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Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

How to approach breast lesions in children and adolescents

Yiming Gao a,b,∗ , Mansi A. Saksena b , Elena F. Brachtel b , Deborah C. terMeulen b ,
Elizabeth A. Rafferty b
a
New York University Langone Medical Center, 221 Lexington Ave., New York, NY 10016, USA
b
Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA

a r t i c l e i n f o a b s t r a c t

Article history: Assessment of a pediatric breast lesion always starts with clinical evaluation. When imaging of a pediatric
Received 16 October 2014 breast is indicated, ultrasound is the mainstay. The vast majority of pediatric breast complaints are of
Received in revised form 10 April 2015 benign etiology, therefore the diagnostic/management approach emphasizes “first do no harm”. Correla-
Accepted 11 April 2015
tion with age and clinical history helps to direct diagnosis. It is essential to be familiar with the imaging
appearance of the normal developing breast at various Tanner stages, in order to diagnose physiologic
Keywords:
breast findings and to minimize unnecessary biopsies in young breasts vulnerable to injury. Normal
Pediatric breast lesions
anatomic structures, developmental conditions, benign neoplastic and non-neoplastic lesions are com-
Breast evaluation in children and
adolescents
mon causes of breast complaints in children. Uncommon benign masses and rarely, secondary more than
Developing breast primary malignancies may present in a pediatric breast. Chest wall masses such as Ewing’s sarcoma or
Breast cancer in children rhabdomyosarcoma occur in children and may involve the breast via contiguous growth or locoregional
Breast ultrasound metastasis. In addition, special attention should be given to any breast lesion in a child with risk factors
predisposing to breast cancer, such as known extramammary malignancy, genetic mutations, prior man-
tle irradiation, or strong family history of breast cancer, which usually requires biopsy to exclude the
possibility of malignancy.
Conclusion: The developing breast is vulnerable to injury, and because breast malignancy is uncommon
in children, diagnostic and management approach emphasizes “first do no harm”. Understanding normal
breast development and the spectrum of common and uncommon pediatric breast lesions are key to the
correct diagnosis.
© 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Clinical evaluation is an essential component of complete

The relatively high prevalence of adult breast cancer is the
source of worry in many parents of children with breast complaints.
One in every eight women in the United States develops invasive
breast cancer during her lifetime [1]. Yet breast cancer hardly ever
afflicts children or adolescents. For example, the reported preva-
lence of breast cancer in females under the age of 20 is well below
0.1 per 100,000 [2].
With that in mind, a tailored diagnostic and management
approach is necessary for pediatric breast complaints. Furthermore,
because the developing breast is uniquely vulnerable to iatrogenic
injury, which can lead to permanent disfigurement, biopsy should
be reserved only for lesions of high suspicion.
∗ Corresponding author at: 221 Lexington Ave., New York, NY 10016, USA.
Tel.: +1 203 606 9310.
E-mail address: yiminggao@gmail.com (Y. Gao).
assessment of pediatric breast complaints. With pertinent his-
tory and physical exam, many pediatric breast complaints can
be correctly categorized as normal developmental processes or
physiologic changes, which require only reassurance. Occasionally,
imaging can be helpful in confirming a normal finding such as an
asymmetric breast bud, or may be necessary when an abnormality
is suspected. When necessary, ultrasound is the primary imaging
modality used in assessing breast lesions in children, given its diag-
nostic specificity and lack of ionizing radiation. Mammography is
seldom used, but is the modality of choice to visualize calcifica-
tions in select cases. Cross-sectional imaging modalities such as
CT or MR are usually reserved for evaluation of disease extent and
occasionally, problem solving.
The vast majority of pediatric breast complaints are of benign
etiology. Normal anatomic structures can mimic breast masses.
Non-neoplastic benign entities in the pediatric breast include
cyst, hematoma, mastitis/abscess, and galactocele. Clinical history
helps clinch the diagnosis in some of these cases. The most com-
mon benign solid mass in the pediatric breast is a fibroadenoma.

http://dx.doi.org/10.1016/j.ejrad.2015.04.011
0720-048X/© 2015 Elsevier Ireland Ltd. All rights reserved.

