Paediatric Grand Round

BREAST LUMP
Case

 16 years old girl

 Weight: 64.5kg, height: 161.6cm (BMI 24.88)
 Referred by GP in July, seen in Paeds clinic in November
 Several months history of right breast lump, possibly up to 1 year
What else would you ask?

 Increase in size over the last few months

 Affects right side only
 No skin changes, no nipple discharge, no cyclical changes
 Menarche at age of 11, regular but painful periods
 No weight loss
 No symptoms of abdominal pain, vomiting or diarrhoea
 Dark skin spots on neck and arms – non itchy
History

 Nil significant past medical history. Nil regular medications.

 No concern of growth and development
 No family history of breast lumps or cancer
 Moved to UK from Carribean 1 year ago
 Lives with aunt and 3 cousins
 Working towards GCSEs at school
Physical exam

 No palpable cervical, axillary or inguinal lymph nodes

 Increased pigment on back of neck and antecubital fossa
 Left breast normal
 Right breast- 5cm diameter, firm mobile lump. Irregular border. No dimpling. Non tender.
No skin tethering.
 Rest of exam- cardiac, respiratory and abdominal exam normal.
Diagnosis

 Fibroadenoma
 Planned for excision
Statistics

 10% of referrals to Breast clinic are under age of 18, of which less than 1% under age of
10
 Affects 3.2% of teenage girls
Normal breast development

 Starts at 5-6th week gestation

 Normal involution except 4th intercostal space
 Primary breast buds evolve and branch into
lactiferous ducts
 Formation of mammary pits> nipple- areolar
complex
Assessment

 History
 Duration and size of mass
 Associated symptoms – nipple discharge, pain
 Previous breast disease
 Chronology of development of secondary sexual characteristics
 Menstrual history
 Pregnancy history
 Medication
 Family history of breast disease/ cancer
Assessment

 Examination
 Location – fibrocystic disease in upper outer quadrant, others subareolar
 Consistency cystic vs solid
 Size (?changes during menstrual cycle)
 Mobility of mass ?thetered
 Tenderness
 Overlying skin changes (peau d’orange, retraction)
 Nipple discharge and appearance
 Hepatosplenomegaly
 Lymphadenopathy
Newborn

 Asymmetry, milky discharge > benign, stimulation from maternal hormones

 Resolves within two weeks for boys, several months in girls
 Polythelia > associated with renal abnormalities
 Athelia/ amastia> rare, associated with other syndromes
Young children

 Premature thelarche (idiopathic)

 Two peaks - before two years, age 6-8
 Isolated breast development, not beyond Tanner stage 3
 absence of other sexual characteristics, normal height/weight, normal bone age
 Lipomastia
 Due to adipose tissue (in obese or overweight children)
Adolescents

 Fibroadenoma
 Imbalance of hormones
 Rubbery, well circumscribed, mobile, upper outer quadrant
 Can present with pain pre-menses, improves during menstruation
 Mastitis, abscess
 Erythema, tenderness, warmth, purulent discharge
 Trauma, piercing

 Rare causes: mammary duct ectasia, cyst of Montgomery, Phyllodes tumour

 Primary breast cancer extremely rare- no incident case in less than 14; as low as 0.2 per 100,000 age 15-19
Investigations

 Ultrasound is the main choice of imaging modality

 Mammography plays no significant role
 Exposure of breast tissue to ionizing radiation
 Paediatric breast tissue are extremely dense- reducing overall sensitibbity
 Incidence of primary breast cancer extremely low in paediatric population
 MRI can be useful but not validated for paediatric population.
Management (fibroadenoma)

 If less than 5cm

 Follow up and reassure
 Mild analgaesia
 Oral contraceptives
 More than 5cm
 Consider excision
Take home messages

 Most breast lumps are benign

 Ultrasound is the primary imaging modality
 Premature thelarche in secondary sexual characteristics – consider alternative cause
References

 Banikarim, C., De Silva, N.K. and Middleman, A.B., 2020. Breast disorders in children
and adolescents. UpToDate. Waltham, MA: UpToDate Inc.
 Association of breast surgery. Guidance and pathway for the assessment of children with
breast symptoms.