CASE REPORT

Prakash Agarwal Æ Anthony L. Sparnon

Benign breast lesions in adolescent girls: an overview witha case report

Accepted: 17 March 2004 / Published online: 2 March 2005� Springer-Verlag 2005

Abstract A wide spectrum of breast disorders occurs inthe paediatric and adolescent age groups, but malignantdisease is very rare. The relative frequencies of theseconditions and their natural history differ substantiallyfrom those of adult patients. The gross findings may bevery deceptive and mislead the clinician until a histo-pathological diagnosis is made. We report a case in anadolescent girl that was initially diagnosed and treatedas fibroadenoma until a histological assessment provedit to be a phyllodes tumour with malignant potential.

Keyword Cystosarcoma phyllodes Æ Breast lesion ÆFibroadenoma Æ Adolescent

Introduction

Breast masses are not uncommon in adolescents and arerarely malignant. Single or multiple fibroadenoma ac-count for most breast masses, followed by fibrocysticdisease, gynaecomastia, and macromastia [1].

Malignancy is a rare cause of breast mass in adoles-cents and is more likely to be secondary or metastaticthan primary [2]. Phyllodes tumour is an unusual stro-mal tumour. These tumours generally occur around the4th and 5th decades of life and are uncommon in chil-dren. Although phyllodes tumours are indolent andbenign, approximately 25% will recur locally if treatedincompletely, and approximately 10% can be expectedto metastasise [1].

Breast lumps in adolescent girls are usually diagnosedas fibroadenoma until proved otherwise. We present ourexperience with an uncommon case and a review of theliterature.

Case report

A 9.5 year old girl presented with her mother withconcerns of early pubertal development. The motherreported that her daughter’s breast development startedat 8.5 years and was subsequently followed by thedevelopment of pubic and axillary hair. The girl had noother positive medical history apart from eczema. Therewas no significant family history of any endocrinopathyor similar features. Her menstrual history was normal.

On general examination she had normal height andweight for her age. The general examination was normalexcept for her generalised eczema. Her breast and pubichair were Tanner’s stage 3. Her bone age was slightlyadvanced compared with the chronological age, as ex-pected from clinical assessment.

On examination the breast appeared normal in size,shape, and contour. In the left breast a 3·3-cm lump wasnoted, which was smooth and ovoid and extended frombelow the nipple to the lower outer quadrant. This wasan incidental finding, and on further questioning thegirl’s mother said that it had existed since infancy buthad never been brought to medical attention.

Ultrasonography of both breasts revealed a normalright breast with a 3·3-cm mass in the left breast at thelevel of the nipple. The lesion was trilocular with mildhyperechogenicity and the appearance of a complexlump not resembling a fibroadenoma. The girl’s com-plete endocrinological profile, including follicle stimu-lating hormone, luteinising hormone, 17-OHprogesterone, adrenocorticotrophic hormone, andro-stenedione, progesterone, oestradiol, DHEAS, and cor-tisol, were within normal limits.

The lump in the left breast was excised via a circu-mareolar incision and subjected to histopathologicalexamination. The lump could be shelled out easilywithout evidence of surrounding infiltration. Sections ofthe tumour showed a fibroadenomatous appearancewith a predominantly pericanalicular pattern, but withsome areas showing an intracanalicular pattern.

P. Agarwal Æ A. L. Sparnon (&)Department of Paediatric Surgery,Women’s and Children’s Hospital, 72 King William Road,North Adelaide, South Australia, Australia, 5006E-mail: tonysparnon@ozemail.com.auFax: +61-8-81616060

Pediatr Surg Int (2005) 21: 381–382DOI 10.1007/s00383-005-1377-x

Stromal elements varied in appearance; epithelialmitoses were readily recognised, and stromal mitoseswere frequent. The histopathological features favoured aphyllodes tumour, predominantly of benign appearancewith a high mitotic rate and thus of indeterminatemalignant status.