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A 2–3 cm probably benign mass on ultrasound in a child with-
out atypical features or rapid enlargement is rarely malignant and
is safe to follow, as has been shown in multiple studies. Biopsy
should be considered however if the mass is larger than 4–5 cm
or undergoing rapid enlargement, to exclude the possibility of a
phyllodes tumor. Other rare benign masses in the pediatric breast
include hamartoma, intraductal papilloma, juvenile papillomatosis
(a marker for familial breast cancer), and fibrous nodule. Malignant
lesions in the pediatric breast are exceedingly rare, more com-
monly metastatic disease to the breast and occasionally primary
breast malignancy. Phyllodes tumor is the most common primary
breast malignancy in children. Invasive ductal carcinoma is rare in
children, of which the secretory subtype is the most common. In
young people with risk factors predisposing to breast cancer, such
as strong family history of breast cancer, known extramammary
malignancy, genetic mutations, or prior mantle irradiation, biopsy
is often required to exclude malignancy regardless of the imaging
appearance of the breast lesion.
In this article, we will review embryology and development
of the breast, discuss the appropriate imaging and management
approach of pediatric breast complaints, and explore the spectrum
of common and uncommon pediatric breast lesions.
2. Imaging approach to the pediatric breast
Because pediatric breast cancer is so rare, diagnostic imaging
emphasizes “First Do No Harm”. Evaluation of pediatric breast
complaints always begins with clinical assessment, which then
determines the need for imaging. Ultrasound remains the primary
and often the only necessary modality for the evaluation of breast
complaints in the pediatric population, given its high sensitivity
for detection of lesions in younger denser breasts [3] and the lack
of ionizing radiation. In contrast, the utility of mammography is
limited in the pediatric population, both due to low diagnostic sen-
sitivity in young and dense breasts, and radiation risks associated
with mammography in this age group. MRI and other cross sec-
tional imaging modalities are generally reserved for assessment of
disease extent, for assessment of deep chest wall lesions or vascular
anomalies, or occasionally for correlation with ultrasound findings.
Breast Imaging Reporting and Data System lexicon (currently
5th edition) is the gold standard for describing and stratifying
breast lesions into categories which correlate with likelihood of
malignancy by imaging appearance (Table 1). Although this is used
both in adults and in children, because it is based on the likelihood
of malignancy, which is exceedingly low in children [2], its utility
may be limited in this setting. For example, the vast majority of
pediatric breast lesions are benign and will be categorized BIRADS
2 or 3, emphasizing appropriate conservative management to “First
Do No Harm”. Highly suspicious lesions or lesions in high risk pedi-
atric patients may warrant biopsy and are categorized BIRADS 4 or
above, but are few and far in between.
3. Normal breast development
The breast begins normal development during the 5–6th week
of fetal gestation [4], with ectodermal cells invaginating into the
deeper mesenchyme to form the mammary ridges or milk lines,
which extend symmetrically along the anterior torso from the axil-
lae to the groin (Fig. 1). Over time, there is normal involution
of the milk lines except at the level of the 4th intercostal space,
where normal breast buds form. If normal involution is incom-
plete, ectopic or accessory nipples and/or breast tissue may form
anywhere along these milk lines. At the 4th intercostal space, the
primary breast buds (invaginated epidermal cells) evolve into sec-
ondary buds and further branch into lactiferous ducts within the
breast parenchyma. Overlying the breast bud at the skin surface, a
small depression or mammary pit forms, which further evolves into
the nipple–areolar complex (Fig. 2). Prior to puberty, the breast is
composed of epithelium lined lactiferous ducts supported by stro-
mal connective tissue [5]. Enlargement of these ducts are a common
cause of self-limited bilateral palpable subareolar nodules in both
male and female infants in the first 6–12 months of life due to
maternal hormonal influence [6].
With the onset of puberty, the breast undergoes further matura-
tion. The term thelarche refers to the onset of normal pubertal phase
of breast development in females, with estrogen stimulating ductal
growth and progesterone promoting lobular and alveolar differen-
tiation, completing the terminal duct lobular unit. The normal age of
onset of thelarche in the U.S. ranges between 9 and 10 years of age,
with the average onset of thelarche in African American girls gener-
ally being earlier compared to that in Caucasian girls [7]. Premature
thelarche therefore, is defined as early onset of breast development
in prepubertal girls, typically before age 7–8. Thelarche after 12
years of age is considered delayed [8].
Idiopathic premature thelarche generally occurs in younger
children between ages 1–3 [6], and is unusual after age 4 [9]. Idio-
pathic premature thelarche is benign and generally self-limited.
This can however mimic a mass when unilateral, and thus fre-
quently comes to clinical attention. The role of ultrasound is to
confirm the presence of normal developing breast tissue or the-
larche (whether premature or appropriate), in the absence of
a discrete mass. Clinical reassurance and followup usually suf-
fice for idiopathic isolated premature thelarche, but occasionally
short term imaging followup may be appropriate. Other possible

Table 1
BI-RADS assessment categories and likelihood of cancer. American College of Radi-
ology BI-RADS© Atlas 2013.

BI-RADS Assessment Likelihood of cancer

category

0 Incomplete – need additional imaging N/A

evaluation
1 Negative Essentially 0%
2 Benign Essentially 0%
3 Probably Benign >0%, ≤2%
4 Suspicious >2%, <95%
5 Highly suggestive of malignancy ≥95%
6 Known biopsy-proven malignancy N/A
Fig. 1. Milk lines or Milk ridges (Y. Gao).

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Fig. 2. Breast development – Ectodermal cells invaginate to form the primary breast bud, which branches into secondary buds, and then subsequently branch and elongate
further to form the lactiferous ducts. Externally a mammary pit or indentation is formed in the skin, which evolves into the nipple areolar complex (Susanne Loomis, MS,
FBCA of MGH REMS Media Service).

Fig. 3. Clinical tanner stages of normal breast development (Susanne Loomis, MS, FBCA of MGH REMS Media Service).

factors linked to isolated premature thelarche include high body
mass index [10] and herbal intake [11].
Premature thelarche can also occur in conjunction with preco-
cious puberty. It is important to ensure that there are no other signs
of sexual maturation associated with premature thelarche such
as development of axillary and pubic hair, in which case further
imaging and laboratory workup would be indicated to exclude hor-
monally active adrenal or gonadal neoplasms as potential causes for
precocious puberty.
There are five Tanner stages of normal pubertal breast devel-
opment based on the clinical appearance of the developing breast
(Fig. 3). Ultrasound appearances of the breast at various Tan-
ner stages have been well described and familiarity with these
appearances is critical for the radiologist performing pediatric
breast evaluation [6,12]. Sonographically, the Tanner stage 1 breast
appears as mildly heterogeneous retroareolar tissue. The Tanner
stage 2 breast appears as a hyperechoic nodule with central lin-
ear or stellate areas of hypoechogenicity which represent evolving
ductal structures. Tanner stage 3 and 4 breast tissues demonstrate
appearance of further expansion of the hyperechoic fibroglandular
elements, with the central retroareolar hypoechoic regions evolv-
ing into more branching and eventually nodular configurations. The
Tanner stage 5 breast shows the appearance of mature echogenic
breast tissue without central hypoechogenicity, as seen in the adult
breast.
4. Common causes of pediatric breast complaints
4.1. Normal anatomic structures
4.1.1. Normal lymph node
Normal lymph nodes reside in the axilla, axillary tail, and
breast parenchyma, and can become clinically palpable. Intra-
mammary lymph nodes are most commonly found in the upper
outer quadrants of the breasts. A prominent node in an otherwise
healthy young patient is most commonly due to reactive nodal

