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Common Breast Problems Common Breast Problems in Adolescentsin Adolescentsin Adolescentsin Adolescents

Amy D. Amy D. DiVastaDiVasta, MD, , MD, MMScMMScDivisions of Adolescent Medicine & GynecologyDivisions of Adolescent Medicine & Gynecology

Christopher Weldon, MD, PhDChristopher Weldon, MD, PhDDepartment of SurgeryDepartment of Surgery

Boston Children’s HospitalBoston Children’s Hospital

ObjectivesObjectives•• Identify the most common etiologies Identify the most common etiologies

of breast complaints in the adolescent of breast complaints in the adolescent femalefemale

•• Recognize the important role of breast Recognize the important role of breast US in distinguishing amongst the US in distinguishing amongst the varying causes of breast masses and varying causes of breast masses and breast dischargebreast dischargebreast dischargebreast discharge

•• Compare management strategies for Compare management strategies for treatment of these lesionstreatment of these lesions

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DisclosuresDisclosures

We have nothing to disclose.We have nothing to disclose.

Normal Breast AnatomyNormal Breast Anatomy

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Tanner StagingStage 1

Stage 2

Stage 3

Stage 4Stage

Stage 5

“Don’t Like How They Look”“Don’t Like How They Look”

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Anatomic AbnormalitiesAnatomic Abnormalities

•• Hear patient’s Hear patient’s concernsconcernsconcernsconcerns

•• Exam in upright Exam in upright positionposition

•• Measure! Measure!

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AmastiaAmastia

•• Very rare: ?low E2 or no response to E2Very rare: ?low E2 or no response to E2–– Protein tyrosine receptor type F gene Protein tyrosine receptor type F gene

(PTPRF)(PTPRF)

•• Usually unilateralUsually unilateral•• Iatrogenic: disruption of breast bud, chest Iatrogenic: disruption of breast bud, chest

wall trauma (chest tube, NICU wall trauma (chest tube, NICU procedures), radiationprocedures), radiation

•• Androgen excess: CAH, gonadal Androgen excess: CAH, gonadal dysgenesisdysgenesis

Poland SyndromePoland Syndrome

•• Absence/hypoplasia Absence/hypoplasia of of pectoralispectoralismusclesmuscles

•• ScoliosisScoliosis•• Rib abnormalitiesRib abnormalitiesRib abnormalitiesRib abnormalities•• Webbed fingersWebbed fingers•• Small nipple/areolar Small nipple/areolar

complexcomplex

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Breast AsymmetryBreast Asymmetry

•• Common! ~25% teens have persistentCommon! ~25% teens have persistentCommon! 25% teens have persistent Common! 25% teens have persistent asymmetryasymmetry

•• Rule out cyst, mass, abscess on larger sideRule out cyst, mass, abscess on larger side

•• Asynchronous development or asymmetry?Asynchronous development or asymmetry?–– By T4, breast mass is developed so “catch up” By T4, breast mass is developed so “catch up”

unlikelyunlikelyyy

–– Don’t overDon’t over--reassure or expect improvement with reassure or expect improvement with timetime

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Breast Asymmetry: ImpactBreast Asymmetry: Impact•• “Just a cosmetic concern”?“Just a cosmetic concern”?

–– ↓ Short Form↓ Short Form--36 role36 role--emotional scale scoreemotional scale score

↓ Rosenberg Self↓ Rosenberg Self--Esteem Scale scoresEsteem Scale scores–– ↓ Rosenberg Self↓ Rosenberg Self--Esteem Scale scores Esteem Scale scores

–– Independent of differences in body massIndependent of differences in body mass

•• Findings suggest that patients suffering Findings suggest that patients suffering from breast asymmetry have poorer from breast asymmetry have poorer emotional wellemotional well--being and lower selfbeing and lower self--esteem than peersesteem than peers

•• Suggest need for early intervention to Suggest need for early intervention to minimize negative outcomesminimize negative outcomes

Nuzzi LC, et al. Nuzzi LC, et al. PlastPlast ReconstrReconstr SurgSurg 20142014

Breast Asymmetry: InterventionsBreast Asymmetry: Interventions

•• Temporary cosmetic measuresTemporary cosmetic measures–– ProstheticsProsthetics

•• Surgical correctionSurgical correction–– Augmentation vs. reductionAugmentation vs. reduction

