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Breast Diseases in Children: the Spectrum of Radiologic Findings in a Cohort Study

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Breast Diseases in Children: the Spectrum of Radiologic Findings in a Cohort Study Diagn Interv Radiol 2017; 23:407–413 BREAST IMAGING © Turkish Society of Radiology 2017 ORIGINAL ARTICLE Breast diseases in children: the spectrum of radiologic findings in a cohort study Emel Durmaz PURPOSE Murat Alp Öztek We aimed to investigate the spectrum of radiologic findings and referral reasons for breast dis- Hatice Arıöz Habibi eases in children considering age-appropriate presentation. Uğur Kesimal METHODS Hakkı Timur Sindel Our retrospective cohort study included 348 consecutive pediatric patients aged <19 years (me- dian, 13 years) referred to radiology with a clinical presentation between 2005 and 2016. Radio- logic findings were reviewed in four age ranges (0–2 years, 2–8 years, 8–15 years, >15 years). RESULTS Of 348 patients, 257 had a referral reason. The most frequent referral reason was a palpable mass (35%). Developmental abnormalities accounted for 48% of all radiologic findings in 348 patients. We did not detect any breast malignancy. According to age groups, the most common radiologic findings were neonatal hypertrophy (0–2 years), early breast development (2–8 years), develop- mental abnormalities by a majority of gynecomastia (8–15 years), and normal findings or devel- opmental abnormalities (>15 years). Interestingly, the frequency of gynecomastia was only 4% in neonatal period or early childhood. Fibroadenomas and fibroadenoma-like solid masses were seen after 8 years and constituted the majority of solid masses (65%). Cysts were seen at a rate of 7% and majority of them were of simple type, which tends to resolve in time. CONCLUSION In our study, the most common referral reason to radiology was a palpable breast mass. Neonatal hypertrophy and early breast development in younger children, and developmental abnormal- ities in older children may be kept in mind as the most common radiologic findings. Our study confirms the substantial absence of malignancies in children as well as a widely different disease spectrum in comparison with the adult population. reast diseases in the pediatric population are uncommon conditions and many ra- diologists lack familiarity with their characteristic imaging features, which may lead to B diagnostic challenges. Understanding normal breast development and the spectrum of pediatric breast lesions is the key to correct diagnosis and management. In our daily practice, clinicians refer children with breast complaints or pathologic findings to breast radiology departments. Although we know that these conditions are usually self-lim- ited and benign, management of breast lesions in children differs from that in the adult pop- ulation. Although, we tend to avoid breast biopsy in children, in some cases it may be neces- From the Department of Radiology (E.D. sary. Breast tissue is vulnerable in children and biopsy can damage the developing tissue and [email protected], M.A.Ö., U.K., H.T.S.), prevent its normal growth. Thus, radiologists should carefully choose proper modality and Akdeniz University School of Medicine, Antalya, management. Ultrasonography is the appropriate initial imaging modality in children (1–3). Turkey; Department of Radiology (H.A.B.), İstanbul University Cerrahpaşa School of Medicine, İstanbul, Mammography should be used rarely due to particularly high sensitivity of the developing Turkey. breast to radiation. Moreover, increased fibroglandular tissue density makes mammography less helpful (4, 5). Magnetic resonance imaging (MRI) of the breast is not widely used in pedi- Received 27 January 2017; revision requested 27 February 2017; last revision received 27 May 2017; atric population but might be helpful in vascular and lymphatic malformations (1, 2). accepted 5 June 2017. In addition to avoiding unnecessary biopsies, diagnosing breast diseases directly and Published online 16 October 2017. distinguishing benign and malignant breast lesions becomes important when parents DOI 10.5152/dir.2017.17033 have a fear of cancer in their children. It will be easier to handle these challenges, if we as You may cite this article as: Durmaz E, Öztek MA, Arıöz Habibi H, Kesimal U, Sindel HT. Breast diseases in children: the spectrum of radiologic findings in a cohort study. Diagn Interv Radiol 2017; 23:407–413. 