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Fig. 4. 17 year old girl with prominence of left axillary tail following intended weight
loss. Ultrasound was performed of the left axilla in the area of clinical concern,
demonstrating a normal lymph node with hypoechoic cortex of normal thickness
(<3 mm) and hyperechoic central fatty hilus.
hypertrophy, or occasionally from relative loss of soft tissue sur-
rounding a lymph node (for example, weight loss), causing it
to become clinically more prominent. Ultrasound is definitive in
the identification of a normal lymph node, which appears as a
bean shaped or oval structure with hypoechoic sub-3-mm cor-
tex and echogenic central fatty hilus (Fig. 4). Hilar vascular flow
is helpful for diagnosis at real time sonography. A normal lymph
node is a benign finding and clinical followup suffices. The typical
appearance of reactive nodal hypertrophy is mild diffuse cortical
thickening. Common causes of reactive axillary lymphadenopathy
include viral illness and vaccination, both frequently encountered
in children. Sonographic evidence of abnormal findings such as
eccentric cortical thickening or displacement of central fatty hilum
suggest possible malignant nodal involvement and warrant tissue
sampling.
4.1.2. Normal breast bud
Asymmetric normal breast development is a common cause of
unilateral subareolar mass in children. Asymmetry between the
breast buds is common, with differences of up to 2 years in the
phase of development between the breasts considered to be within
the normal spectrum [12]. Ultrasound may be performed to con-
firm the presence of normal breast buds and the absence of other
abnormalities (Fig. 5). Early development of the breast bud is called
premature thelarche, which is most common in children under
age 3. Benign isolated premature thelarche usually regresses on
its own. Imaging findings of normal or premature development of
breast buds are similar. Ultrasound shows subareolar hypoechoic
stellate breast tissue without associated mass (Fig. 5). Although
CT is not indicated in this setting, normal breast asymmetry
Fig. 6. 3 year old boy with rhabdomyosarcoma and normal asymmetric breast buds
(arrows) on post treatment surveillance CT.
incidentally noted on CT performed for another indication can occa-
sionally lead to concern for a breast mass (Fig. 6). It is important to
be familiar with the appearances of normal breast buds at differ-
ent stages of evolution in order to avoid unnecessary biopsy which
places the young patient at risk for iatrogenic hypomastia or amas-
tia. Once benign breast bud asymmetry is confirmed, clinical follow
up is appropriate. Further imaging is usually not indicated.
4.1.3. Osseous structures
Osseous structures can occasionally account for areas of clinical
concern in the region of the breast, particularly in thin patients or
patients with rib and chest wall deformities such as pectus exca-
vatum, pectus carinatum, or in the setting of Poland syndrome
(Fig. 7). Clinical exam usually reveals a fixed firm mass contigu-
ous to the remainder of bony structures. If uncertainty remains
after physical examination, chest radiography could obtained to
assess for osseous abnormalities, and ultrasound can be performed
to evaluate the focal area of concern and to exclude a mass or other
abnormality.
Poland syndrome is an autosomal recessive disorder, marked
by unilateral partial or complete absence of the pectoralis mus-
cle, associated with breast hypoplasia or aplasia, rib and chest wall
deformities, as well as ipsilateral limb abnormalities (Fig. 8). It is
important to recognize that breast cancer occurs in the hypoplas-
tic breast in a patient with Poland syndrome, and that routine
mammographic screening is indicated in these patients in adult-
hood [13–15]. Of the reported cases of breast cancer in the setting

Fig. 5. 5 year old boy with mobile subareolar right breast mass discovered by mother. Ultrasound demonstrates asymmetric but normal breast buds, right larger than left.
There is no mass in the subareolar right breast in the area of clinical concern.

