Ultrasound of pediatric and adolescent
breast
Shawnm N.Dawood, MBChB, DMRD
College of Medicine, Hawler Medical University
Shawnm.nasih@med.hmu.edu.iq

Ultrasound of pediatric and adolescent breast
LEARNING OBJECTIVES
 Identify the US features of normal breast development.
 Describe the role of US in the study of breast lesions in
children.
 Discuss the limitations of US in the differential diagnosis of
breast masses in children.

Introduction
• Spectrum of breast diseases is different from that in adults.
• Most lesions are benign.
• Mammography is contraindicated.
• US is the ideal imaging modality.
• Biopsy and surgery should be avoided.

Ultrasound of pediatric and adolescent
breast
 Normal breast development and normal variations
 Congenital and developmental abnormalities
 Pubertal male breast development and gynaecomastia
 Inflammatory lesions
 Benign neoplastic masses
 Non-neoplastic benign lesions
 Primary and secondary malignant tumors
Bloody nipple discharge

Normal breast development and normal variations
 Prenatal Development
• First Trimester
• Second Trimester
• Third Trimester
 Infant Breast
 Pubertal Female Breast Development
-Gross Anatomic Changes….Tanner stages
-The age range in which this can occur is 8½ to 13½ years.
No breast development by 14 years of age in girls should prompt
further investigation.

Development of the mammary gland
(A) Ventral view of an embryo at 28-days gestation showing mammary crests. (B) Similar view at 6-week gestation
showing the remains of the mammary crests. (C) Transverse section of a mammary crest at the site of the
developing mammary gland. (D–F) Similar sections showing successive stages of breast development between the
12th week of gestation and birth
Javed A, Lteif A. Development of the Human Breast. Seminars in Plastic Surgery. 2013;27(1):5-12. doi:10.1055/s-0033-1343989.

Pubertal Female Breast Development and Gross Anatomic
Changes
Tanner stages of breast development
1. The entirely under developed pre-pubertal
2. Breast bud.
3. Enlargement of breast and areola
4. Areola and breast form a mound atop breast tissue
5. Adult configuration
areola and breast having smooth contour
Javed A, Lteif A. Development of the Human Breast. Seminars in Plastic Surgery. 2013;27(1):5-12. doi:10.1055/s-0033-
1343989.

Normal Breast Development: US Characteristics
US image of a 7-year-old healthy girl, shows a small sub-areolar breast
bud (asterisks), mainly consisting of fat and connective tissue, which
appear mildly heterogeneous.

Tanner stage 2 in a 9-year-old patient, showing subareolar relatively hypoechoic
developing breast tissue surrounded by sonographically hyperechoic fat and
connective tissue.
Normal Breast Development: US Characteristics

Tanner stage 3 In a 13-year-old healthy girl, US scan shows hyperechoic glandular tissue
extending away from the retroareolar area (arrows) and a central spider-shaped
hypoechoic retroareolar region (*).
Normal Breast Development: US Characteristics

Tanner stage 4 . In a 14-year-old healthy girl, US scan shows hyperechoic
fibroglandular periareolar tissue (arrows), with a prominent central retroareolar
hypoechoic nodule (*).
Normal Breast Development: US Characteristics

Tanner stage 5 in a 15-year-old patient 3 years after menarche, showing very
dense, hyperechoic glandular tissue in the breast periphery surrounded by a thin
layer of hypoechoic subcutaneous fat.
Normal Breast Development: US Characteristics

Normal Variations in Breast Development
 A common normal variant is the unilateral onset of breast
development that can be clinically misdiagnosed as a tumor.
 Unilateral breast development may exist as long as 2 years
before the other breast becomes palpable.
 Juvenile hypertrophy of the breast (macromastia)
 US shows normal breast tissue in these cases and obviates
surgery or biopsy.

