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1. HOW TO APPROACH BREAST LESIONS
IN CHILDREN AND ADOLESCENT
Presenter: Dr Nguyen Hoang Thanh
Radiology Center - K hospital

2. INTRODUCTION
• Spectrum of breast diseases is different from that in adult
• Most lesions are benign (BC in female < 20yrs: 0.1/100,000)
• US is the first choice
• Mammography is contraindicated
• Biopsy and surgery should be avoided
SEER Cancer Statistics Factsheets: Breast Cancer. National Cancer Institute, Bethesda, MD, http://seer.cancer.gov/statfacts/html/bre

3. Tenor
Normal breast
development
Common cause of
pediatric breast
complaints
Uncommon cause of
pediatric breast
complaints

4. NORMAL BREAST DEVELOPMENT
• The breast begins development during the 5–6th
week of fetal gestation.
• Ectodermal cells invaginating into the deeper
mesenchyme to form the milk lines.
• Over time, there is normal involution of the milk
lines except at the level of the 4th intercostal space,
where normal breast buds form.
• If normal involution is incomplete, accessory nipples
and/or breast tissue may form anywhere along
these milk lines

5. NORMAL BREAST DEVELOPMENT
Fig. 2. Breast development – Ectodermal cells invaginate to form the primary breast bud, which branches
into secondary buds, and then subsequently branch and elongate further to form the lactiferous ducts.
Externally a mammary pit or indentation is formed in the skin, which evolves into the nipple areolar complex

6. • “Thelarche”:
• Estrogen stimulate ductal growth
• Progesterone promote terminal lobules differentiation
• The normal age of onset of thelarche in the U.S. ranges between 9 and 10 years
of age
• Early thelarche: < 7-8 years of age
• Delay thelarche: >12 years of age
NORMAL BREAST DEVELOPMENT
1.Bock K, Duda VF, Hadji P, Ramaswamy A, Schulz-Wendtland R, Klose KJ, et al. Pathologic breas
conditions in childhood and adolescence. J Ultrasound Med 2005;24:1347–54.

7. • Idiopathic premature thelarche:
• Generally occurs in younger children between ages 1–3, and is unusual after age 4
• Benign, can mimic a mass when unilateral
• Other possible factors linked to premature thelarche include high body mass
index (BMI) and herbal intake
NORMAL BREAST DEVELOPMENT
1.Atay Z, Turan S, Guran T, Furman A, Bereket A. The prevalence and risk factors of
premature thelarche and pubarche in 4- to 8-year-old girls. Acta Paediatr
2012;101(2):71–5.

8. Tanner stage 1: Small foci echogenic tissue in
subareolar area
NORMAL BREAST DEVELOPMENT
Tanner stage 2: Hypoechoic subareolar breast
bud with hyperechoic breast parenchyma
composed of adipose tissue and loose
connective tissue
https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2018.19.5.978

9. NORMAL BREAST DEVELOPMENT
Tanner stage 3: Extension of hyperechoic
fibroglandular tissue with central spider-like and
hypoechoic linear projections away from
retroareolar region, reflecting elongated ducts
Tanner stage 4: US shows more widely elongated
hypoechoic breast bud and loss of rounded
appearance. Subcutaneous fat may be present
https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2018.19.5.978

10. https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2018.19.5.978
NORMAL BREAST DEVELOPMENT
Tanner stage 5: US shows mature breast appearance, heterogeneous
echogenicity of breast parenchyma intermixed with echogenic glandular
and stromal tissue, and increased amount of subcutaneous fat

11. COMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Normal breast bud • Polythelia • Cyst • Fibroadenoma
• Osseous structures • Polymastia • Hematoma
• Gynecomastia • Abscess
• Galactocele
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Normal breast bud • Polythelia • Cyst • Fibroadenoma
• Osseous structures • Polymastia • Hematoma
• Gynecomastia • Abscess
• Galactocele

12. • Asymmetric normal breast development is a common cause of unilateral
subareolar mass in children
• Asymmetry between the breast buds is common, with differences of up to 2 years
• Early development of the breast bud is called premature thelarche, which is most
common in children under age 3
Normal anatomic structures Normal breast bud