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Fig. 7. 17 year old girl with Poland syndrome notes a firm lump along the right sternal border. (a) Ultrasound shows a hypoechoic shadowing structure at the right
costomanubrial junction, felt to be related to the thoracic skeleton. (b) Chest radiograph demonstrates near complete absence of the right breast shadow consistent with
Poland syndrome and confirms the source of clinical concern to be a normal anterior rib.
Fig. 8. MLO mammographic views demonstrate absence of the left pectoralis major
muscle and left breast hypoplasia in a patient with Poland syndrome.
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5
of Poland syndrome, the vast majority involve the ipsilateral
hypoplastic breast [13–15].
4.2. Developmental abnormalities
4.2.1. Ectopic breast tissue
Ectopic or accessory breast tissue refers to breast tissue located
somewhere other than the expected location of the normal breast
in the 4th intercostal space, usually along the mammary ridge or
milkline, which extends from the axilla to the vulva. The ectopic
breast tissue represents incomplete involution of the ectodermal
mammary ridge (embryonic progenitors to breast tissue). Ectopic
breast tissue may contain some or all of the components of the
mammary gland, including glandular tissue, areola, and nipple.
Both benign and malignant breast masses arising from ectopic
breast tissue have been described in the literature. Because ectopic
breast tissue is responsive to hormonal influence as much as nor-
mal breast tissue, it is a common source of clinical complaints of
swelling and discomfort, including in children and adolescents. The
most common site of ectopic breast tissue is the axilla [16]. Approx-
imately 2–6% women have axillary ectopic breast tissue [17]. On
ultrasound, ectopic axillary breast tissue appears as a heteroge-
neously echogenic area of focal tissue, similar in sonotexture to
normal breast parenchyma [18] (Fig. 9). It is important to be famil-
iar with the sonographic appearance of ectopic breast tissue, as
recognition and correct diagnosis obviate the need for interven-
tion, particularly in children and adolescents. On mammography
(despite limited utility in children), ectopic axillary breast tis-
sue is best visualized on mediolateral oblique and exaggerated
craniocaudal views and appears as fibroglandular density sepa-
rate from the dominant breast mound overlying the pectoralis
muscle.
4.2.2. Gynecomastia
Gynecomastia is excess breast tissue development in males,
which can present clinically as subareolar tenderness and or a
palpable mass. It can be unilateral or bilateral, and it has been
reported to be familial. The cause of gynecomastia is unknown but
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Fig. 9. 20 year old woman with enlarging left axillary lump. Ultrasound of the left
axilla demonstrates focal area of normal fibroglandular tissue.
Fig. 10. 17 year old boy with right subareolar tender swelling. Ultrasound of the
right breast shows prominent fibroglandular tissue directly deep to the nipple,
consistent with gynecomastia.
thought to be related to relative elevation of circulating estrogen
with respect to testosterone. In adults, gynecomastia may be idio-
pathic or has been associated with chronic liver disease, excess
body fat, marijuana or exogenous steroid intake, or medications
such as cimetidine, digitalis, and tricyclic antidepressants. In chil-
dren, gynecomastia is often physiologic and is most common in
neonates and adolescents. Up to 90% of neonates have transient
breast hypertrophy due to maternal hormonal influence [3], and
clinical reassurance usually suffices. During puberty, gynecomas-
tia is present in up to two thirds of 10–13 year old boys [19],
which usually subsides within two years, and clinical followup is
appropriate. Ultrasound is the modality of choice in children, and
typically demonstrates increased retroareolar fibroglandular tissue
similar to the appearance of the early developing female breast
(Fig. 10), consistent with gynecomastia. In adult males, mammo-
grams are diagnostic for gynecomastia, most commonly showing
retroareolar flame shaped breast tissue.
If however gynecomastia presents in prepubertal boys, other
causes should be considered. Estrogen producing tumors such
as testicular Leydig cell tumor, adrenal cortical tumor, or
gonadotropin secreting tumors such as hepatoblastoma, fibro-
lamellar hepatocellular carcinoma, or choriocarcionoma can
cause gynecomastia. Other causes include prolactinoma, testi-
cular feminization, Klinefelter syndrome, neurofibromatosis type 1,
medications, and herbal remedies [3,6]. In prepubertal boys, clin-
ical exam suggestive of gynecomastia should prompt correlation
with clinical history and further imaging and laboratory exams to
exclude underlying disease.
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4.3. Non-neoplastic lesions
4.3.1. Cyst
Cysts (within the spectrum of fibrocystic change) in the breast
are most common in women between ages 35–50, but they can
also occur in children and adolescents [8]. Cysts may arise from
dilatation of the lobular acini possibly due to imbalance of fluid
secretion and resorption, or due to obstruction of the duct lead-
ing to the lobule [20]. Cysts are more commonly solitary than
multiple in children [6], and can often present as a palpable abnor-
mality in the breast, occasionally associated with tenderness when
associated with inflammation or infection. Most cysts are treated
conservatively, with some rarely requiring antibiotic therapy or
drainage if infection is suspected. On ultrasound, if a simple cyst
is demonstrated as an anechoic structure with imperceptible wall
and posterior acoustic enhancement (Fig. 11), benign diagnosis
is confirmed and no further imaging or intervention is indicated.
However if the cyst appears to be thick walled and or contains
internal echoes, diagnostic considerations should include a com-
plicated cyst, an abscess, a galactocele, or focal duct ectasia in the
appropriate clinical contexts.
4.3.2. Hematoma
A hematoma is an area of localized hemorrhage. In children
and adolescents, hematomas in the breast are often seen in con-
junction with sports injuries, iatrogenic trauma, or activity related
injuries such as bike handle bar injury. A clear history of trauma
and careful physical exam for signs of superficial bruising over the
breast help confirm the diagnosis. On ultrasound, a hematoma can
appear as a solid or complex cystic mass. Sonographic appearance
of a hematoma varies depending on the age of the blood products.
More acutely, a hematoma appears hyperechoic. It becomes pro-
gressively more anechoic as it regresses over time [21]. Because
blood products can incite reactive changes, a hematoma can
have irregular or even spiculated margins, mimicking malignancy
(Fig. 12). This highlights the importance of a thorough clinical his-
tory and a careful clinical exam, which can obviate unnecessary
biopsy. When the diagnosis of hematoma is established, short-term
follow up by ultrasound is recommended to ensure resolution.
4.3.3. Abscess
Although more commonly encountered in lactating women,
mastitis and abscess can occur in childhood. Mastitis occurs most
frequently in infants (age < 2 months; i.e. mastitis neonatorum)
and later childhood (age 8–17), and is thought to be related to
skin infection and or ductal obstruction [22]. Typically, suppura-
tive mastitis presents with edema and erythema, occasionally with
fever and leukocytosis. Ongoing mastitis can lead to the devel-
opment of phlegmon and abscess. The most common pathogen
is Staphylococcus aureus, followed by Streptococcus and less com-
monly Enterococcus species [22]. Ultrasound should be performed
Fig. 11. 17 year old girl presents with persistent “nodule” in the upper outer right
breast. Ultrasound shows a nonvascular circumscribed thin-walled anechoic struc-
ture with posterior acoustic enhancement, consistent with a simple cyst.
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Fig. 12. 15 year old girl with known sports related trauma to the chest presents with
an area of palpable concern. Targeted ultrasound to this site of trauma demonstrates
a non-vascular irregular anti-parallel predominantly hypoechoic mass, with mild
adjacent soft tissue induration, consistent with hematoma. This resolved completely
on the follow up ultrasound six weeks later.
in patients with clinical symptoms of infection to exclude presence
of a drainable fluid collection. The ultrasound typically shows skin
thickening and hyperechoic indurated breast tissue associated with
hyperemia (mastitis). Occasionally, a hypoechoic complex mass
(phlegmon or developing abscess), or an organized thick walled
complex fluid collection is present (frank abscess) (Fig. 13). Treat-
ment includes antibiotic therapy and prompt ultrasound guided
drainage, which helps facilitate healing and provides material for
culture and sensitivity testing to further tailor therapy.
4.3.4. Galactocele
Galactoceles are retention cysts of milky fluid in the breast,
most commonly seen in pregnant, lactating, or early post lacta-
tional women, but can occasionally present in children and young
infants with or without endocrinopathy [3,6]. A galactocele likely
results from occlusion of a lactiferous duct, therefore histologi-
cally represents a cyst with walls lined by cuboidal to columnar
epithelium [31]. Galactoceles can persist up to several years post
lactation. Sonographically, a galactocele appears as a complex cys-
tic mass with variable internal echotexture depending on the
relative milk (hyperechoic) versus water (hypoechoic/anechoic)
Fig. 14. 15 year old Somali refugee who is 1 month postpartum and breast feed-
ing, presents with right breast lump. Ultrasound shows a circumscribed oval cystic
mass of mixed internal echogenicity, in the setting of breast feeding, suggestive of
fatty milky contents. This was aspirated for symptom relief, yielding milky fluid,
consistent with a galactocele.
contents (Fig. 14). Occasionally, a fat-fluid level may be present,
which is visualized on ultrasound as well as on mammography.
This is diagnostic of a galactocele. Clinical history and imaging
appearance often suggestive the diagnosis. Aspiration of milky fluid
confirms the diagnosis of a galactocele in the setting of complex and
or atypical imaging appearance, and provides symptomatic relief.
4.4. Benign masses
4.4.1. Fibroadenoma
Fibroadenomas are benign fibroepithelial tumors and are the
most common solid breast masses found in adolescent girls [23].
Because fibroadenomas arise from proliferation of specialized con-
nective tissue stroma surrounding breast lobules, they do not
usually occur in the male breast where lobules are typically
absent, although male fibroadenomas have been reported in rare
cases. Fibroadenomas are estrogen sensitive tumors and may grow
rapidly during puberty and pregnancy. The classic clinical presen-
tation of a typical fibroadenoma is a nontender palpable mobile
rubbery mass usually 2–3 cm in size [24] (Fig. 15). At ultrasound,
fibroadenomas are usually parallel, circumscribed, oval hypoechoic
masses, but may exhibit macrolobulations and become irregular in
shape as they grow into larger masses [25]. A pseudocapsule may
be seen in certain cases [25] (Fig. 15). The internal echotexture

Fig. 13. 14 year old girl with left areolar swelling, redness, pain, and fever for 1 week. Targeted ultrasound to the periareolar left breast demonstrates skin thickening and an
underlying complex fluid collection, consistent with abscess (a, b). The abscess was drained to completion under ultrasound guidance (c), yielding 3–4 cc of purulent fluid.
This was sent for culture and grew Staphylococcus Aureus.

