Breast masses in children and adolescents

INTRODUCTION — The overwhelming majority of breast masses in children and adolescents are benign and self-limited. Nonetheless, the finding of a breast mass can be disconcerting to the patient and their family [1,2].

The common causes of breast masses in children and adolescents and the approach to the evaluation of an adolescent with a breast mass will be discussed below. An overview of other breast disorders and breast infections in children and adolescents, and the evaluation of breast lumps in adults, are presented separately:

●(See "Breast disorders in children and adolescents".)

●(See "Mastitis and breast abscess in children and adolescents".)

●(See "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass".)

BREAST EXAMINATION — Assessment of breast masses in young females can be challenging due to normal glandular variance. Initial steps in evaluation of breast masses are obtaining a detailed history and physical examination [3]. The breast examination in children and adolescents and breast self-awareness for adolescents are discussed separately. (See "Breast disorders in children and adolescents", section on 'Breast examination'.)

CAUSES OF BREAST ENLARGEMENT IN CHILDREN

Neonates and infants — Breast hypertrophy related to stimulation from maternal hormones can occur in both male and female neonates during the first few weeks of life (picture 1); it is sometimes associated with a thin milky nipple discharge ("witch's milk") [1]. Neonatal breast hypertrophy usually resolves spontaneously within two weeks in males and several months in females. However, it may persist if the breast tissue is stimulated (eg, by attempting to express the milky discharge).

Mastitis and/or breast abscess is another cause of breast enlargement in neonates. It is discussed separately. (See "Mastitis and breast abscess in infants younger than two months", section on 'Introduction'.)

Prepubertal and pubertal children

●Premature thelarche or thelarche – Breast enlargement and/or the development of a breast bud in prepubertal children may be related to thelarche (which heralds the onset of puberty) or premature thelarche. Thelarche and premature thelarche are discussed separately. (See "Normal puberty", section on 'Girls' and "Definition, etiology, and evaluation of precocious puberty", section on 'Premature thelarche'.)

●Lipomastia – In prepubertal children who are overweight or obese (ie, body mass index ≥85^th percentile for age and sex), breast enlargement may be caused by adipose tissue (lipomastia) [4]. Lipomastia is more apparent in the sitting than in the supine position. The diagnosis of lipomastia is usually made clinically: With the child in the supine position, palpation under the areola fails to detect firm glandular tissue. When the diagnosis is inconclusive, the child may be observed for four to six months for signs of pubertal progression.

●Hemangiomas and lymphangiomas – Breast enlargement in prepubertal children also may be caused by hemangiomas or lymphangiomas [2]. The diagnosis of hemangioma or lymphangioma is usually made clinically but can be confirmed with ultrasonography or magnetic resonance imaging [2]. If there is doubt about the diagnosis, a fine needle aspiration may be necessary [2]. (See "Infantile hemangiomas: Evaluation and diagnosis".)

●Other causes – Breast trauma or infection also may cause breast enlargement in prepubertal or pubertal children. They are discussed below. (See 'Breast trauma' below and 'Breast infection' below.)

BREAST ENLARGEMENT IN ADOLESCENT MALES — The evaluation and management of breast enlargement in adolescent males are discussed separately. (See "Gynecomastia in children and adolescents".)

CAUSES OF BREAST MASS IN FEMALE ADOLESCENTS — There are a number of causes of breast mass in adolescents, most of which are self-limited and benign (table 1). Some of the common benign breast lesions seen in adolescents include fibrocystic disease, fibroadenoma, breast trauma, and breast infection [5].

Less common benign breast lesions include mammary duct ectasia and cysts of Montgomery. Phyllodes tumor are usually benign, but may be malignant.

Malignant breast lesions, which are extremely uncommon in adolescents, include primary breast cancer, metastatic cancer, and secondary cancer.

Fibrocystic change — Fibrocystic changes of the breast are common in adolescents. Although the prevalence of fibrocystic changes in adolescents is not known, more than 50 percent of females of reproductive age have fibrocystic changes [6].

The etiology is unknown, but fibrocystic changes are thought to result from an imbalance between estrogen and progesterone. Some studies have suggested that caffeine worsens the symptoms, but others have failed to demonstrate this association [6-9].

Patients with fibrocystic change present with painful breast tissue before menses and report improvement during menstruation [10]. On examination, fibrotic tissue may be palpated and is generally found in the upper outer quadrants of the breast. A serosanguineous discharge may be present. Ultrasonography may be helpful in the diagnosis; mammography is not indicated for adolescents [2].