Congenital and Developmental Abnormalities
Congenital anomalies
Anomalous Nipple and Breast Development
 Polythelia
 Polymastis
 Amastia

Photograph and US show accessory breast tissue distant from the regular developing breast
Bock K. Pathologic Breast Conditions in Childhood and Adolescence Evaluation by Sonographic Diagnosis
JUM October 1, 2005 vol. 24 no. 10 1347-1354
Tanner stage B4 in a 14-year-old patient with a unilateral complete
accessory breast

Poland's syndrome in a 18months old girl
a. Photography of the chest
b-c. Chest XR
d-e. Ultrasound of the breast and chest wall
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 of female breast
Premature thelarche
• Breast development that begins before the age of 7½ years precocious or
premature.
• either isolated or associated with central precocious puberty
• may be unilateral or bilateral
• normal breast tissue is found at US .
• Pelvic US is useful in the early differentiation between isolated premature
thelarche and central precocious puberty by allowing measurements of
the uterus and ovaries .

In a 7-year-old girl with unilateral thelarche, US scans show Tanner stage II development
(arrows) in the right breast (a) and a small hyperechoic retroareolar area (arrows) in the
left breast region (Tanner stage I) (b).
Premature Thelarche
a bb

Isolated unilateral premature thelarche on the left side in a 6-year-old patient.
Tanner stage: left, B3; right, B1.
Bock K. Pathologic Breast Conditions in Childhood and Adolescence Evaluation by Sonographic
DiagnosisJUM October 1, 2005 vol. 24 no. 10 1347-1354

Pubertal Male Breast Development and
Gynaecomastia
• At puberty, no further development of the male breast.
• Up to 40-75% of boys may develop transient gynaecomastia
• Sometimes called physiologic pubertal gynecomastia
• Can be asymmetric or unilateral.
• Although this is transient in most cases, may be a distressing physical
anomaly for a young male
• Rarely, pubertal gynaecomastia may persist
? Other causes of gynaecomastia

Asymmetric pubertal gynecomastia in a 16-year-old boy with a clinically
suspected right breast mass. US scan shows bilateral breast development (arrows)
that is much more pronounced on the right side (a) than on the left (b).
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612
a b

Pseudogynecomastia in an obese 14-year-old boy. US scan shows adipose tissue
accumulation in the breast region.
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612

Inflammatory Lesions
• Can occur in the neonate, children and adolescents.
• Ultrasound ………………cystic or complex masses
• US is not only diagnostic but also helps guide therapeutic
needle aspiration .
• Mastitis may appear as a complex or solid mass at US .
• At Doppler US:
abscesses …………….only peripheral flow
mastitis ………………. central flow.

US scan shows a complex breast mass (cursors) with some debris (arrows) in it.
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612
Breast abscess in a 2-month old female infant.

A 15-year-old girl with 2-week history of painful breast mass and
fever
(A) Sonogram shows a round cystic lesion with low-
level internal echoes and increased through
transmission.
(B) There is increased vascularity peripherally, but no
internal flow with Doppler interrogation.
(C) At the time of follow-up 2 weeks after complete
aspiration under ultrasound guidance the patient's
symptoms resolved and no residual abscess was seen
sonographically.
Jones KN. Imaging of the Adolescent Breast. Seminars in Plastic Surgery. 2013;27(1):29-35

18-year-old woman with left breast abscess. Patient was not lactating but had left
nipple ring and presented with left breast pain for 2 months with new development of
palpable mass and associated erythema.
Left breast abscess a. before (arrow) and b. after drainage
http://www.ajronline.org/doi/full/10.2214/AJR.12.9560

Benign Neoplastic Masses
 Fibroadenoma
 is the most common benign neoplastic lesion in children
 composes 50-60% of all breast lesions in adolescents.
 US………a well-defined hypoechoic homogeneous mass
 1—20 cm in diameter
 multiple masses in 10%—15% of patients
 Doppler US…………67% avascular , 33% may show central vessels.
 Other benign neoplastic lesions
 hemangiomas
 papillomas
 lymphangiomas
 lipomas.

