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Review of breast masses in adolescents
Adolesc Pediatr Gynecol (1994) 7:119-129
Adolescent and Pediatric Gynecology © 1994 Springer-Verlag New York Inc.
Mini Review Review of Breast Masses in Adolescents L.S. Neinstein, M.D. Division of Adolescent Medicine, Childrens Hospital of Los Angeles, Los Angeles, California; and Departments of Pediatrics & Medicine, University of Southern California School of Medicine, Los Angeles, California
Abstract. Breast lesions in adolescent females are a relatively common concern. Studies involving adolescent breast lesions diagnosed since 1960 were reviewed, a total of 1,797 cases were retrospectively analyzed. The most common lesions found were fibroadenomas (68.3%) and fibrocystic changes (18.5%). Malignant lesions were uncommon (0.89%). The two most common malignant tumors were adenocarcinoma and metastatic rhabdomyosarcoma. The diagnosis and management of breast lesions in adolescents is reviewed. In general, conservative management is the rule as breast cancer in adolescents is very rare. Mammography is not helpful in the adolescent. Ultrasound and aspiration may be useful in identification of cysts. Excisional biopsy should be performed for a persistent or enlarging solid mass.
Key Words. Breast lesions-Breast massesBenign breast disease-Breast carcinoma
Introduction Although breast cancer is extremely uncommon during childhood and adolescence, breast lesions in adolescent females are a relatively common concern. These concerns are often exaggerated by the significance placed on breasts in American culture and the common occurrence of breast cancer in adult women. This article will review the medical literature regarding the prevalences of breast lesions in adolescents as well discuss the diagnosis
Address reprint requests to: Lawrence S. Neinstein, M.D., Childrens Hospital of Los Angeles, 4650 Sunset Boulevard, P.O. Box 54700, Los Angeles, CA 90054-0700, USA.
and management of breast conditions in adolescents. Prevalence of Breast Lesions in the Adolescent The types and relative frequency of breast lesions in adolescents were evaluated by a review of prior studies, including cases of breast lesions in adolescent females under the age of 22. These were obtained from a Medline search of English language articles involving cases reviewed since 1960. Studies in which adolescents were evaluated by a breast biopsy were included. Studies that were of predominantly adult populations but included one or two adolescents were excluded. Fifteen retrospective studies were available that examined breast lesions in this age group. No prospective studies were available. The studies ranged from 5 patients to 429, with a median of 95 teens (Table O. The most common lesion found from these retrospective surgical series was a fibroadenoma, comprising 68.3% of the lesions. Fibrocystic changes were responsible for the majority of the remaining lesions (18.5%). Malignant lesions were uncommon, with only 16 malignant tumors reported for a 0.9% prevalence rate. The two most common malignant tumors were adenocarcinoma and metastatic rhabdomyosarcoma. As expected from cases obtained from retrospective surgical studies, most breast masses found in adolescents were fibroadenomas. Unfortunately, there were no cross-sectional or prospective studies that address the incidence of breast problems found in adolescents in the general population. We have recently been conducting a prospective study of adolescents to determine the incidence and the course of such lesions. One of the difficulties in evaluating and understanding breast lesions in the postpubertal female is
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Table 1. Breast Lesions in Surgical Studies in Female Patients Under 22 Years of Age Reference number Method (retro-retrospective) Number of patients Age limits
19 retro 30 <21
Type of Lesion Fibrocystic changes/mastodynia Cyst Fibroadenoma Giant fibroadenoma Cystosarcoma phyllodes Juvenile hypertrophy Intraductal papillomatosis Other benign tumor Abscess/mastitis Other breast lesion Normal breasts Cancer Adenocarcinomallobular or ductal Rhabdomyosarcoma Lymphosarcoma Angiosarcoma Lymphoma Metastatic cancer Synovial sarcoma-knee Metastatic rhabdomyosarcoma Total patients
30
Reference number Method (retro-retrospective) Number of patients Age limits
53 retro 5 1016
Type of Lesion Fibrocystic changes/mastodynia Cyst Fibroadenoma Giant fibroadenoma Cystosarcoma phyllodes Juvenile hypertrophy Intraductal papillomatosis Other benign tumor Abscess/mastitis Other breast lesion Normal breasts Cancer Adenocarcinomallobular or ductal Rhabdomyosarcoma Lymphosarcoma Angiosarcoma Lymphoma Metastatic cancer Synovial sarcoma-knee Metastatic rhabdomyosarcoma Total patients
20 retro 95 1221
18 retro 34 12 18
22 retro
32 retro 40 1222
51 retro 118 1020
2 1
9
11
118
84
40
25 8 169 12
III
I
90
29
24 retro 237 10 20
<16
9 18
23 retro 63 10 20
I
19
52 retro 151 <21 7 119
2 4 I
5
I I
2 2
13 1 5 3
9 6 2
3 1
34 56 retro 429 <21 76
5
111
95
338
57 retro 59 820 4 2 41 6
63 58 retro 145 <21
3
2
2 237
40
59 retro 95 1221
26 104
9 71
2
2
118
151
66 retro 185
Total
%
44
332 21 1,227 19 7 34 22 22 67 26 4 16 5
100 24
2 2 10
1 2 1 2
4 2 4 2
2 II
2 2 9 4
5
429
the multitude of different terms and classifications utilized for benign breast lesions. Love l suggests classifying benign breast lesions into six categories which will be used for this review (Table 2). These conditions, as well as malignant breast diseases in adolescents, will be discussed in the remainder of this article.
59
145
5 20
2 2 5
95
1 185
1,797
1 2 2 1 3 1,797
18.5 1.2 68.3 1.1 0.4 1.9 1.2 1.2 3.7 1.4 0.2 0.9 31.3 6.3 6.3 6.3 12.5 12.5 6.3 18.8
Benign Breast Disease Physiologic Swelling and Tenderness
The breasts of most women of reproductive age have a nodular texture representing the glandular units or lobules of the breast. These units undergo proliferative changes under hormonal stimulation
Neinstein: Breast Masses in Adolescents Table 2. Classification of Benign Breast Lesions Physiologic swelling and tenderness Mastalgia (severe pain, either cyclic or noncyclic) Nodularity (significant lumpiness, both cyclic and noncyclic Dominant lumps (including gross cysts and fibroadenomas) Nipple discharge (including intraductal papilloma and duct ectasia) Infections and inflammations (including subareolar abscess, lactational mastitis, duct ectasia and breast abscess) Adapted from : Love SM: Fibrocystic disease: What's in a name . Patient Care 1990; 24:65-82
during each menstrual cycle. As the lobules enlarge, particularly toward the onset of the menstrual period, the nodular texture of the breast coarsens . There is also an increase in total breast mass due to proliferation and edema. This process can vary from a feeling of fullness in the breast to distinct masses suggestive of a pathologic process. As many as 50% of breast complaints in adolescent females are a result of these physiologic changes. If treatment is needed, analgesics and/or the use of a wellfitting brassiere worn both day and night can be tried. Mastalgia
Mastalgia or severe breast pain is either cyclic or noncyclic and is another relatively common and occasionally distressing breast symptom? No histologic basis has been defined for these symptoms. The pain may coexist with nodularity . Mastalgia may be divided into cyclical , noncyclical, and chest wall pain. The incidence of mastalgia in adolescents is unknown. However, the prevalence in adult females has been reported to be has high as 66%, 45% with mild symptoms and 21% with severe symptoms. 2 Many females fail to obtain medical consultation for mastalgia because of their perception of the lack of concern among medical professionals. With noncyclic mastalgia the affected female can often point to a spot that hurts all the time. Noncyclical mastalgia is commonly bilateral in the upper outer quadrant of the breast. Chest wall mastalgia can include referred pain from costochondritis or cervical radiculopathy. 3 The pain is unilateral in 92% of individuals and usually located on the lateral chest wall or costolchondral junctions with no associated breast nodularity. Many modalities have been used to treat mastalgia including heat, firm support, analgesics, hormonal therapy, evening primrose oil, diuretics, and in adults, danazol, bromocriptine, and tamoxifen. 1,4,5 These latter drugs are not recommended for adolescents. Most adolescents only require reassurance and analgesics , such as the nonsteroidal antiinflammatory agents,
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Diuretics , exclusion diets, and vitamins B I, B6, and E have failed to show significant benefits,2 A compound primarily used in Europe, evening primrose oil, has been shown to be ofbenefit. 2,4 Evening primrose oil is a natural product whose mode of action is thought to be related to its high content of essential fatty acids acting via prostaglandin pathways. The overall response rate is 44% on two 500 mg capsules three times a day. 2,4 The drug is usually tried for 3 months and if the response is good , continued for 2 more months before withdrawal. Nodularity
Most nodularity in adolescents and young adults is associated with proliferative breast changes or fibrocystic changes. Some authorities consider this condition a nondisease. 6 Scanlon defines fibrocystic changes as "a condition in which there are palpable lumps in the breast, usually associated with pain and tenderness, that fluctuate with the menstrual cycles and that become progressively worse until menopause. ,,6 If examined carefully, probably over 50% of women in the reproductive age group have some degree of fibrocystic changes. 7 At autopsy, 58-90% of women of virtually all ages have histologic changes associated with the name "fibrocystic disease." 1,6 The exact prevalence in adolescents is not known. In this current review of retrospective surgical studies, the prevalence was 18.5%, although this cannot be extrapolated to the general adolescent population. Fibrocystic changes are a progressive benign process that usually correlates with the patient's age. Adolescents and women in their 20s have minimally symptomatic fibrotic tissue changes, particularly in the upper outer quadrants of the breasts. Changes in women in their 30s and 40s usually include multiple small cysts , with a diffuse increase in glandular tissue and increasing complaints of pain. Single large cysts are more common in women 35 years of age or older. 8 These progressive changes are illustrated in Figure 1. In general, the nonproliferative lesions found in adolescents are not associated with cancer. Though the exact etiology of breast nodularity or fibrocystic changes is unknown, an imbalance between estrogen and progesterone is one possible factor. 9 Estrogen causes proliferation of breast tissue including ductal alveolar epithelium and stroma; progesterone counteracts these proliferative effects and brings about epithelial differentiation and reduction of mitoses.9 In women with fibrocystic changes, estrogen levels are normal or increased, whereas progesterone levels during the luteal phase are decreased. With relatively higher estradiol to progesterone levels, connective and ep-
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mild analgesics. Oral contraceptives help in up to 70-90% of individuals9 •13 •14 and medroxyprogesterone 10 mg on days 15-25 of the menstrual cycle has had success in up to 85% of women. 13 A decrease in caffeine intake is advocated by some I5 ,16, however, because of its questionable effects I7 •18 , heavy restriction of diet should not be encouraged. Vitamin therapy , including Bl , A, and E, has been used but a beneficial effect has not been proven. 19,20 Danazol has been used in adult women for severe fibrocystic breast changes, but there is little experience with its use in adolescent females.
