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Pediatric Imaging • Review

Kaneda et al. Pediatric and Adolescent Masses

Pediatric Imaging Review

Pediatric and Adolescent Breast Masses: A Review of Pathophysiology, Imaging, Diagnosis, and Treatment

Heather J. Kaneda1 OBJECTIVE. Pediatric breast masses are relatively rare and most are benign. Most are Julie Mack either secondary to normal developmental changes or neoplastic processes with a relatively Claudia J. Kasales benign behavior. To fully understand pediatric , it is important to have a firm Susann Schetter comprehension of normal development and of the various tumors that can arise. Physical ex- amination and targeted history (including family history) are key to appropriate patient man- Kaneda HJ, Mack J, Kasales CJ, Schetter S agement. When indicated, ultrasound is the imaging modality of choice. The purpose of this article is to review the benign breast conditions that arise as part of the spectrum of normal , as well as the usually benign but neoplastic process that may develop within an otherwise normal breast. Rare primary carcinomas and metastatic lesions to the pediatric breast will also be addressed. The associated imaging findings will be reviewed, as well as treatment strategies for clinical management of the pediatric patient with signs or symptoms of breast disease. CONCLUSION. The majority of breast abnormalities in the pediatric patient are be- nign, but do occur. Careful attention to patient presentation, history, and clini- cal findings will help guide appropriate imaging and therapeutic decisions.

hough breast masses are uncom- mary is extremely low in the pe- mon in the pediatric population, diatric population, reducing the utility of mam- the detection of an abnormality is mography as a diagnostic problem-solving tool T often alarming to caregivers and [1]. Ultrasound is generally the primary imag- patients. Fortunately, most breast conditions ing modality used in young patients, aiding in arising in the pediatric age group are benign. the initial diagnosis, assisting in imaging-guid- Integral to the evaluation of these patients is a ed when indicated, and offering a safe thorough clinical examination and history. method of follow-up. In the pediatric patient, Key factors that aid in diagnosis include the MRI of the breast is rarely used, though in Keywords: adolescent breast masses, pediatric breast masses, ultrasound length of time that the mass has been present, select cases, it may be useful for surgical associated pain or other symptoms, whether planning or assessing the extent of disease. DOI:10.2214/AJR.12.9560 the mass affects one breast or both, how rap- idly the mass is growing, and, finally, any Benign Breast Disease Received July 6, 2012; accepted after revision August 26, 2012. family history of breast disease [1]. The most common benign pediatric breast Because most breast tumors in young people lesions can be divided into two main groups: 1 All authors: Department of Radiology, Penn State are benign, a conservative approach is warrant- those that arise as part of the spectrum of University, PO Box 850, Hershey, PA 17033. Address correspondence to J. Mack ([email protected]) and ed. Diagnosis and treatment must be tailored normal breast development and those that H. J. Kaneda ([email protected]). to avoid damaging developing breast tissue, arise as a usually benign but neoplastic pro- which can result in hypoplasia or aplasia [1]. cess within an otherwise normal breast. CME/SAM In the pediatric population, This article is available for CME/SAM credit. plays no significant role in the evaluation of Normal Breast Development WEB breast disease for several reasons. First, the ex- Breast tissue begins to develop at approxi- This is a Web exclusive article. posure of breast tissue to ionizing radiation can mately week 5 of gestation, arising from the induce cellular changes that may lead to the ectoderm on the ventral surface of the em- AJR 2013; 200:W204–W212 Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved development of . Second, young bryo along a curvilinear ridge known as the

0361–803X/13/2002–W204 breast tissue can be extremely dense mammo- “Hughes line” or the “milk line,” extending graphically, reducing the overall sensitivity of from the axilla to the groin [2]. The majority © American Roentgen Ray Society the examination. Finally, the incidence of pri- of the milk line disappears shortly after its