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Fig. 15. 16 year old girl with hard lump in the right breast. Ultrasound shows a cir-
cumscribed oval mass of heterogeneous internal echotexture and a pseudocapsule.
Surgical excision was performed for histologic confirmation, yielding fibroadenoma.
of fibroadenomas can be either homogeneous or heterogeneous.
Posterior acoustic features vary.
Although in the past most palpable solid breast masses under-
went biopsy despite benign features, we now know that short
term followup of solid masses with probably benign sonographic
features is a safe alternative to biopsy in the absence of atypical fea-
tures or rapid enlargement [26–29]. A palpable breast mass meeting
the criteria for a probably benign lesion at ultrasound has less than
1% chance of being malignant in multiple series for all age groups
[26–29], and the chance of such a lesion being malignant in a pedi-
atric patient is even lower. In a developing pediatric breast which
is prone to iatrogenic injury, biopsy of a mass with typically benign
sonographic features should be avoided in favor of periodic imaging
surveillance.
Surgical excision remains indicated in rapidly enlarging or
symptomatic breast masses in children and adolescents regard-
less of benign sonographic features or initially benign pathology
at biopsy (Fig. 16), because a phyllodes tumor cannot be excluded.
A probably benign appearing mass on ultrasound at initial presen-
tation in children with a personal history of malignancy, prior local
radiation, or genetic mutations known to increase risk of breast
cancer such as BRCA1 or 2 mutations, still requires biopsy. Pres-
ence of any malignant features such as spiculation, microlobulation,
Fig. 16. 15 year old lacrosse player presents with left breast lump. Ultrasound demonstrates a parallel non-vascular hypoechoic mass with slightly irregular margins anteriorly
and posterior acoustic enhancement, prompting biopsy showing a fibroadenoma (a, b). A year later, the patient returns feeling “the lump is a lot bigger”. Ultrasound shows
interval enlargement of the same mass, with surgical excisional biopsy recommended, yielding final pathology of fibroadenoma.
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angular margin, marked hypoechogenicity, or shadowing warrants
sampling [25] (Fig. 16). Rarely, a “complex fibroadenoma” has been
described, which appears less homogeneous on ultrasound and
contains foci of sclerosis, adenosis, papillary apocrine metaplasia,
cyst, or calcifications histologically [23]. When present in children,
complex fibroadenomas are associated with a minimally increased
risk of developing breast cancer later in life [23,4].
A histologic variant of fibroadenoma is the juvenile fibroade-
noma which is discussed in a separate section.
5. Uncommon causes of pediatric breast complaints
5.1. Uncommon benign masses
5.1.1. Juvenile fibroadenomas
Juvenile fibroadenoma (cellular fibroadenoma) is an uncom-
mon variant of fibroadenoma, in part due to a lack of consensus
in histologic diagnostic criteria. Histologic features include stromal
hypercellularity accompanied by intraductal epithelial hyperplasia
[30]. These can be comparable in size to classic fibroadenomas, but
often undergo rapid enlargement. When growth reaches greater
than 5–10 cm [5], these lesions are referred to as juvenile giant
fibroadenomas. Juvenile fibroadenomas are more common in the
African American population [30,31]. Given their frequent large
size and rapid progressive growth, surgical excision is indicated
to exclude the possibility of a phyllodes tumor. Definitive diag-
nosis of phyllodes tumors may be difficult in a core biopsy, often
necessitating surgical excision for complete pathologic evaluation.
Sonographically, juvenile fibroadenomas appear similar to classic
fibroadenomas, but demonstrate progressive growth and strikingly
large size (Fig. 17).
5.1.2. Hamartoma
Hamartomas are benign tumors of disorganized mature breast
tissue elements. Despite this being a relatively common lesion in
the adult breast, hamartomas are rare in children and adolescents
[32]. Hamartomas can grow to be very large in size (>10 cm) and
mimic a juvenile giant fibroadenoma [32]. A hamartoma is a benign
mass not associated with any known increased risk of later breast
cancer. The clinical presentation is usually a painless mass, similar
to that of the more common fibroadenoma. On ultrasound, hamar-
tomas appear as well circumscribed oval or round masses which
can be hypoechoic, isoechoic, or heterogeneous in echotexture [33]
(Fig. 18), mimicking the appearance of the more common fibroade-
noma. Although seldom used in children, mammography often
shows a classic “breast within breast” appearance in hamartomas
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Fig. 17. 13 year old girl with rapidly enlarging breast mass. Ultrasound shows a large circumscribed mass exceeding the span of the linear ultrasound probe, estimated up
to 10 cm in the largest dimension, with relatively homogeneous internal echotexture. This was surgically excised with pathology demonstrating juvenile fibroadenoma.
Fig. 18. 18 year old girl with right breast palpable mass. Ultrasound shows a par-
tially circumscribed oval hypoechoic mass which underwent ultrasound guided core
biopsy, demonstrating hamartoma.
due to interspersed areas of radiodense fibroglandular compo-
nents and radiolucent fatty components within an encapsulated
mass.
When representative tissue is available from core biopsy samp-
ling, hamartomas are readily differentiated from fibroadenomas.
Hamartomas appear histologically as disorganized lobules and adi-
pose tissue, usually with a well-defined boundary between the
lesion and normal surrounding tissue [32]. Fibroadenomas are
defined histologically by proliferation of specialized stroma around
lobules. Lobules and fat are usually not present in a fibroadenoma
[34]. Occasionally however, hamartomas may be difficult to reli-
ably distinguish from fibroepithelial lesions at core needle biopsy,
as hamartomatous elements can mimic normal background breast
tissue, particularly if tissue sampling is inadequate [33].
Hamartomas should be included in the differential consider-
ations of a probably benign appearing breast mass on ultrasound,
and is safe to follow in children and adolescents. In the event the
lesion undergoes rapid progressive growth, surgical excision would
be indicated. Hamartomas can recur if excision is incomplete [32].
5.1.3. Intraductal papilloma (solitary central papilloma)
Intraductal papilloma represents a lesion of epithelial prolif-
eration within a lactiferous duct. They are usually solitary and
located in a subareolar duct, often causing post obstructive ductal
dilatation. The clinical presentation is usually spontaneous serous
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9
or serosanguinous nipple discharge. Intraductal papillomas are
uncommon in children, and rare in boys [5,4,31] (Fig. 19). On
ultrasound, a solid intraductal mass is present within a dilated
duct filled with anechoic fluid, occasionally with associated vas-
cularity (Fig. 19). Surgical excision is the treatment of choice, to
exclude rarely associated malignancy. Histologically, a papilloma is
a mass consisting of multiple papillary structures, each defined by
a fibrovascular core made up of connective tissue and small blood
vessels, and lined by benign epithelium (Fig. 19).
5.1.4. Juvenile papillomatosis (multiple peripheral papillomas)
Juvenile papillomatosis is a rare localized proliferative process
in the breast, in which multiple peripheral papillomas are present
(in peripheral ducts). This is distinct from intraductal papilloma,
in which a solitary central intraductal papilloma is present (in a
central subareolar duct). Juvenile papillomatosis is a marker for
familial breast cancer [35]. Histologically, juvenile papillomato-
sis lacks the fibrovascular core (Fig. 19d) which is typical in the
central papilloma. On ultrasound, papillomatosis may appear as
ill-defined irregular hypoechoic tissue or masses, occasionally con-
taining cystic spaces (Fig. 20) [6,36]. There may be associated
clustered microcalcifications [36]. On MRI, papillomatosis presents
as lobulated masses with cystic spaces well seen on T2 weighted
sequences which enhance with gadolinium [6]. Juvenile papillo-
matosis is a benign condition, but is associated with carcinoma in
up to 15% of the cases [37], therefore surgical resection to nega-
tive margins to prevent recurrence is indicated. A disproportionate
number of patients with juvenile papillomatosis have family his-
tory of breast cancer (up to 58%) [37,38], and should be closely
monitored due to increased risk of developing breast cancer later
in life.
5.1.5. Fibrous nodule
Fibrous nodules are benign breast lesions of focally dense col-
lagenous stroma surrounding atrophic epithelial elements [39].
They most commonly present as firm palpable masses in pre-
menopausal women, but rarely may be seen in the pediatric
population (Fig. 21). Other names synonymous with fibrous nodule
include focal fibrosis, fibrous disease, fibrous mastopathy, fibrosis
of the breast, and fibrous tumor [37].
The imaging appearance of fibrous nodules is not well described
in the literature, but small series have shown them to be small
noncalcified lesions (0.6–3.5 cm in Harvey et al.) at mammogra-
phy, and solid hypoechoic masses with circumscribed or indistinct,
and occasionally irregular margins at ultrasound [39]. Histology of
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Fig. 19. 16 year old boy with serosanguinous left nipple discharge for one month. Ultrasound of the subareolar left breast shows an oval iso- to hyperechoic intraductal
mass outlined by fluid within a dilated duct (b). Ultrasound needle localized surgical excision was performed. Whole slide pathology image (a) shows histologic–radiologic
correlation of the intraductal mass. A solitary papilloma is present within an epithelium-lined lactiferous duct (c). Higher power microscopy shows a papillary structure
consisting of a fibrovascular core (d) (black arrows) with connective tissues and small blood vessels, lined by benign epithelium (black arrowhead).