Fig. 1. Pathomorphology of fibrocystic changes. (A) Ductal-lobular proliferation; (B) duct dilation and elongation; (C) terminal ductal cyst formation (From Vorherr H: Fibrocystic breast disease: pathophysiology, pathomorphology, clinical picture , and management. Am J Obstet Gynecol 1986; 154: 161.)
ithelial tissue proliferation occurs. Women with fibrocystic changes also have obstruction and persistent secretory material in alveoli and terminal ducts causing alveolar enlargement and cyst formation . Methylxanthines have also been implicated in fibrocystic changes. Vorherr9 has reviewed studies on methylxanthines and their relationship to fibrocystic changes. Prior studies have been contradictory, but in Vorherr's experience with 400 patients, there was no influence on fibrocystic changes by avoidance of coffee, tea, cola drinks, and chocolate. 9 In addition, several other case-control studies and randomized trials have failed to demonstrate an effect of methylxanthines on fibrocystic changes or mastalgia. 10--12 Fibrocystic changes are usually found either as painless lumps on examination or because of pain or discomfort. Symptoms are most common about 1 week prior to menstruation and are often relieved by menstruation. The pain is often associated with breast swelling that is frequently bilateral, involving the outer upper quadrants. Many modalities have been suggested for treating fibrocystic changes. 9 In most adolescents, the symptoms are not severe enough to warrant aggressive measures. Supportive measures such as a wellpadded brassiere can always be used in addition to
Breast Lumps or Masses These include gross cysts and fibroadenomas; fibroadenomas in adolescents have been reviewed extensively.4,2o,21 ,23-30 In surgical reports 28 they are the most common breast tumor found in adolescents and the most prevalent in women under the age of 25. Of the 1,797 cases in this review, 68.3% were fibroadenomas. There is no evidence of progression to cancer and there is evidence that some may undergo regression. 24 ,31 Fibroadenomas are frequently discovered by the adolescent , often while bathing. Associated symptoms, other than the presence of a breast mass, are unusualY However, some adolescents will complain of breast discomfort during menstruation or pregnancy. 23 The average duration of symptoms is about 5 months. 21 Most adolescents with this condition are over 14, with a large increase in prevalence in 15- and 16-year01ds. 25 The condition has been reported to be twice as common in blacks. 29 On examination, the mass is usually a rubbery, firm , mobile, well-demarcated, nontender lesion, usually distinguishable from surrounding breast tissue. 22 Most commonly, there is only one fibroadenoma, with the largest prevalence in the upper outer quadrant of the breast. Sixty-three percent are in the lateral quadrants. Fibroadenomas are multiple in 10-25% of cases and bilateral in about 10%.31 The tumor ranges in size from less than 1 cm to over 10 cm with an average size of 2-3 cm. 25 On gross appearance , a fibroadenoma appears to be a grayish white, encapsulated, firm, nodular mass. Microscopically, the tumor has stromal proliferation surrounding aggregates of compressed or uncompressed, elongated, and distorted ducts. 25 Some of these tumors, labeled juvenile or giant fibroadenomas, have much more rapid growth with a greater degree of stromal cellularity and the potential to grow to a large size. 31 ,32 Treatment for fibroadenomas may involve either careful follow-up, especially if diagnosis has been confirmed by fine-needle aspiration cytology or elective surgical excision. Many of these operations
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can be performed under local anesthesia and sedation on an outpatient basis, sparing teens the risk of general anesthesia. 33 However, general anesthesia is recommended in adolescents with undue anxiety, with large pendulous breasts, or with deep lesions. In most young women with a solid breast mass, excisional biopsy should be performed through a circumareolar or curvilinear incision. 33 Large cysts are another cause of benign breast masses. Cysts over 1 cm usually occur in women in their 40S. 8 ,9 Cysts are associated with few symptoms, and on examination feel like a well-circumscribed, small, freely movable mass. These can usually be diagnosed and treated by fine-needle aspiration. Giant fibroadenomas, phyllodes tumors, and juvenile hypertrophy may cause large breast tumors in adolescents, particularly at puberty.34 Giant Fibroadenoma. This condition is uncommon, found in 19 of 1,797 (1.1 %) adolescents in this current review. The lesion is most commonly found in young adolescents, with a greater prevalence in black teens. 35 The mass has a rapid and asymmetric growth pattern with the tumor growing to huge proportions, usually greater than 5 cm in diameter. Because of its size, the tumor may cause compression of adjacent breast tissue. The area may feel warmer due to the increased blood supply ofthe tumor. The tumor may be slightly firm, freely movable, round, or oval with a smooth surface and associated with dilated superficial veins and thinning of the overlying skin. 26 Though encapsulated, the tumor may have a consistency similar to normal breast tissue which may make it difficult to differentiate from normal tissue or unilateral virginal hypertrophy. Microscopically, the tumor is similar to a fibroadenoma but with increased stromal cellularity and more hyperplasia of the epithelial components. The condition is benign but can cause massive distortion in the breast. Treatment of giant fibroadenomas is simple excision, sparing as much mammary tissue as possible. 35 These lesions usually separate easily from normal breast tissue. A simple mastectomy for this lesion is not warranted. Phyllodes tumors. Phyllodes tumors (cystosarcoma phyllodes) were the least prevalent cause of massive breast masses in adolescents, occurring in 0.4% of cases (7/1,797). The lesion is almost always benign, but malignant lesions have been reported in adolescents. 36 The tumor usually presents as a bulky mass in the breast. The lesions tend to be large, up to 20 cm, and sharply circumscribed. 22 The mass is firm, mobile, smooth, or irregular. Overlaying skin may be stretched and shiny, with
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distended veins from the rapid growth of the tumor. Compared with juvenile giant fibroadenoma, this lesion is more firm and more discrete. 37 It may be associated with skin retraction, necrosis, nipple retraction, and breast discharge. Briggs et al. 28 reviewed phyllodes tumors in adolescent females. In all of these nine adolescents, the chief complaint was of a recent onset of a rapidly growing nontender breast mass of 3 months duration. In his review, none ofthe adolescents had skin dimpling or nipple retraction. The tumors averaged 6 cm in diameter with a range of 2-13 cm. Gross exam shows a firm, smooth, often irregular or lobulated mass which is usually well circumscribed. Microscopically, benign phyllodes tumors are similar to fibroadenomas, with both epithelial and connective tissue elements, but with a more cellular hyperplastic stroma. 38 Phyllodes tumors lack complete encapsulation and extend into surrounding tissue in multiple projections of varying size. The differentiation between a giant fibroadenoma and a phyllodes tumor can only be made by a pathologist after biopsy. Classification of benign or malignant is based on stromal findings, particularly cellular atypia, anaplasia, and degree of mitotic activity. Though recommendations for treatment range from simple excision to radical mastectomy, little evidence exists to support routine use of mastectomy as initial therapy. 39 Most adolescents and adults are cured by excision alone. The lesion should be excised completely with a surrounding rim of normal breast tissue. There is no need for a mastectomy unless the tumor is found to be malignant. There is also no reason for adjuvant chemotherapy or radiation in the absence of metastatic disease. Virginal Breast Hypertrophy Virginal or juvenile hypertrophy implies diffuse enlargement of the breast that is usually symmetrical, occurring near the time of menarche. It was found in 34/1,797 (0.6%) cases. In this condition, the breasts are usually symmetrically enlarged although unilateral cases have rarely been reported. The breasts are usually pendulous (they can get as large as 30-50 pounds)32 and diffusely firm to palpation without any discrete mass lesions. The tissue may be soft but sometimes has diffuse ropelike thickenings. 22 The enlargement can be so severe as to lead to neck and back strain and difficulty with physical activity.40 The condition can also lead to significant psychologic problems and embarrassment. However, in contrast to the giant fibroadenoma, there is less thinning of the skin, less prevalence of enlarged veins, and less displacement of the nipple or areola.