The treatment of fibrocystic change in adolescents may include [1,2,6]:

●Mild analgesia (eg, nonsteroidal anti-inflammatory agents [NSAIDS]) – In adults, danazol and tamoxifen have been effective, but these drugs have not been studied in adolescents [11-13] (see "Breast pain"). We suggest treatment with ibuprofen for adolescents.

●Oral contraceptives – Oral contraceptives improve symptoms in 70 to 90 percent of females [6].

●Elimination of caffeine – Although controlled studies have failed to demonstrate an association between caffeine and breast pain, limiting caffeine intake may provide relief for some patients [6-9].

Fibroadenoma — Fibroadenoma is the most common benign surgical breast lesion in adolescents [1,6,10,14]. The prevalence in the general population of females in their second or third decade is approximately 2 percent; the prevalence in specialty clinics ranges from 7 to 13 percent [15,16]. Fibroadenomas account for 30 to 50 percent of breast masses in adolescents in medical series and 44 to 94 percent of breast masses in surgical series [17].

Fibroadenomas typically are asymptomatic but may cause discomfort for a few days before the onset of menses. They may increase in size during pregnancy. On examination, fibroadenomas are rubbery, well circumscribed, and mobile [1]. The average size is 2 to 3 cm (range 1 to 10 cm) [6]. They are most frequently found in the upper, outer quadrants but may occur in any quadrant [1]. They have been reported to be recurrent or multiple in 10 to 25 percent of cases [10].

Fibroadenomas can be diagnosed clinically; in equivocal cases, ultrasonography and/or needle aspiration are helpful [2,18]. Ultrasonographic evaluation reveals a solid avascular mass that is well circumscribed. Mammography is not indicated to evaluate masses in the adolescent, because the large amount of glandular tissue present in adolescents makes mammography difficult to interpret [2]. Histologically, fibroadenomas consist of proliferating stroma.

Management of fibroadenomas entails careful follow-up and reassurance [2], as most fibroadenomas in adolescents decrease in size, and some completely disappear with time [5]. Fibroadenomas less than 5 cm without concerning features can be observed at one to two month intervals for growth or regression. When the mass regresses, observation at three to four month intervals (with increasingly longer intervals each time) are appropriate for up to two years while the mass is regressing [17]. If there is persistence of the lesion, an ultrasound can be obtained. If the ultrasound characteristics are entirely consistent with a fibroadenoma, the mass need not be biopsied or excised unless there is overriding clinical concern [19]. The decision to proceed with excision is based on family anxiety, history of breast cancer, and the patient's age. Most clinicians recommend excision of persistent masses as patients approach adulthood because the risk of breast cancer increases [20]. Reports of malignancy associated with a preexisting fibroadenoma in adolescents are rare [21].

However, if there is growth of the lesion, the lesion is greater than 5 cm, or the lesion persists to adulthood, excisional biopsy is warranted [2]. Disadvantages of excisional surgery include scarring at the incision site, dimpling of the breast from the removal of the tumor, damage to the breast's duct system, and mammographic changes (eg, architectural distortion, skin thickening, increased focal density).

Giant fibroadenoma — Giant fibroadenomas grow rapidly to greater than 5 cm and may compress or replace normal breast tissue [1]. Giant fibroadenomas should be excised because they cannot be easily distinguished from phyllodes tumors by physical examination, ultrasonography, or mammography [2,22].

Phyllodes tumor — Phyllodes tumor (previously called cystosarcoma phyllodes) is a rare primary tumor that typically occurs in older females but has been reported in those as young as 10 years of age [23-25]. Although phyllodes tumors are capable of a diverse range of biologic behavior, most are benign [2].

Patients present with a large breast mass that is usually painless [26]; the overlying skin may be shiny and stretched from rapid growth. A bloody discharge may be present if the nipple is involved. Ultrasonographic findings that are suggestive, but not diagnostic, of phyllodes tumors include lobulations, a heterogeneous echo pattern, and an absence of microcalcifications [22].

The recommended treatment is excision; more radical measures may be indicated for malignant lesions.

