Breast masses in adolescent females

Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease

PURPOSE

Breast masses in pediatric patients are often managed similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients.

METHODS

A multi-institutional retrospective cohort study was completed between 1995 and 2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions.

RESULTS

A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p < 0.25) for decisions made on clinical suspicion alone.

CONCLUSION

Despite literature supporting an observation period for pediatric breast masses, half of patients had an intervention within three months with one out of ten patients undergoing an invasive procedure within this time frame. Furthermore, 81.1% of invasive interventions were unnecessary based on final pathologic findings. A formal consensus clinical guideline for the management of pediatric benign breast disease including a standardized clinical observation period is needed to decrease unnecessary procedures in pediatric patients with breast masses.

A population-based analysis of pediatric breast cancer

PURPOSE

The purpose of this study was to evaluate trends in demographics and outcomes of pediatric breast cancer in a United States population-based cohort.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify all pediatric patients with malignant breast tumors between 1973 and 2014. Analysis was performed using Stata Statistical Software version 13.1. Associations between categorical variables were made using X² test. Log-rank test was used for univariate survival analysis. Kaplan-Meier analysis investigated five-year survival rates across several variables. Adjusted analysis was performed using a Cox Proportional-Hazards regression.

RESULTS

134 patients with breast malignancies were identified. Carcinoma was the most prevalent histology (48.5%), followed by fibroepithelial tumors (FETs) (35.1%), and sarcoma (14.2%). FETs were twice as common in black compared to nonblack patients (56.3% vs. 29.0%, p < 0.01). Analyzing histology by stage revealed that 100% of FETs were early stage disease (p < 0.0001). 46.7% of the tumors tested were ER/PR negative, more than twice as many compared to the published adult estimate of 20.0%. Unadjusted survival analysis revealed worse survival for patients with adenocarcinoma/sarcomas, advanced stage, and high grade disease, without a survival difference between races.

CONCLUSION

Breast cancer remains a rare malignancy among pediatric patients. Although black patients were found to have more noncarcinomatous tumors with less advanced disease, this did not confer a survival advantage.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

Diagnosis and management of fibroadenomas in the adolescent breast

Fibroadenomas are benign breast masses that can present a management challenge in adolescent populations. Most fibroadenomas may be managed conservatively without surgery, but those masses that are symptomatic or increasing in size may require surgical excision. In adolescents, the implications of surgical intervention in the breast are unclear, and there is little outcomes data. In this article, the authors discuss the presentation, diagnosis, and management of fibroadenoma in adolescents. Key considerations for physicians in treating these masses in this population are reviewed.

Breast masses in African American teenage girls

PURPOSE

The aim of this study was to evaluate the incidence of malignancy in breast lumps excised from African American teenagers.

METHODS

The authors reviewed the pathology records at King's County Hospital Center between January 1982 and December 1992. The pathology reports and charts of all patients who had breast masses excised during this period were reviewed. Data for this study were derived from the group of African American and black Caribbean American teenage patients who underwent breast biopsies and whose pathology reports and medical records were available. The age of patients, size of the lesion, and diagnosis were recorded.

RESULTS

Medical records from 155 African American and black Caribbean American girls between the ages of 13 and 19 years (inclusive) who underwent breast biopsies between January 1982 and December 1992 were reviewed. Fibroadenoma was the most common diagnosis (127 of 155; 82%). This was followed in frequency by fibrocystic mastopathy (18 of 155; 11.6%) and breast abscess (3 of 155; 2%). None of the patients had a malignancy. Review of tumor registry data from the same time period at Kings County Hospital Center and the University Hospital of Brooklyn showed that the youngest African American or black Caribbean American patient diagnosed with breast cancer was 21 years of age.

CONCLUSIONS

The incidence of malignant breast lumps in African American and black Caribbean American teenagers is distinctly low. Conservative treatment in this population is warranted, and diagnosis can be made easily in most cases with either needle aspiration for cytology or core biopsy of any lesions discovered.

Breast disease in adolescents and young women

Breast lesions, including mastalgia; benign proliferative changes; and benign masses, including fibroadenomas, are common in adolescents and young adult women. Breast cancer is rare in women less than 20 years old and uncommon in women less than 30 years old. Discrete masses in women less than 30 years old that do not feel suspicious on examination can be observed for 1 or 2 months. If they persist, than an FNA can differentiate those that are benign and can be observed versus those that need either an excisional biopsy or definitive surgery. Mammography has little role in the diagnosis of women less than 30 years old except in those individuals with highly suspicious lesions on examination.

Young women's breast self-examination knowledge and practice

A descriptive survey was conducted to identify and describe breast self-examination (BSE) knowledge and practices of young women (< 45 years). The sample consisted of 65 female university nursing students, whose ages ranged between 17 and 45 years (M = 19). Data were collected using a self-administered questionnaire and analyzed using descriptive statistics. The results of the study were that 99% of the sample had performed BSE in the previous 12 months. Fewer than half (44%) of these participants indicated that they would classify their BSEs as regular; only 27% of the participants reported they had examined their breasts from 9 to 12 times in the previous 12 months, which would normally be considered regular BSE. No significant relation was found between a family history of breast cancer and regular BSE (r = .262). A large percentage of the sample (77%) correctly identified the recommended time for BSE in relation to their menstrual cycle, although only 37% of the participants performed BSE at this time. Significant differences were found between the recommended times for performing BSE and the days of the menstrual cycle on which the participants performed BSE, chi 2(16, N = 64) = 35.330, p < .01. Forty percent of participants indicated they would ask their doctor to obtain more information about BSE. A further 36% of participants indicated they would go to a community health center. The most commonly cited community resource stated by the participants for obtaining BSE information was a doctor.

Breast disorders in children and adolescents

A review of pediatric breast disorders is provided, with particular attention given to the topics of fibroadenoma, cystosarcoma phylloides, breast infections, breast cancer, and benign breast disease. The pediatric clinician is strongly encouraged to include the breast system as part of a complete examination and educational process.

Compliance with breast self-examination instruction in healthy adolescents

Compliance with breast self-examination was prospectively assessed in three groups of healthy outpatient adolescents 6 weeks, 3 months, and 6 months after instruction. Although 87%, 59%, and 71% of the three respective groups reported sporadic practice of breast self-examination, only 39%, 9%, and 18%, respectively, performed the procedure timed correctly with the menstrual cycle. Those adolescents tested at 6 weeks demonstrated a high degree of proficiency in replicating the procedure on a silicone model. There was no significant difference between demographic variables or personal health beliefs regarding breast cancer and breast self-examination compliance. Our findings suggest that adolescents can effectively perform breast self-examination, but their practice is erratic. Thus, we recommend that when instruction in breast self-examination is given, the examination schedule should be reinformed at a follow-up visit.