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The etiology of pubertal hypertrophy is not well understood but may represent an abnormal response of the breast to normal serum estrogen levels. Hormonal studies are normal in these individuals. 40 Though this problem typically occurs at puberty, it has also been reported at pregnancy (gravid hypertrophy),32 and with the administration of exogenous estrogen, androgens, corticosteroids, and insulin. The process has also been reported to be worsened by oral contraceptives. 40 The histology of the breast in this condition is an exaggeration of the normally developing adolescent breast. There is stromal hypertrophy, a tremendous increase in periductal fibrous tissue, and proliferation and increased branching of the ducts without lobule formation. The breasts may appear histologically similar to fibroadenoma. 22 No definite guidelines have been developed as to when to peIform surgery and what procedure is best. Though it is preferable to delay surgery until the breasts have matured, this may not be practical in some adolescents, if breast size and/or weight is unbearable. Four modalities of treatment have been recommended,35 the most common of which is reduction mammoplasty. However, many adolescents may continue to have breast enlargement after this procedure. A second approach involves a subcutaneous mastectomy with implantation of a prosthesis; this may be the surgical procedure of choice in individuals with massive recurrent enlargement. A third approach has been hormonal manipulation with either medroxyprogesterone, dydrogesterone, or danocrine. 35 Dydrogesterone may suppress the secretion of growth hormone and also could interfere with development of secondary sexual characteristics. Teratogenic and carcinogenic effects have also been a concern with these medications. Lastly, a combination of medications and surgery has been used, such as the postoperative use of the dydrogesterone to prevent recurrences:5 Nipple Discharge, Intraductal Papilloma, and Duct Ectasia A nipple discharge is not a single disease entity but is a possible sign of several different problems. A bloody discharge may raise fears in the physician and the teen about cancer, but most nipple discharges, even bloody ones in adolescents, do not represent cancer. Nipple discharges in the teen can represent galactorrhea, Montgomery's tubercles, intraductal papillomatosis, or duct ectasia. The color and type of nipple discharge may help differentiate the condition (Table 3).41 A milky discharge generally represents galactorrhea. A sticky discharge of varying colors is typical of duct ectasia. A purulent discharge suggests an infection, and
Table 3. Nipple Discharge Type Milky Multicolored/Sticky Purulent Watery Serous/Serosanguineous
Differential (in order of frequency) Galactorrhea Duct ectasia Mastitis Papilloma Cancer Intraductal papilloma Fibrocystic changes Cancer Duct ectasia
a watery nipple discharge can represent a papilloma or cancer. A serous or serosanguineous discharge is most likely found with an intraductal papilloma followed in frequency by fibrocystic changes, cancer, and duct ectasia. 41 Galactorrhea may be found in teens who are pregnant or following an abortion or miscarriage. It may also be found in teens with pituitary adenomas or hypothyroidism. Numerous drugs can also cause galactorrhea including oral contraceptives, phenothiazines, reserpine, spironolactone, estrogens, and methyltestosterone. The reader is referred to Kletzky and Davajan42 for a review of galactorrhea and hyperprolactinemia. Montgomery's tubercles or Morganis tubercles can also cause a nipple discharge. 43 These lesions are small, soft papules distributed around the areola which enlarge with pregnancy and are involved with lactation. Investigators have suggested that Montgomery's tubercles are formed from sebaceous glands and associated with a lactiferous duct from an underlying mammary lobule. Examination may show either no lump or a small lump under the areola associated with episodic, thin, clear to brown discharge. The discharge usually resolves within 3-5 weeks and the lumps within 4 months. An intraductal papilloma arises from an abnormal proliferation of cells in mammary ducts. 44 The lesion is usually small and most frequently microscopic, consisting of simple proliferations of duct epithelium projecting into a dilated lumen. Because the proliferated epithelium is supported by a vascular stalk, slight local trauma may rupture this stalk leading to a bloody discharge. 41 This local proliferation of cells may grow large enough so that a mass may be palpable. An intraductal papilloma is a relatively infrequent finding in the adolescent. The lesion is most frequent in women in their 20s through 40S.32 In my current review of breast lesions in adolescents, 1.2% of lesion biopsies were secondary to an intraductal papilloma. The typical description of a female with this con-
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dition involves complaints of a bloody nipple discharge. However, in the largest series of teens with intraductal papillomatosis, only 3/13 noted an abnormal spontaneous bloody nipple discharge, and only 9/13 noted an abnormal thickening or enlargement of the breast. 27 On exam, most of the teens had well-defined nodules or thickenings near the areola. The lesion may be difficult to palpate. Oberman noted that in adolescents these lesions are often multiple, and occupy ducts in the periphery of the breast, with a less frequent occurrence of the lesion near the areola. 29 These lesions are uniformly benign and amenable to local excision. Certainly, if associated with a bloody discharge, these lesions should be removed to rule out a malignancy. However, a bloody discharge associated with a soft mass has a 95% chance of being an intraductal pap illoma. 45 Infections and Inflammation
A breast abscess or cellulitis can occur secondary to bacteria introduced from the skin into the ductal system, or from cutaneous infections, foreign bodies, epidermal cysts, and trauma, such as shaving periareolar hair or trauma related to sexual play.46 Breast abscesses are not common in adolescents, with the majority being related to lactation. In adolescent studies of breast lesions, 3.7% of lesions were related to an inflammatory etiology. A similar prevalence, 3.9%, was found by Diehl and Kaplan 31 in a retrospective chart review not relying on surgical specimens. A breast abscess is similar to an abscess elsewhere on the body leading to the sudden onset of a tender or fluctuant mass with skin erythema. Staphylococcus aureus is the most common organism followed by Escherichia coli and pseudomonas. 22 ,31,46,47 Other organisms include group B beta streptococcus and anaerobes. Preceding factors may include trauma, ductal obstruction, or a preexisting cyst. 19 Treatment involves the use of warm compresses and antibiotics. Mastitis is a common occurrence in breast feeding females. 7 It is a result of abrasions on the nipple leading to infection and clogging of lactiferous ducts and consequent stasis of milk. Resulting signs and symptoms include pain, tenderness, induration, and fever. The abscess may be subcutaneous, subareolar, intramammary, or retromammary. The most common bacteria involved is Staphylococcus aureus. However, other organisms include streptococcus, Micrococcus dyogenes, Escherichia coli, Pseudomonas sp and others. 48 An infection is likely with a leukocyte count from breast milk of over 106/ml plus more than 103 bacteria/ml on culture. 49 Culture and sensitivity of breast milk of the affected
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breast is helpful in identifying the organism and choosing an appropriate antibiotic. Heat and antibiotics are utilized in the treatment. Nursing or breast pumping can be continued using the unaffected breast. Nursing on the affected side can be quite painful. Another inflammatory condition affecting the breast is duct ectasia (periductal mastitis, plasma cell mastitis, comedomastitis).50 This is a poorly understood, benign condition which affects the major breast ducts. Some evidence suggests that the condition starts with dilatation of the ducts with secondary inflammation resulting after leakage of ducts contents through the walls of damaged dilated ducts. 50 More recent evidence suggests that the inflammation may occur first leading to cellular wall damage and ductal dilatation. 50 This condition usually affects females outside the adolescent age group with a mean age of presentation of 36. Younger patients with duct ectasia tend to have more signs of inflammation whereas older women have more signs of dilated ducts and nontender masses. The most common manifestations include noncyclical breast pain, nipple discharge, nipple retraction, a subareolar breast lump, a periareolar abscess, and a mammillary fistula. Nipple discharge occurs in about 15-20% of women with this condition. The discharge can be many colors including straw, cream, green, brown, and rarely blood stained. Cancer of the Breast
During the past 70 years there have only been sporadic reports of breast cancer in females under the age of 20. 51 - 53 Less than 1% of all breast tumors in adolescents are cancerous, and 98% of breast cancer occurs in women older than 25 years. 21- 27 ,35,54-62 In surgical breast masses in females under 22,0.9% of lesions were cancerous. Of these, 31% were primary tumors of breast tissue and the rest were either a tumor of nonbreast tissue or some form of metastatic cancer. In tabulation of English mortality data including over 70,000 deaths from breast cancer, there was one case of a child under the age of 5, one between 10 and 14, five between 15 and 19, and 27 between 20 and 24.63 Schydlower46 found that 90% of children and adolescents with breast cancer present with a breast mass. The mass is usually hard and is most commonly subareolar and frequently fixed to the deep tissues. Symptoms are uncommon, with axillary lymphadenopathy present in only a few cases. 22 Up to 30% of affected teens have a family history of breast cancer and the tumor tends to occur earlier in
