass. Of 39 teens returning for at leas1one follow-up visit, 10 had a clinical diagnosis of “fibmcysticchanges.” Of these, the lesions resolved in six. Of the 29 teens with a discrete mass on examination, 7 underwent suegery and were found to have Ebroadenomas. Nine of the 29 teens had masses which resolved over 1-12 months, six teens had masses which remainedunchanged over 3-40 months, while four had pIbasses which became smaller, and two had masses which became larger. One teen with mastitis impmved. Eighteen underwent ultrasonogcaphicexaminationat the breast. Of the 12 teens found to have a solid mass an
From theDivisionofAdolescent Medicine (L.S.N.), aud the Division of Pediatric Surgery (].A.), Childrens Hospital of Los Angeles,DepartmentsofPediatrics and Medicine(L.S.N.), and DepartmentsofSurgery Ij.A.1 and Radiology (M.D.), University ofSouthern California School ofMedicine;and the Departmentof Radhlogy, ValleyPresbyterianHospital (M.D.), LosAngeles, California. Address reprint requeststo: LawrenceS. Nekstein, M.D., Childrens Hospital of Los Angeles, 4650 Sunset Eoulevard, P.O. Box 54700, Los Angeles, CA 90054-0700. Manuscript acceptedNozmber 14, 7992.
ultrasound, none had a mass that resolved on foUow-up examination. Of the six teens that had either a normal ultrasoundor Ebcacystic changes on ultrasound,3/6(50%) had lesions that resolved on follow-up examination.The correlations between ultrasound and clinical findings were length, r = 0.9 (p > O.OOODand width, r = 0.93 (p < O.OOOl).
KEY WORDS:
Breast masses
Fibrctadenomas Fibrocysticchanges
The management of breast masses i: ; adolescents can be a perplexing problem for pediatricians and surgeons. Benign breast lesions are not uncommon duringadolescence, but malignant disease is rare (I-14). However, the prevalence of breast lesions and their natural history in adolescent females has not been well studied. Previous studies have been cetrospective and focused on adolescents undergoing surgery (1-15). This study was undertaken to prospectively examine the prevalence and natural history of breast lesions. In addition, the use of ultrasonogr@+ i-, diagnosing breast lesions was evaluated.
Methods This study was carried out in two pacts: the first examined the prevalence of breast masses in new patients to a general adolescent medicine clinic. The second component included prospective follow-up
0 Society for Adolescent Medicine, 1993 _. . . Published by Ekevier Qience Publishing Co., Inc., 455 Avenue ot the Americas, New York, NY 10010
277
1054-139x0193/$6.00
278
NEINSTEIN ET AL.
(for up to 3.5 years) of adolescents found to have breast lesions. Prevalence Study All females between the ages of 10 and 21 years coming for a new patient examination at the Teenage Health Center of Childrens Hospital of Los Angeles between October 1984 and October 1985 were included. This clinic is a primary care center for adolescents located in a Iarge urban area. No adolescents who were referred from our community clinics for evaluation of a breast mass were included in the prevalence part of the study. All of these adolescents had breast examinations. Those adolescents examined by Adolescent Medicine Fellows and the author were also questioned about their family history for benign and malignant breast problems; their use, length of use, and dose of oraI contraceptives; and their use of caffeinecontaining foods and beverages. Those adolescents who did not have a breast mass served as controls.
Longihtdinal Study For the longitudinal study of breast lesions, all females between the ages of 10 and 21 years with the findings of fibrocystic changes or a discrete breast lesion were eligible. AU teens with breast lesions were examined at the first or second visit and followed by one attending physician (LSN). The group of teens with breast lesions also included those rxferred from affiliated community clinics. Teens with a breast lesion were followed for at least three menstrual cycles before any intervention. At 3 months, ultrasonography was performed OIL those with discrete lesions over 1 cm. All examinations were performed using an Acuson-128 ultrasound imager @uson, Mountainview, CA) with a S megahertz linear array hand-held transducer. If a cystic lesion was diagnosed, needle aspirationwas ordered. If a solid lesion over 2.5 cm in diameter was found, an excisional biopsy was performed. If the lesion was less than 2.5 cm, the teen was observed every 3-6 months. The study was approved by the Hospitals Institutional Review Board committee, and all participating adolescents and their parents gave informed consent. Study results were evaluated, using lhe ClUSP statistics package utilizing descriptive statistics in addition to Students’ t-test and y2 analysis.