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formation, except for a portion at the ante- cocious . Ultrasound allows the ex- idiopathic [7]. Elevated serum levels rior fourth intercostal space [3]. At approxi- clusion of an underlying and can can be caused by increased production of es- mately 10 weeks, the primitive ectodermal- also be used to evaluate the pelvis for signs trogen from testicular tumors (Leydig cell tu- ly derived breast tissue begins to proliferate, of early sexual development [6]. mors) or adrenocortical . Increased growing into the dermis and forming the pri- aromatization of the precursors of estrogen mary mammary bud. Over time, the prima- Asymmetric Breast Bud Development can result in the elevation of and ac- ry bud begins to branch, forming secondary Early normal breast development can be counts for the associated with buds, which ultimately form the mammary quite asymmetric, with up to a 2-year differ- Sertoli cell and sex-cord testicular tumors lobules. The buds continue to branch and in- ence between in the overall timing and in testicular germ cell tumors, liver dis- crease in length and, by the 20th week, form [1]. The asymmetric breast tissue presents as ease (cirrhosis), hyperthyroidism, Klinefel- small openings that fuse to form the lactifer- a unilateral subareolar mass. The role of ul- ter syndrome, and hyperthyroidism. Congeni- ous ducts, which converge into a small open- trasound again is to provide verification that tal testicular aplasia or hypoplasia, testicular ing, forming the . The breast tissue in normal breast tissue is present and to ex- trauma or torsion, viral orchitis, and congeni- the full-term newborn is a discrete palpable clude an underlying mass, reassuring both tal anomalies (such as Klinefelter syndrome) nodule, which may persist for 6–12 months. the patient and . can all be associated with decreased testos- Thereafter, the breast tissue involutes and is terone levels and may lead to pathologic gy- essentially identical in boys and girls until Gynecomastia necomastia. such as spironolac- the onset of puberty [4]. Gynecomastia is the excessive develop- tone and ketoconazole can displace estrogen The second phase of breast development ment of breast tissue in male patients. In the from sex –binding globulin, result- occurs at puberty with the onset of thelar- pediatric population, it can be physiologic or ing in elevated free-estrogen levels. Finally, che, promoted by rising levels of estrogen and pathologic. Physiologic gynecomastia is gen- some herbal and skin care products (includ- . Estrogen stimulation produc- erally seen in three age groups: neonates, pu- ing those containing lavender and tea tree oil) es growth of ducts and fat, while progester- bertal boys (who develop pubertal or patho- have weak estrogenic and antiandrogenic ac- one stimulation results in lobular and alveo- logic gynecomastia), and elderly men. tivity that may cause gynecomastia [11]. lar budding. The mean age for in the Neonatal is a common Typically, ultrasound does not a pri- United States is 8.87 years for African-Amer- transient condition seen in up to 90% of all mary role in the evaluation of the breast in ican girls and 9.96 years for white girls [5]. newborns, both male and female [7]. It is pre- pubertal gynecomastia. If the physical ex- sumed to be caused by transient elevations in amination is suggestive of gynecomastia, a Developmental Breast Lesions estrogen due to transplacental passage of the thorough history and laboratory assessment Prepubertal or peripubertal developmen- hormone [8]. Parental reassurance is general- should follow. However, if the physical find- tal breast lesions can be asymmetric or uni- ly all that is warranted, and ultrasound plays ings are questioned, ultrasound allows verifi- lateral and include , little role in treating these patients. cation of normal-appearing breast tissue and asymmetric development of breast buds, su- Pubertal gynecomastia can be seen in the exclusion of an underlying mass. Ultra- pernumerary breast tissue, and gynecomas- 3.9–64.6% of boys, depending on the criteria sound is also helpful in revealing a lack of tia. Postpubertal variations of development used to define gynecomastia [9]. It is gener- breast tissue in cases of pseudogynecomas- include mammary duct ectasia, cystic breast ally seen in boys aged 10–13 years, with typ- tia [12], which is breast enlargement caused changes, and . ical onset 6 months after the appearance of by fat deposition. Although testicular neo- secondary sex characteristics. Pubertal gy- plasms peak in incidence after puberty, tes- Abnormalities of Embryogenesis necomastia is a benign process that should ticular cancer can be associated with gyne- If fragments of the milk line persist abnor- regress within 2 years of onset (usually by comastia, which may be the only clinical mally, accessory (polythelia) or su- age 17 years). Half of patients report a fam- finding at diagnosis. Ultrasound can be used pernumerary breasts (polymastia) may devel- ily history of gynecomastia [9]. to evaluate for the presence of testicular neo- op. Accessory nipples or accessory breasts are The cause of pubertal gynecomastia is plasms if indicated in these patients (Fig. 1). generally found along the course of the mam- unknown. In the past, an imbalance of tes- mary ridge, most commonly in the axilla. Poly- tosterone and estrogen concentrations has and mastia may be variable, ranging from a nipple been used to explain this entity. However, In children, mastitis has a bimodal distri- without to a fully formed breast. It is es- profiles have not shown a clear bution and is seen most frequently in chil- timated to occur in 1–6% of the population and association. More recent data suggest that dren younger than 2 months and those 8–17 may be associated with renal anomalies [2]. leptin may play a role in its development years old [13]. The majority of cases are [10]. Leptin is found in mammary epitheli- found in girls, and common pathogens in- Premature Thelarche al cells and can enhance enzyme clude Staphylococcus aureus (> 75% of cas- Breast tissue developing in girls before activity in fatty tissue and breast tissue, re- es), gram-negative bacilli, group A Strepto- age 7.5 years is called premature thelarche sulting in an increase in estrogen concentra- coccus species, and Enterococcus species if there are no associated findings of preco- tions. Leptin also can activate estrogen re- [13]. Neonatal mastitis is rare and is pre- cious puberty [1]. Clinically, these patients ceptors in breast tissue. sumed to be caused by mucous membrane Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved present with palpable subareolar masses. Pathologic gynecomastia can be caused by and skin pathogens gaining access to the Most cases are benign and self-limiting, par- an increase in estrogen, a decrease in testos- hormonally stimulated breast tissue ticularly if they are not associated with pre- terone, or or drug use, or it may be through the nipple or ducts [14]. Pediatric

