Breast masses in adolescents seldom found to be malignant.
"The most important thing about breast masses in adolescents is that they are very rarely cancer," said Dr. Braverman, a pediatrician specializing in adolescent health at Cincinnati Children's Hospital Medical Center. "But cancer is the first thing that the patient and the family are worried about. So you can reassure them: 'That is not what I'm worried about. Let's talk about the other things that could be going on.'"
She noted that in a review of 15 retrospective studies involving 1,791 girls and women, younger than age 22 years, who had a biopsy of a breast mass, the most common diagnosis was fibroadenoma, found in 68% (Neinstein L.S., ed. "Adolescent Health Care: A Practical Guide," 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2002). Cancer was the cause in only 0.9% of cases.
Knowledge of normal breast development is key to evaluating masses in adolescents, according to Dr. Braverman. "Breast development starts with the breast bud," she said. "You need to be able to recognize the breast bud because it is not an abnormality."
Fibroadenomas are smooth, rubbery, mobile, firm nodules that are usually very well demarcated and have an average size of 2-3 cm, she noted. "They can last for an average of about 5 months, and can be recurrent and multiple."
Fibroadenomas are usually benign. Because of this, she advised against repeatedly performing biopsies of similar masses in an adolescent after a first biopsy has proven a mass to be a fibroadenoma. Multiple surgical procedures can cause disfigurement, and it would be better to hold off until breast development is complete unless there are characteristics of the mass that suggest it is not benign.
Intraductal papilloma, in addition to causing a mass, can also cause a bloody nipple discharge. These masses usually occur in the subareolar position. "Although intraductal papilloma is benign, it should be excised," Dr. Braverman said at a meeting of the American Academy of Pediatrics.
Juvenile giant fibroadenomas are very rapidly growing masses. "These masses are also a benign condition, but [they] can grow to be very large--more than 5 cm in diameter," she said. These masses can be disfiguring, replacing or compressing the normal breast tissue, which is why they need to be removed."
Cystosarcoma phyllodes, also called phyllodes tumor, can likewise cause a rapidly growing large mass in adolescents that also warrants removal. "Phyllodes tumors are usually benign, but there is a small possibility of malignant transformation," Dr. Braverman noted.
Fibrocystic breast disease creates thickenings and lumps that are generally most pronounced in the week before menstrual periods and regress in between. "Fibrocystic disease is usually totally benign," she said. In adolescents, the symptoms can be addressed with a supportive bra, mild analgesics such as non steroidal anti-inflammatory drugs, and oral contraceptives.
Infectious masses include both breast cellulitis and breast abscesses, said Dr. Braverman. Treatment typically entails application of warm compresses and antibiotic therapy. "You want to try to avoid incision and drainage, if possible, because it can cause damage to the breast tissue," she advised.
Cancer in the adolescent breast is not only rare, but also unlikely to be a primary breast cancer, according to Dr. Braverman. "When we do see malignancies in adolescents, the majority of masses are metastatic lesions from nonbreast tissue. Unlike benign breast masses, those that are cancer usually manifest clinically as masses that are hard and fixed to deep tissue.
Dr. Braverman recommended following the mass through several menstrual cycles. "If the breast mass or breast changes totally resolve between menses, you know that you do not have a problem that you need to worry about.
"If you have a persistent mass or a mass that is growing, the imaging that you want to do in a teenager is ultrasound," she said. Mammograms are not useful because the breast tissue is too dense. If the diagnosis remains uncertain after ultrasound, the patient should be referred to a breast surgeon to be evaluated for a possible excisional biopsy.
Some adolescents may have a family history of breast cancer or known BRCA1 or 2 mutations. Testing for these mutations, however, should be deferred until the adolescent is an adult (usually 18 at a minimum). "It is better for the teen to decide when they are an adult, when they can make that decision for themselves about whether they want to have this genetic information."
In addition, she said, even if one of these mutations is present, initiation of mammographic screening is not recommended until the age of 25-35 years.
Among women with a family history of breast cancer, studies suggest that low-dose birth control pills do not appear to increase the risk of breast cancer beyond the underlying predisposition of these women. So consider giving low-dose birth control pills to adolescents "even when there is a family history of breast cancer or BRCA mutations," she said.
Dr. Braverman reported that she had no financial conflicts of interest relevant to her presentation.
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|Title Annotation:||CLINICAL ROUNDS|
|Date:||Nov 1, 2009|
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