Article ID: WMC003775 ISSN 2046-1690

Spectrum of Disorders in A Pediatric Surgery Clinic: Retrospective Study

Corresponding Author: Dr. Atilla Senayli, Assistant Prof., Pediatric Surgery, Yildirim Beyazit University - Turkey

Submitting Author: Dr. Atilla Senayli, Assistant Prof., Pediatric Surgery, Yildirim Beyazit University - Turkey

Article ID: WMC003775 Article Type: Original Articles Submitted on:26-Oct-2012, 05:59:39 AM GMT Published on: 26-Oct-2012, 06:25:34 PM GMT Article URL: http://www.webmedcentral.com/article_view/3775 Subject Categories:PAEDIATRIC SURGERY Keywords:Breast; Disorders; Children How to cite the article:Senayli A, Karaveliolu A , Koseoglu B , Akln M , Ozguner I . Spectrum of Breast Disorders in A Pediatric Surgery Clinic: Retrospective Study . WebmedCentral PAEDIATRIC SURGERY 2012;3(10):WMC003775 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None

Competing Interests: None

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Spectrum of Breast Disorders in A Pediatric Surgery Clinic: Retrospective Study

Author(s): Senayli A, Karaveliolu A , Koseoglu B , Akln M , Ozguner I

Abstract Paediatricians must pay attention to breast disorders that may be seen at any paediatric age group. (1). Objective: There are a limited and inadequate data Although most of the diseases are benign as a fact, for breast diseases in children. This may be because the possibility of malignancy can never be ignored of low importance expectations of practitioners' for (1-3). The major problem to form a confident clinical breast problems in which laboratory tools are treatment protocol is very little published data for rarely used. However, breast issues of children may breast diseases of adolescence (2,3). possibly remain missing as a consequence of Underestimation of the breast disorders often by insufficient data. In this article, we encourage the clinicians may be the reason of publication authors to share their experiences and publish deficiencies (4). On contrary to this, breast disorders procedures. of children and adolescent must be important topics for physicians and gynecologist (4). Parents anxiety Settings and Methods: Pediatric surgery documents and patients’ fear about progressive breast disorders between 2005 and 2011 were evaluated to are the main reason of this suggestion (4). demonstrate breast disorders. Diagnosis, gender, age, More data is needed to make decisions on breast ultrasonography, treatment modalities and follow-up diseases. For data expansion, we aim to add 6-year procedures were studied in this study. Literature data experience for breast diseases to literature. is compared with the study findings. What could be the lack of practice due to lack of data in the literature are Methods presented.

Results: Seventy-two patients were diagnosed with In Kecioren Education Hospital, documents of breast diseases among 9958 patients. Twenty-eight pediatric surgery between 2005 and 2011 were patients were male and 44 patients were female. evaluated for breast diseases. Some of the authors Median ages of the male and female patients were contributing to this study previously worked in the 12.5 and 14 respectively. Physical examination was hospital. Some authors are still working. In this study, the only practice used for most patients. spectrum of breast disorders, gender, age, Ultrasonography was used for 27 patients. Laboratory ultrasonography, treatment modalities, and follow-up examinations were not used. Only one patient was periods are presented. Diseases were evaluated with operated. Male and female patients were followed for International Classification of Diseases Code-10 2 and 3 years, respectively. (ICD-10). Authors had agreed on similar codes for diagnosis of unknown lesions like masses. Most of Conclusion: Although literature data is present for undefined masses were diagnosed as “Benign Breast breast disorders, clinical documents published by Dysplasia”. paediatric surgery on this subject is rare. Simple treatment modalities, necessity of long follow-up Results periods and clinically unimportant disorders may be the reason of very little published information. Different managements and experiences for breast diseases Seventy-two patients were diagnosed with breast must be published to add value to a lacking and disease in 9958 cases. Twenty-eight patients were neglected issue. The only mission of this study is to male and 44 patients were female. Median ages of the invite authors all over the world to add their data about male and female patients were 12.5 and 14 breast disorders. respectively. Accessory breast (1 patient, 1.4%), benign breast dysplasia (51 patients, 70.8%), Introduction (6 patients, 8.4%), breast hypertrophy (4 patients, 5.5 %), non-puerperal infective (4

