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Puberty mastitis
PUBERTY MASTITIS P H I L I P ROSENBLU1V~, M.D. ~HICAGO,
ILL.
I T H the increase of public education in the field of cancer and W allied medical subjects, it is my impression t h a t parents are often unnecessarily a l a r m e d over a condition t h a t occurs in children at or just before puberty, f r e q u e n t l y in girls but not h l f r e q u e n t l y in boys. This is a tulnorlike enlargement of one or both breasts known as mastitis adolescentium or p u b e r t y mastitis. While this condition is familiar to pediatricians, the general physician is not as well acquMnted with it as he should be to prevent often unnecessary operations and inuch needless worry. There are v e r y few references to the condition; practically none in the pediatric literature, a n d the few descriptions in textbooks on pathology a n d surgery are r a t h e r indefinite and at variance with each other, so t h a t there seems to be no u n a n i m i t y of opinion about it. The v e r y scanty reference to this more or less physiologic process was noted b y Still, who quotes Underwood as giving the first description of mastitis occurring in children at a variable time before puberty. A condition, which Still remarks, is so little known t h a t he has more than once known operations proposed for it because of the mistaken idea that it was a m a l i g n a n t growth. I n Underwood 's early description, " I n d u r a tion of the B r e a s t s , " he says: " I t would be i m p r o p e r to pass over the slightest affection t h a t has on m a n y occasions exceedingly alarmed parents a n d sometimes perplexed the y o u n g e r p a r t of the profession. Of this kind, are affections of the breasts in female children .previously to, or about the time of, their beginning to enlarge. A t this period they sometimes become v e r y painful and u p o n examination a hardness and swelling are discovered and in some instances sharp points m a y be felt, which are v e r y p a i n f u l when pressed. The hardness is deep-seated, a r o u n d and behind the nipple and is sometimes loose and at other times fixed a n d attended with severe ]aneinating pains which have given rise to disagreeable suspicions in regard to the probable n a t u r e of the complaint, and would indeed at a more advanced age claim serious attention. W h e n h a p p e n i n g in families addicted to scrofula, t h a t disorder is n a t u r a l l y suspected, and sometimes a morbid scirrhus has been f e a r e d . " Underwood f u r t h e r states: " I n some instances only one of the breasts i s affected and a f t e r some months the other or sometimes both nearly at the same time. Yet no evil consequence in a n y instance u n d e r m y eye has From the Sarah Morris Children's Hospital of the Michael Reese Hospital.
758
ROSENBLU1Vi :
PUBERTY
1ViAS,TITIS,
759
ever ensued in patients at the above-mentioned age nor have I heard of any from other practitioners though it has sometimes been seriously apprehended." This gives a f a M y clear picture of the condition, and is more accurate than the few references I have seen ~n modern textbooks. Some eighteen or twenty years ago I saw m y first patient with this condition. The mother was v e r y much alarmed about the swelling of her child's breast just behind the nipple. I could find practically no reference to the condition in any pediatric text. Since then I have seen, like all pediatricians, m a n y children with similar swellings. Two years ago I was prompted to write this paper when a mother brought her ten-year-old daughter to me with a story that she had a breast removed six months previousIy and now had, she was sure, a similar swelling in the other breast. I found it a typical ease of mastitis adolescentium. The breast is a modified sudoriferous gland and physiologically is related rather intricately to the reproductive system. The epithelial lining of the duets and a]veoli is derived from the ectoderm and t h e supporting connective tissue from the mesoderm. Each breast consists of fifteen to twenty lobes, which are themselves branched saccular glands whose lactiferous duets open on the surfaee of the nipple near its apex. The main laetiferous duets subdivide into many interlobular ducts about which are clustered the group of secreting acini. Each group forms one of the many lobules included ifl one lobe of the gland. At puberty, and again at the end of pregnancy, marked enlargement of the gland and the development of additional lobules and acini take place. There is also an increase in the deposit of adipose tissue at puberty. Goltz and Evald have shown that the development of the mammary glands at p u b e r t y is due to the action of ovarian hormones, both follicular and luteal. C . W . L u r n e r has demonstrated that the follicular hormone stimulates the development of the duet system, and the corpus iuteum the alveoli. The anterior p i t u i t a r y gland is also active and important in the production of lactation (Stueker and Grueter). Cheatle and Cutler 2 regard p u b e r t y mastiffs as a result of some aberrance in the physiologic hyperplasia of the m a m m a r y tissues, probably an overactivity of the tissues in response to an excess of growth-stimulating substances. Muir ~ speaks of mastiffs adoleseentium as a nonsuppurative acute inflammatory condition similar to puerperal mastiffs. Rose and Carless* write of mastiffs adolescentium as being a condition similar to mastitis neonatorum, which it does resemble very closely.