Mammary duct ectasia — Mammary duct ectasia is characterized by distention of subareolar ducts with fibrosis and inflammation [27]. A nipple discharge (multicolored, sticky) may be present [1]. If the fluid in the cyst is dark, it may appear as a blue mass under the nipple (sometimes referred to as "blue breast") [10]. Ultrasonography can be helpful in making the diagnosis (image 1) [28].

The blocked ducts can predispose to infection, leading to mastitis or breast abscess. In addition, penetration of the duct wall by lipid material may be associated with fever and acute local pain and tenderness.

Mammary duct ectasia often resolves spontaneously, sometimes with a residual subareolar nodule [20]. Surgical excision may be warranted for persistent or recurrent symptoms or an associated persistent cyst [20].

Cysts of Montgomery — The periareolar glands of Montgomery (Montgomery tubercles, also called Morgagni tubercles) (figure 1) are small papular projections at the edge of the areola that may play a role in lactation [2]. Obstruction of these glands may result in acute inflammation, an asymptomatic subareolar mass (cyst of Montgomery), and/or drainage of clear to brownish fluid [10,29,30].

The diagnosis of a cyst of Montgomery (also called a retroareolar cyst) can be made clinically. However, it may be confirmed with ultrasonography, which most commonly demonstrates a single cystic lesion located in the retroareolar area [2].

Management depends upon associated symptoms. If there are signs of infection (eg, erythema, warmth, tenderness), treatment for mastitis should be initiated. (See "Mastitis and breast abscess in infants younger than two months", section on 'Management'.)

In the absence of acute infection or other complications, cysts of Montgomery are observed with serial examination and repeat ultrasonography, if necessary [2]. More than 80 percent resolve spontaneously over weeks to months, but resolution may take up to two years [2,29]. In rare cases, drainage is necessary. Resection may be warranted if the cyst persists or the diagnosis is in question [6,10].

Breast trauma — Trauma to the breast (eg, direct blows to the breast, seatbelt injury) may result in fat necrosis, which can resemble a solid mass [1,10,31]. The radiographic and clinical significance of fat necrosis of the breast is that it can mimic a breast malignancy. Though rare in adolescents, if malignancy is suspected based on symptoms, physical findings, and imaging, biopsy may be warranted.

Breast infection — Breast infection in adolescents is discussed separately. (See "Mastitis and breast abscess in children and adolescents".)

Breast cancer

●Types of breast cancer in adolescent females

•Primary breast cancer – Primary breast cancer is exceedingly rare in children and adolescents [2,5,21,32-38]. Surveillance Epidemiology and End Results (SEER) data from 2000 to 2019 list no incident cases of breast cancer in situ in females less than 14 years and indicated an incidence of invasive breast cancer of 0.1 per 100,000 for females age under age 20 years [39].

•Metastatic cancer – In the adolescent age group, most malignant breast masses are metastatic from other cancers such as Hodgkin lymphoma, non-Hodgkin lymphoma, or neuroblastomas, hepatocellular carcinoma, and rhabdomyosarcoma [20,32,33,40-42]. Rhabdomyosarcoma is one of the most common primary cancers to metastasize to the breast, occurring in 6 percent of female patients with rhabdomyosarcoma [43]. (See "Rhabdomyosarcoma in childhood and adolescence: Clinical presentation, diagnostic evaluation, and staging".)

•Secondary cancer – Secondary cancers, including carcinomas, are another category of tumors of the breast that may occur in adolescents [44]. Secondary cancers typically occur after radiation therapy to the chest to treat another illness (eg, for Hodgkin lymphoma) [42,45].

●Clinical features – The most common examination finding of breast cancer in adolescents is a hard, irregular mass [1,32,35,46]. The mass may or may not be fixed to the underlying tissue. Additional findings may include skin or nipple retraction, skin edema (peau d'orange), nipple involvement, nipple discharge, and lymphadenopathy (axillary, supraclavicular, generalized) [38,46-48]. Metastatic breast cancer may cause dyspnea, generalized skin lesions, upper extremity swelling, back pain, hepatomegaly, and splenomegaly.

●Risk factors and counseling – Effective and accurate counseling for adolescents and their caregivers regarding breast cancer prevention should be a routine component of preventive health services for adolescents. Smoking, alcohol consumption, and limited physical activity have also been associated with breast cancer. (See "Factors that modify breast cancer risk in women".)

