Mini-Reviews

d

Dcky,

3. To understand the fundamentals of treatment of

tential cancer.1,2 A thorough knowledge of the various

and diagnostic evaluation as indicated are needed to

skin changes, or a palpable mass. The clinical presen-

opsy or excision. A prompt evaluation and diagnostic

the primary mammary bud.

the perinatal period, where it appears as an inverted

ststy

Stages of Breast Development

phases. Estrogen stimulates the growth ofof Pediatric Surgery, 315 E. Broadway Street, Suite 565, Louis-

ville, KY 40202; E-mail: mefall01@louisville.edu

J Pediatr Adolesc Gynecol (2008) 21:311e316 Various hormones strongly influence the develop-ment of breast tissue in the prepubertal and pubertal

Address correspondence to: Mary E. Fallat, MD, University of

Louisville School of Medicine, Department of Surgery, Divisiontation and age of the patient will determine if radio-graphic studies are warranted. Many breast lesionsrequire only clinical examination and reassurance,and possibly observation. However, persistent breastcomplaints or worsening symptoms may require bi-

structure. Estrogen influences the development of the brea

buds during the last trimester until a true breanodule forms. This breast nodule is palpable b34 weeks of gestation.reassure the patient and the parents and to avoid miss-ing any rare malignant lesion.3,4

Pediatric breast disorders can occur at any age. Thechief complaints can include abnormal enlargement,asymmetric growth, nipple discharge, breast pain,breast pathologies, a complete physical examination,pediatric and adolescent breast disorders

Introduction

Although the vast majority of breast disorders in pedi-atric patients are benign, the presence of any breastcomplaint frequently raises parental concerns of a po-Breast Disorders in Children an

Mary E. Fallat, MD and Romeo C. Ignacio, Jr, MDepartment of Surgery, University of Louisville, Louisville, Kentu

Key Words. BreastFibroadenomaBreast cancerBreast neoplasmsNipple dischargeDuct hyperplasia

Objectives

1. To understand the embryology and associated dis-orders of breast development

2. To understand an approach to recognition anddiagnosis of breast disease in female childrenand adolescents 2008 North American Society for Pediatric and Adolescent GynecologyPublished by Elsevier Inc. Further growth and branching occurs from week10e16 where lactiferous ducts are seen. Theseducts continue to grow into the underlying mesen-chyme and later develop into the fibrous and adi-pose tissue of the breast.

The areola and nipple develop later in fetal devel-opment. A pigmented areola is seen at week20e24. A true nipple is not present until later inAdolescents

USA

plan are important in order to alleviate any emotionalfears and to plan any necessary surgical therapy ifwarranted. This article reviews the various congenital,infectious, benign, and malignant disorders that canoccur in female children and adolescent patients.

Embryology and Breast Development

Beginning at 4 weeks of embryologic development,a pair of thickened longitudinal streaks of ectodermare seen along the anterior abdominal wall from theaxilla to the labia majora. Breast tissue can developanywhere along these paired ectodermal ridgesknown as milk lines, milk ridges, or Hugheslines.5

The proximal and distal ectodermal ridges atrophyby the tenth week of development except in thepectoral region. The remaining ectodermal tissuegrows into the underlying mesenchyme and forms1083-3188/08/$34.00doi:10.1016/j.jpag.2007.10.007

lactiferous ducts and fibroadipose tissue. Progester-one stimulates the development of lobular tissueand alveolar budding. Excessive prolactin can alsostimulate newborn breast tissue to secrete milk.

The breast tissue in the full-term newborn begins asa discrete, palpable nodule. The nodule may persistfor the first 6e12 months and later involutes.

Puberty is noticed by the development of a pubertalbreast (thelarche) and the growth of pubic hair. Themean onset for breast development in the UnitedStates is 8.87 years in African-American girls and9.96 years in white girls.6

The Tanner stage describes the pubertal develop-ment of breasts into five stages7 (Table 1). Breast

that is often sore to the touch, followed by localizederythema. Although many areas of concern in adoles-

312 Fallat and Ignacio: Breast Disorders in Children and Adolescentscents are noticed first by the patient, self-examinationof the breast in adolescents is controversial, becausethe developing breasts are often asymmetric and pal-pably nodular due to the normal growth and develop-ment of breast tissue, and because of the extremerarity of breast malignancies in girls under 18 yearsold. It is recognized that time might be better spenteducating about the risks of drugs, alcohol, andsmoking.