JOURNAL OF ADOLESCENT HEALTH Vol. 14, No. 4
Results Demographics The mean age of the control group was 15.1 years with a range of 11-19 years. The mean age of the teens with masses was 16.7 years with a range of 12.5 to 21 years. The racial distribution was 29% Hispanic, 41% black, 27% non-Hispanic white, and 3% Asian. Prevalenceof BreastLesions During the first 13 months of the study, 400 new female patients were examined. Ninety-nine had no breast lesions, were seen by Adolescent Medicine Fellows or the author (LSN) and had the breast history form completed. Those adolescents served as controls. Eighteen were found to haxfe a palpable breast lesion (4.5%)of which 13were discrete masses (3.25%)and 5 (1.25%)were fibrocystic changes (multiple pea size or smaller lesions). Comparison of Teens with and without BreastMasses During the 6 years of the study, a total of 61 adolescents were evaIuated for either fibrocystic changes or a discrete breast mass of whom 39 were followed for up to 40 months (mean, 7 months). A comparison between those 61 adolescents with breast lesions and the 99 adolescents without breast lesions is summarized in Table 1. Teens with a breast mass were older and more often gave a positive family history of breast disease. Of the 61 with breast disease, 8 had a history of a mother, aunt, sister, or Table 1. Comparison Between Teens with Breast
Massesand Controls
Mean age (years) Menarche (years) Family history of breast dkarse Oral contraceptive use Past current Months of use
Caffeineuse Prior pregnancy -~
Teens with breast masses (n = 61)
Control group (n = 99)
16.8 12.3
15.1 11
4x01 NS
27%
10.5%
13.1% 19.7% 13.7 95% 16%
9% 6% 4.2 75% 12%
Significance”
co.05 co.05
STUDY OF BREAST MASSES IN ADOLESCENTS
grandmother with breast cancer, whereas 6 of 99 without a breast lesion had such a history. There were no differences in age of menarche or past pregnancies. Those teens with a breast lesion had a greater chance of caffeine and oral contraceptive use, and had a longer duration of use of oral contraceptives than teens without breast lesions. Those teens with breast lesions were, however, on the average, 2 years older than those without breast lesions. When only those 16 years and older were included, there was no difference between caffeine use or oral contraceptive use in those with or without breast lesions. Signs and Symptoms of Breast Le: ‘P.a:s The mean duration of the mass prior to evaluation by a physician was 18 weeks. None of the teens had galactorrhea on examination. Only 1161complained of any nipple discharge; 20162(33%) complained of a painful mass. The findings at initial visit for the adolescents with breast masses are summarized in Table 2. Follow-up of Teens with Breast Lesions While 61 adolescents with a breast lesion were initially entered into the study, 22 were lost to followup. There were no significant differences in age, age of menarche, caffeine use, and nuL_.berof Fregnanties between those followed and those lost to followup. Those teens who were lost to follow-up did, however, have a higher prevalence of oral contraceptive use and included a smaller number with a discrete mass. Following the initial visit, 39/61 teens had a least one follow-up examination (Table 3). The mean duration of follow-up time was 7 months, with 21 of the teens followed for at least 9 months. Seven had persistent lesions larger than 2.5 cm and underwent surgery. All had fibroadenomas. Lesions had reTable 2. InitialFindingsin Adolescents with Breast Lesions Initial Clinical Diagnosis
Number
Percent
Masslfibroadenoma Fibrocystic changes/cyst Mastitis
39 21 1
63 35 2
Length of Mass: 2.9 cm; SD = 2.5. Width of Mass: 2.4 cm; SD = 2.3 cm. N!:i;r’oer of Lesions: 6/61 had more than one discrete mass.
279
Table 3. Findings at Follow-Up Evaluation Diagnosis
Number
Mass resolved No change Fibroadenoma (by biopsy) Smaller mass
15 11 7 4 2
Larger mass
Percent -
39 28 18 10 5
solved in 15139 adolescents, of whom 9/15 initially had discrete masses whereas five had fibrocystic changes, and one had a clinical diagnosis of mastitis. No change at follow-up was found in 11/39adolescents. Seven of these 11 were felt to have had discrete lesions at initial visit, whereas four had fibrocystic changes initially. The mean follow-up in this group was 12.3 months. Of the remaining 6/39, 4 had smaller lesions at follow-up, and 2 had lesions that had grown (from less than 1 cm to 1 x 2 cm and from 2.5 X 2 cm to 3 x 2.5 cm, respectively). In the longitudinal study, almost all of the outside referrals were from a Job Corps site. Job Corps teens had an average age of 18.9 years versus 16.1 years in the Adolescent Clinic population. Otherwise, the groups were similar, except for variables that were affected by age such as oral contraceptive use. The initial diagnoses were similar in the two groups but there was a higher rate of teens lost to follow-up among the Job Corps group. Outcome Based on initial Clinical Diagnosis
Of the 39 teens, 10 had an initial clinical diagnosis of fibrocystic changes. At follow-up, six had resolution and four were unchanged. Of the 28 adolescents with lesions described as solitary masses on initial examination, seven underwent surgery because of the absolute size of their lesions or the fact that they were enlarging. Resolution occurred over 1-12 months in B/28 adolescents with discrete masses. Thirteen adolescents had masses that did not resolve on follow-up. Of these, seven remained unchanged over 3-40 months, four became smaller, and two had grown. Symptoms resolved in the one teen with mastitis. Outcome Based on Ultrasound Findings
Ultrasonography was completed in 18 adolescents of whom 12 had a solid mass [Table 4). Of these 12, five had surgery which confirmed a diagnosis of fibroadenoma, four had masses that decreased in
280
NEMTEIN ET AL.