•• Most Most payorspayors do not cover asymmetrydo not cover asymmetry–– “No functional impairment” from asymmetry“No functional impairment” from asymmetry

O l 52% d t i tit ti 2008O l 52% d t i tit ti 2008 20132013–– Only 52% covered at our institution 2008Only 52% covered at our institution 2008--20132013

•• Disparity of careDisparity of care–– Covered if cancerCovered if cancer--related, but not congenitalrelated, but not congenital

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MacromastiaMacromastia/Hypertrophy/Hypertrophy•• Usually bilateral findingUsually bilateral finding

–– Unilateral suggests large tumor (>5Unilateral suggests large tumor (>5--10 cm) or 10 cm) or lymphomalymphomalymphomalymphoma

•• May lead to breast pain, back pain, May lead to breast pain, back pain, limitation of activities, postural issues, limitation of activities, postural issues, skin breakdown, emotional distress, skin breakdown, emotional distress, depression, depression, intertrigointertrigoAssociated with obesityAssociated with obesity•• Associated with obesityAssociated with obesity–– Not causative; wide range of BMI reportedNot causative; wide range of BMI reported

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MacromastiaMacromastia: Impact: Impact•• Prospective study at BCHProspective study at BCH

•• Subjects 12Subjects 12--21 y21 y

CerratoCerrato F, et al. Pediatrics 2012F, et al. Pediatrics 2012




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Myths and MisconceptionsMyths and Misconceptions•• Solely a cosmetic concernSolely a cosmetic concern

–– 80% patients become symptomatic at puberty80% patients become symptomatic at puberty

•• Result of obesity; resolves with weightResult of obesity; resolves with weight•• Result of obesity; resolves with weight Result of obesity; resolves with weight lossloss–– Exercise becomes difficult/impossibleExercise becomes difficult/impossible

–– No research indicates obesity as a causeNo research indicates obesity as a cause

•• No surgery until >18 y, or children bornNo surgery until >18 y, or children borng y y,g y y,–– Postpone until growth completedPostpone until growth completed

–– Ductal system typically spared, sensation okayDuctal system typically spared, sensation okay

•• Not covered by insuranceNot covered by insurance

Surgical CorrectionSurgical Correction•• No clear guidelines for timing of surgeryNo clear guidelines for timing of surgery

•• Individualize treatment based on emotional and Individualize treatment based on emotional and ph sical readiness mat ritph sical readiness mat ritphysical readiness, maturityphysical readiness, maturity

–– Too late: psychosocial and physical distressToo late: psychosocial and physical distress

–– Too soon: potential to need second Too soon: potential to need second procedure, lack of risk comprehensionprocedure, lack of risk comprehension

•• Reduction mammoplasty, once growth Reduction mammoplasty, once growth completecomplete

–– 97% covered at our institution 200897% covered at our institution 2008--20132013

•• Typical volume removed ~2000 gTypical volume removed ~2000 g

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Surgical CorrectionSurgical Correction•• Complications same as adults: infection, Complications same as adults: infection,

scarring, sensory loss, breastfeeding scarring, sensory loss, breastfeeding iiissuesissues

•• Correction improves Correction improves HRQoLHRQoL scores scores ((NetoNeto 2012)2012)

•• No recurrence if timing appropriateNo recurrence if timing appropriate

I d i li ti i b itI d i li ti i b it•• Increased minor complications in obesityIncreased minor complications in obesity

MammaplastyMammaplasty & Obesity& Obesity

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Insurance CoverageInsurance Coverage

•• Neck/shoulder painNeck/shoulder pain

Sh ld i f b i tSh ld i f b i t•• Shoulder grooving from brassiere strapsShoulder grooving from brassiere straps

•• Skin changes under the breasts, such as Skin changes under the breasts, such as rash, thinning, or breakdownrash, thinning, or breakdown

•• Chest radiographyChest radiography

Mi i f 500 i i d t bMi i f 500 i i d t b•• Minimum of 500 g is required to be Minimum of 500 g is required to be removed from each breastremoved from each breast

XueXue AS, et al. JPAG 2013AS, et al. JPAG 2013

Juvenile (“Virginal”) Breast Juvenile (“Virginal”) Breast HypertrophyHypertrophy

•• Alarmingly rapid enlargement of breast Alarmingly rapid enlargement of breast connective tissue during pubertyconnective tissue during puberty

•• Persistent overgrowthPersistent overgrowth–– Erythema, firm/tense breast, Erythema, firm/tense breast, striaestriae

•• Estrogen hypersensitivity?Estrogen hypersensitivity?

