Leonard M. Glassman MD Uncommon Signs of Malignancy

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Breast Disease in the Pediatric Patient

Leonard M. Glassman MD FACR

American Institute for Radiologic Pathology

Washington Radiology Associates, PC

Breast Imaging in Girls

• Up to age 18

Spectrum Different from Adults

• Almost always benign• Arises from normal or abnormal

development– Usually bilateral

• Also infection, trauma and cysts and tumors– Usually unilateral

• After puberty– Females – fibroadenoma– Males - gynecomastia

More Common Benign Lesions

• Fibroadenoma– Juvenile– Giant

• Phyllodes benign• Granular cell tumor• Lactating adenoma• Hamartoma

• Fibrocystic change• Intraductal papilloma• Juvenile

papillomatosis• Mastitis• Juvenile hypertrophy• Diabetic mastopathy

Less Common Benign Lesions

• Pseudoangiomatous stroma hyperplasia (PASH)• Granulomatous mastitis• Fibromatosis• Adenosis• Fibroadenomatoid hyperplasia or nodule• Fibrosis• Mondor’s disease• Varix• Rosai-Dorfman disease (Sinus histiocytosis with

lymphadenopathy)

Evaluation of the Pediatric Breast

• Physical examination• Sonography• Mammography and CT

– Rarely used

• MRI– Deep lesions involving chest wall

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Normal Development

• Begins in 5th – 6th fetal week– Milk line

• Axilla to groin• Involutes except for 4th

intercostal space usually• Prepubertal

– Epithelial lined ducts surrounded by connective tissue

• Pubertal girls– Ducts elongate– Lobules (TDLUs) form

• 5 Tanner stages– Prepubertal to mature

Tanner Stages

• Tanner 1 (prepubertal)• No glandular tissue• <10 years

• Tanner 2 (breast bud)• 10-11.5 years

Tanner Stages

• Tanner 3• Tissue beyond

areola• 11.5-13 years

• Tanner 4• Secondary mound

beyond areola• 13-15 years

Tanner Stages

• Tanner 5 (mature)

Developmental Abnormalities

• Polythelia • Polythelia

Developmental Abnormalities

• Polymastia • Polymastia

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Juvenile Hypertrophy

• Rapid excessive breast development– Bilateral or unilateral– Occurs at onset of menses

• Usually age 11-14• Usually coincides with first menses• Usually lasts 3-6 months• Unilateral or bilateral palpable mass• Iatrogenic amastia if removed

Juvenile Hypertrophy

Cystic Lesions

• Mammary duct ectasia

• Galactoceles• Retroareolar cysts• Abscess and

mastitis (s. aureus)• Hematomas• Cysts

• Duct ectasia

Cysts in 13 year old

Cystic Lesions

• Galactocele • Galactocele

Cystic Lesions

• Abscess • Abscess

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Cystic Lesions

• Hematoma • Cyst

Cysts 13 year old

Benign Masses

• Fibroadenoma• Lactating adenoma• Intraductal papilloma• Juvenile papillomatosis• Granular cell tumor• PASH

Fibroadenoma

• Multiple in 16 – 25% of patients clinically– Do complete bilateral ultrasound?– Multiple makes it BIRADS 2

• Found in 25% of breasts examined microscopically

Fibroadenoma• Youngest patient age 5 in our series

Fibroadenoma

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Giant Fibroadenoma vs. Juvenile Fibroadenoma

• Giant fibroadenoma• Large lesion > 10 cm

• Juvenile fibroadenoma– Age 20 years or younger– Typically rapid growth and large size– Usually pericanicular type with cellular stroma

Giant Fibroadenoma

Juvenile Fibroadenoma• Age 14

Juvenile Fibroadenoma 15 year old���������

Lactating Adenoma

• Young women• Pregnant or

lactating women• Circumscribed

lobulated mass

Lactating Adenoma

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Lactating Adenoma in Pregnancy Intraductal Papilloma