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patients, 5.5 %), non-puerperal breast abscess (3 Therefore, we performed a randomized treatment. We patients, 4.2%), fissure (2 patients, 2.8%), and invite authors to share their experience in this regard. diffuse (1 patient, 1.4%) was the result of Otherwise, the disease can’t be formulated for better the study. Breast ultrasonography was used for 27 decision-making. patients. Very few patients had blood samples and other laboratory tests were performed. Therefore, Breast masses have usually been diagnosed as laboratory studies are not included in article. Physical benign physiologic enlargements or developmental examination has been the main assessment and changes (6). Fibroadenoma is the most seen benign management tool. Only one patient was operated. dysplasia of female (1-3). Fibroadenoma could be Male and female patients were followed-up for 3 and 2 72-75% of the breast masses (4). In our series, 70.8% years respectively. Results were demonstrated in patients (n=51/72) were diagnosed with benign breast Table-1. dysplasia. In International coding system for diseases is limited on breast problems. Seeing this, “Benign Discussion Breast Dysplasia” was preferred for the description of breast masses in our practice. Thirty patients (30/72, 41.6%) in this group were female and all female Breast disorders can be diagnosed also in children patients had fibroadenoma. Fibroadenomas are (3,5). Although most breast disorders of this age are -sensitive tumors. Due to this sensitivity, benign, parents are always fear of malignancy (1). fibroadenomas can be seen in patients premenarchal Parents' concerns are the most effective factor for the and 20 years old (4). Patients, in our study, are found treatment of breast disorders. Sometimes, these to be premenarchal or older, as mentioned in literature. concerns may force physicians for surgical Ultrasound (US) is important for the diagnosis of intervention. Physicians must know the process of breast disorders especially masses (1,2). Only 13 these diseases at adolescence to do the right thing for ultrasonography examinations were performed for the child and to convince parents. In contrast, the female patients in this group and therefore, the literature contains adolescence diseases is limited, number of evaluations for diagnosis may be accepted and physicians have often overlooked the diseases. insufficient. Typical physical examination findings of breast masses may be one of the reasons. Low Breast problems are rarely examined in pediatric expectations for USG findings about the masses of surgery clinics. Therefore, collections of the patients' patients may be another important reason. Also, data at any number will be meaningful. Total number follow-up decisions of the authors may interrupt of our patients is 72. Nevertheless, we share our ultrasonography evaluations. experience for accessory breast, benign breast dysplasia, gynecomastia, breast hypertrophy, Breast masses, particularly fibroadenoma, due to the non-puerperal infective mastitis, non-puerperal breast can be treated with . For abscess, nipple fissure and diffuse breast cyst. this purpose, to monitor two or three menstrual cycles, may be sufficient to decide (1). However, to our Accessory breast is a true polymastia containing all knowledge, management schedule of these problems components of mammary but the disease forms a is not present, yet. In this section; the breast masses small percentage of the polymastia disorders. (5). variations, ultrasound necessity, sufficiency of Polythelia, the existence of accessory nipple and ultrasound, or predicting factors are still unknown. In areolae, is the most seen anomaly of this issue. (5). In fact, we realize that our data was also defective for all literature, enough data about the demography, these factors. Therefore, practices in our clinic will also characteristics and statistics for accessory breast be revised. disorders has not been collected. In our clinics, only one case was present and the disease was at the On the other hand, twenty-one male patients (21/72, axillary region. Ultrasonography was used for the 29%) were diagnosed with benign breast dysplasia. confirmation of disease. At the same time, she was the Median age of these patients was 12 and only 6 were only patient who underwent surgery for breast disorder. evaluated with ultrasonography (U.S.). Ultrasound In our series, the incidence of accessory breast was examinations were normal in 3 patients, 2 patients had 1.4%. To our knowledge, predictors like incidence and cystic lesions, and there was a fibroadenoma. The age for the operations of accessory breast in literature data is also limited in male patients suffering from is not clear. Also, evaluation mechanisms for breast masses. These masses may be breast tissue of pathogenesis of the disease are not sufficient. premature , cysts, or fibroadenomas. (3). The