•• TherapyTherapyTamoxifenTamoxifen medroxyprogesteronemedroxyprogesterone–– TamoxifenTamoxifen, , medroxyprogesteronemedroxyprogesterone

–– Surgical reduction; average >5000 g removedSurgical reduction; average >5000 g removed

–– Recurrence prevention (~40% recur)Recurrence prevention (~40% recur)

–– MastectomyMastectomy

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Virginal HypertrophyVirginal Hypertrophy

Tuberous Breast DeformityTuberous Breast Deformity•• Congenital anomalyCongenital anomaly

•• Appearance: Appearance: I f i h l iI f i h l i–– Inferior hypoplasia Inferior hypoplasia and skin deficiencyand skin deficiency

–– Constriction at breast Constriction at breast basebase

–– Overdeveloped Overdeveloped nipple/areolar complex nipple/areolar complex (“areolar herniation”)(“areolar herniation”)

–– Superior malposition Superior malposition of the of the inframammaryinframammaryfoldfold

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Tuberous Breast DeformityTuberous Breast Deformity

KolkerKolker AR and Collins MS. AR and Collins MS. PlastPlast ReconstrReconstr SurgSurg 20152015

Tuberous Deformity: CorrectionTuberous Deformity: Correction


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18 18 momo followfollow--up:up:---- Bilateral implants, bilateral Bilateral implants, bilateral mastopexymastopexy, release of , release of constrictionconstriction



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“Red, Black, or Blue”“Red, Black, or Blue”

InfectionInfection

Firm, tender to touch, red, warmFirm, tender to touch, red, warm

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AbscessAbscess

Mastitis and AbscessMastitis and Abscess

•• Risk factors: postRisk factors: post--partum, trauma, piercing, partum, trauma, piercing, preexisting ductal blockage, areolar hair preexisting ductal blockage, areolar hair removalremoval

•• Typical organisms: staph, strep, Typical organisms: staph, strep, enterococcus, anaerobes. Consider local enterococcus, anaerobes. Consider local MRSA prevalence.MRSA prevalence.

•• Imaging: Ultrasound differentiates cyst v. Imaging: Ultrasound differentiates cyst v. solidsolid–– Complex cyst, debris in cystComplex cyst, debris in cyst

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14 y CC: R breast pain, swelling, 14 y CC: R breast pain, swelling, erythemaerythema

Mastitis and AbscessMastitis and Abscess•• Risk factors: postRisk factors: post--partum, trauma, piercing, partum, trauma, piercing,

preexisting ductal blockage, areolar hair removalpreexisting ductal blockage, areolar hair removal

•• Typical organisms: staph, strep, enterococcus,Typical organisms: staph, strep, enterococcus,Typical organisms: staph, strep, enterococcus, Typical organisms: staph, strep, enterococcus, anaerobes. Consider local MRSA prevalence.anaerobes. Consider local MRSA prevalence.

•• Imaging: Ultrasound differentiates cyst v. solidImaging: Ultrasound differentiates cyst v. solid–– Complex cyst, debris in cystComplex cyst, debris in cyst

•• TxTx: : DicloxacillinDicloxacillin or Augmentin or Clindamycin x or Augmentin or Clindamycin x 10d10d10d 10d

•• If persistent If persistent –– drainagedrainage

•• If recurrent: suspect ductal If recurrent: suspect ductal ectasiaectasia or duct or duct anomaly in teen, anomaly in teen, hemangiomahemangioma/anomaly in infant/anomaly in infant

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IRIR SURGERYSURGERY

Mastitis and AbscessMastitis and Abscess

•• <3cm<3cm

•• SimpleSimple

•• MultifocalMultifocal

•• Concerns with lactation Concerns with lactation or or cosmesiscosmesis

•• SubareloarSubareloar

•• >5cm>5cm

•• ComplexComplex

•• MultiloculatedMultiloculated

•• LongstandingLongstanding

SubareloarSubareloar

Expert Rev Anti Infect Expert Rev Anti Infect TherTher 2014, 2014, epubepub

Abscess: SequelaeAbscess: Sequelae•• Neonatal mastitis may be associated with Neonatal mastitis may be associated with

longlong--term consequencesterm consequences–– N=8/10 girls followedN=8/10 girls followed--up 10up 10--15 y later15 y laterN 8/10 girls followedN 8/10 girls followed up 10up 10 15 y later15 y later