Although the mass was considered to have probablybeen completely excised, a formal wide excision with a 1-cm margin was performed via an inframammary inci-sion. No evidence of phyllodes tumour was identified inthe additional resected tissue.

Discussion

Breast lesions in adolescent females can be quite per-plexing and have confused surgeons from time to timeregarding the appropriate investigation for a diagnosisand correct therapy.

Fibroadenoma is the most common neoplasmencountered in the adolescent female breast. Cystosar-coma phyllodes usually cannot be differentiated clini-cally from fibroadenoma because both present asdiscrete masses, although a diagnosis of cystosarcomaphyllodes may be suspected if there is a history of rapidgrowth. Differentiation depends on histological exami-nation of the excised tumour [1].

Phyllodes tumour is an uncommon tumour closelyrelated to fibroadenoma, but it has distinguishable fea-tures. Histologically it demonstrates even more hyper-trophy and greater cellularity of the fibrous tissuestroma [3, 4].

The sonographic features of phyllodes tumour areusually identical to those of fibroadenoma with a solidmass and a nonspecific appearance. Internal heteroge-necity of echogenecity, posterior acoustic enhancement,and hyperechoic clefts may be seen [5].

The management of cystosarcoma phyllodes remainscontroversial, varying from simple excision to radicalmastectomy [6]. Deciding how to treat these young pa-tients may be a more difficult problem than arriving at adiagnosis. Briggs et al. [7] reviewed 44 cases of cysto-sarcoma phyllodes in adolescent girls from varioussources. Treatment varied from local excision to

mastectomy, with recurrences reported in one of 37 be-nign and two of six malignant cystosarcoma phyllodes.The three patients with recurrent tumour were renderedfree of disease by reexcision without removal of thebreast. In a later literature review, Adachi et al. [8] de-scribed cystosarcoma phyllodes in 97 young patientsunder 20 years of age (including the cases reported byBriggs et al.) and noted a 12% local recurrence rate afterprimary excision.

Conclusion

Cystosarcoma phyllodes in young women usually has abenign course. Whenever possible, initial surgical treat-ment should be limited to excisional biopsy. Reexcisionshould be considered if the margins are found to be in-volved microscopically and the tumour has an invasivegrowth pattern. Mastectomy should be reserved forrecurrent tumours not amenable to excision and forhigh-grade malignant cystosarcoma phyllodes that can-not be adequately removed by excisional biopsy.

References

1. Selamzade M, Gidener C, Koyuncuoglu M, Mevsim A (1999)Borderline phyllodes tumour in an 11-year-old girl. Pediatr SurgInt 15:427–428

2. Dehler LP, Hill DA, Deschryver K (1999) Pathology of thebreast in children, adolescents, and young adults. Semin DiagnPathol 16:235–247

3. McCrea ES, Johnson C, Keramati B (1986) Cystosarcomaphyllodes. South Med 79:543–547

4. Seashore JH (1986) Disorders of the breast. In: Welch KJ,Randolph JG, Ravitch MM, O‘Neill JA Jr, Rowe MI (eds)Pediatric surgery. Year Book Medical Publishers, Chicago, pp559–563

5. Rumack CM, Wilson SR, William Charboneau J (1997) Diag-nostic ultrasound. In: Mendelson EB (ed) The breast, 2nd edn.Mosby Year Book, St. Louis, pp 751–789

6. Pietruszka M, Barnes L (1987) Cystosarcoma phyllodes; a clin-icopathological analysis of 42 cases. Cancer 41:1974–1983

7. Briggs RM, Walters M, Rosenthal D (1983) Cystosarcomaphyllodes in adolescent female patients. Am J Surg 146:712–714

8. Adachi Y, Matsushima T, Kido A, et al. (1993) Phyllodes tu-mour in adolescents. Report of two cases and review of litera-ture. Breast Dis 6:285–293

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