size over time, two had no change over time, and one had a mass that increased in size. None of the adolescents with a solid mass on ultrasound had resolution of the mass during follow-up. Two teens had an ultrasound consistent with fibrocystic changes. In 1, there was resolution and in the other, no change with time. Four teens had a normal ultrasound, of whom two underwent resolution, one had no change and the other experienced enlargement of her mass. In 15 adolescents with an initial clinical diagnosis of a mass, the diagnosis of a solid mass was ccmfirmed in 12 by ultrasound.In two others, fibrocystic changes were found, and one teen had a normal ultrasound. In all 12 teens with a solid mass confirm& by ultrasound, the clinical dimensions were 1 cm or over in length and width. In the three teens with a discrete mass not confirmed by ultrasound, the mass was smaller than 1 cm in one or both dimensions. Clinical measurement of length and width was compared to ultrasound measurements. The correlations were length, r = 0.9 (p < 0.001) and width, t = 0.93 (p < 0.0001). In five of the adolescents, there were complete sets of clinical measurements, ultrasound measurements, and measurements from pathology reports. Despite the good correlations with the clinical measurements, there was an even better correlation between the ultrasound and final pathology report.
Discussion Thisstudy providesdata on the prevalenceof breast lesions, their natural history, and the value of breast ukasonograph in adolescent females. Many studies of breast lesions in adolescents have been reported in the past, all of which have been retrospective chart reviews (I-15). Almost all have been of surgical cases (l-14). Such studies will, by the nature of their subject, be biased in the direction of a higher yield of fibroadenomas and other lesions that do not resolve, rather than providing a more representative distribution of breast lesions in the adolescentpopulation. In our study, the prevalence of clinically diagnosed breast lesions in adolescent females at an urban adolescent cl& was found to be low, about 4.0%. Diehl and Kaplan (15) report on the uatural history of breast lesions, but also through a retrospective chart review. In their study, 50.8%of the teens had fibrocystic disease, 14.6%fibroadenomas, 13.1% normal breasts, 4.6% mastalgia, 4.6% unknown,
JGURNAL OF ADOLESCENTHEALTH Vol. 14, No. 4
3.9% abscess/mastitis, and no teens were found to have breast cancer. Reviewing 14 surgical series involving 1612 females under age 22 years, the prevalence of cancer was 0.74%, with about 41.6% of these being primary breast cancer and the rest priznarilymetastatic tumors (I-14). Our study confiis that most surgical specimens are fibroadenomas and that the prevalence of malignancies is low (0%). In our study, there was a significant number of teens that had lesions that either resolved or did not enlarge. This supports the conservative management of female breast masses that many authorities advocate (1,13,15). Mammography has generally been discouraged in this age group because of the difficulty in interpreting results in view of the high radiodensity of normal adolescent breast tissue and the low prevalence of cancer (13,16,17).In addition, there is concern that starting mammography in adolescents might unnecessarily increaselifetime exposure to radiation, Ultrasonograph has, however, been suggested to be a helpful modality in differentiating between solid and cystic lesions in teens. This study confirms its usefulness. The finding of a solid mass on ultrasound in this study was 100% predictive of a lesion that did not resolve with follow-up. The differential diagnosis of discrete breast masses in teens includes fibrocystic changes, fibroadenomas, abscesses, and less common lesions such as intraducta! papillomatosis, lipoma, and cancer. Of our teens with an initial clinical diagnosis of fibrocystic changes, 60% ticsolved and 40%remained unchanged. This correlates well with the 47% resolution rate reported by Diehi and Kaplan (15) and the 77%reported by Fur&al et al. (18). Even among discrete masses, spontaneous resolution occurred. Spontaneous resolution of fibroadenomas has been previously reported to occur (15,19). More than likely, however, most of the lesions that resolved in this current study represented cysts or fibrocystic changes. There were no lesions identified as a solid mass by ultrasound that completely resolved, although 4 lesions decreased in size over time. Fibrocystic changes are common in the adult population, although the prevalence, in adolescents is not known. In retrospective surgical studies, the prevalence ranges from 0%30%, although this cannot be extrapolated to the general adolescent population (2-4,7,9,11,14,20). Although the prevalence was low in this study, the actual prevalence may be higher. First, outside referrals were mainly for discrete breast lesions and not fibrocystic changes. In addition, small fibrocystic changes, as
June 1993
STUDYOF BREAST MASSES IN ADOLESCENTS
found in adolescents, may have been missed by some of the medical students and residents. One limitation of this study includes the low follow-up rate and size of the group followed. This is a recurrent problem in long-term studies of adolescents whether done retrospectively or prospectively. In the retrospective study of natural history of breast lesions by Diehl and Kaplan, 55% of teens with fibrocystic lesions and 58% of the teens with discrete lesions were lost to follow-up (15). Another limitation of this study is the lack of a biopsy-confirmed diagnosis in all teens. As no biopsies were done in the adolescents who did not undergo surgery, the diagnosis cannot be made with certainty. The role of fine needle aspiration in evaluating breast masses in adolescents is an area that is in need of further studies and one that would benefit from a multicenter project to obtain an appropriate sample size. In the prevalence study, a follow-up period of 13 months was chosen because of the difficulty in getting rotating staff to keep up with a protocol involving all new patients. A longer period may have given a more accurate picture of breast lesions. Because a major part of this study was the longitudinal follow-up, which was conducted for 6 years, 13 months was chosen as a compromise for the prevalence component. Benign breast lesions are common in adolescents. Most lesions found at surgery are fibroadenomas. However, many clinically diagnosed discrete breast
281
lesions do not require surgery and may resolve over a 6-month period of time. An ultrasound of the breast can be useful in distinguishing solid from cystic lesions and finding those lesions less likely to resolve with time.