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the daughter than in the mother. The size varies from 1 to 2.5 cm in diameter,64 with the right and left breast equally affected. 22 Among teenagers, survival is similar to adults whereas the prognosis of carcinoma of the breast in prepubertal children seems better than in adults. 22 Primary sarcomas of the breast are even rarer than carcinomas-fibrosarcoma and liposarcoma are the most common types. The adolescent breast may also be affected by systemic malignancies including lymphoma, Hodgkin's disease, leukemia, and multiple myeloma. Rarely a sarcoma of the breast may develop following radiation for another tumor. 65 Diagnosis The evaluation of the adolescent with a breast complaint includes a family history of breast tumors (both benign and malignant), a history of trauma to the breast, menstrual and reproductive histories, and a review of the use of contraceptives and other hormones. 13 The most significant risk factor is a history of breast cancer in several members of the teen's mother's family. Breast cancer in two or more of the following adds significantly to the risk profile: the teen's mother, maternal aunts, and the maternal grandmother, sister, and daughter. A complete breast examination consisting of inspection of both breasts to observe for asymmetry or skin retraction is important. 8,13,44,66,67 Traditionally, this has been performed as described by Haagensen, with the individual seated and in three different positions: leaning forward, extending her arms over her head, and pressing her hands against her hips.68 However, these three positions are seldom helpful in the screening examination unless a mass is palpated. 68 For this reason and the potential discomfort for the adolescent, the author would recommend skipping this maneuver for the screening examination. The examiner should next palpate the breast for a mass or discharge; palpation is performed in the supine position. First, the teen's arm, on the side to be examined, should be placed behind her head. The examiner can also place a pillow or folded sheet under the posterior ribs. The breast should be palpated in an orderly fashion in one of several ways. In the first method, the examiner uses a pattern similar to the spokes of a wheel. Starting with the tail ofthe breast in the axilla, the examiner moves in a straight line to the nipple. Using straight lines from the outer boundary of the breast to the nipple, the examiner can work around the whole breast. A second method involves covering the breast in either concentric circles or a spiral pattern around the breast. A third method, the vertical strip method,
has been demonstrated to be the most effective method for breast self-examination. 69 Whichever method is used, the entire anterior chest wall should be palpated applying varying degrees of pressure with the pads of the second, third, and fourth fingers rotating in small, dime-sized circles. Some examiners find the use of talc helpful in palpating the breast. Masses larger than 1 cm may be best felt by compressing them between the thumb and index finger. The examiner should also palpate for supraclavicular, infraclavicular, and axillary nodes. The palpation of a firm, rubbery, and mobile mass with a smooth or slightly irregular surface is suggestive of a fibroadenoma. Rapidly enlarging tumors of the breast are usually either a juvenile fibroadenoma or phyllodes tumors. Particular attention should be given to the nipple and areolar areas, as 15% of breast cancers are located here. The areolae should be compressed to elicit nipple discharge. 22 Throughout the examination, it is helpful to explain to the teen what is being done, utilizing the examination time to discuss self-examination skills. Explain to the teen that she may be the best individual to notice if something has changed with her breasts. Combining this educational maneuver with the physical examination can be a useful method in alleviating fear and tension during the breast examination?7 In addition, reassure the teen that the breast has many lumps and bumps that may change, particularly with menstrual cycles. Though it is not as evident from chart reviews that malignancies are found on self-exam in adolescents 70, Hein et al. 62 found that 81 % of a group of 95 teens with breast masses found the lesions by self-detection. One significant dilemma in adolescents is the management of breast masses. If a mass were easy to diagnose by palpation, then a biopsy would not be needed, but palpation cannot exclude a malignant tumor. However, conservative management of breast masses in teens is advocated by the author and others 31 ,34,40,60 because of the rarity of malignant breast tumors: < 1% of all cancers of childhood and <0.5% of all breast cancer cases. 27 ,37,64 It is recommended that a breast mass in an adolescent be observed through at least one complete menstrual cycle. 71 Furnival et al. 72 report that 77% of women have some resolution of fibrocystic changes. Many authorities recommend an excisional biopsy if a mass is persistent over 3-6 months or continues to increase in size. Other authorities would argue for at least a fine-needle aspiration with cytologic studies in these individuals, although the role of fine-needle aspiration has not been evaluated in the adolescent population. However, this procedure may be a good diagnostic test for breast masses in adolescents as the surgical risks and scars
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of excisional biopsies are avoided. An excisional biopsy is also recommended for a hard mass, or if there is a fixed mass, skin dimpling, edema, ulceration or fixation to chest wall, patient or paternal anxiety about the mass, or a strong positive family history.22.25 Multiple or recurrent lesions that are stable in size should not be excised. If feasible, cysts can be aspirated and the fluid, if bloody, sent for cytological examination. 22,60 Other diagnostic modalities include mammography and ultrasound. Mammography is not generally helpful in the adolescent because breast tissue is very dense,39,73,74 and the prevalence rate of malignancy is low. In women less than 30 years, there is poor correlation between mammographic diagnosis and tissue diagnosis 33 as masses may be hidden in dense breast parenchyma. Mammography is more reliable in older patients as breast tissue begins to atrophy. Another diagnostic technique is the ultrasound of the breast. 75- 77 Simple cysts, particularly in adolescents, are generally considered benign. An ultrasound is helpful in differentiating a solid mass from a cystic mass, however, it cannot differentiate between a benign and malignant solid mass. An ultrasound can also help in guiding a needle into an abscess or cyst. In women aged 30 or less, the ultrasound can be helpful as a primary imaging examination to evaluate a breast mass. If a cyst is found, an aspiration can be done without need for further studies. There is no evidence to suggest a role for ultrasound as a sole imaging technique for breast cancer screening. In some centers, a fine-needle aspiration is done as the primary technique without a primary ultrasound. This can be done by the primary care physician, if trained in this technique, or by a surgeon. If nonbloody fluid is found, it is considered benign and not sent for cytology. The teen should be checked for a reoccurrence in 4-6 weeks. If a solid mass is encountered, then an aspiration is performed with a cytologic smear made up for evaluation. In summary, most adolescent breast masses are benign. Fibroadenomas are the most common solid mass. Conservative management is the rule. The teen and her family should be reassured that breast cancer in adolescents is very rare. Mammography is not helpful in the adolescent. Ultrasound and aspiration may be useful in identification of cysts. Excisional biopsy should be performed for a persistent or enlarging solid mass. References 1. Love SM: Fibrocystic disease: What's in a name.
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2. Maddox PR, Mansel RE: Management of breast pain and nodularity. World J Surg 1989; 13:699 3. Watkins F, Giacomantonio M, Salisbury S: Nipple discharge and breast lump related to Montgomery's tubercles in adolescent females. J Pediatr Surg 1988; 23:718 4. Pye JK, Mansel RE, Hughes, LE: Clinical experience of drug treatments for mastalgia. Lancet 1985; 2:373 5. Corriveau S, Jacobs JS: Macromastia in adolescence. Clin Plast Surg 1990; 17:151 6. Love SM, Gelman RS, Silen W: Fibrocystic disease of the breast - a nondisease? N Engl J Med 1982; 307: 1010 7. Teimourian B, Hakki AR: Benign disease of the female breast. Hosp Med 1987; 23:85 8. Scott EB: Fibrocystic breast disease. Am Fam Physician 1986; 36: 119 9. Vorherr H: Fibrocystic breast disease: pathophysiology, pathomorphology, clinical picture, and management. Am J Obstet Gynecol 1986; 154:161 10. Lubin F, Ron E, Wax Y, et al: A case-control study of caffeine and methylxanthines in benign breast disease. JAMA 1985; 253:2388 11. Ernster VL, Mason L, Goodson WH 3d, et al. Effects of caffeine-free diet on benign breast disease: a randomized trial. Surgery 1982; 91 :263 12. Heyden S, Fopdor JG: Coffee consumption and fibrocystic breasts: an unlikely association. Can J Surg 1986; 29:208 13. Cox EB: Benign breast lesions and breast cancer: Is there a relation? Female Patient 1986; 11:52 14. London RS, Sundaram GS, Goldstein PJ: Medical management of mammary dysplasia. Obstet Gynecol 1982;59:519 15. Dodd GD, Goodson III WH, Marchant DJ: Fibrocystic breast: long-term care. Patient Care 1987; 21:41 16. Minton JP, Abou-Issa H, Reiches N, Roseman JM: Clinical and biochemical studies on methlxanthinerelated fibrocystic breast disease. Surgery 1981; 90: 299 17. Ernster VL, Mason L, Goodson WH: Effects ofcaffeine-free diet on benign breast disease: a randomized trial. Surgery 1982; 91:263 18. Lubin F, Ron E, Wax Y, et al: A case-control study of caffeine and methyxanthines in benign breast disease. JAMA 1985; 253:2388 19. London RS, Sundaram GS, Murphy L, et al: The effect of vitamin E on mammary dysplasia: a doubleblind study. Obstet Gynecol 1985; 65:104 20. Ernster VL, Goodson WH, Hunt TK, et al: Vitamin E and benign breast "disease": a double-blind, randomized, clinical trial. Surgery 1985; 4:490 21. Turbery WJ, Buntain WL, Dudgeon DL: The surgical management of pediatric breast masses. Pediatrics 1975; 56:736 22. Seashore JH: Breast enlargements in infants and children. Pediatr Ann 1975; 4:542 23. Daniel WA Jr, Mathews MD: Tumors ofthe breast in adolescent females. Pediatrics 1968; 41:743
