BREAST MASS

1. BREAST
MASS
IN
ADOLESCENT
DR.
KAWITA
BAPAT

2. Breast
Masses
• Uncommon
In
Children
And
Adolescents
• Associated
With
Significant
Pa:ent
And
Family
Distress
• The
Prevalence
Of
Breast
Masses
In
Teenage
Girls
Is
3.2%.

3. • Adolescent
Breast
Masses
Are
Typically
Benign
•
Although
Breast
Malignancies
Reported.
– Surgically
Removed
Breast
Masses
• 95%
Benign
Fibroadenomas
• Only
0.02%
Malignancies

4. Differen:al
Diagnosis
• Similar
To
Those
In
Adults
• Phyllodes
Tumors
• Primary
Breast
Cancer
• Sarcoma
• Lymphangioma
• Hemangioma
• Metasta:c
Cancer,
• Intraductal
Papilloma
• Fibroadenoma
(And
Giant
Fibroadenoma)
• Abscesses
• Benign
Cysts

5. • The
prevalence
of
breast
masses
among
teenage
girls
is
approximately
3.2
percent.
• Common
causes
include
fibroadenoma,
cysts,
hamartoma,
fat
necrosis,
or
abscess.
• Because
the
diagnosis
of
a
primary
breast
carcinoma
is
rare,
• the
differen:al
diagnosis
includes
rare
metasta:c
disease
from
malignant
tumors,
including
rhabdomyosarcoma,
lymphoma,
and
neuroblastoma

6. For
Evalua:on
Of
Any
Breast
Mass.
• History
And
Physical
Exam
are
essen:al
to
guiding
diagnosis.
• Careful
detail
pertaining
to
the
breast
mass,
• Pain
• Nipple
Discharge
• Precipita:ng
Factors
• Dura:on
And
Progression
• Ultrasound
provides
the
best
imaging
in
the
adolescent
age
group
and
is
an
essen:al
diagnos:c
tool.

7. For
Evalua:on
Of
Any
Breast
Mass.
• Fine
Needle
Aspira:on
(FNA)
• Excisional
Biopsy
• Magne:c
Resonance
Imaging
(MRI)
Provides
An
Imaging
Modality
Without
Radia:on
Exposure
To
Children,
But
Efficacy
And
Accuracy
Of
MRI
Breast
Evalua:on
In
Children
Has
Not
Yet
Been
Validated.

8.
Sebaceous
Cyst
• An
Epidermal
Cyst
• Classic
Feature
Of
A
Superficial
Swelling
• Filled
With
A
Cheese
Like
Or
Oily
Material.
• Grows
Slowly
Not
Painful.
• How
We
Have
Reached
To
Diagnosis
• Based
On
The
Clinical
History
And
Physical
Examina:on
Findings
• Biopsy
Or
An
Ultrasound
Examina:on
Performed
To
Exclude
Alterna:ve
Pathology

9. Sebaceous
Cyst
• Therapeu:c
interven:on
• Small
non
inflamed
-­‐-­‐-­‐-­‐
no
need
any
therapeu:c
interven:on.
•
For
acutely
inflamed
cysts-­‐-­‐-­‐-­‐
a
short
course
of
an:bio:cs
• Recurrent
infec:ons
or
very
large
cysts
may
warrant
drainage
and/or
excision.

10.
Fibroadenoma
• Ultrasonography
features
• Classic
Appearance
• Well
Defined
•
Smoothly
Marginated
• Hypoechoic

11.
Fibroadenoma
• Risk
Factors
And
Cause
• Unknown
E:ology
• Most
Common
Benign
Tumors
Of
The
Breast
• Risk
Factor
The
Use
Of
Oral
Contracep:ves
Before
Age
20
Years
• These
Tumors
Have
An
Increased
Risk
For
Breast
Cancer
(About
A
1.5-­‐2
Times
Greater
Risk
Than
That
Of
Women
Without
Breast
Changes).