13. Normal anatomic structures Normal breast bud
5 year old boy with subareolar right breast mass discovered by mother. Ultrasound demonstrates
asymmetric but normal breast buds, right larger than left. There is no mass in the subareolar right
breast in the area of clinical concern.
https://www.ejradiology.com/artic…/S0720-048X(15)00185-0/pdf

14. Normal anatomic structures Osseous structure
Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 1366
Pectus carinatum

15. Normal anatomic structures Osseous structure
Poland syndrome

16. COMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele

17. Developmental abnormalities Polythelia & Polymastia

18. Bock K. Pathologic Breast Conditions in Childhood and Adolescence Evaluation by Sonographic
Diagnosis JUM October 1, 2005 vol. 24 no. 10 1347-1354
Developmental abnormalities Polythelia

19. Developmental abnormalities Polymastia
https://www.sciencesource.com/CS.aspx?VP

20. • Can be unilateral or bilateral, and it has been reported to be familial
• The cause of gynecomastia is thought to be related to relative elevation of
estrogen
• In adults, gynecomastia may be idiopathic or has been associated with chronic
liver disease, excess body fat, marijuana or steroid intake, or medications such as
cimetidine, digitalis, and tricyclic antidepressants
• In children, gynecomastia is often physiologic and is most common in neonates
and adolescents
Developmental abnormalities Gynecomastia

21. • Up to 90% of neonates have transient breast hypertrophy due to maternal
hormonal influence
• During puberty, gynecomastia is present in up to two thirds of 10–13 year old boys
which usually subsides within two years
• If however gynecomastia presents in prepubertal boys, other causes should be
considered
• Estrogen producing tumors such as testicular Leydig cell tumor, adrenal cortical
tumor, or gonadotropin secreting tumors such as hepatoblastoma, fibrolamellar
HCC can cause gynecomastia
Developmental abnormalities Gynecomastia

22. Developmental abnormalities Gynecomastia
20 year-old-boy

23. COMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele

24. • Most common in women between ages
35–50
• Cysts are more commonly solitary than
multiple in children
Non-neoplastic lesions Cyst

25. • 15-year-old girl with trauma at chest
related to bike handed bar
Non-neoplastic lesions Hematoma

26. • Although more commonly encountered in lactating women, mastitis and abscess
can occur in childhood.
• Mastitis occurs most frequently in infants (age<2 months; i.e. mastitis neonatorum)
and later childhood (age 8–17), and is thought to be related to skin infection and or
ductal obstruction
• The most common pathogen is Staphylococcus aureus > Streptococcus >
Enterococcus species
Non-neoplastic lesions Abscess

27. Non-neoplastic lesions Abscess
- 14 year old girl with left areolar swelling, redness, pain, and fever for 1 week.
- US: skin thickening and an underlying complex fluid collection, consistent with abscess.
 Drained to completion under ultrasound guidance, yielding 3–4 cc of purulent fluid.
 Sent for culture and grew Staphylococcus Aureus.

28. • Most commonly seen in pregnant, lactating, or early post lactational women
• Can occasionally present in children and young infants with or without
endocrinopathy.
• Likely results from occlusion of a lactiferous duct.
• Can persist up to several years post lactation.
• US: appears as a complex cystic mass with variable internal echotexture depending
on the relative milk versus water contents.
Non-neoplastic lesions Galactocele

29. Non-neoplastic lesions Galactocele
Galactocele in a 15-year-old girl that was
confirmed by aspiration of milky fluid

30. COMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele
Normal anatomic
structures
Developmental
abnormalities
Non-neoplastic lesions Benign masses
• Polythelia • Cyst • Fibroadenoma
• Normal breast bud • Polymastia • Hematoma
• Osseous structures • Gynecomastia • Abscess
• Galactocele

31. • The most common solid breast masses
found in adolescent girls.
• Arise from proliferation of connective tissue
stroma surrounding breast lobules
 Do not usually occur in the male
breast where lobules are typically absent.
• Sensitive with estrogen  May grow rapidly
during puberty and pregnancy.
Benign masses Fibroadenoma

