Table of Contents
Benign and malignant breast masses are uncommon in adolescents. Despite being rare, breast masses usually cause significant worry and distress to the adolescent and their family. Breast masses in adolescents are usually benign fibroadenomas. Malignant breast masses constitute only 0.02% of the masses identified in adolescents.
|Pubertal breast development is mainly under the influence of:|
|Lactiferous ducts||Lobular tissue and alveolar budding|
|Female adolescent breast tissue is very dense and responsive to hormonal changes.|
The estimated prevalence of breast masses in adolescents is approximately 3.2%. The most common type is fibroadenoma, which is diagnosed in up to 95% of cases.
Malignant breast masses are very rare in adolescent girls but have been reported to exist. Approximately 0.02% of the identified breast masses in adolescents are found to be cancerous. Phyllodes tumors, primary breast cancer, sarcoma, lymphangioma, hemangioma, and metastatic cancer are some examples of the malignant breast masses seen in adolescents.
Intraductal papilloma is the most common cause of non-bloody nipple discharge in an adolescent and often causes pain. It is important to note the duration and progression of symptoms. Physical examination of the breast with palpation can express nipple discharge. These benign lesions are usually found in the subareolar area and are usually nonpalpable.
A cytology exam is indicated when nipple discharge is present in an adolescent. Ductal cells are usually observed on cytological examination. Ultrasonography is indicated to identify the cause of the nipple discharge and can be used to visualize the intraductal papilloma. The gold-standard diagnostic tool is a ductogram; however, this procedure is considered to be too invasive for an adolescent, who is much more likely to have a benign condition than a malignant lesion.
While intraductal papilloma itself is not a premalignant condition, the risk of breast cancer in an adult with a previous history of intraductal papilloma has been shown to be increased. Therefore, the treatment of choice of an intraductal papilloma in an adolescent is local surgical excision.
Phyllodes tumors are cystic lesions that resemble fibroadenomas but with increased stromal content. The term “cystosarcoma phyllodes” can also be used to describe the lesions. Patients present with a rapidly growing tumor that is large and painless. A clinical examination may be inconclusive, as phyllodes tumors are difficult to distinguish from giant fibroadenomas.
When the main complaint from the adolescent is a large breast mass, the first diagnostic test should be ultrasonography, which can reveal lobulations and heterogenicity without microcalcifications. Unfortunately, these findings are not specific enough to detect phyllodes tumors. A core needle biopsy is therefore recommended.
The typical histology finding for phyllodes tumors is a fibroadenoma with significantly increased stromal proliferation. It is important to identify the degree of dysplasia and proliferation, as grading the tumors has been linked with survival rate. The 5-year survival rate for benign phyllodes tumors is 96%, but this declines to 74% for intermediate phyllodes tumors. The survival rate after complete resection of malignant phyllodes tumors is approximately 66%.
The treatment of phyllodes tumors in adolescents is similar to adults, i.e., complete surgical resection. The main difference in treatment between adult and adolescents is that a 1-cm surgical margin is unnecessary.
Fibroadenomas usually present as firm, non-tender, well-demarcated masses. The most common site is the upper outer quadrant of the breast. The masses can become tender or show cyclic size changes related to the menstrual cycle. Breast asymmetry is also a common presenting problem in adolescents. The typical mousy feel of the fibroadenomas — i.e., sliding between the fingers during palpation — is usually observed during physical examination. The skin overlying the tumors is normal.
The diagnosis of fibroadenomas in adolescents is simple and usually based on history and physical examination. If nipple discharge is present, cytology is indicated.
Ultrasonography is the imaging modality of choice for confirmation of the diagnosis. Mammography is not recommended due to the presence of high-density breast tissue.
The potential for malignant transformation in adolescents who have fibroadenomas is very low. Therefore, treatment can be challenging. When fibroadenoma is diagnosed for the first time, a follow-up should be arranged to see if the mass disappears after the next menstrual period. If it does not disappear and is small and not painful, treatment can comprise mainly observation and follow-up. If the lesions are growing in size or are associated with tenderness, then surgical excision of the tumors is indicated.
|Clinical follow-up||Surgical excision||NSAIDs or OCPs|
|Most require only clinical follow-up||Surgical excision for symptomatic, rapidly growing||NSAIDs or OCPs to help pain with hormone-dependent changes|
Primary Breast Cancer
The incidence of breast cancer in adolescents is 1 in 1,000,000. Adolescents with breast cancer usually present quite late to the clinic and therefore the mass is usually large. Physical examination reveals a firm, nonmobile mass with poorly circumscribed borders. Nipple discharge and retraction are uncommon in adolescents with breast cancer compared with adults.
The most common type of breast cancer in adolescents is secretory adenocarcinoma. These tumors are characterized by their cystic appearance on ultrasound, with a thick wall. Mortality and nodal metastasis are uncommon. Medullary and inflammatory cancer has been also reported in adolescents and pediatrics. Mammography is not recommended in the diagnostic workup for breast masses in adolescents due to the relatively higher density of the adolescent breast compared with the adult breast. Core needle biopsy is indicated for grading and histological examination.
Complete surgical resection should be attempted in all cases. Because a complete breast resection may be psychologically traumatic to the adolescent, reconstructive surgery is also indicated. Axillary lymph node staging is indicated. Ultrasonography should be used to assess the status of the axillary lymph nodes and if no metastasis is identified, then a sentinel lymph node should be obtained during surgery.
The role of radiotherapy and chemotherapy in primary breast cancer in adolescents is controversial and therefore should be considered carefully.
Metastatic Cancers of the Breast
Many cancers have been associated with metastatic diseases of the breast. The most common examples are hepatocarcinoma, non-Hodgkin lymphoma, leukemia, and rhabdomyosarcoma. The management of these tumors should also cover breast metastatic disease if present.
Management of Breast Infections
- Common in lactating adolescents
- Group A strep or Staphyloccus aureus
- May present with fever alone, then develop into erythematous, confluent painful rash
- Fever is common
- Treat with cephalexin or clindamycin
- Warm compresses