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24. Kern WH, Clark RW: Retrogression of fibroadenomas of the breast. Am J Surg 1973; 126:59 25. Bower R, Bell MJ, Ternberg JL: Management of breast lesions in children and adolescents. J Pediatr Surg 1976; 11:337 26. Gogas J, Sechas M, Skalkeas GR: Surgical management of disease of the adolescent female breast. Am J Surg 1979; 137:634 27. Farrow JH, Ashikari H: Breast lesions in young girls. 1%9; 49:261 28. Briggzs RM, Walter M, Rosenthal D: Cystosarcoma phylloides in adolescent female patients. Am J Surg 1983; 146:712 29. Organ CH J r, Organ BC: Fibroadenoma of the female breast: a critical clinical assessment. J Natl Med Assoc 1983; 75:701 30. Ashikari R, Farrow JH, O'Hara J: Fibroadenomas in the breast of juveniles. Surg Gynecol Obstet, Feb. 1971, pp 250-262 31. Diehl T, Kaplan DW: Breast masses in adolescent females. J Adolesc Health Care 1985; 6:353 32. Oberman HA: Breast lesions in the adolescent female. Pathol Ann 1979; 1:175 33. Ligon RE, Stevenson DR, Diner W: Breast masses in young women. Am J Surg 1980; 140:779 34. Wulsin JH: Large breast tumors in adolescent females. Ann Surg 1960; 152:151 35. Bauer BS, Jones KM, Talbot CW: Mammary masses in the adolescent female. Surg Gynecol Obstet 1987; 165:63 36. Hoover HC, Trestioreanu A, Ketcham AS: Metastatic cystosarcoma phylloides in an adolescent girl: an unusually malignant tumor. Ann Surg 1975; 181: 279 37. Dudgeon DL: Pediatric breast lesions: take the conservative approach. Cont Pediatr Jan 1985; 61 38. Amerson RJ: Cystosarcoma phyllodes in adolescent females. Ann Surg 1970; 171:849 39. Mollit DL, Golladay ES, Gloster ES, Jimenez JF: Cystosarcoma phylloides in the adolescent female. J Pediatr Surg 1987; 22:907 40. Greydanus DE, Hofmann AD: The thorax. In: Adolescent Medicine, (2nd ed.). Norwalk, Conn, Appleton and Lang, 1989, pp 69-78 41. Pilnik S: Clinical diagnosis of benign breast disease. J Reprod Med 1979; 22:277 42. Kletzky OA, Davajan V: Hyperprolactinemia. In: Infertility, Contraception and Reproductive Endocrinology. Edited by DR Mishell Jr, V. Davajan. Oradell, New Jersey, Medical Economics Books, 1986, pp 275-302 43. Watkins F, Giacomantonio M, Salisbury S: Nipple discharge and breast lump related to Montgomery's tubercles in adolescent females. J Pediatr Surg 1988; 23:718 44. Marchang DJ: Evaluation, diagnosis, and treatment of the fibrocystic breast. Mod Med 1987; 55:42
45. Bachman JW: Breast Problems Primary Care. 1988; 15:643 46. Schydlower M: Breast masses in adolescents. Am Fam Physician 1982; 25: 141 47. Jimerson GK: The adolescent breast: disorders and evaluation. Med Aspects Hum Sexuality 1985; 19:66 48. Greydanus DE, Parks DS, Farrell EG: Breast disorders in children and adolescents. Pediatr Clin North Am 1989; 36:601 49. Cunningham GF, MacDonald PC, Gant NF (eds): Williams Obstetrics (18th ed.). Appleton and Lange, 1989 50. Dixon JM: Periductal mastitis/duct ectasia. World J Surg 1989; 13:715 51. Oberman HA, Stephens PJ: Carcinoma of the breast in childhood. Cancer 1971; 30:470 52. Seltzer MH, Skiles MS: Diseases of the breast in young women. Surg Gynecol Obstet 1980; 150:360 53. Hammar B: Childhood breast carcinoma: report of a case. J Ped Surg 1981; 16:77 54. Skiles MS, Seltzer MH: Adolescent breast disease. Natl Med Soc N J 1980; 77:891 55. Sandison AT, Walker JC: Diseases of the adolescent female breast. Br J Surg 1968; 55:443 56. 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 1%9; 101:100 57. Nichini FM, Goldman L: Inflammatory carcinoma of breast in a 12-year-old girl. Arch Surg 1972; 105:505 58. Ashikari R, Jun MY, Farrow JH: Breast carcinoma in children and adolescents. Clin Bull 1977; 7:55 59. Raju CG: Breast masses in adolescent patients in Trinidad. Am J Surg 1985; 149:219 60. Goldstein DP, Miler V: Breast masses in adolescent females. Clin Pediatr 1982; 21: 17 61. Stone AM, Shenker IR, McCarthy K: Adolescent breast masses. Am J Surg 1977; 134:275 62. Hein K, Dell R, Cohen MI: Self-detection of a breast mass in adolescent females. J Adolesc Health Care 1982; 3:15 63. Close MB, Maximov NG: Carcinoma of breast in young girls. Arch Surg 1%5; 91:386 64. McDivitt RW, Stewart FW: Breast carcinoma in children. JAMA 1966; 195:388 65. Squire R, Bianchi A, Jakate SM: Radiation-induced sarcoma of the breast in a female adolescent. Case report with histologic and therapeutic considerations. Cancer 1988; 61:2444 66. Hindle WH: Changing concepts in the evaluation of dominant breast masses. Female Patient 1990; 15:40 67. Hindle WH: Examination for breast cancer: assuring against a missed diagnosis. Mod Med 1991; 59:34 68. Sapira JD: The breast. in: Art and Science of Bedside Diagnosis. Baltimore, Urban and Schwarzenberg, 1990, pp 239-244 69. Atkins JE, Solomon LJ, Worden JK, Foster RS Jr: Relative effectiveness of methods of breast selfexamination. J Behav Med 1991; 14:357 70. Simmons PS, Wold LE: Surgically treated breast dis-
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ease in adolescent females : a retrospective review of 185 cases. Adolesc Pediatr Gynecol 1989; 2:95 71. Emans SJR, Goldstein DP: The breast: examination and lesions. In: Pediatric and Adolescent Gynecology (3rd ed.). Boston: Little, Brown and Co, 1990, pp 437-450 72. Furnival CM, Irwin JRM, Gray GM: Breast disease in young women. Med J Aust 1983; 2:167 73. Egan RL, Mostellar RC: Breast cancer mammography patterns. Cancer 1977; 40:2087
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74. Eddy DM: Screening for breast cancer. Ann Int Med 1989; 111:389 75. Bassett LW, Kimme-Smith C: Breast sonography: technique, equipment, and normal anatomy. Semin Ultrasound CT MR 1989; 10:82 76. Adler DD: Ultrasound of benign breast conditions. Semin Ultrasound CT MR 1989; 10: 106 77. Feig SA: The role of ultrasound in a breast imaging center. Semin Ultrasound CT MR 1989; 10:90
Adolescent and Pediatric Gynecology © 1994 Springer-Verlag New York Inc.
Mini Review Review of Breast Masses in Adolescents L.S. Neinstein, M.D. Division of Adolescent Medicine, Childrens Hospital of Los Angeles, Los Angeles, California; and Departments of Pediatrics & Medicine, University of Southern California School of Medicine, Los Angeles, California
Abstract. Breast lesions in adolescent females are a relatively common concern. Studies involving adolescent breast lesions diagnosed since 1960 were reviewed, a total of 1,797 cases were retrospectively analyzed. The most common lesions found were fibroadenomas (68.3%) and fibrocystic changes (18.5%). Malignant lesions were uncommon (0.89%). The two most common malignant tumors were adenocarcinoma and metastatic rhabdomyosarcoma. The diagnosis and management of breast lesions in adolescents is reviewed. In general, conservative management is the rule as breast cancer in adolescents is very rare. Mammography is not helpful in the adolescent. Ultrasound and aspiration may be useful in identification of cysts. Excisional biopsy should be performed for a persistent or enlarging solid mass.
Key Words. Breast lesions-Breast massesBenign breast disease-Breast carcinoma
Introduction Although breast cancer is extremely uncommon during childhood and adolescence, breast lesions in adolescent females are a relatively common concern. These concerns are often exaggerated by the significance placed on breasts in American culture and the common occurrence of breast cancer in adult women. This article will review the medical literature regarding the prevalences of breast lesions in adolescents as well discuss the diagnosis
Address reprint requests to: Lawrence S. Neinstein, M.D., Childrens Hospital of Los Angeles, 4650 Sunset Boulevard, P.O. Box 54700, Los Angeles, CA 90054-0700, USA.
and management of breast conditions in adolescents. Prevalence of Breast Lesions in the Adolescent The types and relative frequency of breast lesions in adolescents were evaluated by a review of prior studies, including cases of breast lesions in adolescent females under the age of 22. These were obtained from a Medline search of English language articles involving cases reviewed since 1960. Studies in which adolescents were evaluated by a breast biopsy were included. Studies that were of predominantly adult populations but included one or two adolescents were excluded. Fifteen retrospective studies were available that examined breast lesions in this age group. No prospective studies were available. The studies ranged from 5 patients to 429, with a median of 95 teens (Table O. The most common lesion found from these retrospective surgical series was a fibroadenoma, comprising 68.3% of the lesions. Fibrocystic changes were responsible for the majority of the remaining lesions (18.5%). Malignant lesions were uncommon, with only 16 malignant tumors reported for a 0.9% prevalence rate. The two most common malignant tumors were adenocarcinoma and metastatic rhabdomyosarcoma. As expected from cases obtained from retrospective surgical studies, most breast masses found in adolescents were fibroadenomas. Unfortunately, there were no cross-sectional or prospective studies that address the incidence of breast problems found in adolescents in the general population. We have recently been conducting a prospective study of adolescents to determine the incidence and the course of such lesions. One of the difficulties in evaluating and understanding breast lesions in the postpubertal female is
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Table 1. Breast Lesions in Surgical Studies in Female Patients Under 22 Years of Age Reference number Method (retro-retrospective) Number of patients Age limits
19 retro 30 <21
Type of Lesion Fibrocystic changes/mastodynia Cyst Fibroadenoma Giant fibroadenoma Cystosarcoma phyllodes Juvenile hypertrophy Intraductal papillomatosis Other benign tumor Abscess/mastitis Other breast lesion Normal breasts Cancer Adenocarcinomallobular or ductal Rhabdomyosarcoma Lymphosarcoma Angiosarcoma Lymphoma Metastatic cancer Synovial sarcoma-knee Metastatic rhabdomyosarcoma Total patients
30
Reference number Method (retro-retrospective) Number of patients Age limits
53 retro 5 1016
Type of Lesion Fibrocystic changes/mastodynia Cyst Fibroadenoma Giant fibroadenoma Cystosarcoma phyllodes Juvenile hypertrophy Intraductal papillomatosis Other benign tumor Abscess/mastitis Other breast lesion Normal breasts Cancer Adenocarcinomallobular or ductal Rhabdomyosarcoma Lymphosarcoma Angiosarcoma Lymphoma Metastatic cancer Synovial sarcoma-knee Metastatic rhabdomyosarcoma Total patients
20 retro 95 1221
18 retro 34 12 18
22 retro
32 retro 40 1222
51 retro 118 1020
2 1
9
11
118
84
40
25 8 169 12
III
I
90
29
24 retro 237 10 20
<16
9 18
23 retro 63 10 20
I
19
52 retro 151 <21 7 119
2 4 I
5
I I
2 2
13 1 5 3
9 6 2
3 1
34 56 retro 429 <21 76
5
111
95
338
57 retro 59 820 4 2 41 6
63 58 retro 145 <21
3
2
2 237
40
59 retro 95 1221
26 104
9 71
2
2
118
151
66 retro 185
Total
%
44
332 21 1,227 19 7 34 22 22 67 26 4 16 5
100 24
2 2 10
1 2 1 2
4 2 4 2
2 II
2 2 9 4
5
429
the multitude of different terms and classifications utilized for benign breast lesions. Love l suggests classifying benign breast lesions into six categories which will be used for this review (Table 2). These conditions, as well as malignant breast diseases in adolescents, will be discussed in the remainder of this article.