myofibroblastoma [39]. Fibrous nodule is an acceptable benign

histologic diagnosis for a discrete mass at mammography or ultra-
sound [39,40]. Periodic imaging surveillance of any mass meeting
defined imaging criteria is a reasonable and safe approach. How-
ever if there are any imaging features suspicious for malignancy,
sampling and excision should be considered.

5.2. Malignant masses

5.2.1. Metastatic disease

Fig. 20. 22 year old woman with Juvenile papillomatosis. Ultrasound shows a mass-
like area of hypoechoic tissue containing multiple anechoic cystic spaces, consistent
with papillomatosis at histology (Courtesy of Dr. Katherine Humphrey).
these lesions shows dense fibroconnective tissue similar to that
in adjacent breast tissue with scant or absent adipose tissue, as
well as an absence of features of other stromal lesions such as
pseudoangiomatous stromal hyperplasia, fibroadenoma, lympho-
cytic or diabetic mastopathy, nodular fasciitis, fibromatosis, or
Malignant masses are rare in the pediatric breast, of which,
metastatic disease is more common than primary breast malig-
nancy. Primary tumors known to metastasize to the breast in
children include rhabdomyosarcoma, neuroblastoma, lymphoma,
leukemia, Ewing sarcoma, melanoma, and renal cell carcinoma
[41,42]. An enlarging breast mass in a child with a known history of
primary malignancy warrants sampling even if probably benign in
imaging appearance. Metastatic disease in the breast can be solitary
or multiple masses, involving one or both breasts.
Imaging appearances of metastatic lesions in the breast are
variable. Ultrasound may show a circumscribed or irregularly
marginated mass which is heterogeneous or hypoechoic in echo-
texture [42]. Mammography is less relevant in the pediatric
population, but can show a circumscribed, partially obscured, or