References 1. Goldstein DP, Miler V. Breast masses in adolescent females. Clin Pediatr 1982;21:17-9.
2.
TurberyWI,Buntain WL, Dudgeon DL. The surgical management of pediatric breast masses. Pediatrics 1975;56:736_9.
3. Daniel WA Jr, Mathews MD. Tumors of the breast in adolescent females. Pediatrics 1968;41:743-9.
4. Stone AM, Shenker IR, McCarthy K, Adolescent breast masses. Am J Surg 1977;13&275-7.
5. Bower R, Bell MJ, Temberg IL. Management of breast lesions in children and adolescents. J Pediatr Surg 1976;11:337-46.
6. Hein K, DeJ! R, Cohen Ml. Self detection of a breast mass in adolescent females. J Adolesc Health Care 1982;3:15-7.
7. Farrow JH, Ash&art H. Breast lesions in young girls, 1969;49:261-9.
8. Skiles MS, Seltzer MH. Adolescent breast disease. Nat Med Sot NJ 1980;77891-3.
9. Gogas J, Sechas M, Skalkeas CR. Surgical management of disease of the adolescent female breast Am J Surg 1979; 137634-7.
10. Sandison AT, Walker JC. Diseases of the adolescent female breast. Br j Surg 1968;55443-8.
11. Seashore JH. Breast enlargements in infants and children. Pediatr Ann 1975;4542-64.
12. Simpson JS, Barson AJ. Breast tumors in infants and children: A 40-year review of cases at a children’s hospital. Can Med Assoc J 1969;101:100-2.
13. Bauer BS, Jones KM, Talbot CW. Mammary masses in the adolescent female. Surg Gynecol Obstet 1987;165:63-5.
Table 4. Follow-Upof Adolescentswith Baseline Ultrasound Diagnosis
14. Raju CG. Breast masses in adolescent patients in Trinidad. Am J Surg 1985;149:219-20.
Outcome
Number(%)
15. Diehl T, Kaplan D111:Breast Masses hr adolescent females.
Fibroadenoma (at surgery) Smaller No change Larger Resolved
5 (42) 4 (33) 2 (17) 1 (8) 0
16. Egan RL, Mosteflar RC. Breast cancer mammography pat-
Fibrocystic changes (n = 2)
Resolved No change
l(50) 1Cw
Normal (n = 4)
Resolved No change
2 (50)
Ultrasound Diagnosis
Solid mass (n = 12)
Larger
1(25) 1(25)
J Adolesc Health Care 1985;6:353-7. terns. Cancer 1977;4Oz2887-90.
17. Eddy DM. Screening for breast cancer. Ann Intern Med 1989;111:389-99. 18. Fumival CM, hwin JRM,Gray GM. Breast disease in young women. Med J Aust 1983;2:167-9. 19. Kern WH, Clark RW. Retrogression of fibroadenomas of the breast Am J Surg 1973;126:59-62.
20. Simmons FS, Wold LE. Surgically treated breast disease in adolescent females: A retrospective review of 185 cases. Adolest Pediatr Gynecol1989;2:95-8.