59
145
5 20
2 2 5
95
1 185
1,797
1 2 2 1 3 1,797
18.5 1.2 68.3 1.1 0.4 1.9 1.2 1.2 3.7 1.4 0.2 0.9 31.3 6.3 6.3 6.3 12.5 12.5 6.3 18.8
Benign Breast Disease Physiologic Swelling and Tenderness
The breasts of most women of reproductive age have a nodular texture representing the glandular units or lobules of the breast. These units undergo proliferative changes under hormonal stimulation
Neinstein: Breast Masses in Adolescents Table 2. Classification of Benign Breast Lesions Physiologic swelling and tenderness Mastalgia (severe pain, either cyclic or noncyclic) Nodularity (significant lumpiness, both cyclic and noncyclic Dominant lumps (including gross cysts and fibroadenomas) Nipple discharge (including intraductal papilloma and duct ectasia) Infections and inflammations (including subareolar abscess, lactational mastitis, duct ectasia and breast abscess) Adapted from : Love SM: Fibrocystic disease: What's in a name . Patient Care 1990; 24:65-82
during each menstrual cycle. As the lobules enlarge, particularly toward the onset of the menstrual period, the nodular texture of the breast coarsens . There is also an increase in total breast mass due to proliferation and edema. This process can vary from a feeling of fullness in the breast to distinct masses suggestive of a pathologic process. As many as 50% of breast complaints in adolescent females are a result of these physiologic changes. If treatment is needed, analgesics and/or the use of a wellfitting brassiere worn both day and night can be tried. Mastalgia
Mastalgia or severe breast pain is either cyclic or noncyclic and is another relatively common and occasionally distressing breast symptom? No histologic basis has been defined for these symptoms. The pain may coexist with nodularity . Mastalgia may be divided into cyclical , noncyclical, and chest wall pain. The incidence of mastalgia in adolescents is unknown. However, the prevalence in adult females has been reported to be has high as 66%, 45% with mild symptoms and 21% with severe symptoms. 2 Many females fail to obtain medical consultation for mastalgia because of their perception of the lack of concern among medical professionals. With noncyclic mastalgia the affected female can often point to a spot that hurts all the time. Noncyclical mastalgia is commonly bilateral in the upper outer quadrant of the breast. Chest wall mastalgia can include referred pain from costochondritis or cervical radiculopathy. 3 The pain is unilateral in 92% of individuals and usually located on the lateral chest wall or costolchondral junctions with no associated breast nodularity. Many modalities have been used to treat mastalgia including heat, firm support, analgesics, hormonal therapy, evening primrose oil, diuretics, and in adults, danazol, bromocriptine, and tamoxifen. 1,4,5 These latter drugs are not recommended for adolescents. Most adolescents only require reassurance and analgesics , such as the nonsteroidal antiinflammatory agents,
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Diuretics , exclusion diets, and vitamins B I, B6, and E have failed to show significant benefits,2 A compound primarily used in Europe, evening primrose oil, has been shown to be ofbenefit. 2,4 Evening primrose oil is a natural product whose mode of action is thought to be related to its high content of essential fatty acids acting via prostaglandin pathways. The overall response rate is 44% on two 500 mg capsules three times a day. 2,4 The drug is usually tried for 3 months and if the response is good , continued for 2 more months before withdrawal. Nodularity
Most nodularity in adolescents and young adults is associated with proliferative breast changes or fibrocystic changes. Some authorities consider this condition a nondisease. 6 Scanlon defines fibrocystic changes as "a condition in which there are palpable lumps in the breast, usually associated with pain and tenderness, that fluctuate with the menstrual cycles and that become progressively worse until menopause. ,,6 If examined carefully, probably over 50% of women in the reproductive age group have some degree of fibrocystic changes. 7 At autopsy, 58-90% of women of virtually all ages have histologic changes associated with the name "fibrocystic disease." 1,6 The exact prevalence in adolescents is not known. In this current review of retrospective surgical studies, the prevalence was 18.5%, although this cannot be extrapolated to the general adolescent population. Fibrocystic changes are a progressive benign process that usually correlates with the patient's age. Adolescents and women in their 20s have minimally symptomatic fibrotic tissue changes, particularly in the upper outer quadrants of the breasts. Changes in women in their 30s and 40s usually include multiple small cysts , with a diffuse increase in glandular tissue and increasing complaints of pain. Single large cysts are more common in women 35 years of age or older. 8 These progressive changes are illustrated in Figure 1. In general, the nonproliferative lesions found in adolescents are not associated with cancer. Though the exact etiology of breast nodularity or fibrocystic changes is unknown, an imbalance between estrogen and progesterone is one possible factor. 9 Estrogen causes proliferation of breast tissue including ductal alveolar epithelium and stroma; progesterone counteracts these proliferative effects and brings about epithelial differentiation and reduction of mitoses.9 In women with fibrocystic changes, estrogen levels are normal or increased, whereas progesterone levels during the luteal phase are decreased. With relatively higher estradiol to progesterone levels, connective and ep-
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mild analgesics. Oral contraceptives help in up to 70-90% of individuals9 •13 •14 and medroxyprogesterone 10 mg on days 15-25 of the menstrual cycle has had success in up to 85% of women. 13 A decrease in caffeine intake is advocated by some I5 ,16, however, because of its questionable effects I7 •18 , heavy restriction of diet should not be encouraged. Vitamin therapy , including Bl , A, and E, has been used but a beneficial effect has not been proven. 19,20 Danazol has been used in adult women for severe fibrocystic breast changes, but there is little experience with its use in adolescent females.
Fig. 1. Pathomorphology of fibrocystic changes. (A) Ductal-lobular proliferation; (B) duct dilation and elongation; (C) terminal ductal cyst formation (From Vorherr H: Fibrocystic breast disease: pathophysiology, pathomorphology, clinical picture , and management. Am J Obstet Gynecol 1986; 154: 161.)
ithelial tissue proliferation occurs. Women with fibrocystic changes also have obstruction and persistent secretory material in alveoli and terminal ducts causing alveolar enlargement and cyst formation . Methylxanthines have also been implicated in fibrocystic changes. Vorherr9 has reviewed studies on methylxanthines and their relationship to fibrocystic changes. Prior studies have been contradictory, but in Vorherr's experience with 400 patients, there was no influence on fibrocystic changes by avoidance of coffee, tea, cola drinks, and chocolate. 9 In addition, several other case-control studies and randomized trials have failed to demonstrate an effect of methylxanthines on fibrocystic changes or mastalgia. 10--12 Fibrocystic changes are usually found either as painless lumps on examination or because of pain or discomfort. Symptoms are most common about 1 week prior to menstruation and are often relieved by menstruation. The pain is often associated with breast swelling that is frequently bilateral, involving the outer upper quadrants. Many modalities have been suggested for treating fibrocystic changes. 9 In most adolescents, the symptoms are not severe enough to warrant aggressive measures. Supportive measures such as a wellpadded brassiere can always be used in addition to
Breast Lumps or Masses These include gross cysts and fibroadenomas; fibroadenomas in adolescents have been reviewed extensively.4,2o,21 ,23-30 In surgical reports 28 they are the most common breast tumor found in adolescents and the most prevalent in women under the age of 25. Of the 1,797 cases in this review, 68.3% were fibroadenomas. There is no evidence of progression to cancer and there is evidence that some may undergo regression. 24 ,31 Fibroadenomas are frequently discovered by the adolescent , often while bathing. Associated symptoms, other than the presence of a breast mass, are unusualY However, some adolescents will complain of breast discomfort during menstruation or pregnancy. 23 The average duration of symptoms is about 5 months. 21 Most adolescents with this condition are over 14, with a large increase in prevalence in 15- and 16-year01ds. 25 The condition has been reported to be twice as common in blacks. 29 On examination, the mass is usually a rubbery, firm , mobile, well-demarcated, nontender lesion, usually distinguishable from surrounding breast tissue. 22 Most commonly, there is only one fibroadenoma, with the largest prevalence in the upper outer quadrant of the breast. Sixty-three percent are in the lateral quadrants. Fibroadenomas are multiple in 10-25% of cases and bilateral in about 10%.31 The tumor ranges in size from less than 1 cm to over 10 cm with an average size of 2-3 cm. 25 On gross appearance , a fibroadenoma appears to be a grayish white, encapsulated, firm, nodular mass. Microscopically, the tumor has stromal proliferation surrounding aggregates of compressed or uncompressed, elongated, and distorted ducts. 25 Some of these tumors, labeled juvenile or giant fibroadenomas, have much more rapid growth with a greater degree of stromal cellularity and the potential to grow to a large size. 31 ,32 Treatment for fibroadenomas may involve either careful follow-up, especially if diagnosis has been confirmed by fine-needle aspiration cytology or elective surgical excision. Many of these operations
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can be performed under local anesthesia and sedation on an outpatient basis, sparing teens the risk of general anesthesia. 33 However, general anesthesia is recommended in adolescents with undue anxiety, with large pendulous breasts, or with deep lesions. In most young women with a solid breast mass, excisional biopsy should be performed through a circumareolar or curvilinear incision. 33 Large cysts are another cause of benign breast masses. Cysts over 1 cm usually occur in women in their 40S. 8 ,9 Cysts are associated with few symptoms, and on examination feel like a well-circumscribed, small, freely movable mass. These can usually be diagnosed and treated by fine-needle aspiration. Giant fibroadenomas, phyllodes tumors, and juvenile hypertrophy may cause large breast tumors in adolescents, particularly at puberty.34 Giant Fibroadenoma. This condition is uncommon, found in 19 of 1,797 (1.1 %) adolescents in this current review. The lesion is most commonly found in young adolescents, with a greater prevalence in black teens. 35 The mass has a rapid and asymmetric growth pattern with the tumor growing to huge proportions, usually greater than 5 cm in diameter. Because of its size, the tumor may cause compression of adjacent breast tissue. The area may feel warmer due to the increased blood supply ofthe tumor. The tumor may be slightly firm, freely movable, round, or oval with a smooth surface and associated with dilated superficial veins and thinning of the overlying skin. 26 Though encapsulated, the tumor may have a consistency similar to normal breast tissue which may make it difficult to differentiate from normal tissue or unilateral virginal hypertrophy. Microscopically, the tumor is similar to a fibroadenoma but with increased stromal cellularity and more hyperplasia of the epithelial components. The condition is benign but can cause massive distortion in the breast. Treatment of giant fibroadenomas is simple excision, sparing as much mammary tissue as possible. 35 These lesions usually separate easily from normal breast tissue. A simple mastectomy for this lesion is not warranted. Phyllodes tumors. Phyllodes tumors (cystosarcoma phyllodes) were the least prevalent cause of massive breast masses in adolescents, occurring in 0.4% of cases (7/1,797). The lesion is almost always benign, but malignant lesions have been reported in adolescents. 36 The tumor usually presents as a bulky mass in the breast. The lesions tend to be large, up to 20 cm, and sharply circumscribed. 22 The mass is firm, mobile, smooth, or irregular. Overlaying skin may be stretched and shiny, with
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distended veins from the rapid growth of the tumor. Compared with juvenile giant fibroadenoma, this lesion is more firm and more discrete. 37 It may be associated with skin retraction, necrosis, nipple retraction, and breast discharge. Briggs et al. 28 reviewed phyllodes tumors in adolescent females. In all of these nine adolescents, the chief complaint was of a recent onset of a rapidly growing nontender breast mass of 3 months duration. In his review, none ofthe adolescents had skin dimpling or nipple retraction. The tumors averaged 6 cm in diameter with a range of 2-13 cm. Gross exam shows a firm, smooth, often irregular or lobulated mass which is usually well circumscribed. Microscopically, benign phyllodes tumors are similar to fibroadenomas, with both epithelial and connective tissue elements, but with a more cellular hyperplastic stroma. 38 Phyllodes tumors lack complete encapsulation and extend into surrounding tissue in multiple projections of varying size. The differentiation between a giant fibroadenoma and a phyllodes tumor can only be made by a pathologist after biopsy. Classification of benign or malignant is based on stromal findings, particularly cellular atypia, anaplasia, and degree of mitotic activity. Though recommendations for treatment range from simple excision to radical mastectomy, little evidence exists to support routine use of mastectomy as initial therapy. 39 Most adolescents and adults are cured by excision alone. The lesion should be excised completely with a surrounding rim of normal breast tissue. There is no need for a mastectomy unless the tumor is found to be malignant. There is also no reason for adjuvant chemotherapy or radiation in the absence of metastatic disease. Virginal Breast Hypertrophy Virginal or juvenile hypertrophy implies diffuse enlargement of the breast that is usually symmetrical, occurring near the time of menarche. It was found in 34/1,797 (0.6%) cases. In this condition, the breasts are usually symmetrically enlarged although unilateral cases have rarely been reported. The breasts are usually pendulous (they can get as large as 30-50 pounds)32 and diffusely firm to palpation without any discrete mass lesions. The tissue may be soft but sometimes has diffuse ropelike thickenings. 22 The enlargement can be so severe as to lead to neck and back strain and difficulty with physical activity.40 The condition can also lead to significant psychologic problems and embarrassment. However, in contrast to the giant fibroadenoma, there is less thinning of the skin, less prevalence of enlarged veins, and less displacement of the nipple or areola.