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mastitis in the older age group is generally histologic diagnosis by core biopsy may be PASH associated with skin , instrumenta- appropriate, particularly if the imaging fea- PASH is a benign tumorlike proliferation tion or piercings, or lactation. Clinically, the tures are atypical or if clinical history shows of breast stroma exhibiting interconnected patient will present with erythema, warmth, that the lesion has shown rapid growth. channels lined by thin spindle cells [24]. The and focal tenderness in the breast. Leukocy- spaces in these tumors contain a mucopoly- tosis may or may not be present. saccharide substance and are lined by myofi- Ultrasound is helpful in differentiating Fibroadenoma is a benign mass caused by broblasts. The interconnected slitlike spaces mastitis from abscess [14]. At sonography, overgrowth of the specialized connective tis- resemble vessels, hence the name “pseudoan- mastitis can show both decreased echoge- sue stroma of the breast lobule. It comprises giomatous.” It is a relatively common entity, nicity (early phlegmon) or increased echo- 91% of all solid breast masses in girls young- frequently seen microscopically in normal tis- genicity (usually due to of the fat- er than 19 years [19]. can be sue at breast biopsy and in speci- ty tissue). Hyperemia is usually present on microscopic or large; multiple lesions may be mens. PASH is often associated with prolifer- color Doppler imaging. Enlarged reactive present. These estrogen-sensitive tumors are ative and nonproliferative fibrocystic changes lymph nodes may be present. An abscess generally not seen before puberty. On physical in areas of gynecomastia and is frequently as- can be diagnosed when a round, oval, or ir- examination, they usually present as mobile sociated with lobular [25]. Histo- regular hypoechoic collection is evident. painless “rubbery” masses. At sonography, logically, it can be mistaken for a low-grade The collection often is complex but gener- they often form oval or round well-circum- angiosarcoma or phyllodes tumor. PASH is ally shows decreased flow centrally on color scribed hypoechoic masses with parallel orien- most likely to be confused histologically with Doppler. Antibiotic therapy is the treatment tation, an abrupt interface, and variable poste- angiosarcoma if red blood cells are found of choice. Ultrasound can be used to direct rior acoustic alteration [19]. They can have a within the spaces on core biopsy. needle-guided aspiration of abscess contents macrolobulated contour. Their internal echo- PASH has been hypothesized to repre- for culture and assessment of antibiotic sen- texture can be heterogeneous or homogeneous. sent an exaggerated response of estrogen- sitivities or to direct drainage [15] (Fig. 2). Color Doppler may show the lesion as avascu- primed breast tissue to progesterone [24]. lar or with mildly increased flow. Management Although it is more commonly seen in pre- is controversial and varies among institutions. menopausal women as an incidental finding A galactocele is a cystic collection of breast If the sonographic appearance is classic and at biopsy [26], PASH can present as a clin- milk. They are frequently seen in lactating the lesion does not show rapid growth, short- ically or mammographically detected rub- women and are rare in children. They usually term follow-up ultrasound can be used to mon- bery tumorlike mass [27] and has been re- present as a palpable mass and can be vari- itor the mass, because up to 10% can regress ported in children [28]. able in echogenicity, from purely anechoic