12.
Fibroadenoma
• A
defini:ve
diagnosis
• The
tumors
are
mobile
and
composed
of
glandular
and
stromal
elements
• Typically
made
based
on
findings
from
imaging
studies
(eg,
ultrasonography,
mammography)
and
biopsies.
• Lesions
that
are
atypical
on
ultrasonography,
are
larger
than
2
cm,
or
exhibit
rapid
growth
should
be
biopsied.
• Treatment
• Removal
of
the
lesions
is
generally
recommended,
and
it
is
usually
done
by
formal
surgical
excision.
• Smaller
lumps
can
be
removed
by
minimally
invasive
techniques,
such
as
vacuum-­‐assisted
biopsy
or
cryoabla:on.

13.
Fibrocys:c
Diseases

14.
Fibrocys:c
Diseases
• What
are
fibrocys:c
changes
• Changes
In
The
Glandular
And
Stromal
Tissues
• Commonly
In
Young
• Although
Breast
Cysts
Can
Occur
At
Any
Age
• Cysts
Are
Generally
Mul:ple
• May
Be
Unilateral
Or
Bilateral
• Wax
And
Wane
With
The
Menstrual
Cycle
• What
are
Symptoms
• include
swollen,
tender/painful,
and/or
thick
or
lumpy
breasts;
some:mes
a
discharge
is
present.

15. Fibrocys:c
Diseases
• Ultrasound
study
and
fine-­‐needle
aspira:on
(FNA)
is
usually
obtained.
• Although
most
cysts
are
considered
benign
• Warning
signs
that
require
addi:onal
workup
include
1. Bloody
aspira:on
2. Failure
to
completely
collapse
upon
aspira:on
3. Solid
:ssue
components.

16. Fibrocys:c
Diseases
No
Defini:ve
Treatment
• Suppor:ve
Measures
1. Analgesics
2. Applying
Heat/Ice
• Pharmacotherapy
1. Oral
Contracep:ves,
2.
Tamoxifen
3.
Androgens
• Aspira:on
May
Performed
• For
Symptoma:c
Relief
• Repeated
Aspira:ons
May
Be
Needed
As
Cysts
Recur

17. Breast
TB
• Incidence
increases
to
3-­‐4%
in
areas
with
endemic
TB
such
as
India
and
Africa)
• Classified
as
nodular,
diffuse,
or
sclerosing.
• Most
commonly
seen
in
young
lacta:ng
mul:parous
women.

18. Breast
TB
Typical
features
of
Breast
TB
• A
unilateral
painless
breast
mass
• Specially
in
the
middle
or
upper
outer
breast
quadrant
• Persistent
draining
sinus
• Axillary
lymphadenopathy
• Nipple
retrac:on.
• Breast
cancer
must
be
ruled
out
• Pa:ents
generally
do
not
have
systemic
TB

19. Breast
TB
• workup
• Ziehl
Neelsen
staining
or
culture
for
acid-­‐fast
Bacilli
(gold
standard)
• Mantoux
tes:ng
• Fna
• Polymerase
chain
reac:on
• Histopathology,
and
imaging
studies
(eg,
ultrasonography,
computed
tomography,
nuclear
MRI).
• Treatment
•
Involves
an:-­‐TB
chemotherapy
and
surgery.

20. Phyllodes
Tumor
• Younger
pa:ents
are
less
likely
to
have
malignancy
•
so
clinicians
must
formulate
an
age-­‐
appropriate
differen:al
diagnosis
list.
• This
ultrasound
image
shows
a
in
a
young
woman—a
typically
benign
tumor
with
malignant
poten:al
that
should
be
excise

21. Phyllodes
Tumors
• also
known
as
cystosarcoma
phyllodes,
• stromal
tumors
of
the
breast.
• They
are
most
common
• These
can
be
• large,
• painless,
• rapidly
growing
tumors
• that
are
difficult
to
dis:nguish
clinically
from
giant
fibroadenomas.

22. • Phyllodes
tumors
should
be
treated
with
complete
surgical
resec:on.
In
adults,
a
1-­‐cm
surgical
margin
is
recommended.
• However,
there
is
some
thought
that
adolescent
phyllodes
tumors
are
less
aggressive
and
a
smaller
surgical
margin
may
be
acceptable.