760
THE
JOURNAL
OF
PEDIATRICS
K a u h n a n n 5 states t h a t p u b e r t y mastitis is probably the r e s u k of irritation of the ducts ,due to the retention' of the material secreted by the ducts. This secreted material provides a favorable medium for the growth of organisms. W a l t h e r 6 remarks t h a t the enlargement of the breasts in p u b e r t y very often coincides with the presence of a positive tuberculin reaction. In other words, he believes t h a t this type of mastitis is a manifestation of a tuberculous infection. The connective tissue proliferation is explained on an allergic basis. Oehsenius/ although not completely contradicting Walther, reports three cases in which the tuberculin reaction was negative.
Fig. 1.
Fig. 2.
F i g . 1 , - - G i r l , n i n e y e a r s old. Swelling of left br'east for one m o n t h . Typical t u m o r l i k e e n l a r g e m e n t b e h i n d nipple. 1V~ass c o m p l e t e l y d i s a p p e a r e d in f o u r m o n t h s . This girl had a severe eczema and asthma. F i g . 2 ~ - - B o y , s i x t e e n y e a r s old. S w e l l i n g o f b o t h b r e a s t s b u t m o r e m a r k e d in left. L o c a t i o n t y p i c a l l y b e h i n d nipple, Compl'ete d i s a p p e a r a n c e in f i v e m o n t h s .
I n none of m y patients was there a positive tuberculin reaction, and I feel definitely there is no relationship. Of the ten or twelve cases I have seen in the last two or three years, five or six h a d a definite allergy characterized b y a severe eczema, asthma, or both. Harbeson s describes a case of mastitis adolescentium in which the t u m o r began in the u p p e r outer q u a d r a n t of the left breast. Then two months later another t u m o r developed in the same location. Soon afterward, the right breast was the site of a similar tumor. The location, relative to the nipple, was not mentioned, and the last note several months later stated t h a t the tumors were smaller but still present. They
ROSENBLUIVI :
PUBERTY
MASTIT:IS
761
were p r o b a b l y fibroadenomas, l:Iarbeson thinks it is due to a preponderance of luteal hormone which produees an overstimulation and r a p i d development of the acini before development of the ducts. The children I have seen with this t u m o r in the breast all had charaeteristies similar to those described by Underwood one h u n d r e d and fifty or more years ago. They oecur more frequently between the ages of eight or nine and fifteen or sixteen years. The m a j o r i t y are f o u n d between the ninth a n d eleventh years in girls. One or both breasts m a y be involved, and one side m a y precede the other by as long as a y e a r or more. The areola becomes darker in color and, as Cheatle and Cutler described, the lesion assumes definite and v e r y eharaeteristie features.
J~'ig. 3.
2~ig. 4.
Figs. 3 and 4.--Periaeinous and perieanalieular infiltration and epithelial hyperplasia. ( F i g . 3, X 9 0 ; Fig'. 4, X 1 5 0 . ) (These photomicrographs were kindly lent by D r . M a x C u t l e r , of 2r Reese IKospital.)