–– N=7/8 had surgical drainageN=7/8 had surgical drainage

Outcome Number affected n (%)

Asymmetry 2 (25%)

Change in texture 4 (50%)

Intraductal dilatation,fib l t d

2 (25%)fibrous elements and calcifications

Fibrous changes 1 (13%)

Breast tissue trapped under scar

1 (13%)

PanteliPanteli C. Arch Dis Child 2012C. Arch Dis Child 2012

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TraumaTrauma

•• Fat necrosisFat necrosis

•• BurnsBurns

•• ContusionContusion

•• HematomaHematoma

•• Management: Pain meds, ice, bindingManagement: Pain meds, ice, binding

“Leaky”“Leaky”

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Nipple DischargeNipple Discharge•• Type/Color of discharge?Type/Color of discharge?

–– Bloody?Bloody?

–– Clear and sticky?Clear and sticky?Clear and sticky?Clear and sticky?

–– White, milky? White, milky? GalactorrheaGalactorrhea





•• Unilateral or bilateral?Unilateral or bilateral?

•• History of stimulation? Sexual history?History of stimulation? Sexual history?

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•• Medications? Medications?







•• Medications? Medications? A tiA ti h tih ti t i lit i li SSRISSRI–– AntiAnti--psychotics, psychotics, tricyclicstricyclics , SSRIs, SSRIs

–– MetoclopromideMetoclopromide

–– VerapamilVerapamil

–– OpioidsOpioids

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R i fR i f•• Review of systems:Review of systems:–– HeadacheHeadache

–– Visual disturbancesVisual disturbances

–– Menstrual historyMenstrual history








ROS h d h i l di b lROS h d h i l di b l•• ROS: headache, visual disturbances, menstrual ROS: headache, visual disturbances, menstrual historyhistory

•• Examination of breast: Gentle fluid expressionExamination of breast: Gentle fluid expression

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#1 Take Home Point:#1 Take Home Point:

Every fluid that comes out of Every fluid that comes out of the breast is NOT milkthe breast is NOT milk

Nipple Discharge: EtiologiesNipple Discharge: Etiologies

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Pregnancy postPregnancy post pregnancy postpregnancy post AbAbPregnancy, postPregnancy, post--pregnancy, postpregnancy, post--AbAbMedicationsMedicationsProlactinomaProlactinoma//MicroadenomaMicroadenomaThyroid diseaseThyroid disease


•• Jogger’s nipple/eczemaJogger’s nipple/eczemagg ppgg pp

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Nipple DischargeNipple Discharge

•• Smear of discharge for cytologySmear of discharge for cytology

•• Laboratory evaluationLaboratory evaluationyy–– Pregnancy testPregnancy test

–– Prolactin, TFTs, Prolactin, TFTs,

•• Unclear etiology? Fat stainingUnclear etiology? Fat staining

•• Bloody discharge? Gram stain & cultureBloody discharge? Gram stain & culture

•• If unilateral or mass palpated, ultrasoundIf unilateral or mass palpated, ultrasound

•• If elevated PRL x 2, consider pituitary MRIf elevated PRL x 2, consider pituitary MR

Mammary Duct Mammary Duct EctasiaEctasia

•• Distension ofDistension of subareolarsubareolar ducts withducts with•• Distension of Distension of subareolarsubareolar ducts with ducts with fibrosis and inflammation fibrosis and inflammation

•• Nipple discharge or massNipple discharge or mass

•• Usually spontaneous resolution <1 yUsually spontaneous resolution <1 y

•• May present as a “blue breast”May present as a “blue breast”•• May present as a blue breastMay present as a blue breast

•• Risk factor for mastitisRisk factor for mastitis

•• Persistent symptoms Persistent symptoms excisionexcision

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15 y CC: unilateral serous 15 y CC: unilateral serous discharge, lumpdischarge, lump

RetroareolarRetroareolar CystsCysts

•• aka Cysts of Montgomeryaka Cysts of Montgomery

•• Discharge not from nippleDischarge not from nipple

•• If obstructedIf obstructed–– Acute inflammationAcute inflammation

–– Asymptomatic massAsymptomatic mass

•• Can confirm dx with USCan confirm dx with US

•• Can Can txtx with NSAIDs/with NSAIDs/AbxAbx

•• 80% spontaneously 80% spontaneously resolve; can take up to 2yresolve; can take up to 2y

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16 16 yoyo intermittent brown intermittent brown dischargedischarge

“Lumps and Bumps”“Lumps and Bumps”

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Evaluation of Breast MassEvaluation of Breast Mass

•• Duration, location, rate of growthDuration, location, rate of growth

•• Inspection, palpation, measurementInspection, palpation, measurementInspection, palpation, measurementInspection, palpation, measurement

•• Imaging studies:Imaging studies:–– Ultrasound: cyst vs. solid; measurementUltrasound: cyst vs. solid; measurement

–– Mammogram: No!Mammogram: No!