32. • Short term followup is the first choice
• Biopsy: malignant features or rapid enlargement
• Surgical excision: rapidly enlarging masses regardless of benign US features or
initially benign pathology at biopsy, because a Phyllodes tumor cannot be excluded.
Benign masses Fibroadenoma

33. Benign masses Malignant masses
• Juvenile fibroadenomas • Metastatic disease
• Hamartoma • Hematologic malignancy/Cutaneous T-
celllymphoma
• Intraductal papilloma (solitary central papilloma) • Phyllodes tumors
• Juvenile papillomatosis (multiple peripheral
papillomas)
• Invasive secretory carcinoma
UNCOMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Benign masses Malignant masses
• Juvenile fibroadenomas • Metastatic disease
• Hamartoma • Hematologic malignancy/Cutaneous T-
celllymphoma
• Intraductal papilloma (solitary central papilloma) • Phyllodes tumors
• Juvenile papillomatosis (multiple peripheral
papillomas)
• Invasive secretory carcinoma

34. • An uncommon variant of fibroadenoma
• Rapid enlargement (Juvenile giant fibroadenoma: > 5-10 cm)
• Common in the African American population
• Surgical excision is indicated to exclude the possibility of a phyllodes tumor
• US: similar to classic fibroadenomas, but demonstrate progressive growth and
strikingly large size
Benign masses Juvenile fibroadenoma

35. A 12 year-old-girl with a rapidly growing right
breast mass > 13 cm observed during the
preceding 3 months. A surgical excision was
performed, and the mass was diagnosed as a
Giant Juvenile Fibroadenoma
https://doi.org/10.6065/apem.2014.19.1.45
Benign masses Juvenile fibroadenoma

36. • Benign tumor, also known as fibroadenolipoma
• Rare in children and adolescents
• Can grow to be very large in size (>10 cm) and mimic a juvenile giant
fibroadenoma
• US: appear as well circumscribed oval or round masses which can be hypoechoic,
isoechoic, or heterogeneous in echotexture
Benign masses Hamartoma

37. • Histology:
• Hamartomas: Disorganized lobules and adipose tissue, usually with a well-defined
boundary between the lesion and normal surrounding tissue.
• Fibroadenomas: Proliferation of specialized stroma around lobules.
 Lobules and fat are usually not present in a fibroadenoma.
• Hamartomas is safe to follow in children and adolescents.
• Surgical excision: when the lesion undergoes rapid progressive growth (can recur if
excision is incomplete).
Benign masses Hamartoma

38. Benign masses Hamartoma
18 year old girl with left breast palpable mass
http://dx.doi.org/10.1016/j.ejrad.2015.04.011

39. • Also known as Solitary central papilloma
• Uncommon in children, and rare in boys
• Represents a lesion of epithelial proliferation within a lactiferous duct.
• Usually solitary and located in a subareolar duct, often causing post obstructive
ductal dilatation.
• Clinical presentation: usually spontaneous serous or serosanguinous nipple
discharge
Benign masses Intraductal papilloma

40. • US: a solid intraductal mass is present within a dilated duct filled with anechoic
fluid.
• Surgical excision is the treatment of choice, to exclude rarely associated
malignancy.
Benign masses Intraductal papilloma

41. Benign masses Intraductal papilloma
• 16 year-old-boy
• Serosanguinous left nipple discharge for one
month.

42. • Also known as Multiple peripheral papillomas (Swiss cheese disease)
• JP is a benign condition, but is associated with carcinoma in up to 15% of the cases
• Histological: Lack the fibrovascular core, which is typical in the central papilloma
• US: may appear as ill-defined irregular hypoechoic tissue or masses, occasionally
containing cystic spaces
• Surgical resection to negative margins to prevent recurrence is indicated.
• “Up to 58% number of patients with JP have family history of breast cancer”
Benign masses Juvenile papillomatosis
Rosen PP. Benign mesenchymal neoplasms. In: Rosen’s breast pathology.
Philadelphia, PA: Lippincott-Raven; 1996. p. 658–705.