23. Primary
Breast
Cancer
• Primary
Breast
Cancer
Is
Rare
In
Children
And
Adolescents.
•
Less
Than
1%
Of
Breast
Cancer
Pa:ents
Are
Younger
Than
30
Years
• The
Incidence
Of
Breast
Cancer
In
Women
Younger
Than
20
Years
Is
1
In
1,000,000.

24. Primary
Breast
Cancer
• Thirty-­‐nine
cases
of
primary
breast
cancer
in
pediatric
pa:ents
have
been
published
to
date.
• Younger
pa:ents
are
more
likely
than
older
adults
to
present
with
a
large
mass
at
the
:me
of
breast
cancer
diagnosis.

25. Primary
Breast
Cancer
•
Physical
exam
demonstrates
a
firm,
nonmobile,
poorly
circumscribed
mass,
similar
to
adult
women
with
breast
cancer.
• However,
nipple
retrac:on
and
discharge
appear
less
common
in
children.

26. Secretory
adenocarcinoma
• (Formerly
known
as
juvenile
carcinoma)
• Most
common
primary
breast
cancer
• Popula:on
and
accounts
for
31
of
the
39
reported
cases
(84%).
• Unique
capsule
that
is
thick
walled

27. Secretory
adenocarcinoma
• The
mass
to
appear
cys:c
on
ultrasound.
• Slow-­‐growing
and
benign
clinical
picture.
• (9.7%)
iden:fied
nodal
metastases
at
the
:me
of
surgical
excision
• No
mortali:es
have
been
published
secretory
adenocarcinoma;
• Long-­‐term
follow-­‐up
data
are
lacking

28. • Medullary
carcinoma
has
been
reported
in
six
pa:ents
under
the
age
of
18
years
(11%),
four
of
whom
expired
from
associated
metasta:c
disease.
• less
common
than
secretory
carcinoma
but
are
associated
with
more
aggressive
disease
pathology.
• Two
cases
of
inflammatory
cancer,
both
12-­‐year-­‐
old
girls,
have
been
published,
with
one
death
and
no
follow-­‐up
reported
on
the
other
pa:ent.

29. Work
up
• surgical
management
of
primary
breast
cancer
remains
controversial.
•
Complete
surgical
resec:on
is
the
goal
in
all
cases,
• however,
maintaining
normal
breast
development
should
also
be
considered
whenever
possible.

30. Work
up
•
The
need
for
axillary
lymph
node
staging
or
axillary
dissec:on
remains
unclear.
• With
at
least
9.7%
nodal
metastases
observed
in
secretory
carcinoma
• the
aggressive
nature
of
medullary
and
inflammatory
cancers,
recommend
lymph
node
staging
in
all
pa:ents.

31. Work
up
•
Axillary
ultrasound
for
clinical
preopera:ve
workup,
as
in
adults,
is
recommended.
•
Extrapola:ng
from
management
of
breast
cancers
in
adults,
sen:nel
lymph
node
surgery
for
nodal
staging
is
recommended
for
clinically
node-­‐nega:ve
cases
and
axillary
dissec:on
for
node
posi:ve
cases.

32. Work
up
•
Furthermore,
radia:on
and
chemotherapy
can
be
associated
with
increased
risk
of
subsequent
cancers
in
young
pa:ents;
• therefore,
risk
and
benefit
should
be
carefully
considered
based
on
tumor
type
and
stage
of
disease.

33. • Radia:on
exposure
for
girls
during
peak
breast
development,
typically
10
to
16
years
of
age,
is
most
harmful.
• Approximately
40%
of
girls
treated
with
radia:on
for
Hodgkin
lymphoma
will
develop
breast
cancer;
it
takes
an
average
of
20
years
to
develop.
• For
these
women,
annual
clinical
breast
examina:on
and
annual
MRI
for
screening
of
breast
cancer
development
is
recommended
• bilateral
prophylac:c
mastectomies
to
decrease
risk
of
breast
cancer
development
can
be
considered.