A 14-year-old patient with a palpable breast mass
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation. Ellen M. Chung, Regino
Cube, Gregory J. Hall, Candela González, J. RadioGraphics 2009 29:3, 907-931

(a) Extended-field-of-view sonogram shows the hyperechoic septation (arrowhead) and smaller
anechoic clefts (arrow) within a homogeneously hypoechoic, well-marginated mass with posterior
acoustic enhancement
(b) Photograph of sectioned gross specimen demonstrates a central fibrous septation and multiple
smaller reddish grooves or clefts. Scale is in centimeters
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation. Ellen M et
al,RadioGraphics 2009 29:3, 907-931
Juvenile fibroadenoma in a 15-year-old girl
a
b

US shows an inhomogeneous, mostly hypoechoic tumor (asterisks), with not always
well-defined borders, macrolobulated, and slightly enhanced sound transmission
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation. Ellen M. Chung, Regino
Cube, Gregory J. Hall, Candela González, J. RadioGraphics 2009 29:3, 907-931
15-year-old patient with a palpable breast mass

Ultrasound showed hypoechoic macrolobulated mass (asterisk) of mixed echogenicity. Mass
shows cystic and solid components.
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation. Ellen M. Chung, Regino
Cube, Gregory J. Hall, Candela González, J. RadioGraphics 2009 29:3, 907-931
15-year-old girl presented with palpable right retroareolar mass.

US showing predominantly benign sonographic characteristics.It was histologically confirmed as
infarcted tubular adenoma by open surgical excision.
Tanner stage B4 in a 17-year-old patient with a palpable breast mass

Sonogram shows a 5.4-cm oval circumscribed hypoechoic mass, Surgical excision
demonstrated a benign phyllodes tumor
Jones, Katie N. “Imaging of the Adolescent Breast.” Seminars in Plastic Surgery 27.1 (2013): 29–35
An 18-year-old girl with a growing breast mass.

Non-neoplastic Benign Lesions
 Breast cysts
• solitary or multiple, 1—5 cm in diameter
• most commonly located near the nipple and areola
• can manifest as a palpable mass or as a result of secondary
infection
• Uninfected cysts appear as anechoic masses in the breast tissue.
Uninfected cysts may be multiple in number, round or lobular in
shape, contain internal septations or isolated echoes be avascular
at Doppler US
• When infected, the cysts may contain echogenic debris, septations,
or fluid-fluid levels, and increased vascularity is noted peripherally

Non-neoplastic Benign Lesions(cont.)
 Fibrocystic disease or mammary dysplasia
• may be seen in late adolescence
• US is non-specific and may show solid or cystic masses
 Other benign lesions
 galactocele
 Post-surgical fibrosis
 fat necrosis
 hematoma
 extramedullary hematopoiesis.

Different images of breast cysts
http://clinicalgate.com/breast-ultrasound

US scan shows small well-defined retroareolar cysts (arrows)
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612
Breast cysts in a 14-year-old girl.

Infected retroareolar cyst in an 11-year-old girl with a breast mass and fever. Doppler US
scan shows a predominantly cystic lesion (arrowheads), with increased peripheral flow.
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612

Color Doppler sonogram reveals a well-circumscribed, round cystic structure with homogeneous
internal echogenicity, posterior acoustic enhancement, and flow to the cyst wall only
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation
Ellen M. Chung, Regino Cube, Gregory J. Hall, Candela González, J. Thomas Stocker, and Leonard M.
Glassman RadioGraphics 2009 29:3, 907-931
Galactocele in a 15-year-old girl that was confirmed by aspiration of milky fluid

well-circumscribed oval complicated cystic lesion (arrow) with multiple internal
septations and posterior acoustic enhancement, consistent with galactocele.
http://www.ajronline.org/doi/full/10.2214/AJR.12.9560
19-year-old woman, 2 months postpartum and breast-feeding, who presented
with palpable lump in her right breast.

US scan shows a well-defined and complex posttraumatic breast mass (arrows).
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612
Breast hematoma in a 1-year-old boy after breast trauma.