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Fig. 21. 16 year old boy with multiple small left breast nodules. Ultrasound shows
multiple circumscribed hypoechoic masses with a representative lesion displayed
here, which shows an echogenic rim. Fine needle aspiration was performed, showing
fibroconnective tissue with scant adipose tissue, suggestive of a fibrous nodule.
irregular. Particular attention should be given to children and ado-
lescents with known history of extramammary malignancies and
genetic mutations linked to breast cancer, who present with a
breast complaint.
5.2.2. Hematologic malignancy/Cutaneous T-cell lymphoma
Lymphoma and leukemia are among the most common malig-
nancies to metastasize to the breast secondarily [31]. Primary
breast lymphoma however, is extremely rare and usually manifests
as non-Hodgkin’s lymphoma. Of the primary breast lymphomas,
the majority are of B-cell type (Burkitt’s); T-cell lymphomas are
exceedingly rare [43].
Cutaneous T-cell lymphomas (CTCLs) are an uncommon sub-
group of non-Hodgkin’s lymphoma that arises primarily in the skin,
and can rarely present as a breast mass (Fig. 22) with or without
involvement of axillary lymph nodes. CTCLs account for about 4%
of all cases of non-Hodgkin’s lymphoma. The age-adjusted annual
incidence of cutaneous T-cell lymphoma is approximately six cases
per million [44]. CTCLs increase in incidence with age and primarily
affect adults, but can affect people of all ages, including children.
More indolent subtypes of CTCL include mycosis fungoides,
primary cutaneous anaplastic large cell lymphoma, lymphoma-
toid papulosis, subcutaneous panniculitis-like T cell lymphoma,
and primary cutaneous CD4+ small/medium pleomorphic T cell
Fig. 22. 16 year old girl with cutaneous T cell lymphoma involving the right breast, initially presenting as non healing rash. CT shows an irregular infiltrative mass along the
superficial aspect of the right breast (a), which is FDG avid on PET CT (b), and consistent with subcutaneous panniculitis-like cutaneous T cell at biopsy.
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11
lymphoma. Aggressive subtypes of CTCL include Sézary syndrome,
primary cutaneous CD8+ aggressive epidermotropic T cell lym-
phoma, primary cutaneous gamma/delta T cell lymphoma, and
extranodal natural killer/T cell lymphoma [45].
Physical exam may show palpable masses or persistent papu-
lar rash involving the skin. Comprehensive physical examination
including a thorough skin examination is indicated to assess for
multifocal disease. These masses are hypervascular and often
appear hypoechoic/anechoic but may appear hyperechoic on ultra-
sound. They enhance on MRI and are FDG avid on PET CT [46]
(Fig. 22). Mammography plays a minor role in children, but CTCL
appears as multiple and occasionally solitary superficial irregular
masses. Treatment focuses on systemic and topical therapy, with
stem cell transplantation reserved for refractory, progressive cases.
5.2.3. Chest wall malignancies
Chest wall malignancies in children may occasionally involve
the breast via contiguous growth or locoregional metastasis. The
most frequent chest wall malignancies in children are the malig-
nant small round cell tumors (Ewing’s sarcoma, PNET/Primitive
Neuroectodermal Tumor), followed by various sarcomas including
rhabdomyosarcoma, osteosarcoma, or chondrosarcoma. Disease
commonly involves extramammary chest structures, and diagno-
sis relies on cross sectional imaging tools such as CT, MR, or FDG
PET. Ultrasound and mammography are helpful in isolated breast
lesions without known history of primary chest wall malignancy.
Treatment usually includes local surgical resection and adjuvant
chemotherapy.
5.2.4. Phyllodes tumors
Phyllodes tumors are rare fibroepithelial lesions which arise
from the specialized connective tissues around mammary lob-
ules with indeterminate malignant potential. Phyllodes tumors
were previously termed cystosarcoma phyllodes due to their cystic
appearance and sarcoma-like characteristics including a propen-
sity for hematogenous spread, therefore metastasizing to the lung
rather than axillary lymph nodes. Phyllodes tumors are rare, but
nevertheless represent the most common primary breast malig-
nancy in children and adolescents when malignant [6]. Phyllodes
tumors are histologically categorized into low, intermediate, and
high grade, all of which may recur, and rarely, metastasize.
There is significant clinical, imaging, and histologic over-
lap between phyllodes tumors and juvenile fibroadenomas, thus
biopsy of any rapidly enlarging breast mass is warranted to evalu-
ate for phyllodes tumor. Phyllodes tumors tend to be large (>6 cm)
at clinical presentation [47], and appear as circumscribed, oval or
round masses which are hypoechoic or heterogeneous, often with
posterior acoustic enhancement on ultrasound [6]. Intralesional
cysts and clefts (Fig. 23) are highly suggestive of the diagnosis,
although these may also be present in juvenile fibroadenomas
[6]. Ultrasound guided biopsy is indicated in any large or rapidly
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Fig. 23. 13 year old girl notes a subcutaneous mass in the right breast, present for 6 weeks. Ultrasound shows a large solid and cystic complex mass with heterogeneous
internal echotexture and interspersed linear anechoic clefts (a, arrows). Biopsy was the mass was performed, with whole pathology slide (b) demonstrating an intermediate
grade phyllodes tumor with overall variegated architecture consisting of fronds, classic for phyllodes tumor. Spaces between fronds correlate well with the sonographic
feature of clefts often seen in these tumors.
enlarging breast mass in children (more specific features of a phyl-
lodes tumor). Surgical excision with wide margins is required for
all phyllodes tumors.
Low grade phyllodes tumors are generally associated with lower
rate of recurrence [48]. In children, recurrence rate of phyllodes
tumor is even lower, estimated at approximately 10% [49]. Local
recurrence does not alter prognosis. Histologic features of phyl-
lodes tumors include increased stromal cellularity, cellular atypia,
stromal overgrowth, and presence of sarcomatous elements, the
latter of which used to define the malignant type [48]. Based on
these histologic criteria, phyllodes tumors are generally classi-
fied into low-grade, intermediate-grade, or high-grade (malignant)
tumors (Fig. 23). Classification into benign and malignant lesions is
occasionally used. Phyllodes tumors exhibit an overall variegated
architecture (Fig. 23b), and consist of fronds (cellular stromal tissue
lined by epithelium), allowing for cystic or cleft like spaces between
abutting fronds on ultrasound (Fig. 23a).
5.2.5. Invasive secretory carcinoma
Primary breast carcinomas are exceedingly rare in the pediatric
population. Primary breast cancer incidence is noted to be approxi-
mately 0.1 case per million in females younger than 20 years of age
[2]. Boys are even less affected (Figs. 24 and 25).
The most common subtype of invasive breast cancer in children
is invasive secretory carcinoma, which carries a more favorable
prognosis as compared to the less common subtypes of breast can-
cer seen in children (invasive ductal, invasive lobular, medullary,
inflammatory, and anaplastic carcinomas) [5,50,51]. Secretory car-
cinomas are small circumscribed masses (usually < 3 cm) that
present as painless palpable masses (Fig. 24). On ultrasound,
they typically appear as circumscribed or partially microlobu-
lated hypoechoic masses with heterogeneous internal echotexture
[52] (Fig. 24). Secretory carcinoma contains bubbles of secretory
components or cytoplasmic vacuoles on histology, which are char-
acteristically positive by PAS stain (Fig. 24b). Treatment is surgical
excision, sentinel node biopsy, with or without systemic adjuvant
therapy depending on the disease extent.
5.2.6. Post radiation breast cancer
Children who receive high dose mantle irradiation for Hodgkin’s
disease are at significantly increased risk for developing breast
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cancer later in life. This population has a cumulative incidence
of breast cancer of 12–20% by about age 40, comparable to that
in the BRCA (breast cancer susceptibility) gene mutation carriers
(10–19%), whereas in the general population, women of the same
age group have a cumulative incidence of breast cancer of 1% [53].
Young women at the greatest risk are those treated with therapeu-
tic radiation between ages 10–16, with the majority of the tumors
developing in the radiation field [3]. The risk of breast cancer
increases with years post irradiation, therefore routine screening
is important. Annual screening mammogram with adjunctive MRI
screening are generally recommended in young women at least 25
years of age, 8–10 years following completion of radiation therapy
as per the American College of Radiology guidelines [54]. The imag-
ing appearance of breast cancer arising after therapeutic irradiation
is not different from other primary breast cancers.
5.2.7. Hereditary breast cancer/Cowden syndrome
Approximately 10% breast cancers are hereditary. Known asso-
ciated factors include not only the BRCA1 and BRCA2 mutations,
but also rare germline mutations such as TP53 mutations in Li-
Fraumeni syndrome, STK11 mutations in Peutz-Jeghers syndrome,
and PTEN mutations in Cowden syndrome [55]. New mutations
continue to emerge with further advances in genomic technology.
The hallmark of hereditary breast cancer is early onset of disease,
highlighting the importance of early screening.
Cowden syndrome is also known as multiple hamartoma
syndrome. Together with Bannayan-Riley-Ruvalcaba syndrome,
Cowden syndrome belongs to the spectrum of hamartomatous
overgrowth syndromes associated with germ line mutations in the
tumor suppressor PTEN gene which is located on 10q23.3, with an
autosomal dominant inheritance. However, not all patients with
clinical diagnosis of Cowden syndrome have an identifiable PTEN
mutation [56]. PTEN mutation carriers are at significantly increased
risks for breast, thyroid, endometrial, and renal cell carcinomas
(Fig. 26). Cowden syndrome patients carry a cumulative breast can-
cer risk of 77% by age 70, and 75% of these patients have breast
lesions of some kind (Fig. 26) [57]. Given the markedly elevated
risks for breast cancer, guidelines have proposed commencing clin-
ical breast exam and screening breast ultrasound at age 25, and
starting screening mammogram and MRI at age 30 or 5 years before
earliest known breast cancer in the family [57].
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Fig. 24. 8 year old boy with family history of breast cancer presents with a painless right periareolar breast lump for 1.5 years with recent increase in size. Ultrasound shows
a circumscribed oval predominantly hypoechoic mass (a) which corresponds well with whole slide pathology mount (b). Surgical excisional biopsy shows invasive secretory
carcinoma, solid variant, and in situ secretory carcinoma. Mastectomy was ultimately performed for positive surgical margin at the initial resection. Sentinel node biopsy was
negative. Higher power microscopy of the mass shows jagged edges of invasive tumor cells along the periphery (c. arrows). PAS stain is positive, highlighting the presence
of intracytoplasmic vacuoles (arrows).

