1. Pediatric Breast Mass Corey Johnson, MD R2 Seattle Children’s Hospital
Pediatric Surgery Case Presentation

2. JG 11 year old girl with Left breast mass PMH Exam Ultrasound
increasing in size
inflamed appearance
no discharge
beginning to have pain
PMH
pre-menarche
no medications
no significant personal or family medical history
Exam
Ultrasound

3. JG DDx of pediatric breast mass Hypertrophy
Thelarche or premature thelarche
Fibrocystic change
Fibroadenoma
Giant fibroadenoma
Phyllodes tumor
Lipoma
Hemangioma
PASH
Intraductal papilloma
Duct ectasia
Montgomery tubercles
Infection
Trauma
Neoplasm
Primary (secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, lymphoma)
Metastasis (lymphoma, neuroblastoma, hepatocellular carcinoma, rhabdomyosarcoma)
Secondary (history of chest radiation therapy)

4. JG DDx of pediatric breast mass Hypertrophy
Thelarche or premature thelarche
Fibrocystic change
Fibroadenoma
Giant fibroadenoma
Phyllodes tumor
Lipoma
Hemangioma
PASH
Intraductal papilloma
Duct ectasia
Montgomery tubercles
Infection
Trauma
Neoplasm
Primary (secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, lymphoma)
Metastasis (lymphoma, neuroblastoma, hepatocellular carcinoma, rhabdomyosarcoma)
Secondary (history of chest radiation therapy)

5. JG
Image courtesy of Dr. Kenneth Gow

6. JG
Image courtesy of Dr. Kenneth Gow

7. Fibroadenoma Most common breast lesion in adolescents
91% (44/49) of solid breast masses on ultrasound
Clinical Dx: 2-3 cm rubbery, well-circumscribed mass in upper outer quadrant
Ultrasound shows a well-circumscribed, solid, homogeneous mass, posterior enhancement
Bimodal age distribution
Recurrent or multiple in 10-25% of patients

8. Fibroadenoma Approximately 50% resolve in 5 years
Malignancy within a fibroadenoma is extremely rare
1.3 to 2.1 relative risk increase for breast cancer
Indications for biopsy
rapid growth
lesion >5cm
persistence into adulthood

9. Giant Fibroadenoma >5cm or >500g Rapid growth
Association with pregnancy and lactation
May be lobulated on ultrasound
FNA and core needle biopsy cannot differentiate from phyllodes
Excisional biopsy

10. Giant Fibroadenoma Adult type Juvenile type 4% of fibroadenomas
Hypocellular to variably cellular stroma
Juvenile type
0.5-2% of fibroadenomas
Mean age 15, range 10-39
Uniformly hypercellular stroma
No leaf-like architecture, periductal stromal condensation or infiltration of surrounding tissue
No stromal atypia, mitotic rate <3/hpf, no stromal overgrowth

11. Phyllodes Reported in girl as young as 10 years of age
% of all breast masses
Large breast mass, usually painless
Bloody discharge if nipple involved
Ultrasound shows heterogeneous mass with lobulations
Benign, borderline or malignant based on histology
Borderline and malignant have potential for mets
Review of 173 patients with 179 tumors
101 (56.4%) benign, 50 (27.9%) borderline, 28 (15.6%) malignant
Malignant associated with older patients and larger tumor size

12. Resources
Morris A, Shaffer K. Recurrent bilateral giant fibroadenomas of the breasts. Radiology Case Reports. [Online] 2007;2:96.
Sanchez R, Ladino-Torres MF, Bernat JA, Joe A, DiPietro MA. Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings. Pediatric Radiology Oct;40(10):
Kempson RL, Rouse RV. Juvenile fibroadenoma of the breast. Surgical Pathology Criteria. Stanford School of Medicine.
Tse GMK, Putti TC, Lui P, Lo A, Scoyler R, Law B, Karim R, Soon Lee C. Modern Pathology (2004) 17, 827–831.
Greenburg R, Skornick Y, Kaplan O. Management of breast fibroadenomas. J Gen Intern Med September; 13(9): 640–645.
Karl SR, Ballantine TV, Zaino R. Juvenile secretory carcinoma of the breast. J Pediatr Surg August;20(4):
Louvet C, Brunel P, Espie M, de Rocquancourt A, Schaisn G, Extra JM, Marty M. Breast cancer in patients under 18 years. Report of an inflammatory case and review of the literature. Breast August;5(4):
Ashikari H, Jun MY, Farrow JH, Rosen PP, Johnston SF. Breast carcinoma in children and adolescents. Clin Bull. 1977;7(2):55-62