Prepared by Thomas B. Poulton, MD, of Aultman Hospital,
A10-year-old black girl presented to her pediatrician with
marked bilateral breast enlargement with asymmetry. Following her
second office visit for the same problem, a mammogram was ordered
and completed at the insistence of the clinician (figure 1). The
presence of dense tissue limited the usefulness of this modality.
However, on clinical exam, mobile hard discrete masses were
palpated bilaterally (figure 2) with a small amount of normal soft
tissue identified in the inferior left breast.
Bilateral breast sonography with Doppler interrogation (figure
3) revealed well-defined solid hyperechoic masses with a few
vascular channels. At surgery, two masses were removed from the
right breast, and one mass from the left breast (figure 4).
Multiple giant (juvenile) fibroadenomas
Breast masses are uncommon in childhood, the majority of which
are related to inflammation (infection or abscess).
Symmetric and asymmetric gynecomastia can also masquerade as a
focal mass. Ultrasound coupled with Doppler imaging has been
invaluable in assessing the nature of breast masses, particularly
in younger women where mammography is limited because of overall
density, its inability to differentiate cystic from solid masses,
and increased sensitivity of breast tissue to radiation.
Although lesions of the breast are uncommon in children and
adolescents, the fibroadenoma accounted for 70% of lesions in a
review by Pettinato et al.
Other entities in this age group include gynecomastia, inflammatory
lesions such as infection and hematoma, other benign neoplasms
including lipomas and phyllodes tumor, and malignancies, both
primary (malignant phyllodes tumor, lymphoma, rhabdomyosarcoma, and
secretory carcinoma) and secondary. Adenocarcinoma is extremely
rare, accounting for less than 1% of breast masses in children.
The nomenclature of fibroadenomas found in younger women is
confusing. According to Hughes et al,
only 5% to 10% of fibroadenomas discovered in teenagers are
designated as "juvenile fibroadenomas." This term should be
reserved for tumors that 1) occur in an adolescent, 2) rapidly
enlarge, 3) reach a size that is two to four times the opposite
breast (when unilateral), 4) stretches the skin, and 5) displaces
the nipple. These features overlap with the description of "giant
fibroadenomas" which some authors reserve for tumors >5 cm. in
diameter. Sudden rapid growth is also a feature of this entity.
Multiple giant fibroadenomas are rare and 90% of the 20 reported
cases are in young black women.
As with older patients, clinical examination is essential in
evaluating the location, size, and number of palpable lesions. In
this case, identification of mobile masses from normal breast
tissue guided to the use of sonography, the breast imaging test of
choice in younger women with a mass. Sonography is not only useful
in the differentiation of cystic from solid masses of the breast,
but as in this case allows for discrimination of a mass of altered
echo texture from the normal glandular tissue with confidence.
Sonographic features of solid lesions suggesting, but not specific
for, malignancy include: irregular or angulated margins, marked
hypo-echoic or heterogeneous echogenicity, vertical orientation
(taller than wide), and acoustical shadowing. Doppler evaluation of
solid breast masses has been reported by some to reliably
differentiate benign from malignant lesions,
but its accuracy is still controversial. For many indeterminate
solid masses in adult women, ultrasound-guided core biopsy is an
appropriate minimally invasive procedure to identify the nature of
the lesion. When juvenile fibroadenomas are suspected, surgery is
the treatment of choice. Recurrences are not uncommon. This patient
had one local recurrence a year after initial surgery.
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