–– Fine needle aspiration: NoFine needle aspiration: No

–– Core Needle BiopsyCore Needle Biopsy

–– MRIMRI

Masses IN the breastMasses IN the breast

•• HemangiomaHemangioma•• HemangiomaHemangioma

•• Lymph nodeLymph node

•• Skin lesionSkin lesion

•• Malignant tumor (secondary cancer)Malignant tumor (secondary cancer)

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Masses OF the breastMasses OF the breast

•• FibroadenomasFibroadenomas 67% to 94%67% to 94%•• FibroadenomasFibroadenomas ---- 67% to 94%67% to 94%

•• Fibrocystic changesFibrocystic changes

•• Simple cystsSimple cysts

•• Abscess/mastitisAbscess/mastitis

•• Vast majority resolve or do not enlargeVast majority resolve or do not enlarge

Benign Breast LumpsBenign Breast Lumps

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Fibrocystic ChangesFibrocystic Changes•• Diffuse cordDiffuse cord--like thickening and nodularity, painlike thickening and nodularity, pain•• Varies with menstrual cycle (improve w/period)Varies with menstrual cycle (improve w/period)•• Exam:Exam:•• Exam:Exam:

–– NonNon--distinct margins; Serial examinations distinct margins; Serial examinations show changes show changes

–– May cause dischargeMay cause discharge•• Treatment: Treatment:

Firm brassiere and NSAIDsFirm brassiere and NSAIDs–– Firm brassiere and NSAIDsFirm brassiere and NSAIDs–– OCPs improve 70OCPs improve 70--90% cases (20 mcg EE)90% cases (20 mcg EE)–– Caffeine avoidanceCaffeine avoidance–– Vitamin E, evening primrose oilVitamin E, evening primrose oil

Benign Breast DiseaseBenign Breast Disease

•• Risk factors during adolescence:Risk factors during adolescence:–– Alcohol consumption ages 18Alcohol consumption ages 18--22 y22 yAlcohol consumption ages 18Alcohol consumption ages 18 22 y22 y

•• Risk BBD increases 15% for every 10 g Risk BBD increases 15% for every 10 g EtOHEtOHconsumed per dayconsumed per day

–– Thinner during childhoodThinner during childhood•• OR 0.91 per kg/mOR 0.91 per kg/m22; p<0.04; p<0.04

–– Most rapid growth (OR 1.88; p=0.04)Most rapid growth (OR 1.88; p=0.04)Most rapid growth (OR 1.88; p 0.04)Most rapid growth (OR 1.88; p 0.04)

–– No association between age at menarche & No association between age at menarche & BBDBBD

BerkeyBerkey CS.PediatricsCS.Pediatrics 2010; Liu et al Pediatrics 20122010; Liu et al Pediatrics 2012

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FibroadenomaFibroadenoma•• Benign; 67Benign; 67--94% of teen breast masses94% of teen breast masses

•• Rubbery, discrete, upper outer quadrantRubbery, discrete, upper outer quadrant

US llUS ll i ib di ib d h h ih h i•• US: wellUS: well--circumscribed, circumscribed, hypoechoichypoechoic

•• Conservative, nonsurgical managementConservative, nonsurgical management–– <5 cm: Serial exams, observation (2/3 stay <5 cm: Serial exams, observation (2/3 stay

same size or regress), asymptomaticsame size or regress), asymptomatic

–– > 5 cm, symptomatic: remove> 5 cm, symptomatic: remove 5 cm, symptomatic: remove 5 cm, symptomatic: remove

–– CosmesisCosmesis and psychological concerns*and psychological concerns*

•• No increased lifetime risk of breast CA No increased lifetime risk of breast CA with simple with simple fibroadenomafibroadenoma