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The etiology of pubertal hypertrophy is not well understood but may represent an abnormal response of the breast to normal serum estrogen levels. Hormonal studies are normal in these individuals. 40 Though this problem typically occurs at puberty, it has also been reported at pregnancy (gravid hypertrophy),32 and with the administration of exogenous estrogen, androgens, corticosteroids, and insulin. The process has also been reported to be worsened by oral contraceptives. 40 The histology of the breast in this condition is an exaggeration of the normally developing adolescent breast. There is stromal hypertrophy, a tremendous increase in periductal fibrous tissue, and proliferation and increased branching of the ducts without lobule formation. The breasts may appear histologically similar to fibroadenoma. 22 No definite guidelines have been developed as to when to peIform surgery and what procedure is best. Though it is preferable to delay surgery until the breasts have matured, this may not be practical in some adolescents, if breast size and/or weight is unbearable. Four modalities of treatment have been recommended,35 the most common of which is reduction mammoplasty. However, many adolescents may continue to have breast enlargement after this procedure. A second approach involves a subcutaneous mastectomy with implantation of a prosthesis; this may be the surgical procedure of choice in individuals with massive recurrent enlargement. A third approach has been hormonal manipulation with either medroxyprogesterone, dydrogesterone, or danocrine. 35 Dydrogesterone may suppress the secretion of growth hormone and also could interfere with development of secondary sexual characteristics. Teratogenic and carcinogenic effects have also been a concern with these medications. Lastly, a combination of medications and surgery has been used, such as the postoperative use of the dydrogesterone to prevent recurrences:5 Nipple Discharge, Intraductal Papilloma, and Duct Ectasia A nipple discharge is not a single disease entity but is a possible sign of several different problems. A bloody discharge may raise fears in the physician and the teen about cancer, but most nipple discharges, even bloody ones in adolescents, do not represent cancer. Nipple discharges in the teen can represent galactorrhea, Montgomery's tubercles, intraductal papillomatosis, or duct ectasia. The color and type of nipple discharge may help differentiate the condition (Table 3).41 A milky discharge generally represents galactorrhea. A sticky discharge of varying colors is typical of duct ectasia. A purulent discharge suggests an infection, and
Table 3. Nipple Discharge Type Milky Multicolored/Sticky Purulent Watery Serous/Serosanguineous
Differential (in order of frequency) Galactorrhea Duct ectasia Mastitis Papilloma Cancer Intraductal papilloma Fibrocystic changes Cancer Duct ectasia
a watery nipple discharge can represent a papilloma or cancer. A serous or serosanguineous discharge is most likely found with an intraductal papilloma followed in frequency by fibrocystic changes, cancer, and duct ectasia. 41 Galactorrhea may be found in teens who are pregnant or following an abortion or miscarriage. It may also be found in teens with pituitary adenomas or hypothyroidism. Numerous drugs can also cause galactorrhea including oral contraceptives, phenothiazines, reserpine, spironolactone, estrogens, and methyltestosterone. The reader is referred to Kletzky and Davajan42 for a review of galactorrhea and hyperprolactinemia. Montgomery's tubercles or Morganis tubercles can also cause a nipple discharge. 43 These lesions are small, soft papules distributed around the areola which enlarge with pregnancy and are involved with lactation. Investigators have suggested that Montgomery's tubercles are formed from sebaceous glands and associated with a lactiferous duct from an underlying mammary lobule. Examination may show either no lump or a small lump under the areola associated with episodic, thin, clear to brown discharge. The discharge usually resolves within 3-5 weeks and the lumps within 4 months. An intraductal papilloma arises from an abnormal proliferation of cells in mammary ducts. 44 The lesion is usually small and most frequently microscopic, consisting of simple proliferations of duct epithelium projecting into a dilated lumen. Because the proliferated epithelium is supported by a vascular stalk, slight local trauma may rupture this stalk leading to a bloody discharge. 41 This local proliferation of cells may grow large enough so that a mass may be palpable. An intraductal papilloma is a relatively infrequent finding in the adolescent. The lesion is most frequent in women in their 20s through 40S.32 In my current review of breast lesions in adolescents, 1.2% of lesion biopsies were secondary to an intraductal papilloma. The typical description of a female with this con-
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dition involves complaints of a bloody nipple discharge. However, in the largest series of teens with intraductal papillomatosis, only 3/13 noted an abnormal spontaneous bloody nipple discharge, and only 9/13 noted an abnormal thickening or enlargement of the breast. 27 On exam, most of the teens had well-defined nodules or thickenings near the areola. The lesion may be difficult to palpate. Oberman noted that in adolescents these lesions are often multiple, and occupy ducts in the periphery of the breast, with a less frequent occurrence of the lesion near the areola. 29 These lesions are uniformly benign and amenable to local excision. Certainly, if associated with a bloody discharge, these lesions should be removed to rule out a malignancy. However, a bloody discharge associated with a soft mass has a 95% chance of being an intraductal pap illoma. 45 Infections and Inflammation
A breast abscess or cellulitis can occur secondary to bacteria introduced from the skin into the ductal system, or from cutaneous infections, foreign bodies, epidermal cysts, and trauma, such as shaving periareolar hair or trauma related to sexual play.46 Breast abscesses are not common in adolescents, with the majority being related to lactation. In adolescent studies of breast lesions, 3.7% of lesions were related to an inflammatory etiology. A similar prevalence, 3.9%, was found by Diehl and Kaplan 31 in a retrospective chart review not relying on surgical specimens. A breast abscess is similar to an abscess elsewhere on the body leading to the sudden onset of a tender or fluctuant mass with skin erythema. Staphylococcus aureus is the most common organism followed by Escherichia coli and pseudomonas. 22 ,31,46,47 Other organisms include group B beta streptococcus and anaerobes. Preceding factors may include trauma, ductal obstruction, or a preexisting cyst. 19 Treatment involves the use of warm compresses and antibiotics. Mastitis is a common occurrence in breast feeding females. 7 It is a result of abrasions on the nipple leading to infection and clogging of lactiferous ducts and consequent stasis of milk. Resulting signs and symptoms include pain, tenderness, induration, and fever. The abscess may be subcutaneous, subareolar, intramammary, or retromammary. The most common bacteria involved is Staphylococcus aureus. However, other organisms include streptococcus, Micrococcus dyogenes, Escherichia coli, Pseudomonas sp and others. 48 An infection is likely with a leukocyte count from breast milk of over 106/ml plus more than 103 bacteria/ml on culture. 49 Culture and sensitivity of breast milk of the affected
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breast is helpful in identifying the organism and choosing an appropriate antibiotic. Heat and antibiotics are utilized in the treatment. Nursing or breast pumping can be continued using the unaffected breast. Nursing on the affected side can be quite painful. Another inflammatory condition affecting the breast is duct ectasia (periductal mastitis, plasma cell mastitis, comedomastitis).50 This is a poorly understood, benign condition which affects the major breast ducts. Some evidence suggests that the condition starts with dilatation of the ducts with secondary inflammation resulting after leakage of ducts contents through the walls of damaged dilated ducts. 50 More recent evidence suggests that the inflammation may occur first leading to cellular wall damage and ductal dilatation. 50 This condition usually affects females outside the adolescent age group with a mean age of presentation of 36. Younger patients with duct ectasia tend to have more signs of inflammation whereas older women have more signs of dilated ducts and nontender masses. The most common manifestations include noncyclical breast pain, nipple discharge, nipple retraction, a subareolar breast lump, a periareolar abscess, and a mammillary fistula. Nipple discharge occurs in about 15-20% of women with this condition. The discharge can be many colors including straw, cream, green, brown, and rarely blood stained. Cancer of the Breast
During the past 70 years there have only been sporadic reports of breast cancer in females under the age of 20. 51 - 53 Less than 1% of all breast tumors in adolescents are cancerous, and 98% of breast cancer occurs in women older than 25 years. 21- 27 ,35,54-62 In surgical breast masses in females under 22,0.9% of lesions were cancerous. Of these, 31% were primary tumors of breast tissue and the rest were either a tumor of nonbreast tissue or some form of metastatic cancer. In tabulation of English mortality data including over 70,000 deaths from breast cancer, there was one case of a child under the age of 5, one between 10 and 14, five between 15 and 19, and 27 between 20 and 24.63 Schydlower46 found that 90% of children and adolescents with breast cancer present with a breast mass. The mass is usually hard and is most commonly subareolar and frequently fixed to the deep tissues. Symptoms are uncommon, with axillary lymphadenopathy present in only a few cases. 22 Up to 30% of affected teens have a family history of breast cancer and the tumor tends to occur earlier in