The swelling forms a firm disMike or spherical t u m o r v a r y i n g f r o m 3 to 5 era. in diameter, which is p a i n f u l on pressure only. I t is situated directly behind the nipple, whieh usually is flattened and often slightly inverted by the enlargement. Occasionally a few drops of an opaque serous fluid m a y be expressed f r o m the nipple. The location in those I have seen is always behind the areola, and this differs f r o m most of the other possible tumors of the m a m m a r y gland. P u b e r t y mastitis is not a true inflammation, but is due to an increased physiologic h y p e r t r o p h y of the perieanalieular and periacinous connective tissue. The proliferative changes closely resemble those which are produced by the injection of estrin (as shown by Laeassane). I t is possible t h a t t r a u m a m a y aggravate it or be responsible for its appearance
762
THE JOURNAL OF PEDIATRICS
in only one breast. Usually the induration disappears as the breast develops fully. Some disappear in a few weeks while others require months. In the male sex this condition begins at the earliest in the fourteenth or fifteenth year of life, and it may be so marked as to constitute a true fibrous tumor. Zappert is of the opinion that in the male this state is associated with an advanced development of the genital glands. This condition is not to be confused with certain tumors which may arise only occasionally in breasts of children. In aII the children I have seen with p u b e r t y mastitis, the mothers were worried because they feared a cancer or tumor. The age, location and characteristics outlined will be sufficient readily to differentiate it from other pathologic entities. SUMMARY
P u b e r t y mastitis (mastitis adoleseentium) has definite characteristics. I t is always behind the nipple and occurs in girls between eight and twelve years of age and in boys between fourteen and eighteen years. It is probably caused by some endocrine dysfunction and local trauma may play a rSle. Pathologically it is a perieanalicular and periaeinous infiltration with connective tissue and lymphoeytes, together with epithelial hyperplasia. The condition is benign and disappears within a few months. I~EFEREN CES
1. Underwood: ed. 4, Vol. II. 2. Cheatle, G. Lenthal, and Cutler, Max: Turnouts of the B r e a s t : Their Pathology, Symptoms, Diagnosis and Treatment, Philadelphia, 1931, Lippincott. 3. Muir, 1%: Text Book of Pathology, Philadelphia, 1924, Lippineott, p. 710. 4. Rose a n d Carless: M a n u a l of. Surgery, ed. 11. 5. K a u f m a n n , E.: L e h r b u e h der speziellen pathologischen A n a t o m l e fiir Studierende u n d Xrzte, B a n d I, 1931, N i n t h - T e n t h Edition. 6. W a l t h e r , E.: Monatsehr. f. Kinderh. 58: 452, 1933. 7. Oehsenius, K.: 1V[onatschr. f. Islinderh. 59" 120, 1934. 8. IIarbeson~ A.E.:
Canad. M. A. J. 30: 648, 1934.
104 S. 1V[ICHIGANAVENUE
ILL.
I T H the increase of public education in the field of cancer and W allied medical subjects, it is my impression t h a t parents are often unnecessarily a l a r m e d over a condition t h a t occurs in children at or just before puberty, f r e q u e n t l y in girls but not h l f r e q u e n t l y in boys. This is a tulnorlike enlargement of one or both breasts known as mastitis adolescentium or p u b e r t y mastitis. While this condition is familiar to pediatricians, the general physician is not as well acquMnted with it as he should be to prevent often unnecessary operations and inuch needless worry. There are v e r y few references to the condition; practically none in the pediatric literature, a n d the few descriptions in textbooks on pathology a n d surgery are r a t h e r indefinite and at variance with each other, so t h a t there seems to be no u n a n i m i t y of opinion about it. The v e r y scanty reference to this more or less physiologic process was noted b y Still, who quotes Underwood as giving the first description of mastitis occurring in children at a variable time before puberty. A condition, which Still remarks, is so little known t h a t he has more than once known operations proposed for it because of the mistaken idea that it was a m a l i g n a n t growth. I n Underwood 's early description, " I n d u r a tion of the B r e a s t s , " he says: " I t would be i m p r o p e r to pass over the slightest affection t h a t has on m a n y occasions exceedingly alarmed parents a n d sometimes perplexed the y o u n g e r p a r t of the profession. Of this kind, are affections of the breasts in female children .previously to, or about the time of, their beginning to enlarge. A t this period they sometimes become v e r y painful and u p o n examination a hardness and swelling are discovered and in some instances sharp points m a y be felt, which are v e r y p a i n f u l when pressed. The hardness is deep-seated, a r o u n d and behind the nipple and is sometimes loose and at other times fixed a n d attended with severe ]aneinating pains which have given rise to disagreeable suspicions in regard to the probable n a t u r e of the complaint, and would indeed at a more advanced age claim serious attention. W h e n h a p p e n i n g in families addicted to scrofula, t h a t disorder is n a t u r a l l y suspected, and sometimes a morbid scirrhus has been f e a r e d . " Underwood f u r t h e r states: " I n some instances only one of the breasts i s affected and a f t e r some months the other or sometimes both nearly at the same time. Yet no evil consequence in a n y instance u n d e r m y eye has From the Sarah Morris Children's Hospital of the Michael Reese Hospital.