Table 1. Tanner Staging of Breast Development

Stage Characteristics

1 Elevation of breast papilla only2 Elevation of the breast bud and papillae as a small mound

Enlargement of the areola diameterAreola becomes pinker

3 Further enlargement of the breast and areola with noseparation of their contours. Montgomerys tubercles appear.

4 Further enlargement with projection of the areola and papillato form a secondary mound above the level of the breast.

5 Projection of the papilla only, resulting from the recession ofthe areola to the general contour of the breastdevelopment normally is complete by 2e4 yearsafter thelarche.

Delayed breast growth is considered a lack of de-velopment by age 13.5 These patients require an ex-tensive evaluation and referral to an endocrinologistfor potential causes for delayed development suchas eating disorders, Turner syndrome, chronicillnesses such as Crohn disease, or a sexual differ-entiation disorder.

Presentation

The majority of breast masses with the exception ofinfection are first noticed because of incidental palpa-tion of a lump or thickening by either the parent orpatient.2 Infection may first be noticed as a firm areaImaging

Ultrasound is the diagnostic test of choice to evaluatea palpable mass, but it is a poor screening examina-tion.5,7 Fat is hypoechoic and glandular tissue isechogenic relative to hypoechoic fat. Ultrasound isideal for differentiating solid from cystic masses.Mammography is relatively contraindicated in adoles-cent women and less helpful due to increased fibro-glandular tissue in developing breasts leading topoor pathologic correlation.2,7 However, in cases ofpersistent nipple discharge without a palpable mass,oblique mammographic views done by an experi-enced breast radiographer may be helpful.

Disorders of Breast Development

Polythelia occurs in 2% of the population and canappear anywhere along the milk line. Polymastia oraccessory breast tissue may accompany polythelia.Surgical intervention is considered for symptoms,which may include cyclical tenderness or irritationbased on location of the tissue. Ectopic breast tissuecan be seen in the axilla, presenting as a soft tissuemass that responds to cyclical hormone stimulation.4

Nipple inversion is a normal variant and often famil-ial. It should be considered pathologic only if the con-dition was not initially present at birth but occurssubsequently, because new onset may represent infec-tion or an occult tumor.

Neonatal hypertrophy can occur in either sex, re-sults from maternal estrogen stimulation, and maybe unilateral or bilateral. It may be associated witha clear or cloudy discharge (witchs milk), and mayself-perpetuate with manipulation. Parents should beencouraged to avoid palpation of the breast areabecause the condition is self-limited.

Thelarche begins with the onset of puberty, is thefirst sign of puberty, and should occur by age 13.5

Breast asymmetry is common as the breasts are devel-oping.2,7 The age of thelarche has been decreasing inthe American population and also varies based onrace. The mean onset for breast development in theUnited States is 8.87 years in African-American girlsand 9.96 years in white girls.6 Premature thelarche isbreast development before age 7 years in white girlsand age 6 years in African-American girls. It oftenmanifests as early as age 1e3 and may be unilateralor asymmetric. This early breast development mayprogress, remain stationary, or regress. It is usuallybenign and may be familial. Puberty occurs normallyin these situations. A screening bone age may be doneto determine the need for a more extensive workup forprecocious puberty. Plasma estradiol may be elevated.

Amastia is a rare disorder and may be associatedwith other congenital anomalies of the chest wall such

313Fallat and Ignacio: Breast Disorders in Children and Adolescentsas Polands Syndrome. Small breasts with otherwisenormal pubertal development are usually normal. Iflack of breast development is associated with delayedpuberty, a workup for ovarian failure is indicated. Thecauses of ovarian failure include sexual differentiationdisorders such as gonadal dysgenesis, androgen insen-sitivity syndrome, or congenital adrenal hyperplasia;or other disorders including hypothyroidism or poly-cystic ovary syndrome.