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literature is not sufficient for the evaluation of the to decide about gynecomastia. Other possible etiologic subject. So, age characteristics, determinant factors, factors, predictor parameters and management reasons for the existence, management procedures schedules have to be evaluated in the future. and control criteria are not satisfactory in the literature after a thorough evaluation. When breast overgrowth is present for female gender, it is called breast hypertrophy (1,5). Hypertrophy may Exact diagnosis breast masses with physical be unilateral or bilateral (5). Breast hypertrophy is examination and ultrasound is difficult sometimes. named as before the 7 years old Therefore, “Benign Breast Dyplasia” is our preference (1, 5). However, ethnic differences must be taken into as a code for breast masses. International coding account because of hormonal influence on breast system of diseases (ICD-10) is restricted for activities (9). Hypertrophy may be seen diseases. Therefore, descriptions with “Breast as an over-response of breast tissue to estrogen disorders, undefined”, “Breast masses, undefined” and activities (1, 4). In our series, patients with hypertrophy “Breast, undefined” are not useful for breast problems. were in prepubertal period but none of them had According to us, “Benign Breast Dyplasia” is the most premature thelarche. Median age is 11 and incidence effective description in the coding system. This name of hypertrophy in our series is 5.5%. They had all can be used for different problems including bilateral hypertrophy. There was no laboratory fibroadenoma, hypertrophy, and cysts. It is hard to find algorithm for this topic. Therefore, our benign dysplasia classification in literature. recommendations did not inform about the etiologic Nevertheless, benign dysplasia is a pre-diagnosis that factors in detail. Also, treatment modalities are not forms the largest group in our series. For more definitive on this subject. So far, the only thing that can descriptive definitions, evaluations procedures must be done, is to inform the patient about a possible be developed. surgery after (1).

Gynecomastia is glandular enlargement of one or two Breast infections and abscesses may also occur in breast of male gender (4,7). Subaerolar growth of childhood (1, 4, 5). Inflammation consists of 4% of breast tissue is characteristic feature in gynecomastia breast diseases (1). Also, infection incidence with an and it may reach up to 3 cm in diameter. (4). abscess was 7% (4). In our series, mastitis was 5.5% Unfortunately, a measurement schedule is not present and abscess formation was 4.2%. Inflammation of the to diagnose gynecomastia. Therefore, we had only tissues around the breast before thelarche referred to used physical examinations as diagnostic tool. as cellulite. (5). If present in neonate, mastitis can be Gynecomastia is separate from the general or seen with different clinical presentations including breast hypertrophy (3). When it appears in male septicemia (4). In our series, mastitis and abscesses newborn, it is named as neonatal breast hypertrophy presented with mean age of patients, respectively, (4). Among our patients we have no neonatal 14.5 and 14. Breast infections may occur by foreign hypertrophy. Gynecomastia, generates 60% of all bodies, epidermoid cysts, trauma, nipple piercing, male breast diseases (7). Our findings are different folliculitis after shaving periareolar hair, sexual trauma, from the literature. In our series, incidence of acne lesion, duct abnormality, , and gynecomastia was 21.4 % (6/28 male patients) and altered immune defence (1,4). Mastitis, abscess, the disease is the second most seen problem. hematoma and fat necrosis especially occurs due to Gynecomastia may be unilateral or bilateral (4). nipple trauma. (5). The trauma related to underwear Bilateral gynecomastia is common especially in the clothes may be the reason of mastitis and abscess in neonatal and prepubertal periods (7). Our patients’ our patients. There were not anatomical deformities of median age was 16 years and this finding is correlated the and . Unfortunately, patients’ with the literature. All patients had bilateral histories were not definite for some other factors, and gynecomastia and none of them were operated. certain parameters, like sexual activity, were not Resolving spontaneously in 2 years follow-up periods appropriate for the research in our social life. Cystic is the reason of conservative treatment (4). A specific lesions were present in two patients who had mastitis cause of gynecomastia is difficult to find and the and abscess. In addition, we could not demonstrate reason for 90% of them are unknown (7). Testicular what causes cysts, mastitis and abscess. calcifications may be the sign of hyperactivity of testicle and stimulate gynecomastia Fissure of nipple was found in two patients in our formation (8). To our knowledge, this is the only series. One patient was 8 years old male and other etiological theory of gynecomastia. This is not enough was 14 years old female. The disorder incidence in our