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the daughter than in the mother. The size varies from 1 to 2.5 cm in diameter,64 with the right and left breast equally affected. 22 Among teenagers, survival is similar to adults whereas the prognosis of carcinoma of the breast in prepubertal children seems better than in adults. 22 Primary sarcomas of the breast are even rarer than carcinomas-fibrosarcoma and liposarcoma are the most common types. The adolescent breast may also be affected by systemic malignancies including lymphoma, Hodgkin's disease, leukemia, and multiple myeloma. Rarely a sarcoma of the breast may develop following radiation for another tumor. 65 Diagnosis The evaluation of the adolescent with a breast complaint includes a family history of breast tumors (both benign and malignant), a history of trauma to the breast, menstrual and reproductive histories, and a review of the use of contraceptives and other hormones. 13 The most significant risk factor is a history of breast cancer in several members of the teen's mother's family. Breast cancer in two or more of the following adds significantly to the risk profile: the teen's mother, maternal aunts, and the maternal grandmother, sister, and daughter. A complete breast examination consisting of inspection of both breasts to observe for asymmetry or skin retraction is important. 8,13,44,66,67 Traditionally, this has been performed as described by Haagensen, with the individual seated and in three different positions: leaning forward, extending her arms over her head, and pressing her hands against her hips.68 However, these three positions are seldom helpful in the screening examination unless a mass is palpated. 68 For this reason and the potential discomfort for the adolescent, the author would recommend skipping this maneuver for the screening examination. The examiner should next palpate the breast for a mass or discharge; palpation is performed in the supine position. First, the teen's arm, on the side to be examined, should be placed behind her head. The examiner can also place a pillow or folded sheet under the posterior ribs. The breast should be palpated in an orderly fashion in one of several ways. In the first method, the examiner uses a pattern similar to the spokes of a wheel. Starting with the tail ofthe breast in the axilla, the examiner moves in a straight line to the nipple. Using straight lines from the outer boundary of the breast to the nipple, the examiner can work around the whole breast. A second method involves covering the breast in either concentric circles or a spiral pattern around the breast. A third method, the vertical strip method,
has been demonstrated to be the most effective method for breast self-examination. 69 Whichever method is used, the entire anterior chest wall should be palpated applying varying degrees of pressure with the pads of the second, third, and fourth fingers rotating in small, dime-sized circles. Some examiners find the use of talc helpful in palpating the breast. Masses larger than 1 cm may be best felt by compressing them between the thumb and index finger. The examiner should also palpate for supraclavicular, infraclavicular, and axillary nodes. The palpation of a firm, rubbery, and mobile mass with a smooth or slightly irregular surface is suggestive of a fibroadenoma. Rapidly enlarging tumors of the breast are usually either a juvenile fibroadenoma or phyllodes tumors. Particular attention should be given to the nipple and areolar areas, as 15% of breast cancers are located here. The areolae should be compressed to elicit nipple discharge. 22 Throughout the examination, it is helpful to explain to the teen what is being done, utilizing the examination time to discuss self-examination skills. Explain to the teen that she may be the best individual to notice if something has changed with her breasts. Combining this educational maneuver with the physical examination can be a useful method in alleviating fear and tension during the breast examination?7 In addition, reassure the teen that the breast has many lumps and bumps that may change, particularly with menstrual cycles. Though it is not as evident from chart reviews that malignancies are found on self-exam in adolescents 70, Hein et al. 62 found that 81 % of a group of 95 teens with breast masses found the lesions by self-detection. One significant dilemma in adolescents is the management of breast masses. If a mass were easy to diagnose by palpation, then a biopsy would not be needed, but palpation cannot exclude a malignant tumor. However, conservative management of breast masses in teens is advocated by the author and others 31 ,34,40,60 because of the rarity of malignant breast tumors: < 1% of all cancers of childhood and <0.5% of all breast cancer cases. 27 ,37,64 It is recommended that a breast mass in an adolescent be observed through at least one complete menstrual cycle. 71 Furnival et al. 72 report that 77% of women have some resolution of fibrocystic changes. Many authorities recommend an excisional biopsy if a mass is persistent over 3-6 months or continues to increase in size. Other authorities would argue for at least a fine-needle aspiration with cytologic studies in these individuals, although the role of fine-needle aspiration has not been evaluated in the adolescent population. However, this procedure may be a good diagnostic test for breast masses in adolescents as the surgical risks and scars
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of excisional biopsies are avoided. An excisional biopsy is also recommended for a hard mass, or if there is a fixed mass, skin dimpling, edema, ulceration or fixation to chest wall, patient or paternal anxiety about the mass, or a strong positive family history.22.25 Multiple or recurrent lesions that are stable in size should not be excised. If feasible, cysts can be aspirated and the fluid, if bloody, sent for cytological examination. 22,60 Other diagnostic modalities include mammography and ultrasound. Mammography is not generally helpful in the adolescent because breast tissue is very dense,39,73,74 and the prevalence rate of malignancy is low. In women less than 30 years, there is poor correlation between mammographic diagnosis and tissue diagnosis 33 as masses may be hidden in dense breast parenchyma. Mammography is more reliable in older patients as breast tissue begins to atrophy. Another diagnostic technique is the ultrasound of the breast. 75- 77 Simple cysts, particularly in adolescents, are generally considered benign. An ultrasound is helpful in differentiating a solid mass from a cystic mass, however, it cannot differentiate between a benign and malignant solid mass. An ultrasound can also help in guiding a needle into an abscess or cyst. In women aged 30 or less, the ultrasound can be helpful as a primary imaging examination to evaluate a breast mass. If a cyst is found, an aspiration can be done without need for further studies. There is no evidence to suggest a role for ultrasound as a sole imaging technique for breast cancer screening. In some centers, a fine-needle aspiration is done as the primary technique without a primary ultrasound. This can be done by the primary care physician, if trained in this technique, or by a surgeon. If nonbloody fluid is found, it is considered benign and not sent for cytology. The teen should be checked for a reoccurrence in 4-6 weeks. If a solid mass is encountered, then an aspiration is performed with a cytologic smear made up for evaluation. In summary, most adolescent breast masses are benign. Fibroadenomas are the most common solid mass. Conservative management is the rule. The teen and her family should be reassured that breast cancer in adolescents is very rare. Mammography is not helpful in the adolescent. Ultrasound and aspiration may be useful in identification of cysts. Excisional biopsy should be performed for a persistent or enlarging solid mass. References 1. Love SM: Fibrocystic disease: What's in a name.
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2. Maddox PR, Mansel RE: Management of breast pain and nodularity. World J Surg 1989; 13:699 3. Watkins F, Giacomantonio M, Salisbury S: Nipple discharge and breast lump related to Montgomery's tubercles in adolescent females. J Pediatr Surg 1988; 23:718 4. Pye JK, Mansel RE, Hughes, LE: Clinical experience of drug treatments for mastalgia. Lancet 1985; 2:373 5. Corriveau S, Jacobs JS: Macromastia in adolescence. Clin Plast Surg 1990; 17:151 6. Love SM, Gelman RS, Silen W: Fibrocystic disease of the breast - a nondisease? N Engl J Med 1982; 307: 1010 7. Teimourian B, Hakki AR: Benign disease of the female breast. Hosp Med 1987; 23:85 8. Scott EB: Fibrocystic breast disease. Am Fam Physician 1986; 36: 119 9. Vorherr H: Fibrocystic breast disease: pathophysiology, pathomorphology, clinical picture, and management. Am J Obstet Gynecol 1986; 154:161 10. Lubin F, Ron E, Wax Y, et al: A case-control study of caffeine and methylxanthines in benign breast disease. JAMA 1985; 253:2388 11. Ernster VL, Mason L, Goodson WH 3d, et al. Effects of caffeine-free diet on benign breast disease: a randomized trial. Surgery 1982; 91 :263 12. Heyden S, Fopdor JG: Coffee consumption and fibrocystic breasts: an unlikely association. Can J Surg 1986; 29:208 13. Cox EB: Benign breast lesions and breast cancer: Is there a relation? Female Patient 1986; 11:52 14. London RS, Sundaram GS, Goldstein PJ: Medical management of mammary dysplasia. Obstet Gynecol 1982;59:519 15. Dodd GD, Goodson III WH, Marchant DJ: Fibrocystic breast: long-term care. Patient Care 1987; 21:41 16. Minton JP, Abou-Issa H, Reiches N, Roseman JM: Clinical and biochemical studies on methlxanthinerelated fibrocystic breast disease. Surgery 1981; 90: 299 17. Ernster VL, Mason L, Goodson WH: Effects ofcaffeine-free diet on benign breast disease: a randomized trial. Surgery 1982; 91:263 18. Lubin F, Ron E, Wax Y, et al: A case-control study of caffeine and methyxanthines in benign breast disease. JAMA 1985; 253:2388 19. London RS, Sundaram GS, Murphy L, et al: The effect of vitamin E on mammary dysplasia: a doubleblind study. Obstet Gynecol 1985; 65:104 20. Ernster VL, Goodson WH, Hunt TK, et al: Vitamin E and benign breast "disease": a double-blind, randomized, clinical trial. Surgery 1985; 4:490 21. Turbery WJ, Buntain WL, Dudgeon DL: The surgical management of pediatric breast masses. Pediatrics 1975; 56:736 22. Seashore JH: Breast enlargements in infants and children. Pediatr Ann 1975; 4:542 23. Daniel WA Jr, Mathews MD: Tumors ofthe breast in adolescent females. Pediatrics 1968; 41:743
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74. Eddy DM: Screening for breast cancer. Ann Int Med 1989; 111:389 75. Bassett LW, Kimme-Smith C: Breast sonography: technique, equipment, and normal anatomy. Semin Ultrasound CT MR 1989; 10:82 76. Adler DD: Ultrasound of benign breast conditions. Semin Ultrasound CT MR 1989; 10: 106 77. Feig SA: The role of ultrasound in a breast imaging center. Semin Ultrasound CT MR 1989; 10:90