Juvenile hypertrophy is a condition of pathologicovergrowth of the breasts. An end organ sensitivityto estrogens is one hypothesis.4 This condition maybe familial. The usual onset is at menarche, it is usu-ally symmetric, and each breast may weigh as muchas 30e50 pounds. If asymmetric, there is a higherlikelihood of a mass causing the condition, such asa giant fibroadenoma or lymphoma. Juvenile hyper-trophy can lead to back and neck strain. Surgicalintervention by reduction mammoplasty is oftenconsidered in the older teen or young adult once thebreasts achieve maturity.

Tuberous breasts are breasts that have limited di-mensions at the base with an overdeveloped nippleareolar complex. The condition may result from theuse of exogenous steroids, and surgical optionsinclude mammoplasty, tissue expansion, or flapreconstruction.

Infections of the Breast and Nipple

Inflammatory disorders account for approximately 4%of all childhood breast conditions. Causes include lo-cal infection, epidermoid cysts, foreign bodies,trauma, nipple piercing, and folliculitis from shavingperiareolar hair. Infection usually presents as local-ized tenderness and induration followed by appear-ance of erythema and then a fluctuant mass. Breastabscesses may occur at any age, including in infants.Initial management includes antimicrobial therapy.Aspiration or incision and drainage may be needed.Procedures in the prepubertal female breast shouldbe done judiciously with small incisions and minimaltissue disruption because of the risk of damage to theunderlying breast bud. The most common organismscausing breast infections are Staphylococcus aureus,beta-hemolytic Streptococcus, E. coli, and Pseudomo-nas aeruginosa.3,4 Antimicrobial coverage should ini-tially include methicillin-resistant Staph aureus, untilculture and sensitivity results are available.

Benign Breast Disorders

Breast pain (mastodynia or mastalgia) that is not asso-ciated with a mass or infection is usually due to hor-mone stimulation, possibly an imbalance in estrogenand progesterone stimulation. Symptoms mayfluctuate with the menstrual cycle. After alternatecauses are sought and ruled out, the condition maybe treated with oral contraceptives with reasonableresults.

Although cystic disease is not typical of the adoles-cent age group, breast tenderness may be associatedwith tender lumps detected by the patient that fluc-tuate in size. Ultrasound is often normal, as the lumpsare areas of normal breast tissue responding to hor-mone stimulation.2 True cystic disease is possible,but not common, and has been linked to the use ofmethylxanthines. Cyst aspiration under ultrasoundguidance is helpful for persistent, large, symptomaticcysts. Complex cysts should be biopsied.2 Oral con-traceptives may result in improved symptoms.

A fibroadenoma is the most commonly encoun-tered breast mass in adolescents.1 This typically pres-ents as a rubbery, discrete, nontender mass, and maybe lobular, bilateral (10%), or multiple (10e15%).There is epidemiologic evidence that the overallincidence of fibroadenomas is higher, and that fibroa-denomas are often multiple and bilateral, in African-American girls, compared with white females ofsimilar age.4 The average size is 2e3 cm, but a soli-tary fibroadenoma can be as large as 10e15 cm (giantfibroadenoma). Ultrasound characteristics includea well circumscribed, hypoechoic mass. The naturalhistory is one of slow enlargement over time. Enlarge-ment is more likely in pregnancy. Although someauthors report spontaneous resolution of small fibroa-denomas, this seems debatable. At least one longitudi-nal study in teens showed no resolution of discrete,solid masses followed for up to 6 years, but spontane-ous resolution of the majority of fibrocystic changes.2

Histologically, Dupont describes two groups of fi-broadenomas, simple and complex.8 Complex fibroa-denoma refers to fibroadenomas with foci of cysts,sclerosing adenosis, epithelial calcifications, and pap-illary apocrine metaplasia. The future risk of breastcancer is higher after removal of a complex fibroade-noma for 20 years after diagnosis, but simple fibroa-denomas in patients with no family history of breastcancer or proliferative disease adjacent to the fibroa-denoma do not seem to be associated with an in-creased risk of breast cancer.8

The giant fibroadenoma (juvenile cellular fibroade-noma) is an uncommon variant of fibroadenoma char-acterized by rapid growth.. The size of the lesion isgenerally over 5 cm.4 This fibroadenoma is encapsu-lated, benign, and the affected breast may be warmand have dilated veins over the surface. The underly-ing mass may cause a major distortion to the breastcontour (Fig. 1). Giant fibroadenomas should be ex-cised because they cannot readily be distinguishedfrom cystosarcoma phylloides using physical exami-nation, radiographic studies, or fine needle aspiration.