Different images of fat necrosis

• Kim YR, Kim HS, Kim H-W. Are Irregular Hypoechoic Breast Masses on Ultrasound
Always Malignancies?: A Pictorial Essay. Korean Journal of Radiology.
2015;16(6):1266-1275. doi:10.3348/kjr.2015.16.6.1266.
A. Transverse ultrasonography (US) shows irregular hypoechoic mass in her left
Pathologically, necrosis was confirmed by US-guided core needle biopsy. B. Follow-up
US image after 3 years demonstrates decrease in lesion size with increased posterior
acoustic shadowing.
Fat necrosis without trauma history

Primary Malignant Tumors
• Primary malignant tumors are rare in children
 Cystosarcoma phyllodes
• Although rare in adolescents, it is the most common malignant breast mass in this
age group.
• have been reported in children as young as 10 years old
• these can be large, painless, rapidly growing tumors
• difficult to distinguish clinically from giant fibroadenomas
• US……….well-defined oval or lobulated masses with a smooth margin and may
contain fluid-filled cysts or clefts….
• Core needle biopsy for diagnosis can help guide surgical planning
In large tumors, heterogeneity in cellularity across the spectrum of fibroadenoma
and phyllodes tumor can be seen and therefore excision is indicated
Kennedy RD, Boughey JC. Management of Pediatric and Adolescent Breast Masses. Seminars in Plastic
Surgery. 2013;27(1):19-22. doi:10.1055/s-0033-1343991.

Primary Malignant Tumors
 Cystosarcoma phyllodes
 adenocarcinoma of the breast
 Extremely rare in childeren
 May be less aggressive than in adults
 Histopathologic results are similar to those of adult adenocarcinoma
US….. variable and nonspecific; most commonly as a hypoechoic mass with
inhomogeneous internal echoes, irregular margins, and variable acoustic shadowing
 Other primary malignant breast tumors
• Lymphoma
• Rhabdomyosarcoma
• angiosarcoma

Secondary Malignant Tumors
• Malignant breast lesions are more likely to be secondary to
metastatic or disseminated tumor in children and are
described in lymphoma, leukemia, rhabdomyosarcoma,
and neuroblastoma .
• US…… is nonspecific.
In leukemia………solid, well-defined, and relatively hypoechoic
mass that is sometimes bilateral.
In metastatic neuroblastoma, US may reveal multiple
hypoechoic breast lesions .
•

US scan shows a moderately hypoechoic, well-defined breast mass (arrows).
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor Dinamarca, Oscar Navarro, Alan
Daneman, Hernán García, and Andreina Cattani RadioGraphics 2000 20:6, 1605-1612
Metastatic leukemia in a 15-month-old girl.

Bloody Nipple Discharge
causes
• infantile mammary ectasia
• chronic cystic mastitis
• intraductal cysts
• intraductal papillomas
• can also be related to the fact that the breasts are actively
hematopoietic in the embryo, and hematopoietic tissue is
readily detected in the newborn, Doppler US …shows no
abnormalities.

Intraductal Papilloma
• Usually subareolar
• Gold standard diagnosis is a
ductogram
• Ultrasound is first-line study in
children
• Adult studies show an increased risk
of breast cancer; however, in the
pediatric population have proven
benign in all cases
•Treatment of intraductal papillomas
in all ages is by local surgical excision.

Conclusion
Given knowledge of the ultrasound appearance of physiologic
breast development and specific lesions, breast sonography is
most helpful in identifying and characterizing abnormalities
and guiding further investigation.

References:
Javed A, Lteif A. Development of the Human Breast. Seminars in Plastic Surgery.
2013;27(1):5-12. doi:10.1055/s-0033-1343989.
Breast US in Children and Adolescents Cristián J. García, Aníbal Espinoza, Víctor
Dinamarca, Oscar Navarro, Alan Daneman, Hernán García, and Andreina Cattani
RadioGraphics 2000 20:6, 1605-1612
Breast Masses in Children and Adolescents: Radiologic-Pathologic Correlation
Ellen M. Chung, Regino Cube, Gregory J. Hall, Candela González, J. Thomas Stocker,
and Leonard M. Glassman RadioGraphics 2009 29:3, 907-931
Jones KN. Imaging of the Adolescent Breast. Seminars in Plastic Surgery.
2013;27(1):29-35
Bock K. Pathologic Breast Conditions in Childhood and Adolescence Evaluation by
Sonographic Diagnosis
JUM October 1, 2005 vol. 24 no. 10 1347-1354
Upadhyaya, V.S., Uppoor, R., Shetty, L. Mammography and ultrasound features of fat
necrosis of the breast. Indian J Radiol Imaging. 2013;23:366–372.