34. Management
Of
Breast
Masses
• Conserva:ve
• Guided
By
Clinical
Diagnosis
• Diligent
Follow-­‐up.
Palpable
symptoma:c
cysts
– ultrasound-­‐guided
fine-­‐needle
aspira:on,
– with
collapse
of
the
cyst
– clinical
follow-­‐up
to
assess
stability.

35. Management
Of
Breast
Masses
Fibroadenomas
• Clinical
observa:on
over
two
to
four
months
is
appropriate.
• grow
by
more
than
1
cm,
and
those
larger
than
2
cm
warrant
directed
• to
confirm
that
they
are
benign
– Ultrasonography
– Percutaneous
Biopsy

36. Management
Of
Breast
Masses
Surgical
excision
recommended
in
the
situa:ons
– Mass
Larger
Than
5
Cm
– (Even
If
Biopsy
Confirms
A
Fibroadenoma),
– Rapidly
Enlarging
Mass
– Pain
– Distor:on
Of
The
Breast
Architecture,
–
Skin
Changes.

37. Management
Of
Breast
Masses
Surgical
excision
– Large
Masses
Is
Recommended
– Prevent
Distor:on
Of
Breast
Architecture
– Need
For
Augmenta:on
To
Fill
The
Postopera:ve
Defect.
Surgical
exper:se
is
cri:cal
to
protect
the
development
of
the
breast
bud
while
maintaining
a
good
cosme:c
outcome.

38. Breast
Mass
Disconcer:ng
Can
Provoke
Anxiety
Fear
First
Point
Of
Contact,
And
Should
– Ini:ate
Appropriate
Inves:ga:on
– While
Providing
A
Respeciul,
Communica:ve
Approach
– Alleviate
Anxiety
And
Body
Image
Issues.

39. Management
Of
Breast
Masses
Use
Of
Minimally
Invasive
Procedures,
Such
As
Cryoabla:on
Of
Masses
In
Adolescents,
Is
Limited.
In
Pa:ents
Who
Do
Not
Accept
Surveillance
Of
Mul:ple
Or
Small
Masses
(Less
Than
2
Cm)
And
Who
Are
Concerned
About
Surgical
Scarring,
Management
With
Vacuum-­‐assisted,
Ultrasound-­‐guided
Percutaneous
Excision
Can
Be
An
Alterna:ve
To
Surgery

40. Clinical
assessment
• History:
the
site,
dura:on,
associated
pain,
rela:onship
to
menstrual
cycle
and
any
recent
change
in
the
size
of
the
lump
should
be
established.
•
Any
previous
history
of
breast
lumps,
relevant
inves:ga:ons
or
opera:ons
should
be
noted.

41. Clinical
examina:on
• Both
breasts
should
be
examined
• Site,
size
and
consistency
of
lump
• Area
of
abnormal
texture
should
be
noted
• Correlated
clearly
with
the
site
of
symptoms
• Any
associated
signs
of
malignancy
such
as
skin
tethering
or
nipple
inversion
should
be
sought.
• The
axillary
and
the
supraclavicular
lymph
nodes
should
be
examined

42. Assessment of the axilla
• Ultrasound
of
the
axilla
should
be
carried
out
in
all
pa:ents
when
malignancy
is
expected.
•
If
lymph
nodes
showing
abnormal
morphology
on
ultrasound
are
found,
needle
sampling
should
be
carried
out
under
ultrasound
guidance.
• Lymph
node
sampling
may
be
performed
using
FNAC
or
needle
core
biopsy

43. One-­‐stop
assessment
Triple
assessment
are
performed
during
a
single
visit
this
provides:
• A
basis
for
defini:ve
diagnosis
• Reassurance
with
no
need
for
further
alendance
• Informa:on
for
mul:disciplinary
mee:ng
(MdM)
• Treatment
planning
prior
to
review
of
those
diagnosed
to
have
cancer

44. Outcome
of
assessment
• Following
triple
assessment,
a
defini:ve
diagnosis
of
either
benign/
physiological
changes
or
malignancy
will
be
made
in
most
pa:ents.
• Where
a
defini:ve
diagnosis
is
not
established,
repeat
clinical
assessment
and
needle
biopsy
should
be
considered.