Risk factors for breast cancer that may affect adolescent patients include:

•Personal history of cancer – Malignancies that occur in the adolescent breast are more likely metastatic from another malignancy than primary breast cancer. In a patient with a known malignancy and an enlarging breast mass, even one with a benign ultrasound appearance, the mass should be investigated promptly with a biopsy.

•Radiation exposure and childhood cancer – Exposure to ionizing radiation (eg, radiation therapy to the chest) and childhood cancer are risk factors for secondary breast cancer in adolescents. Guidelines for survivors of childhood cancer generally recommend that females who received chest radiation during treatment for childhood cancer begin breast cancer surveillance with mammography or magnetic resonance imaging eight years after treatment or at age 25 years, whichever occurs last [49,50]. (See "Factors that modify breast cancer risk in women", section on 'Exposure to therapeutic ionizing radiation' and "Overview of cancer survivorship care for primary care and oncology providers", section on 'Screening for subsequent primary cancers'.)

APPROACH TO BREAST MASS IN THE FEMALE ADOLESCENT PATIENT — The majority of adolescent patients who present with a breast mass have normal physiologic breast tissue or fibrocystic changes; breast cancer is extremely rare [10]. For most adolescent patients who present with a breast mass, after a careful history and examination to rule out life-threatening disease, it is reasonable to observe the mass through one or two menstrual cycles [6,32,51]. This approach is based on the observations that most adolescents who present to their primary care clinician with breast lumps have normal nodularity or fibrocystic change, and that most breast masses that are surgically excised are fibroadenomas [10].

History and examination — Important aspects of the history and examination for the adolescent patient with a breast mass include (table 2) [10,46]:

●Characteristics of the mass

•Duration – Affects management. (See 'Subsequent management' below.)

•Size and changes in size over time – Fibroadenomas are generally smaller (average 2 to 3 cm) than phyllodes tumors (average 7 cm); enlarging solid masses may indicate malignancy.

•Consistency (cystic versus solid).

-Mammary duct ectasia and cysts of Montgomery are generally cystic.

-Fibroadenoma, phyllodes tumors, fat necrosis, and malignant breast tumors are generally solid.

•Mobility – Fibroadenomas are usually mobile, whereas malignant breast tumors are usually (but not always) fixed to the underlying tissue.

•Tenderness – Tenderness may be present before the onset of menses in adolescents with fibrocystic change and fibroadenoma. Tenderness also may occur in patients with infection, trauma, or mammary duct ectasia with blocked ducts.

•Overlying skin changes – Overlying skin changes may occur in large fibroadenomas (prominent superficial veins), infection (erythema, warmth), phyllodes tumors (the skin is shiny and stretched from rapid growth), and in breast cancer (peau d'orange, retraction).

●Associated findings

•Nipple discharge (see "Breast disorders in children and adolescents", section on 'Nipple discharge'):

-Nonbloody green or brown – Fibrocystic disease.

-Clear to brown – Cysts of Montgomery.

-Multicolored, sticky – Mammary duct ectasia.

-Bloody – Phyllodes tumor, breast cancer.

-Purulent – Infection.

•Appearance of the nipple:

-The nipple may appear to be blue or to have a blue mass under it in patients with mammary duct ectasia.

-Nipple retraction may occur in patients with breast cancer.

•Fever – May be present in breast infection or mammary duct ectasia with penetration of the duct wall.

•Lymphadenopathy – Lymphadenopathy may be present in patients with breast infection (axillary) or cancer (axillary, supraclavicular, generalized).

•Hepatomegaly and/or splenomegaly – May be an indication of metastatic cancer.

●Additional history

•Previous breast disease – Fibroadenomas may recur.

•Previous or intercurrent malignancy or chest irradiation – Metastatic breast cancer, secondary breast cancer.

•Pregnancy history – Fibroadenomas may increase in size during pregnancy.

•Use of oral contraceptive pills – May improve symptoms associated with fibrocystic change.

•Family history of breast cancer – Having a first-degree relative with breast cancer increases the risk of breast cancer. (See "Factors that modify breast cancer risk in women", section on 'Personal and family history of breast cancer'.)

Imaging — Imaging may be necessary to differentiate cystic from solid masses or if the mass persists for more than one or two menstrual cycles (image 2). Ultrasonography is the preferred imaging modality for breast masses in adolescents because of the increased density of the adolescent breast; the large amount of fibroglandular tissue makes mammography difficult to interpret [14,20,28,41,52]. Thus, mammography is not recommended in the evaluation of breast masses in adolescents.