43. 16-year-old girl. (a) Photograph of the sectioned gross specimen shows multiple tiny cysts
(arrowheads ). (b) Sonogram shows a slightly hypoechoic mass that contains multiple, small
anechoic cysts (arrowheads)
Benign masses Juvenile papillomatosis
https://www.researchgate.net/figure/

44. UNCOMMON CAUSES OF PEDIATRIC
BREAST COMPLAINTS
Benign masses Malignant masses
• Juvenile fibroadenomas • Metastatic disease
• Hamartoma • Hematologic malignancy/Cutaneous T-
celllymphoma
• Intraductal papilloma (solitary central papilloma) • Phyllodes tumors
• Juvenile papillomatosis (multiple peripheral
papillomas)
• Invasive secretory carcinoma
Benign masses Malignant masses
• Juvenile fibroadenomas • Metastatic disease
• Hamartoma • Hematologic malignancy/Cutaneous T-
celllymphoma
• Intraductal papilloma (solitary central papilloma) • Phyllodes tumors
• Juvenile papillomatosis (multiple peripheral
papillomas)
• Invasive secretory carcinoma

45. • In the pediatric breast, metastatic disease is more common than primary
breast malignancy
• Primary tumors: rhabdomyosarcoma, neuroblastoma, lymphoma, leukemia,
Ewing sarcoma, melanoma, and RCC
• Imaging appearances of metastatic lesions in the breast are variable.
• Solitary or multiple masses, involving one or both breasts
Malignant masses Metastatic disease

46. • Lymphoma and leukemia are among the most common malignancies to metastasize to the breast
• Primary breast lymphoma is extremely rare and usually manifests as non-Hodgkin’s lymphoma
• Of the primary breast lymphomas, the majority are of B-cell type; T-cell lymphomas are
exceedingly rare
• Cutaneous T-cell lymphomas (CTCLs) are an uncommon sub-group of non-Hodgkin’s lymphoma
that arises primarily in the skin, and can rarely present as a breast mass with or without axillary
lymph nodes.
• CTCLs account for about 4% of all cases of non-Hodgkin’s lymphoma
Malignant masses
Hematologic
malignancy/Cutaneous
T-cell lymphoma

47. Malignant masses
Hematologic
malignancy/Cutaneous
T-cell lymphoma
16 year old girl with cutaneous T cell lymphoma involving the right breast.

48. • Phyllodes tumors were previously termed cystosarcoma phyllodes due to their cystic appearance and
sarcoma-like characteristics
• Propenity for hematogenous spread  metastasize to the lung rather than axillary lymph nodes
• Tend to be large (>6 cm) at clinical presentation
• US:
• A solid mass containing single or multiple, round or cleft like cystic spaces
• Posterior acoustic enhancement
Malignant masses Phyllodes tumors

49. Malignant masses Phyllodes tumors
13 year old girl notes a
subcutaneous mass in
the right breast, present
for 6 weeks.

50. • ISC is the most common type of breast cancer in children, accounting for <0.1% of
all invasive breast cancers
• Appear as small circumscribed masses (usually < 3 cm) that present as painless
palpable masses
• US: typically appear as well - circumscribed or partially microlobulated hypoechoic
masses
Malignant masses
Invasive secretory
carcinoma (ISC)

51. • There is no consensus on ideal treatment strategy for secretory
breast carcinoma
• However, breast conservative surgery (BCS) is considered the
mainstay of treatment
Malignant masses
Invasive secretory
carcinoma (ISC)

52. Malignant masses
Invasive secretory
carcinoma (ISC)
• 11-year-old girl
• Painful lump and watery discharge from
right breast for 3–4 months
 US, MRI
 Biopsy: Invasive secretory carcinoma
IHC: ER, PR, HER2 (-). Genetic analysis:
BRCA1, BRCA2 genes (-)
 Staging CT: Lung met

54. REFERENCES
• Yiming Gaoa,b, Mansi A. Saksenab, Elena F. Brachtelb, Deborah C. terMeulenb, Elizabeth A. Raffertyb:
How to approach breast lesions in children and adolescents
• SEER Cancer Statistics Factsheets: Breast Cancer. National Cancer Institute, Bethesda, MD
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6319105/
• http://radiopaedia.com
• http://seer.cancer.gov/statfacts/html/breast.html
• https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2018.19.5.978
• https://www.globalradcme.com/single-post/Juvenile-Papillomatosis-breast
• https://www.researchgate.net/figure

55. THANK YOU