45. Breast mass : etiology
§ More than 90% of palpable breast
masses in adolescence
§ Differential Diagnosis:
ü Fibrocystic changes
ü Fibroadenoma
ü Fat necrosis
ü Phyllodes tumor
ü Intraductal papilloma
ü Breast cancer

46. • Breast
Masses
from
Metasta:c
Disease
• Breast
masses
caused
by
metasta:c
disease
have
also
been
described
in
pediatric
pa:ents
and
are
more
common
than
primary
breast
cancer.
• Primary
malignancies
have
included
• hepatocarcinoma,
• non-­‐Hodgkin
lymphoma,

47. Conclusion
• Pediatric
and
adolescent
breast
masses
are
fortunately
uncommon
and
unlikely
to
require
surgical
interven:on

48. Conclusion
• Thus
limited
data
are
available
pertaining
to
their
management.
• However,
cases
of
malignancy,
including
phyllodes
tumors,
ductal
adenocarcinomas,
and
metasta:c
lesions,
have
been
documented
in
children
and
adolescents.

49. CONCLUSION
• The
preferred
imaging
modality
in
adolescents
is
breast
ultrasonography
• Which
can
beler
characterize
and
delineate
breast
masses,
differen:ate
cys:c
from
solid
masses
• Increase
sensi:vity
while
avoiding
radia:on
exposure.

50. CONCLUSION
Mammography
is
rarely,
if
ever,
indicated
in
adolescents
because
of
the
dense
nature
of
the
breast,
which
significantly
reduces
mammographic
sensi:vity.
When
a
malignancy
is
suspected,
magne:c
resonance
imaging
may
be
useful
to
evaluate
the
extent
of
disease.

51. CONCLUSION
• Tailor
Care
Of
The
Adolescent
• Recognizing
The
Differen:al
• Importance
Of
Diligent
Follow-­‐up
• Take
A
Conserva:ve
Approach.

52. CONCLUSION
When
clinical
features
provoke
concern
for
a
higher-­‐risk
mass,
exper:se
with
this
adolescent
popula:on
is
important
to
op:mize
outcomes.

53.
Dr.
Kawita
Bapat
• MS.FICOG
• DIRECTOR OF ONE CENTRE FOR GYNAECOLOGICAL EXCELLENCE
• Senior practicing OBGYN at Indore
• ONE DAY HYSTERECTOMY SPECIALIST
• FOGSI Affiliated colposcopy center
• Chairperson female breast diseases committee FOGSI
• Past president OBGYN Society INDORE
• GOVRNING COUNCIL MEMBER ICOG
• Past President LIONS Club INDORE
• TREASURER IMS INDORE Chapter
• Award winner of Nayika Indore and captain of industry
• bapatkawita@gmail.com
• www.onegynae.com
• BAPAT HOSPITAL BAPAT CHORAHA SUKHLIA INDORE
• +919826055666

54. BREAST COMMITTEE ROADMAP
Establishing Awareness in Public & OBGY domains
• Detailing a module about breast health
• Communication Collaterals like:
• PowerPoint presentation
• Handbills
• Pamphlets
• Books
• Monthly magazine or newsletter
• Encouraging sharing of stories about breast cancer
survivors
• Adolescent breast health checkup, counseling &
knowledge enrichment
• Educational Seminars

55. BREAST COMMITTEE ROADMAP
• Collaborations with NGOs, Clubs & other social & community organizations
• Celebrity endorsements by those celebrities who are already working for
breast health
• Spreading knowledge about Mammography Screening, Breast checkups in
all corporate and social units
• Frequent awareness rallies
• Grand Marathon Events with mass participation where people will Run for
Breast Health Awareness
• Participation & support from in international agencies and organization
• Collaboration with government & related units that can help the cause