to spontaneously [15]. At ultrasound, tumorlike PASH is most of- isoechoic, depending on fat and protein con- Complex fibroadenomas are defined as ten solid and hypoechoic, oval in shape, and tent. Occasionally, fat-fluid levels can be vis- those containing cysts, sclerosing adenosis, oriented parallel to the chest wall [26]. Sono- ualized [16]. Histologically, cuboidal to co- epithelial calcifications, or areas of papillary graphically, they are often similar in appear- lumnar epithelium is noted within the walls apocrine metaplasia. They are more typical- ance to a fibroadenoma and can be multiple of these cysts, and the adjacent breast tissue ly seen in older patients [20]. Children and in number. Posterior acoustic enhancement may show lactational change [17]. Factors that adolescents with complex fibroadenomas are or no alteration of posterior acoustics is gen- may play a role in their development in the pe- at slightly higher subsequent risk for devel- erally seen. In a minority of cases, small an- diatric population include stimulation by pro- oping breast cancer [19] (Fig. 4). echoic spaces may be evident, corresponding lactin, epithelial cell secretion forming a cyst to apocrine-lined cysts at histopathology. after trauma, and ductal obstruction [18]. Juvenile Fibroadenoma Management requires thorough evaluation Treatment consists of either monitoring the Juvenile or cellular fibroadenomas are an of the biopsy specimens to ensure that the le- galactocele with serial clinical or ultrasound uncommon variant of fibroadenoma seen sion is benign and not a sarcoma. Generally, examinations or aspirating the galactocele to more frequently in the African-American imaging follow-up is sufficient for pathologi- provide symptomatic relief [16] (Fig. 3). population [21, 22]. A minority of these tu- cally benign lesions. In the pediatric popula- mors show rapid growth and can attain large tion, if surgical excision is considered, it should Neoplastic Processes size [21]. Clinically, their presentation is be approached cautiously to avoid injury to the Neoplasms in the pediatric population are variable, ranging from small mobile pain- developing breast bud [29]. Rarely, tumoral overwhelmingly benign. The most common less masses to rapidly growing tumors. Juve- PASH may grow rapidly in adolescents and re- benign tumor is a fibroadenoma (seen more nile fibroadenomas are well-circumscribed quire more extensive surgery [23] (Fig. 6). commonly in adolescence) or the more rap- lesions with hypercellular stroma, accom- idly growing juvenile fibroadenoma [17]. panied by intraductal epithelial hyperplasia Juvenile Papillomatosis Rare benign lesions include pseudoangioma- [21]. The sonographic features of a juvenile Juvenile papillomatosis is a benign rare tous stromal hyperplasia (PASH), juvenile fibroadenoma may not differ significant- proliferative breast mass uncommonly seen papillomatosis, and vascular lesions such ly from those of a phyllodes tumor [19, 23]. in children. Histologically, the lesion is char- as hemangiomas. Malignant neoplasms are Generally, surgical excision is advised for acterized by papillary epithelial hyperplasia Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved rare and include phyllodes tumors, metastat- any rapidly growing mass in the adolescent found within the small ducts and lobules [30]. ic disease, and breast carcinoma. In the ado- breast, even if it has been previously char- Numerous cysts and dilated ducts are present, lescent patient presenting with a breast mass, acterized as benign by core biopsy (Fig. 5). separated by areas of dense stroma, giving