758
ROSENBLU1Vi :
PUBERTY
1ViAS,TITIS,
759
ever ensued in patients at the above-mentioned age nor have I heard of any from other practitioners though it has sometimes been seriously apprehended." This gives a f a M y clear picture of the condition, and is more accurate than the few references I have seen ~n modern textbooks. Some eighteen or twenty years ago I saw m y first patient with this condition. The mother was v e r y much alarmed about the swelling of her child's breast just behind the nipple. I could find practically no reference to the condition in any pediatric text. Since then I have seen, like all pediatricians, m a n y children with similar swellings. Two years ago I was prompted to write this paper when a mother brought her ten-year-old daughter to me with a story that she had a breast removed six months previousIy and now had, she was sure, a similar swelling in the other breast. I found it a typical ease of mastitis adolescentium. The breast is a modified sudoriferous gland and physiologically is related rather intricately to the reproductive system. The epithelial lining of the duets and a]veoli is derived from the ectoderm and t h e supporting connective tissue from the mesoderm. Each breast consists of fifteen to twenty lobes, which are themselves branched saccular glands whose lactiferous duets open on the surfaee of the nipple near its apex. The main laetiferous duets subdivide into many interlobular ducts about which are clustered the group of secreting acini. Each group forms one of the many lobules included ifl one lobe of the gland. At puberty, and again at the end of pregnancy, marked enlargement of the gland and the development of additional lobules and acini take place. There is also an increase in the deposit of adipose tissue at puberty. Goltz and Evald have shown that the development of the mammary glands at p u b e r t y is due to the action of ovarian hormones, both follicular and luteal. C . W . L u r n e r has demonstrated that the follicular hormone stimulates the development of the duet system, and the corpus iuteum the alveoli. The anterior p i t u i t a r y gland is also active and important in the production of lactation (Stueker and Grueter). Cheatle and Cutler 2 regard p u b e r t y mastiffs as a result of some aberrance in the physiologic hyperplasia of the m a m m a r y tissues, probably an overactivity of the tissues in response to an excess of growth-stimulating substances. Muir ~ speaks of mastiffs adoleseentium as a nonsuppurative acute inflammatory condition similar to puerperal mastiffs. Rose and Carless* write of mastiffs adolescentium as being a condition similar to mastitis neonatorum, which it does resemble very closely.
760
THE
JOURNAL
OF
PEDIATRICS
K a u h n a n n 5 states t h a t p u b e r t y mastitis is probably the r e s u k of irritation of the ducts ,due to the retention' of the material secreted by the ducts. This secreted material provides a favorable medium for the growth of organisms. W a l t h e r 6 remarks t h a t the enlargement of the breasts in p u b e r t y very often coincides with the presence of a positive tuberculin reaction. In other words, he believes t h a t this type of mastitis is a manifestation of a tuberculous infection. The connective tissue proliferation is explained on an allergic basis. Oehsenius/ although not completely contradicting Walther, reports three cases in which the tuberculin reaction was negative.
Fig. 1.
Fig. 2.
F i g . 1 , - - G i r l , n i n e y e a r s old. Swelling of left br'east for one m o n t h . Typical t u m o r l i k e e n l a r g e m e n t b e h i n d nipple. 1V~ass c o m p l e t e l y d i s a p p e a r e d in f o u r m o n t h s . This girl had a severe eczema and asthma. F i g . 2 ~ - - B o y , s i x t e e n y e a r s old. S w e l l i n g o f b o t h b r e a s t s b u t m o r e m a r k e d in left. L o c a t i o n t y p i c a l l y b e h i n d nipple, Compl'ete d i s a p p e a r a n c e in f i v e m o n t h s .