314 Fallat and Ignacio: Breast Disorders in Children and AdolescentsHistology shows mitotically poor cellular stroma andminimal cytological atypia.4

If a young woman presents with a solitary, discrete,palpable breast mass that is clinically and radiograph-ically consistent with a small fibroadenoma, the op-tions are observation vs. excision. Fine needleaspiration is seldom necessary with clinical follow-up being preferable. Observation requires serialexams and ultrasounds every six months to a year tomonitor size. Operation is indicated for symptomatic,large, or rapidly growing masses, if the girl or herfamily desire excision, or for solid masses that haveultrasound characteristics differing from a typical fi-broadenoma. Mass excision can be done under localanesthesia (depending on the size), conscious sedationwith local anesthesia, or general anesthesia. A cir-cumareolar incision lends itself well to excision ofmost fibroadenomas and is cosmetically acceptable.Since fibroadenomas are encapsulated, the breast tis-sue can be divided down to the mass, and many lendthemselves well to simple finger dissection as they sitin a small cavity. It is not necessary to remove a mar-gin of normal breast tissue. If a girl decides to chooseobservation, consideration should be given to mass

Fig. 1. (A) Adolescent with a giant fibroadenoma of theright breast causing contour distortion. Note dilated veinson the skin surface over the mass. (B) Gross appearanceof the giant fibroadenoma as it is being removed from thebreast.excision by age 18, because follow-up will becomemore challenging unless the young lady is willing tocommit to continued surveillance by an adultpractitioner.

Nipple Discharge

Nipple discharge may occur at any age, including ininfants, and is usually associated with benign dis-ease.9 It may occur in young girls as they enter pu-berty and last for several months without associatedunderlying pathology. Brown episodic dischargemay occur from Montgomerys tubercles, which arethe areolar tubercles involved in lactation.

Nipple discharge may occur after exercise, or maybe due to cold trauma.3 The discharge usually re-solves spontaneously and manipulation will perpetu-ate it.

Nipple discharge that is unilateral, single duct, in-termittent, and persistent should be evaluated. Appro-priate imaging studies are needed if there is anassociated palpable mass. A ductogram may be help-ful.10,11 Pathologic causes of galactorrhea or milkynipple discharge include prolactin-secreting tumors,pregnancy, the post-partum state, hypothyroidismand hyperthyroidism, duct ectasia, or papillary ducthyperplasia.9 Hyperprolactinemia has also been asso-ciated with breast stimulation, chest trauma, and tho-racotomy.10 Nipple discharge may also be associatedwith interrupted puberty or with primary or secondaryamenorrhea. Drugs associated with nipple drainage orgalactorrhea include oral contraceptives, tricyclic an-tidepressants, H2 antagonists, cannabis, phenothia-zines, and antihypertensive agents.9,10 Exfoliativecytological examination of nipple discharge andscrape smears has a low sensitivity for diagnosis.10

The disorders of papillary duct hyperplasia arerarely seen in children or adolescents.12,13 Intraductalpapillomas arise from a proliferation of ductal cellsprojecting into the duct lumen. Intraductal papillomasmay be solitary ductal or multiple intraductal.14 Nip-ple discharge may be sanguineous or serosanguinousand associated with a mass. Although an increasedrisk of breast cancer is associated with all forms ofpapilloma in adults,14 this condition has been uni-formly benign in adolescents.12,13 A ductogram aidsin diagnosis, and injection of the duct with methyleneblue may aid in excision (microdochectomy).11 Papil-lomatosis refers to papillary hyperplasia of ductal ep-ithelium involving multiple ducts. Sclerosingpapilloma/papillomatosis denotes distortion of theductal pattern and disruption by a desmoplastic prolif-eration of stromal cells within and external to theducts. Treatment of all of these disorders is by localexcision. Recurrences of all types have beendescribed.13

persistent and localized. If localized, a ductogram

3

frequently spreads beyond the breast to regionallymph nodes or by hematogeneous dissemination.4

315Fallat and Ignacio: Breast Disorders in Children and Adolescentsmay prove helpful in evaluation and later excisionof a focal area of involvement.10