The accuracy of ultrasonography in differentiating solid from cystic lesions is 96 to 100 percent [53-56]. Ultrasonography also can be helpful in differentiating a fibroadenoma from a simple cyst or galactocele and in determining the extent of a breast abscess [10,52].

Subsequent management

●Cystic breast lesions – Cystic breast lesions (eg, related to fibrocystic changes, mammary duct ectasia, cysts of Montgomery) typically resolve spontaneously over weeks to months.

Cystic breast lesions that are suspected to be caused by infection (eg, breast abscess) require prompt drainage and/or treatment with antibiotics. (See "Mastitis and breast abscess in children and adolescents", section on 'Management'.)

Cystic breast lesions that are not suspected to be caused by infection may be observed for one menstrual cycle with close follow-up. If the lesion persists, ultrasonography should be performed to confirm that the lesion is cystic rather than solid. After observing a cystic breast lesion for at least one menstrual cycle, needle aspiration maybe indicated but is rarely necessary in children and adolescents [10]. Aspirated fluid that is clear may be discarded [2]. Bloody fluid and other aspirated material should be sent for cytology [2,10,57]. Lesions that resolve with aspiration are assumed to be due to a cyst and should be reevaluated for recurrence three months after aspiration [10].

Surgical resection (excisional biopsy) may be warranted for cystic lesions that do not resolve with aspiration or when aspiration is not productive or not feasible [10].

●Solid breast masses – Excisional biopsy may be warranted for solid masses that are suspicious for malignant breast cancer. Suspicious solid lesions include those that are:

•Nonmobile.

•Hard.

•Enlarging.

•Associated with skin changes, hepatomegaly, splenomegaly, lymphadenopathy or symptoms (eg, dyspnea, generalized skin lesions, upper extremity swelling, back pain).

•A source of considerable anxiety for the patient and caregivers.

Asymptomatic solid breast masses that are consistent with a fibroadenoma and <5 cm can be observed at one- to two-month intervals [10]. Those that are ≥5 cm should be excised because giant fibroadenomas are difficult to differentiate from phyllodes tumors on examination or imaging. (See 'Fibroadenoma' above and 'Giant fibroadenoma' above and 'Phyllodes tumor' above.)

SUMMARY

●Causes of breast enlargement in infants and children

•Neonates

-Stimulation from maternal hormones (see 'Neonates and infants' above)

-Infection (picture 1) (see "Mastitis and breast abscess in infants younger than two months")

•Prepubertal and pubertal children (see 'Prepubertal and pubertal children' above)

-Breast buds as a sign of premature thelarche or thelarche (see "Normal puberty")

-Adipose tissue (lipomastia)

-Hemangioma or lymphangioma

-Breast trauma or infection (see 'Breast trauma' above and "Mastitis and breast abscess in children and adolescents")

●Causes of breast mass in female adolescents

•Most of the causes of breast mass in female adolescents are self-limited and benign (table 1). (See 'Causes of breast mass in female adolescents' above.)

•Fibroadenoma is the most common breast lesion in adolescents. Fibroadenomas are rubbery, well-circumscribed, mobile masses with an average size of 2 to 3 cm. They may cause discomfort for a few days before the onset of menses. (See 'Fibroadenoma' above.)

•Breast cancer is exceedingly rare in children and adolescents. Predisposing factors include a personal history of cancer and exposure to ionizing radiation. (See 'Breast cancer' above.)

●Evaluation and management of breast masses in female adolescents

•The initial approach to the adolescent patient with a breast mass includes a careful history and physical examination (table 2). (See 'History and examination' above.)

•Imaging may be necessary to differentiate cystic from solid masses or if the mass persists through more than one menstrual cycle. Ultrasonography is the preferred imaging modality for breast masses in adolescents. (See 'Imaging' above.)

•The subsequent management of the adolescent with a breast mass depends upon whether the mass is cystic or solid. (See 'Subsequent management' above.)

-Aspiration may be warranted for persistent cystic lesions.

-Excisional biopsy may be warranted for cystic lesions that do not resolve with aspiration, when aspiration is not productive or not feasible, and for suspicious solid lesions (eg, those that are nonmobile; hard; enlarging; associated with overlying skin changes (peau d'orange), hepatomegaly, splenomegaly, lymphadenopathy, dyspnea, generalized skin lesions, upper extremity swelling, or back pain).