W206 AJR:200, February 2013 Pediatric and Adolescent Breast Masses

the lesion a “Swiss cheese” appearance [31]. Recurrence rates correspond with tumor bi- neoplastic tumor, developing most frequent- Clinically, patients with juvenile papilloma- ology, with more benign phyllodes showing ly in young girls who undergo mantle irradia- tosis present with a firm but mobile well-cir- a lower recurrence rate (10–25%), whereas tion for the treatment of Hodgkin disease. The cumscribed mass that can be mistaken for a malignant phyllodes tumors have a recur- breast cancer risk for women who are survi- fibroadenoma. Juvenile papillomatosis on ul- rence rate of up to 40% [34]. vors of Hodgkin disease is 75 times that of the trasound shows a heterogeneous echotexture At ultrasound, these tumors can appear general population [41]. Those at greatest risk with small anechoic areas along the border, identical to fibroadenomas and juvenile or gi- are young women who were treated between representing the numerous small cystic spaces ant fibroadenomas, displaying circumscribed the ages of 10 and 16 years. The majority of seen histologically [32]. Surgical excision is borders, low-level internal echoes, and small tumors develop within the field of radiation. the treatment of choice. Patients with juvenile cysts [35]. Histologic examination with ul- Because the risk for solid tumors continues to papillomatosis are at a slightly increased risk trasound-guided core needle biopsy is indi- increase with years past survival, screening is for the development of breast cancer simulta- cated when children and adolescents pres- integral, and consideration should be given to neously or at a later date. This risk is greater if ent with rapidly growing lesions that may be chemoprevention. American College of Radi- there is bilateral or recurrent disease or there phyllodes tumors, because imaging findings ology guidelines recommend screening mam- is a family history of breast cancer. Juvenile and fine-needle aspiration do not distinguish mography 8–10 years after completion of ther- papillomatosis is also considered a marker for between benign and malignant forms. apy but not before age 25 years [42]. Women familial breast cancer. With the diagnosis of who have received radiation treatment to the papillomatosis, there is an increased rate of Metastatic Disease chest are at increased risk for development of having a positive family history of breast can- In the pediatric population, metastatic can- breast cancer, and MRI screening is recom- cer, ranging from 33% to 58% of cases [23]. cer of the breast is more common than prima- mended in this group as an adjunct to screen- Therefore, patients with juvenile papillomato- ry breast cancer. Lymphoma, leukemia, and ing mammography [43]. sis should be monitored closely (Fig. 7). rhabdomyosarcoma are the most common primary tumors that metastasize to the breast Role of Percutaneous Procedures in Pediatric Vascular Lesions in pediatric patients [17] (Fig. 9). Breast Lesions Unlike in adults, vascular lesions in the pedi- When developmental variations are dis- atric breast are usually benign, most common- Primary Breast Carcinoma covered, biopsy is not indicated and can dam- ly hemangiomas [17]. These hamartomatous Primary breast carcinoma is exceeding- age the developing breast bud. With careful lesions are extremely rare, and their outcome ly rare in pediatric patients, comprising less sonographic technique, many lesions can be and clinical features vary with the histologic than 1% of childhood cancers and less than characterized as benign by ultrasound and features. Some lesions grow rapidly and often 0.1% of all breast cancers [36]. The tumor can be followed for growth, avoiding biopsy. involute rapidly, whereas others simply grow most frequently reported in the literature is However, lesions that are growing or atypical slowly [33]. In general, pediatric breast heman- secretory carcinoma, which is less aggressive in appearance may require biopsy, and core giomas do not respond to corticosteroids, and, than infiltrating ductal carcinoma, though it biopsy is preferred as the least invasive meth- if the lesions do not resolve spontaneously, ex- does possess malignant potential and can re- od of establishing a diagnosis. cision may be required (Fig. 8). cur locally and metastasize to axillary nodes. A recent review of Surveillance, Epidemiol- Conclusion Phyllodes Tumor ogy and End Results data [37] included se- When pediatric patients present to their pri- Phyllodes tumor is a rare stromal tumor cretory carcinomas in patients ranging in age mary care physician with a possible breast that, like the fibroadenoma, arises from the from 11 to 86 years and noted a 5-year over- abnormality, parental concern is often high. specialized lobular connective tissue. It is all survival of 87.2%, with no deaths reported However, many of the breast findings in child- the most common primary breast malignan- among the patients treated with lumpectomy hood are variations of normal development cy in adolescents [15]. There is a higher inci- and radiation therapy. Clinically, secretory and require reassurance but no imaging. When dence of phyllodes tumors in people of Asian carcinoma of the pediatric breast presents as a patient is referred for imaging, a complete heritage [34]. Clinically, these lesions pres- a firm and immobile painless enlarging mass history is essential in guiding management. ent as rapidly growing breast lumps. [38]. At sonography, the lesions are most fre- Ultrasound is the preferred imaging tool and In children and adolescents, most phyl- quently round or oval, with circumscribed can be used to both characterize benign physi- lodes tumors exhibit a benign behavior. How- or partially microlobulated margins and hy- ologic changes of the breast (e.g., asymmetric ever, some lesions show a high rate of recur- poechoic relative to fatty breast tissue [39]. breast development or gynecomastia) as well rence or can metastasize. Generally, several Treatment is surgical, though there is great as more fully characterize neoplastic process- histologic features (including increased stro- debate and variability in the extent of surgery es of the breast. When a neoplastic process is mal cellularity, cellular atypia, stromal over- performed for these lesions. evident on imaging, ultrasound can be used growth, and the presence of sarcomatous ele- to monitor stability or interval growth. His- ments, infiltrative margins, and necrosis) are Primary Breast Carcinoma as a tologic diagnosis by core biopsy is appropri- used to predict which tumors have a more Secondary ate when the lesion shows rapid growth or has malignant behavior [34]. The malignant va- Children who undergo radiation treatment atypical features. As with any needle-guided Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved riety contains sarcomatous elements, infiltra- for cancer are at elevated risk for develop- procedure, careful radiologic-pathologic cor- tive margins, stromal cell atypia with nucle- ing secondary neoplasms [40]. Breast cancer relation is required to ensure accurate diagno- ar pleomorphism, and stromal overgrowth. is the most commonly seen solid secondary sis. In the pediatric patient, MRI of the breast