6. Management algorithm

Given the risk of iatrogenic injury to the developing breast and

Fig. 25. A 29 year old woman found to have breast cancer 15 years post mantle radi-
ation for Hodgkin’s disease as a girl at the age of 14. Ultrasound shows a taller than
wide irregular hypoechoic mass with echogenic halo, consistent with an invasive
ductal carcinoma at biopsy.
the extremely low incidence of malignancy in children, an algo-
rithm for diagnosis and management is proposed, emphasizing
“first do no harm” (Fig. 27). All pediatric breast complaints should
begin with a clinical assessment, taking into account the patient’s
age, presentation, past medical history, family history, and symp-
toms. Newborns with subareolar nodules and nipple discharge
likely experience these symptoms due to maternal hormonal
influence, and parents should be reassured. Similarly, subareolar
nodules in infants under age 1 are likely due to maternal hormonal
influence, which are generally self limited. Prepubertal children
with asymmetric breast buds can present with a palpable subareo-
lar mass in the breast, which can be confirmed using ultrasound if
clinical exam is uncertain. These are common and usually resolve
by puberty.
In older children and adolescents, ultrasound remains the
primary diagnostic tool to evaluate breast complaints. Normal
structures such as a lymph node or benign lesions such as a simple
cyst or a lipoma can be diagnosed at ultrasound without need for
further imaging. In the setting of known trauma, a hematoma can be
assessed and followed to resolution using ultrasound. In the setting
of infection, ultrasound can exclude the presence of a phlegmon or
abscess, the latter of which can be drained under sonographic guid-
ance to facilitate healing while under antibiotic treatment. Probably
benign masses (circumscribed margin, oval shape, parallel orienta-
tion) measuring up to 3–4 cm in young girls are most likely to be
fibroadenomas and are safe to follow by ultrasound whether palpa-
ble or not, except when atypical features exist or rapid enlargement

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Fig. 26. 15 year old girl with Cowden syndrome presents with innumerable palpable bilateral circumscribed homogeneous breast masses with a representative example
displayed here on ultrasound (a). The patient had already undergone prior bilateral breast biopsies demonstrating benign histologies including a complex sclerosing lesion
with PASH (b), therefore surveillance of the remaining masses rather than biopsy was recommended. This patient also has a history of papillary thyroid cancer requiring
thyroidectomy, and has over 50 polyps throughout the gastrointestinal tract in the esophagus, stomach, and colon.

Fig. 27. How to approach breast lesions in children and adolescents – a diagnostic and management algorithm.

occurs. Larger than 5 cm masses meeting criteria as probably benign
cannot be readily differentiated from phyllodes tumors, and there-
fore, biopsy is indicated. Mass lesions with malignant features on
ultrasound (indistinct/angular/microlobulated/spiculated margin,
irregular shape, and anti-parallel orientation) should be biopsied.
Initial discovery of any breast mass, regardless of appearance in
patients with known extramammary malignancy, prior mantle
radiation, genetic mutations or syndromes, warrants sampling.
Other cross sectional imaging modalities such as CT, MR, FDG-PET
are often helpful in defining disease extent.
Gynecomastia is most commonly physiologic in neonates and
teenage boys. A clinical and laboratory workup should be consid-
ered however, in prepubertal boys with gynecomastia to exclude
estrogen secreting tumors in rare cases. Children with nipple dis-
charge should be examined and ultrasound may rarely show an
intraductal papilloma or juvenile papillomatosis, both of which
require surgical resection, the latter of which is associated with
elevated risk of developing breast cancer later in life.
7. Conclusion
Breast malignancy is exceedingly rare in children. Diagnostic
and management approach of the pediatric breast is therefore
appropriately conservative. It is important to understand that
the spectrum of pediatric breast disease differs from that of the
adult breast. Knowledge of common and uncommon benign and

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malignant pediatric breast lesions and their appearances on imag-
ing help direct diagnosis and management.
Conflicts of interest
The authors declare no conflicts of interest.
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