Neoplasms and Malignant Breast Disorders

Phylloides tumors, more commonly known ascystosarcoma phylloides, are stromal tumors that arehistologically classified as benign, intermediate, ormalignant. However, even benign tumors may metas-tasize or locally recur. These are mixed epithelial andstromal neoplasms with sarcomatous changes.4 Be-nign tumors should be surgically excised with at leasta 1-cm margin of normal tissue and malignant tumorsmay require mastectomy. Clinically palpable nodesare present in about 20% of patients and should be re-moved, but the primary route of metastasis is hemato-geneous to lung, pleura, soft tissue, bone, pancreas,and central nervous system. Re-excision is indicatedfor inadequate margins or local recurrence. Adjuvanttherapy plays a limited role in treatment, although ra-diation therapy should be considered if an adequatemargin cannot be achieved on the chest wall. Theoverall prognosis is more favorable than its presumedcounterpart in adults.

Very few primary breast cancers occur in childrenand adolescents. The average age of the 39 cases ofprimary breast cancer that had been reported in chil-dren as of 2000 was 11 years (range 3e19 years),Juvenile papillomatosis is a distinct clinopatho-logic entity that occurs at a young age as a localizedmass, is grossly nodular (Swiss cheese appear-ance), and microscopically is characterized by cystsin combination with epithelial hyperplasia and otherdistinct features that include marked papillomatosis,papillary apocrine metaplasia, and mild cytologicalatypia.4,15 Ultrasound features include poor mass def-inition, with internal echoes of variable strength, andone or more small, rounded, relatively echo-free areasmainly at the border of the lesion.16 Treatment is totalresection with preservation of the normal breast. Thecondition is a marker for families having a relativelyhigh frequency of breast carcinoma.4,15,17,18

Mammary duct ectasia may be found in adolescentwomen.10 It may be associated with inflammation(periductal mastitis). Presenting symptoms includenipple discharge, noncyclical breast pain, nipple re-traction, or a subareolar abscess. Ultrasound shows tu-bular anechoic structures or ducts filled with debris.5

Treatment with anti-staphylococcal antibiotics is ap-propriate in the presence of obvious infection or a pos-itive culture. Mammary duct ectasia in adolescentsusually resolves and does not require excision. Watch-ful waiting, serial breast examinations, and ultra-sounds are appropriate unless the process isThe tumor has a thick-walled capsule and surgical ex-cision is the primary treatment. Adjuvant therapy israrely needed. Medullary and inflammatory carcino-mas are less common, more aggressive and often le-thal. Treatment is controversial and inconsistentbecause of the low number of cases, but is generallyguided by histologic subtype. Treatment of Hodgkindisease with chest wall radiation increases the lifetimerisk for breast cancer.3

Malignant breast masses in children more com-monly result from metastases than from primary le-sions.1 Examples included rhabdomyosarcoma,Hodgkin and non-Hodgkin lymphoma, melanoma,and neuroblastoma.

There are two critical genes responsible for 7e9%of all breast cancers. In girls with an inherited predis-position to breast cancer (i.e. BRCA1 on chromosome17 and BRCA2 on chromosome 13), monthly self-ex-aminations are recommended beginning between ages18 and 21, and mammography at age 25e35 years.Hereditary breast cancer linked to BRCA1 gene isautosomal dominant with late onset (earliest casesin the third decade). Initial studies imply that a carrierhas an 80% lifetime risk for breast cancer anda 40e60% risk for ovarian cancer.21 Adolescent ge-netic testing has been judged ethically unacceptableby most professional organizations because of thecurrent absence of beneficial medical interventionsin children that might affect the course of thedisease.21,22

References

1. Dehner LP, Hill DA, Deschryver K: Pathology of the breastin children. Semin Diagn Pathol 1999; 16:235

2. Foxcroft LM, Evans EB, Hirst C, et al: Presentation anddiagnosis of adolescent breast disease. Breast 2001; 10:399

3. Brandt M. In: Grosfeld JL, ONeill JA Jr, Fonkalsrud EW,Coran AG, editors. Pediatric Surgery, (6th ed)., Disordersof the breast, vol. 1. Philadelphia, Mosby Elsevier, 2006,pp 885e893and most were reported in girls. The usual presenta-tion is with an enlarging, painless, firm, nontender,immobile, poorly circumscribed lesion located in thelateral breast quadrants. As opposed to adults, nippledischarge and retraction are uncommon. Diagnosticimaging has limited usefulness but a fine needle aspi-ration may be helpful.