ORIGINAL ARTICLE
LAWRENCE MICHAEL
S. NEINSTEIN, DIAMENT,
M.D.,
JAMES ATKINSON,
M.D.,
XND
34. D.
This study examined the prevalence and outcome of breast masses in adolescent females and comparedthese
teens to those without breast masses. A longitudinal study of adolescents with bwast masses was conducted from October 1964 through January 1990. The prevalence of discrete breast masses in the 13-month study peeiad was 1.3/400(3.25%)among new female patients. The mean length and width of the masses were 2.8 and 1.9 cm; 86% had a solitary mass. Of 61 diagnosed with breast masses, 39 were followed for up to 40 months (mean, 7 months). Teens with a mass were older 06.8 versus 15.1 years, p C 0.001) and had a greaterchance of a family history of breast disease (26%versus 10.5%,p < 0.05) than those without a breast mass. Of 39 teens returning for at leas1one follow-up visit, 10 had a clinical diagnosis of “fibmcysticchanges.” Of these, the lesions resolved in six. Of the 29 teens with a discrete mass on examination, 7 underwent suegery and were found to have Ebroadenomas. Nine of the 29 teens had masses which resolved over 1-12 months, six teens had masses which remainedunchanged over 3-40 months, while four had pIbasses which became smaller, and two had masses which became larger. One teen with mastitis impmved. Eighteen underwent ultrasonogcaphicexaminationat the breast. Of the 12 teens found to have a solid mass an
From theDivisionofAdolescent Medicine (L.S.N.), aud the Division of Pediatric Surgery (].A.), Childrens Hospital of Los Angeles,DepartmentsofPediatrics and Medicine(L.S.N.), and DepartmentsofSurgery Ij.A.1 and Radiology (M.D.), University ofSouthern California School ofMedicine;and the Departmentof Radhlogy, ValleyPresbyterianHospital (M.D.), LosAngeles, California. Address reprint requeststo: LawrenceS. Nekstein, M.D., Childrens Hospital of Los Angeles, 4650 Sunset Eoulevard, P.O. Box 54700, Los Angeles, CA 90054-0700. Manuscript acceptedNozmber 14, 7992.
ultrasound, none had a mass that resolved on foUow-up examination. Of the six teens that had either a normal ultrasoundor Ebcacystic changes on ultrasound,3/6(50%) had lesions that resolved on follow-up examination.The correlations between ultrasound and clinical findings were length, r = 0.9 (p > O.OOODand width, r = 0.93 (p < O.OOOl).
KEY WORDS:
Breast masses
Fibrctadenomas Fibrocysticchanges
The management of breast masses i: ; adolescents can be a perplexing problem for pediatricians and surgeons. Benign breast lesions are not uncommon duringadolescence, but malignant disease is rare (I-14). However, the prevalence of breast lesions and their natural history in adolescent females has not been well studied. Previous studies have been cetrospective and focused on adolescents undergoing surgery (1-15). This study was undertaken to prospectively examine the prevalence and natural history of breast lesions. In addition, the use of ultrasonogr@+ i-, diagnosing breast lesions was evaluated.
Methods This study was carried out in two pacts: the first examined the prevalence of breast masses in new patients to a general adolescent medicine clinic. The second component included prospective follow-up
0 Society for Adolescent Medicine, 1993 _. . . Published by Ekevier Qience Publishing Co., Inc., 455 Avenue ot the Americas, New York, NY 10010
277
1054-139x0193/$6.00
278
NEINSTEIN ET AL.
(for up to 3.5 years) of adolescents found to have breast lesions. Prevalence Study All females between the ages of 10 and 21 years coming for a new patient examination at the Teenage Health Center of Childrens Hospital of Los Angeles between October 1984 and October 1985 were included. This clinic is a primary care center for adolescents located in a Iarge urban area. No adolescents who were referred from our community clinics for evaluation of a breast mass were included in the prevalence part of the study. All of these adolescents had breast examinations. Those adolescents examined by Adolescent Medicine Fellows and the author were also questioned about their family history for benign and malignant breast problems; their use, length of use, and dose of oraI contraceptives; and their use of caffeinecontaining foods and beverages. Those adolescents who did not have a breast mass served as controls.
Longihtdinal Study For the longitudinal study of breast lesions, all females between the ages of 10 and 21 years with the findings of fibrocystic changes or a discrete breast lesion were eligible. AU teens with breast lesions were examined at the first or second visit and followed by one attending physician (LSN). The group of teens with breast lesions also included those rxferred from affiliated community clinics. Teens with a breast lesion were followed for at least three menstrual cycles before any intervention. At 3 months, ultrasonography was performed OIL those with discrete lesions over 1 cm. All examinations were performed using an Acuson-128 ultrasound imager @uson, Mountainview, CA) with a S megahertz linear array hand-held transducer. If a cystic lesion was diagnosed, needle aspirationwas ordered. If a solid lesion over 2.5 cm in diameter was found, an excisional biopsy was performed. If the lesion was less than 2.5 cm, the teen was observed every 3-6 months. The study was approved by the Hospitals Institutional Review Board committee, and all participating adolescents and their parents gave informed consent. Study results were evaluated, using lhe ClUSP statistics package utilizing descriptive statistics in addition to Students’ t-test and y2 analysis.