Juvenile Papillomatosis

• Firm discrete mass– Localized cystically dilated ducts with

intraductal proliferation• 2/3 less than 20 years old• Association with family history of breast

carcinoma– 10% develop carcinoma within 10 years

• Treat with excisional biopsy

Juvenile Papillomatosis

Juvenile Papillomatosis Juvenile Papillomatosis

• Physician’s daughter with palpable mass

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Granular Cell Tumor

• Neural cell origin • Wide age range (17-75 years)– Average age 30’s

• Discrete round mass or spiculated mass– Push or invasive margin

• Rare metastasis to axillary nodes– One case in literature

of lung metastases

Granular Cell Tumor

Granular Cell Tumor PASH (Pseudoangiomatous Stromal Hyperplasia)

• Wide age range• Focal lesion usually• Histologically shows

slit-like separation of stromal cells

• Exaggerated stromal response to hormone stimulation

PASH PASH

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Malignant Masses

• Phyllodes tumor – All can act malignant

• Metastatic• Hematologic• Sarcoma• Carcinoma

– DCIS– Invasive

Phyllodes Tumor

• Benign epithelial elements and cellular spindle cell stroma

• Can act malignant– Local recurrence– Distant blood born metastases– Lymph node enlargement reactive usually

• Well circumscribed lobulated mass• Similar appearance on sonography to

fibroadenoma– May have cystic spaces

Phyllodes Tumor Phyllodes Tumor

• Benign (15% recurrence)– Pushing margins– Mild atypia– May recur locally– Rare metastases

• Intermediate (25% recurrence)• Malignant (30% recurrence)

– Invasive or pushing margin– Moderate to severe atypia– Common local recurrence– Hematogenous metastases

Phyllodes Tumor

• Treatment– Wide local excision– Each recurrence may show grade deterioration

Benign Phyllodes

• Can occur in girls under 10 years old– Usually older than 10 years

• Tendency to recur but not metastasize• Pushing margins without invasion

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Benign Phyllodes Phyllodes Benign

Phyllodes Benign Intermediate Phyllodes Tumor

Malignant Phyllodes Tumor Metastatic and Hematologic

• Most common malignant tumors in children and adolescents– Rhabdomyosarcoma– Neuroblastoma– Leukemia and lymphoma

• Already widely disseminated

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Metastatic and Hematologic

• B cell Lymphoma• Neurofibrosarcoma

Angiosarcoma

• 14 – 82 years– Mean of 35

• Lobulated mass• Highly aggressive

lesion– Axillary metastasis

rare– Hematogenous

metastasis usual

Angiosarcoma Angiosarcoma

Invasive Ductal Carcinoma

• Most common carcinoma• Youngest patient 6 years (not in this series)• Signs similar to older patients

Medullary Carcinoma

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Medullary Carcinoma

• Age 17

Secretory Carcinoma

• Previously called juvenile carcinoma– Variant of invasive ductal carcinoma

• Initial report age 3-15– Oldest patient 87

• Limited aggressiveness in younger patients– Nearly 100% curable in young patients

Secretory Carcinoma Ductal Carcinoma in Situ (DCIS)

• Screening mammography in high risk patients

• Mass or nipple discharge

Conclusions

• Ultrasound is the primary modality in this age group

• MRI is used for deep lesions and malignant lesions

• Mammography and CT are rarely used

Conclusions

• Cysts are rare especially in the younger age groups

• Most solid lesions are benign– Fibroadenoma most common

• Juvenile hypertrophy and juvenile papillomatosis are unique to this age group and have specific appearances on imaging

Leonard M. Glassman MD Uncommon Signs of Malignancy

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Conclusions

• Malignant lesions occur and look like malignant lesions in older women– Phyllodes are most common– Metastatic and hematologic lesions are common– Invasive ductal carcinoma is rare

Conclusions

• Malignant lesions occur and look like malignant lesions in older women– Invasive ductal carcinoma most common carcinoma