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J Pediatr Surg 2011; Cancer J Clin 2007; 57:75–89 (Figures follow on next page) Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved

W208 AJR:200, February 2013 Pediatric and Adolescent Breast Masses

A B Fig. 1—17-year-old boy with unilateral asymmetric gynecomastia of right breast, with pain for 4 years. Patient is of Ashkenazi Jewish descent. A, Ultrasound of right breast shows hypertrophied tissue (arrow). B, Comparison image of normal left breast shows normal thickness of breast tissue (asterisk). Because of patient’s elevated risk of BRCA1 and BRCA2 mutations, family history of breast cancer, and psychosocial issues related to significant asymmetry of his breasts, elective unilateral mastectomy was performed.

Fig. 2—19-year-old woman with left breast abscess. Patient was not lactating but had left nipple ring and presented with left for 2 months with new development of palpable mass and associated erythema. A, Single ultrasound image shows left breast abscess (arrow) at 4 o’clock radian, 3 cm from nipple. Note peripheral ring of increased vascularity. Abscess is round and hypoechoic with mobile internal debris of mixed echogenicity. B, Image obtained after ultrasound-guided aspiration shows nearly complete collapse of abscess cavity (asterisk). After needle aspiration, patient underwent incision and drainage of abscess performed by breast surgeon, with placement of drain. Cultures showed gram-positive cocci. Patient was given appropriate oral antibiotic therapy and showed interval improvement during her follow-up examination with no recurrence of abscess. A B

Fig. 3—19-year-old woman, 2 months postpartum and breast-feeding, who presented with palpable lump in her right breast. Antiradial sonographic image of right breast at 9 o’clock radian, 1 cm from nipple, shows well-circumscribed oval

Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved complicated cystic lesion (arrow) with multiple internal septations and posterior acoustic enhancement, consistent with galactocele. Short-term surveillance was chosen. Ultrasound of left breast performed 6 months later at follow-up (she was still nursing) showed no change in galactocele. Because this lesion was palpable, it was recommended that patient be monitored with clinical breast examinations.