JOURNAL OF ADOLESCENT HEALTH Vol. 14, No. 4
Results Demographics The mean age of the control group was 15.1 years with a range of 11-19 years. The mean age of the teens with masses was 16.7 years with a range of 12.5 to 21 years. The racial distribution was 29% Hispanic, 41% black, 27% non-Hispanic white, and 3% Asian. Prevalenceof BreastLesions During the first 13 months of the study, 400 new female patients were examined. Ninety-nine had no breast lesions, were seen by Adolescent Medicine Fellows or the author (LSN) and had the breast history form completed. Those adolescents served as controls. Eighteen were found to haxfe a palpable breast lesion (4.5%)of which 13were discrete masses (3.25%)and 5 (1.25%)were fibrocystic changes (multiple pea size or smaller lesions). Comparison of Teens with and without BreastMasses During the 6 years of the study, a total of 61 adolescents were evaIuated for either fibrocystic changes or a discrete breast mass of whom 39 were followed for up to 40 months (mean, 7 months). A comparison between those 61 adolescents with breast lesions and the 99 adolescents without breast lesions is summarized in Table 1. Teens with a breast mass were older and more often gave a positive family history of breast disease. Of the 61 with breast disease, 8 had a history of a mother, aunt, sister, or Table 1. Comparison Between Teens with Breast
Massesand Controls
Mean age (years) Menarche (years) Family history of breast dkarse Oral contraceptive use Past current Months of use
Caffeineuse Prior pregnancy -~
Teens with breast masses (n = 61)
Control group (n = 99)
16.8 12.3
15.1 11
4x01 NS
27%
10.5%
13.1% 19.7% 13.7 95% 16%
9% 6% 4.2 75% 12%
Significance”
co.05 co.05
STUDY OF BREAST MASSES IN ADOLESCENTS
grandmother with breast cancer, whereas 6 of 99 without a breast lesion had such a history. There were no differences in age of menarche or past pregnancies. Those teens with a breast lesion had a greater chance of caffeine and oral contraceptive use, and had a longer duration of use of oral contraceptives than teens without breast lesions. Those teens with breast lesions were, however, on the average, 2 years older than those without breast lesions. When only those 16 years and older were included, there was no difference between caffeine use or oral contraceptive use in those with or without breast lesions. Signs and Symptoms of Breast Le: ‘P.a:s The mean duration of the mass prior to evaluation by a physician was 18 weeks. None of the teens had galactorrhea on examination. Only 1161complained of any nipple discharge; 20162(33%) complained of a painful mass. The findings at initial visit for the adolescents with breast masses are summarized in Table 2. Follow-up of Teens with Breast Lesions While 61 adolescents with a breast lesion were initially entered into the study, 22 were lost to followup. There were no significant differences in age, age of menarche, caffeine use, and nuL_.berof Fregnanties between those followed and those lost to followup. Those teens who were lost to follow-up did, however, have a higher prevalence of oral contraceptive use and included a smaller number with a discrete mass. Following the initial visit, 39/61 teens had a least one follow-up examination (Table 3). The mean duration of follow-up time was 7 months, with 21 of the teens followed for at least 9 months. Seven had persistent lesions larger than 2.5 cm and underwent surgery. All had fibroadenomas. Lesions had reTable 2. InitialFindingsin Adolescents with Breast Lesions Initial Clinical Diagnosis
Number
Percent
Masslfibroadenoma Fibrocystic changes/cyst Mastitis
39 21 1
63 35 2
Length of Mass: 2.9 cm; SD = 2.5. Width of Mass: 2.4 cm; SD = 2.3 cm. N!:i;r’oer of Lesions: 6/61 had more than one discrete mass.
279
Table 3. Findings at Follow-Up Evaluation Diagnosis
Number
Mass resolved No change Fibroadenoma (by biopsy) Smaller mass
15 11 7 4 2
Larger mass
Percent -
39 28 18 10 5
solved in 15139 adolescents, of whom 9/15 initially had discrete masses whereas five had fibrocystic changes, and one had a clinical diagnosis of mastitis. No change at follow-up was found in 11/39adolescents. Seven of these 11 were felt to have had discrete lesions at initial visit, whereas four had fibrocystic changes initially. The mean follow-up in this group was 12.3 months. Of the remaining 6/39, 4 had smaller lesions at follow-up, and 2 had lesions that had grown (from less than 1 cm to 1 x 2 cm and from 2.5 X 2 cm to 3 x 2.5 cm, respectively). In the longitudinal study, almost all of the outside referrals were from a Job Corps site. Job Corps teens had an average age of 18.9 years versus 16.1 years in the Adolescent Clinic population. Otherwise, the groups were similar, except for variables that were affected by age such as oral contraceptive use. The initial diagnoses were similar in the two groups but there was a higher rate of teens lost to follow-up among the Job Corps group. Outcome Based on initial Clinical Diagnosis
Of the 39 teens, 10 had an initial clinical diagnosis of fibrocystic changes. At follow-up, six had resolution and four were unchanged. Of the 28 adolescents with lesions described as solitary masses on initial examination, seven underwent surgery because of the absolute size of their lesions or the fact that they were enlarging. Resolution occurred over 1-12 months in B/28 adolescents with discrete masses. Thirteen adolescents had masses that did not resolve on follow-up. Of these, seven remained unchanged over 3-40 months, four became smaller, and two had grown. Symptoms resolved in the one teen with mastitis. Outcome Based on Ultrasound Findings
Ultrasonography was completed in 18 adolescents of whom 12 had a solid mass [Table 4). Of these 12, five had surgery which confirmed a diagnosis of fibroadenoma, four had masses that decreased in
280
NEMTEIN ET AL.