The various histologic subtypes include secretorycarcinoma and infiltrating ductal carcinoma.1,19,20 Se-cretory carcinoma is one of a small group of invasiveductal carcinomas with a favorable prognosis that in-

4. Pettinato G, Manivel JC, Kelly DR, et al: Lesions of thebreast in children exclusive of typical fibroadenomaand gynecomastia. A clinicopathologic study of 113 cases.In: Rosen PP, Fechner RE, editors. Pathology AnnualPart 2 Volume 24. Connecticut, Appleton & Lange,1989, pp 295e328

5. Weinstein SP, Conant EF, Orel SG, et al: Spectrum of USfindings in pediatric and adolescent patients with palpablebreast masses. Radiographics 2000; 20:1613

6. Kaplowitz PB, Overfield SE: Drug and Therapeutics andExecutive Committee of the Lawson Wilkins Pediatric En-docrine Society: Reexamination of the age limit for defin-ing when puberty is precocious in girls in the UnitedStates: implications for evaluation and treatment. Pediat-rics 1999; 104:936

7. Garcia CJ, Espinoza A, Dinamarca V, et al: Breast US inchildren and adolescents. Radiographics 2000; 20:1605

8. Dupont WD, Page DL, Parl FF, et al: Long-term risk ofbreast cancer in women with fibroadenoma. N Engl JMed 1994; 331:10

9. Jardines L: Management of nipple discharge. Am Surg1996; 62:119

10. Sakorafas GH: Nipple discharge: current diagnostic andtherapeutic approaches. Cancer Treat Rev 2001; 27:275

11. Wong L, Chung YFA, Wong CY: Microdochectomy forsingle-duct nipple discharge. Ann Acad Med Singapore2000; 29:198

12. Rosen PP: Papillary duct hyperplasia of the breast in chil-dren and young adults. Cancer 1985; 56:1611

13. Wilson M, Cranor ML, Rosen PP: Papillary duct hyperpla-sia of the breast in children and young women. ModernPathol 1993; 6:570

14. Gutman H, Schachter J, Wasserberg N, et al: Are solitarybreast papillomas entirely benign? Arch Surg 2003; 138:1330

15. Rosen PP, Holmes G, Lesser ML, et al: Juvenile papillo-matosis and breast carcinoma. Cancer 1985; 55:1345

16. Kersschot EAJ, Hermans ME, Pauwels C, et al: Juvenilepapillomatosis of the breast: sonographic appearance.Radiology 1988; 169:631

17. Bazzocchi F, Santini D, Martinelli G, et al: Juvenile papil-lomatosis (epitheliosis) of the breast. Am J Clin Pathol; 86:745

18. Taffurelli M, Santini D, Martinelli G, et al: Juvenile papil-lomatosis of the breast. A multidisciplinary study. PatholAnnu 1991; 26(Pt 1):25

19. Ferguson TB Jr, McCarty KS Jr, Filston HC: Juvenile se-cretory carcinoma and juvenile papillomatosis: diagnosisand treatment. J Pediatr Surg 1987; 22:637

20. Murphy JJ, Morzaria S, Gow KW, et al: Breast cancer ina 6-year-old child. J Pediatr Surg 2000; 35:765

21. Elger BS, Harding TW: Testing adolescents for a hereditarybreast cancer gene (BRCA1): respecting their autonomy isin their best interest. Arch Pediatr Adolesc Med 2000; 154:113

22. Kopelman L: Using the Best Interests Standard to decidewhether to test children for untreatable, late-onset geneticdiseases. J Med Philos 2007; 32:375

316 Fallat and Ignacio: Breast Disorders in Children and Adolescents

Breast Disorders in Children and AdolescentsObjectivesIntroductionEmbryology and Breast DevelopmentStages of Breast DevelopmentPresentationImagingDisorders of Breast DevelopmentInfections of the Breast and NippleBenign Breast DisordersNipple DischargeNeoplasms and Malignant Breast DisordersReferences