17 17 yoyo CC: painful R breast lumpCC: painful R breast lump

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Ultrasound FindingsUltrasound Findings

•• Reassuring USReassuring US

•• Uniform, Uniform, hyperechoichyperechoic

•• NonNon--reassuring USreassuring US

•• Irregular shapeIrregular shape,, ypyppattern, pattern,

•• Circumscribed marginCircumscribed margin

•• Oval, round, Oval, round, macrolobulatedmacrolobulated (<2(<2--3) 3) shapeshape

g pg p

•• MicrolobulationMicrolobulation

•• Increased number of Increased number of lobulationslobulations

•• SpiculatedSpiculated marginmargin

MicrocalcificationsMicrocalcificationsshapeshape

•• Thin echogenic Thin echogenic capsulecapsule

•• MicrocalcificationsMicrocalcifications

•• Ductal extensionDuctal extension

•• Internal cystic Internal cystic changeschanges

PhyllodesPhyllodes TumorsTumors

•• Stromal tumor (Stromal tumor (cystosarcomacystosarcoma phyllodesphyllodes))

•• Only 0 3% to 1% of breast masses in teensOnly 0 3% to 1% of breast masses in teens•• Only 0.3% to 1% of breast masses in teensOnly 0.3% to 1% of breast masses in teens

•• More common in AfricanMore common in African--AmericansAmericans

•• Large (4Large (4--13 cm), firm, rapidly growing13 cm), firm, rapidly growing, skin , skin

•• 3 variants 3 variants –– benign, borderline, malignantbenign, borderline, malignant

US/CNB diffi lt t diff ti tUS/CNB diffi lt t diff ti t•• US/CNB: difficult to differentiateUS/CNB: difficult to differentiate

•• Treatment: Surgical removalTreatment: Surgical removal

•• Met workMet work--upup

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MalignancyMalignancy

•• 1/8 women get breast cancer1/8 women get breast cancer•• 1/8 women get breast cancer1/8 women get breast cancer•• 90% of woman have CIS in their 90’s in 90% of woman have CIS in their 90’s in

autopsy seriesautopsy series•• Primary breast cancer in young women is Primary breast cancer in young women is

RARE RARE –– 2020--24 24 yrsyrs 0.2/100,0000.2/100,000–– <20 <20 yrsyrs 0.8/100,000 0.8/100,000

Cumulative Breast CA 2000Cumulative Breast CA 2000--20052005Risk of Breast Cancer as Risk of Breast Cancer as Function of Age Estimated Function of Age Estimated From Women Diagnosed inFrom Women Diagnosed inFrom Women Diagnosed in From Women Diagnosed in the US SEER17 Registries,the US SEER17 Registries,20042004

Anders CK Anders CK SeminSemin OncolOncol 20092009

Age (yr)

Risk

15 1:571,429

20 1:75,188

25 1:8,684

30 1:1,523

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MalignancyMalignancy

•• Secondary breast lesions far more Secondary breast lesions far more common in younger patientscommon in younger patientscommon in younger patientscommon in younger patients–– RhabdomyosarcomaRhabdomyosarcoma–– NeuroblastomaNeuroblastoma–– ‘Liquid’ cancers‘Liquid’ cancers

•• Childhood CA survivors with previous Childhood CA survivors with previous chest XRT require careful screeningchest XRT require careful screeningchest XRT require careful screeningchest XRT require careful screening

Screening for CA survivorsScreening for CA survivors

Mulder RL Mulder RL Lancet Lancet OncolOncol.. 20132013

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MalignancyMalignancy•• Familial association common (20Familial association common (20--30%)30%)•• Hereditary predisposition is 5Hereditary predisposition is 5--10% 10%

S d b t l iS d b t l iSecondary breast lesionsSecondary breast lesions–– BRCA 1, BRCA 2 (AD)BRCA 1, BRCA 2 (AD)

•• 22--3x greater risk and 85% cumulative risk at 75 y3x greater risk and 85% cumulative risk at 75 y•• Monthly SBE at 18 yMonthly SBE at 18 y•• MR yearly at 25 y with biannual visitMR yearly at 25 y with biannual visit•• Prophylactic mastectomies 10 years before indexProphylactic mastectomies 10 years before indexProphylactic mastectomies 10 years before index Prophylactic mastectomies 10 years before index

case of CAcase of CA

–– LiLi--FraumeniFraumeni syndrome syndrome –– p53 mutation and p53 mutation and incomplete penetrance of breast v other incomplete penetrance of breast v other malignanciesmalignancies