size over time, two had no change over time, and one had a mass that increased in size. None of the adolescents with a solid mass on ultrasound had resolution of the mass during follow-up. Two teens had an ultrasound consistent with fibrocystic changes. In 1, there was resolution and in the other, no change with time. Four teens had a normal ultrasound, of whom two underwent resolution, one had no change and the other experienced enlargement of her mass. In 15 adolescents with an initial clinical diagnosis of a mass, the diagnosis of a solid mass was ccmfirmed in 12 by ultrasound.In two others, fibrocystic changes were found, and one teen had a normal ultrasound. In all 12 teens with a solid mass confirm& by ultrasound, the clinical dimensions were 1 cm or over in length and width. In the three teens with a discrete mass not confirmed by ultrasound, the mass was smaller than 1 cm in one or both dimensions. Clinical measurement of length and width was compared to ultrasound measurements. The correlations were length, r = 0.9 (p < 0.001) and width, t = 0.93 (p < 0.0001). In five of the adolescents, there were complete sets of clinical measurements, ultrasound measurements, and measurements from pathology reports. Despite the good correlations with the clinical measurements, there was an even better correlation between the ultrasound and final pathology report.
Discussion Thisstudy providesdata on the prevalenceof breast lesions, their natural history, and the value of breast ukasonograph in adolescent females. Many studies of breast lesions in adolescents have been reported in the past, all of which have been retrospective chart reviews (I-15). Almost all have been of surgical cases (l-14). Such studies will, by the nature of their subject, be biased in the direction of a higher yield of fibroadenomas and other lesions that do not resolve, rather than providing a more representative distribution of breast lesions in the adolescentpopulation. In our study, the prevalence of clinically diagnosed breast lesions in adolescent females at an urban adolescent cl& was found to be low, about 4.0%. Diehl and Kaplan (15) report on the uatural history of breast lesions, but also through a retrospective chart review. In their study, 50.8%of the teens had fibrocystic disease, 14.6%fibroadenomas, 13.1% normal breasts, 4.6% mastalgia, 4.6% unknown,
JGURNAL OF ADOLESCENTHEALTH Vol. 14, No. 4
3.9% abscess/mastitis, and no teens were found to have breast cancer. Reviewing 14 surgical series involving 1612 females under age 22 years, the prevalence of cancer was 0.74%, with about 41.6% of these being primary breast cancer and the rest priznarilymetastatic tumors (I-14). Our study confiis that most surgical specimens are fibroadenomas and that the prevalence of malignancies is low (0%). In our study, there was a significant number of teens that had lesions that either resolved or did not enlarge. This supports the conservative management of female breast masses that many authorities advocate (1,13,15). Mammography has generally been discouraged in this age group because of the difficulty in interpreting results in view of the high radiodensity of normal adolescent breast tissue and the low prevalence of cancer (13,16,17).In addition, there is concern that starting mammography in adolescents might unnecessarily increaselifetime exposure to radiation, Ultrasonograph has, however, been suggested to be a helpful modality in differentiating between solid and cystic lesions in teens. This study confirms its usefulness. The finding of a solid mass on ultrasound in this study was 100% predictive of a lesion that did not resolve with follow-up. The differential diagnosis of discrete breast masses in teens includes fibrocystic changes, fibroadenomas, abscesses, and less common lesions such as intraducta! papillomatosis, lipoma, and cancer. Of our teens with an initial clinical diagnosis of fibrocystic changes, 60% ticsolved and 40%remained unchanged. This correlates well with the 47% resolution rate reported by Diehi and Kaplan (15) and the 77%reported by Fur&al et al. (18). Even among discrete masses, spontaneous resolution occurred. Spontaneous resolution of fibroadenomas has been previously reported to occur (15,19). More than likely, however, most of the lesions that resolved in this current study represented cysts or fibrocystic changes. There were no lesions identified as a solid mass by ultrasound that completely resolved, although 4 lesions decreased in size over time. Fibrocystic changes are common in the adult population, although the prevalence, in adolescents is not known. In retrospective surgical studies, the prevalence ranges from 0%30%, although this cannot be extrapolated to the general adolescent population (2-4,7,9,11,14,20). Although the prevalence was low in this study, the actual prevalence may be higher. First, outside referrals were mainly for discrete breast lesions and not fibrocystic changes. In addition, small fibrocystic changes, as