407 radiologists know the most common find- into six groups; a) normal, b) solid masses, projection if necessary to seek any addition- ings or diseases in pediatric patients. Here, c) cysts, d) non-neoplastic lesions (ductal al malignant finding. The mammograms we aimed to investigate the most common dilatation, lipomastia), e) inflammatory le- were obtained as full-field digital mam- breast findings and referral reasons consid- sions (mastitis, abscess), f) developmental mography (Giotto, IMS). ering age-appropriate clinical presentation abnormalities (juvenile hypertrophy, asym- We used descriptive statistics, frequency, in pediatric patients. metric growth, early breast development and crosstabs analyses. Positive and nega- [premature thelarche], neonatal hypertro- tive predictive values and false positive rate Methods phy, and gynecomastia). These six groups were calculated. Data collection and patient selection and their subgroups were addressed in four Our institutional review board approved age ranges (0–2 years, 2–8 years, 8–15 years, Results this retrospective cohort study in accordance >15 years). Of 348 patients, 126 (34%) were male and with the Helsinki Declaration. We searched The characteristics of the mass such as 222 (64%) were female. The mean age was patient information and images between shape, contour, parallel or not parallel align- 12.2±4.5 years (median, 13 years; ranging January 2005 and October 2016 from picture ment, and multiplicity were evaluated on from 6 months to 19 years). The distribution archiving and communication system (PACS) sonography images or videos. We recom- of age ranges was as follows: 9.5% of the of our hospital. We used 3 different radiolo- mended a short-term follow-up for prob- patients were 0–2 years of age, 11.5% were gy/patient information programs since our ably benign masses (BI-RADS category 3 2–8 years of age, 43.7% were 8–15 years of hospital updated PACS in 2014 and infor- assessment in initial diagnosis). Biopsy was age, and 35.3% were >15 years of age. mation for some patients had been kept in recommended in case of any suspicious Of 348 patients, 257 had a referral rea- previous databases. The following programs finding at the initial diagnosis or interval son on our digital database. The most fre- were used: Medi Hasta. (16.53, 1997/2014, changes for malignancy during follow-up quent referral reason was palpable mass A.U. Hospital); Mia-Med (version 1.0.1.2808, of probably benign masses. Biopsy type with a rate of 35% (n=90) and the second Mia Technology); Sectra (dedicated only to and pathologic results were noted. Also, most common reason was gynecomastia radiology PACS, IDS7, version 17.3). the number of patients who underwent bi- with 22% (n=57). The distribution of refer- Data from 358 patients <19 years, re- opsy at the discretion of the parents or the ral reasons is listed in Table 1. Of 90 patients ferred from pediatrics or pediatric surgery pediatric surgeon were taken into account. referred to radiology with a palpable mass, outpatient clinics to radiology department Patients underwent either percutaneous ul- 24 (27%) had no real lesion in their breasts were evaluated by three radiologists. Data trasonography (US)-guided core biopsy (14 reported by negative or normal radiologic collection comprised digital images, radiol- gauge needle, Magnum, C.R. Bard Medical) findings. ogy reports, notes from pediatricians or pe- or surgical excision biopsy. In 6 patients with breast enlargement, diatric surgeons such as breast symptoms Cysts were subcategorized as simple, although clinicians did not clearly specify and examination findings, referral reasons, clustered, complicated, and complex cysts. the finding or complaint as asymmetrical, demographic information such as age at Biopsy was recommended for complex radiologic diagnosis consisted of asymmet- the time of diagnosis and sex, and pathol- cysts, if not corresponding to benign le- rical lesions including one gynecomastia, ogy results (when available). Ten of 358 pa- sions like oil cyst. The status of axilla was two juvenile hypertrophies, one cyst and tients were excluded from the analysis due evaluated for inflammatory lesions such as two neonatal hypertrophies. Thus, we think to absence of radiologic findings and refer- abscess or mastitis in terms of lymphade- there is an overlap between asymmetrical ral reasons in the database. Remaining 348 nopathy. enlargement (6.6%) and breast enlarge- patients having unilateral or bilateral radio- Fibroglandular echogenicity on US was ment (2.3%) and swelling (2.3%) symptoms. logic findings in their breasts constituted considered as “gynecomastia” in boys. The However, palpable mass was again the our study population. Referral reasons were diagnosis was “early breast development” most frequent reason by far in our study, analyzed in 257 patients for whom data in girls <8 years old. Findings were consid- even if we add premature thelarche (2.7%) were available. ered “normal” in case of: a) no remarkable as a referral reason to others mentioned US findings in males, b) no remarkable US above (Table 1). Imaging methods and review of findings in girls <8 years of age, and c) only Of 257 patients with a referral reason, radiologic findings fibroglandular tissue in girls >8 years of age 17 (6.6%) were referred because of nipple Radiologic findings were categorized (peripubertal and adolescents girls). We did discharge. The most common findings in not use the US findings compatible with these children were fibroglandular tissue or the stage of thelarche adopted from Tan- normal US findings (n=10), followed by fo- Main points ner’s classification, since this kind of evalu- cal US abnormalities, namely gynecomastia ation would not contribute to our purpose (n=1) and simple or multiple cysts (n=6). • The spectrum of breast diseases in children is (2, 5, 6). Of 348 patients, the most frequent find- quite different from that in adults.
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