BCH DataBCH Data•• 1515--yr retrospective review (1993 to 2008)yr retrospective review (1993 to 2008)•• 276 masses in 214 women276 masses in 214 women

–– 89% benign89% benign–– 0.4% 0.4% phyllodesphyllodes–– 2% malignant2% malignant–– 9% total cohort non9% total cohort non--neoplasticneoplastic–– NONO primary epithelial breast malignanciesprimary epithelial breast malignancies

•• Since 2008, 2 more malignanciesSince 2008, 2 more malignancies–– 1 benign 1 benign phyllodesphyllodes–– 1 juvenile/secretory epithelial breast CA1 juvenile/secretory epithelial breast CA

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BCH DataBCH Data•• Surgical principlesSurgical principles

–– AVOID surgeryAVOID surgery•• Q4 month US x 1 year/repeat visits/SBE Q4 month US x 1 year/repeat visits/SBE QmoQmo•• REASSURANCEREASSURANCE

–– Operate for:Operate for:•• Mental anguishMental anguish•• SymptomsSymptoms•• GrowthGrowth

–– PeriareolarPeriareolar incisionsincisions–– PeriareolarPeriareolar incisionsincisions–– Breast preservationBreast preservation–– Compression vest 4 weeks/Sports bra 4 weeksCompression vest 4 weeks/Sports bra 4 weeks–– No activity 4 weeks/No contact sports 8 weeksNo activity 4 weeks/No contact sports 8 weeks

BCH DataBCH Data

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BCH DataBCH Data

To operate or not to operate?To operate or not to operate?

•• NCI: most tumors involving the breast in NCI: most tumors involving the breast in hildh d t hhildh d t hchildhood are noncancerous; watch childhood are noncancerous; watch

without biopsywithout biopsy

•• Reasons for surgery: palpable mass, Reasons for surgery: palpable mass, progressive growth, no regression in size, progressive growth, no regression in size, complex US findings, family history ofcomplex US findings, family history ofcomplex US findings, family history of complex US findings, family history of breast cancer, patient’s past history of breast cancer, patient’s past history of malignant diseasemalignant disease

EzerEzer SS. JPAG 2013SS. JPAG 2013

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BCH DataBCH Data

To examine, or not to examine?To examine, or not to examine?•• MetaMeta--analyses of randomized and nonanalyses of randomized and non--

randomized studies of SBE have shown randomized studies of SBE have shown that SBE has no effect on mortality from that SBE has no effect on mortality from yybreast CAbreast CA Warner E NEJM 2011Warner E NEJM 2011

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MastalgiaMastalgia•• Breast pain, often cyclic and Breast pain, often cyclic and

premenstrualpremenstrual•• Mild swelling and nodularityMild swelling and nodularityMild swelling and nodularityMild swelling and nodularity•• Usually due to hormonal stimulationUsually due to hormonal stimulation•• TreatmentTreatment

–– Supportive measures: wellSupportive measures: well--fitting brafitting bra–– ReassuranceReassurance–– Smoking cessationSmoking cessation–– Caffeine limitationCaffeine limitation–– Meds: NSAIDs, OCPs, Vitamin E 1,200 IU Meds: NSAIDs, OCPs, Vitamin E 1,200 IU

daily, evening primrose oil 3000 mg dailydaily, evening primrose oil 3000 mg daily

SummarySummary•• Majority of adolescent breast Majority of adolescent breast

complaints have benign etiologiescomplaints have benign etiologiesp g gp g g•• Conservative medical therapy Conservative medical therapy

appropriate for management of most appropriate for management of most breast massesbreast masses

•• Nipple discharge may have a variety of Nipple discharge may have a variety of benign causes: evaluation necessarybenign causes: evaluation necessarybenign causes: evaluation necessarybenign causes: evaluation necessary

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ObjectivesObjectives•• Identify the most common etiologies Identify the most common etiologies

of breast complaints in the adolescent of breast complaints in the adolescent femalefemale

•• Recognize the important role of breast Recognize the important role of breast US in distinguishing amongst the US in distinguishing amongst the varying causes of breast masses and varying causes of breast masses and breast dischargebreast dischargebreast dischargebreast discharge

•• Compare management strategies for Compare management strategies for treatment of these lesionstreatment of these lesions

Thank youThank you

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