I n none of m y patients was there a positive tuberculin reaction, and I feel definitely there is no relationship. Of the ten or twelve cases I have seen in the last two or three years, five or six h a d a definite allergy characterized b y a severe eczema, asthma, or both. Harbeson s describes a case of mastitis adolescentium in which the t u m o r began in the u p p e r outer q u a d r a n t of the left breast. Then two months later another t u m o r developed in the same location. Soon afterward, the right breast was the site of a similar tumor. The location, relative to the nipple, was not mentioned, and the last note several months later stated t h a t the tumors were smaller but still present. They
ROSENBLUIVI :
PUBERTY
MASTIT:IS
761
were p r o b a b l y fibroadenomas, l:Iarbeson thinks it is due to a preponderance of luteal hormone which produees an overstimulation and r a p i d development of the acini before development of the ducts. The children I have seen with this t u m o r in the breast all had charaeteristies similar to those described by Underwood one h u n d r e d and fifty or more years ago. They oecur more frequently between the ages of eight or nine and fifteen or sixteen years. The m a j o r i t y are f o u n d between the ninth a n d eleventh years in girls. One or both breasts m a y be involved, and one side m a y precede the other by as long as a y e a r or more. The areola becomes darker in color and, as Cheatle and Cutler described, the lesion assumes definite and v e r y eharaeteristie features.
J~'ig. 3.
2~ig. 4.
Figs. 3 and 4.--Periaeinous and perieanalieular infiltration and epithelial hyperplasia. ( F i g . 3, X 9 0 ; Fig'. 4, X 1 5 0 . ) (These photomicrographs were kindly lent by D r . M a x C u t l e r , of 2r Reese IKospital.)
The swelling forms a firm disMike or spherical t u m o r v a r y i n g f r o m 3 to 5 era. in diameter, which is p a i n f u l on pressure only. I t is situated directly behind the nipple, whieh usually is flattened and often slightly inverted by the enlargement. Occasionally a few drops of an opaque serous fluid m a y be expressed f r o m the nipple. The location in those I have seen is always behind the areola, and this differs f r o m most of the other possible tumors of the m a m m a r y gland. P u b e r t y mastitis is not a true inflammation, but is due to an increased physiologic h y p e r t r o p h y of the perieanalieular and periacinous connective tissue. The proliferative changes closely resemble those which are produced by the injection of estrin (as shown by Laeassane). I t is possible t h a t t r a u m a m a y aggravate it or be responsible for its appearance
762
THE JOURNAL OF PEDIATRICS
in only one breast. Usually the induration disappears as the breast develops fully. Some disappear in a few weeks while others require months. In the male sex this condition begins at the earliest in the fourteenth or fifteenth year of life, and it may be so marked as to constitute a true fibrous tumor. Zappert is of the opinion that in the male this state is associated with an advanced development of the genital glands. This condition is not to be confused with certain tumors which may arise only occasionally in breasts of children. In aII the children I have seen with p u b e r t y mastitis, the mothers were worried because they feared a cancer or tumor. The age, location and characteristics outlined will be sufficient readily to differentiate it from other pathologic entities. SUMMARY
P u b e r t y mastitis (mastitis adoleseentium) has definite characteristics. I t is always behind the nipple and occurs in girls between eight and twelve years of age and in boys between fourteen and eighteen years. It is probably caused by some endocrine dysfunction and local trauma may play a rSle. Pathologically it is a perieanalicular and periaeinous infiltration with connective tissue and lymphoeytes, together with epithelial hyperplasia. The condition is benign and disappears within a few months. I~EFEREN CES
1. Underwood: ed. 4, Vol. II. 2. Cheatle, G. Lenthal, and Cutler, Max: Turnouts of the B r e a s t : Their Pathology, Symptoms, Diagnosis and Treatment, Philadelphia, 1931, Lippincott. 3. Muir, 1%: Text Book of Pathology, Philadelphia, 1924, Lippineott, p. 710. 4. Rose a n d Carless: M a n u a l of. Surgery, ed. 11. 5. K a u f m a n n , E.: L e h r b u e h der speziellen pathologischen A n a t o m l e fiir Studierende u n d Xrzte, B a n d I, 1931, N i n t h - T e n t h Edition. 6. W a l t h e r , E.: Monatsehr. f. Kinderh. 58: 452, 1933. 7. Oehsenius, K.: 1V[onatschr. f. Islinderh. 59" 120, 1934. 8. IIarbeson~ A.E.:
Canad. M. A. J. 30: 648, 1934.
104 S. 1V[ICHIGANAVENUE