AJR:200, February 2013 W209 Kaneda et al.

Fig. 4—15-year-old girl with complex fibroadenoma. Patient presented with palpable right retroareolar mass. Initial ultrasound showed hypoechoic macrolobulated mass (asterisk) of mixed echogenicity in right breast at 6 o’clock radian, 3 cm from nipple. Mass shows cystic and solid components and mixed posterior acoustic shadowing, and it enhanced through transmission of sound. Given that mass was new, palpable, and complex in appearance, ultrasound- guided core biopsy and surgical consultation were recommended. Patient and her family decided against ultrasound-guided core biopsy and instead chose excisional biopsy. Pathologic analysis confirmed that lesion was complex fibroadenoma.

A B Fig. 5—16-year-old girl with juvenile fibroadenoma who presented with painless lump in subareolar region in left breast at 3 o’clock radian. A, At ultrasound-guided biopsy, mass (arrow) proved to be juvenile fibroadenoma. Juvenile fibroadenomas usually present as hypoechoic mass of mixed echogenicity. Short-term (6-month) clinical and imaging follow-up was recommended. B, Follow-up ultrasound and clinical breast examination showed stability of lesion. Patient opted to have mass excised because of increasing discomfort. Surgical pathologic examination verified presence of juvenile fibroadenoma. Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved

W210 AJR:200, February 2013 Pediatric and Adolescent Breast Masses

A B

C D E Fig. 6—16-year-old girl with tumoral pseudoangiomatous stromal hyperplasia (PASH) who presented with painless rapid enlargement of her left breast over 6-month period. A, Initial evaluation was performed with ultrasound of left breast followed by ultrasound-guided core biopsy. Lesion (arrow) was diagnosed as tumoral PASH. B–E, Bilateral breast MRI was then performed to evaluate extent of lesion and to guide surgical therapy. MRI included T1-weighted contrast-enhanced (B), T1-weighted contrast-enhanced with subtraction (C), T1-weighted contrast-enhanced multiplanar reformation (D), and T2-weighted SPAIR (spectral adiabatic inversion recovery) (E) sequences. MRI examinations show large well-encapsulated hypervascular mass (asterisk, B), with large peripheral vessels causing mass effect on adjacent breast tissue. Removal of tumoral PASH was performed by breast surgeon in conjunction with for reconstruction of left breast to achieve breast symmetry.

Fig. 7—14-year-old girl with juvenile papillomatosis. Patient presented with complaint of new soft palpable mass in upper inner quadrant of right breast. Initial diagnostic ultrasound shows oval-shaped mass (arrow) that is parallel in orientation, measuring 4.9 × 2.8 cm, at 1 o’clock radian, 3 cm from nipple, in right breast. Mass is of mixed echogenicity with both solid and cystic components. Patient returned for ultrasound-guided core needle biopsy and surgical consultation. Pathologic analysis

Downloaded from www.ajronline.org by University Of Chicago Library on 05/12/13 IP address 128.135.12.127. Copyright ARRS. For personal use only; all rights reserved of core needle biopsy showed juvenile papillomatosis without atypia. Right breast lumpectomy with wide margins was performed, with surgical pathologic analysis also showing extensive juvenile papillomatosis without atypia. Close clinical follow- up by breast surgeon was recommended because of slightly elevated risk of breast cancer associated with this lesion.

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Fig. 8—3-year-old girl with left breast hemangioma. Contrast-enhanced chest CT was performed with positive PPD (purified protein derviative) to evaluate hilar adenopathy. Multiple enhancing masses (arrow) are noted in left breast, supplied by left internal mammary and axillary vessels. Findings are consistent with patient’s known left breast hemangioma, which was being followed clinically.

A B Fig. 9—12-year-old girl with metastatic rhabdomyosarcoma to left breast. A, There was asymmetric soft-tissue density in left breast (arrow), in comparison with right breast, which increased on subsequent follow-up. B, On follow-up examination, patient also developed metastatic disease (arrow) to ribs, lungs, meditational lymph nodes, and other soft tissues, as well as large pericardial effusion, not fully visualized on these single images. She died within few months after this CT examination.

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W212 AJR:200, February 2013