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series was 2.8%. There is little information about branches from internal and surgical medicine nipple fissure in the literature. The most plausible concerning on breast disorders may work together to reason seems to be accused of trauma. Nevertheless, structure evaluation charts of breast disorders for mastitis and abscess reasons that were mentioned children. Also, by this article, we want to invite authors above may also be the reason of fissure. to share their experiences to strengthen the database of the task. In the literature, cystic incidence was 6-10 % (4). In our series, the incidence is 1.4 %. Only Reference(s) one female patient was diagnosed as a benign cyst. The patient was 7 years old. We have followed up the patient for 2 years without surgery. As usual, the 1. Fallat ME, Ignacio RC,Jr: Breast Disorders in cause of cyst formation was not detected. Breast cysts Children and Adolescent. 2008; 21: 311-316. may be benign cysts, sclerosing adenosis, 2. Umanah IN, Akhiwu W, Ojo OS: Breast tumors of parenchymal fibrosis, and duct ectasia (5). Cysts may adolescents in an African population.Availablefrom: also be fibrocystic (5). Under all circumstances, cystic http://www.afrjpaedsurg.org/text.asp?2010/7/2/78/628 masses usually resolve spontaneously in time. (5). 49;7: 78-80 3. Garcia CJ, Espinoza A, Dinamarca V, et al: Breast Radiographic studies, especially ultrasonography US in Children and Adolescent. Radiographics 2000; (US), are important for breast evaluations (1,3). US is 20: 1605-1612 useful for palpable masses, and solid masses can be 4. Greydanus DE, Matytsina L, Gains M: Breast differentiate from cystic lesions by US but it is a poor Disorders in Children and Adolescents. Prim Care Clin evaluation tool (1,2). Umanah et al reported that only Office Pract 2006; 33: 455-502 41% of the breast tumors can be diagnosed with US 5. Simmons PS: Diagnostic Considerations in Breast and only 3.8% of them are treated with biopsy and Disorders of Children And Adolescents. Obstet excision (2). In our series, 27 (37.5%) of 72 patients Gynecol Clin Nort Am 1992; 19: 91-102 were evaluated with ultrasonography. In the literature, 6. McHoney M, Munro F, Mackinlay G: Mammary duct to find a similar study is not easy. Therefore, we can’t ectasia in children: Report of the short series and compare our findings with another study. Also, criteria review of the literature. Earl Hum Dev 2011; 87: of necessity, and reliability for ultrasonography is 527-530 lacking in the literature. 7. Hoevenaren IA, Schott DA, Otten BJ, et al: Prepubertal unilateral gynecomastia: a report of two There are some other problems for the evaluation of cases. Eur J Plast Surg 2011; 34: 395-398 the breast disorders for clinicians because of weak 8. Grandone A, del Giudice EM, Cirillo G, et al: database. First, breast problems have usually been Prepubertal Gynecomastia in Two Monozygotic Twins evaluated in surgical clinics (2). Subsequently, with Peutz-Jeghers Syndrome: Two Years’ Treatment pediatric clinics are not interested in the diseases in with Anastrozole and Genetic Study. Horm Res details. Second, surgical evaluations have usually Paediatr 2011; 75: 374-379 been underestimated because surgeons suggest that 9. Novonty R, Daida Y, Morimoto Y, et al: Puberty, many of the disorders can be managed only by clinical Body Fat, and Breast Density in Girls of Several Ethnic examinations or by reassurance of the patient and/or Groups. Am J Hum. Biol. 2011; 23: 359-36 parents (1). Third, surgical procedures for breast disorders at pediatric age group are thought to be limited because of the possibility of breast deformity in later periods (3). This limitation altered surgeons’ interest in breast disorders. Conclusion(s)

In conclusion, we realized that our patients for breast disorders had not been evaluated in details. However, when we evaluated the literature to structure a clinical algorithm, we could not find out data revealing pediatric managements in detail. We think that

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Illustrations Illustration 1

Table-1: Distribution of the diseases with the evaluation of gender, age, ultrasonography, operation and follow-up periods

Breast Disorders Gender (M/F) Age( M/F)(Median) USG (M/F) Operation Follow-up in children (Median) (M/F) (M/F)(years) (Median) Accessory Breast 0/1 0/15 0/1 0/1 0/1 Benign Breast 21/30 12/13 6/13 0/0 2/3 Dysplasia Gynecomastia 6/0 16/0 0/0 0/0 3/0 Breast 0/4 0/11 0/1 0/0 0/3 Hypertrophy Non-puerperal, 0/4 0/14.5 0/2 0/0 0/2 infective mastitis Non-puerperal, 0/3 0/14 0/2 0/0 0/1 breast abscess Nipple fissure 1/1 8/14 0/1 0/0 3/0

Breast Diffuse 0/1 0/7 0/1 0/0 0/2 Cyst Total 28/44 12.5/14 6/21 0/1 3/2

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