June 1993
STUDYOF BREAST MASSES IN ADOLESCENTS
found in adolescents, may have been missed by some of the medical students and residents. One limitation of this study includes the low follow-up rate and size of the group followed. This is a recurrent problem in long-term studies of adolescents whether done retrospectively or prospectively. In the retrospective study of natural history of breast lesions by Diehl and Kaplan, 55% of teens with fibrocystic lesions and 58% of the teens with discrete lesions were lost to follow-up (15). Another limitation of this study is the lack of a biopsy-confirmed diagnosis in all teens. As no biopsies were done in the adolescents who did not undergo surgery, the diagnosis cannot be made with certainty. The role of fine needle aspiration in evaluating breast masses in adolescents is an area that is in need of further studies and one that would benefit from a multicenter project to obtain an appropriate sample size. In the prevalence study, a follow-up period of 13 months was chosen because of the difficulty in getting rotating staff to keep up with a protocol involving all new patients. A longer period may have given a more accurate picture of breast lesions. Because a major part of this study was the longitudinal follow-up, which was conducted for 6 years, 13 months was chosen as a compromise for the prevalence component. Benign breast lesions are common in adolescents. Most lesions found at surgery are fibroadenomas. However, many clinically diagnosed discrete breast
281
lesions do not require surgery and may resolve over a 6-month period of time. An ultrasound of the breast can be useful in distinguishing solid from cystic lesions and finding those lesions less likely to resolve with time.
References 1. Goldstein DP, Miler V. Breast masses in adolescent females. Clin Pediatr 1982;21:17-9.
2.
TurberyWI,Buntain WL, Dudgeon DL. The surgical management of pediatric breast masses. Pediatrics 1975;56:736_9.
3. Daniel WA Jr, Mathews MD. Tumors of the breast in adolescent females. Pediatrics 1968;41:743-9.
4. Stone AM, Shenker IR, McCarthy K, Adolescent breast masses. Am J Surg 1977;13&275-7.
5. Bower R, Bell MJ, Temberg IL. Management of breast lesions in children and adolescents. J Pediatr Surg 1976;11:337-46.
6. Hein K, DeJ! R, Cohen Ml. Self detection of a breast mass in adolescent females. J Adolesc Health Care 1982;3:15-7.
7. Farrow JH, Ash&art H. Breast lesions in young girls, 1969;49:261-9.
8. Skiles MS, Seltzer MH. Adolescent breast disease. Nat Med Sot NJ 1980;77891-3.
9. Gogas J, Sechas M, Skalkeas CR. Surgical management of disease of the adolescent female breast Am J Surg 1979; 137634-7.
10. Sandison AT, Walker JC. Diseases of the adolescent female breast. Br j Surg 1968;55443-8.
11. Seashore JH. Breast enlargements in infants and children. Pediatr Ann 1975;4542-64.
12. Simpson JS, Barson AJ. Breast tumors in infants and children: A 40-year review of cases at a children’s hospital. Can Med Assoc J 1969;101:100-2.
13. Bauer BS, Jones KM, Talbot CW. Mammary masses in the adolescent female. Surg Gynecol Obstet 1987;165:63-5.
Table 4. Follow-Upof Adolescentswith Baseline Ultrasound Diagnosis
14. Raju CG. Breast masses in adolescent patients in Trinidad. Am J Surg 1985;149:219-20.
Outcome
Number(%)
15. Diehl T, Kaplan D111:Breast Masses hr adolescent females.
Fibroadenoma (at surgery) Smaller No change Larger Resolved
5 (42) 4 (33) 2 (17) 1 (8) 0
16. Egan RL, Mosteflar RC. Breast cancer mammography pat-
Fibrocystic changes (n = 2)
Resolved No change
l(50) 1Cw
Normal (n = 4)
Resolved No change
2 (50)
Ultrasound Diagnosis
Solid mass (n = 12)
Larger
1(25) 1(25)
J Adolesc Health Care 1985;6:353-7. terns. Cancer 1977;4Oz2887-90.
17. Eddy DM. Screening for breast cancer. Ann Intern Med 1989;111:389-99. 18. Fumival CM, hwin JRM,Gray GM. Breast disease in young women. Med J Aust 1983;2:167-9. 19. Kern WH, Clark RW. Retrogression of fibroadenomas of the breast Am J Surg 1973;126:59-62.
20. Simmons FS, Wold LE. Surgically treated breast disease in adolescent females: A retrospective review of 185 cases. Adolest Pediatr Gynecol1989;2:95-8.