Pre-Pubescent Ultrasound

Amit Sura, MD/MBA Assistant Professor and Fellowship Director, Children’s Hospital Los Angeles SPR 2017 Sunrise Session Department of Radiology 4/3/2017

Categorize Patient

• Age

• Symptoms / PE

• Imaging

• Differential Diagnosis

• Recommendations Age

• Neonate (first 28 days after birth)

• Neonate-Infant (28 days – 1 year old)

• Pre pubertal Symptoms and Questions to Ask?

• discharge?

• Palpable nodule?

• Asymmetric breast tissue?

• Discoloration of soft tissue? Different Clinical Scenarios: Imaging Not Necessary

• Neonate with – Response to maternal , “witch’s milk”

– Should disappear within 2 weeks as levels start to dissipate

– Maternal  causes varying degree of breast enlargement in newborn1 • Usually with the breast bud measuring 1 to 2 cm 2

– Postnatally falling levels of maternal estrogen thought to trigger prolactin secretion 3 • Causes milk secretion in 5 to 20% of newborns 4 – Inadequate let-out of milk, either due to improper canalization of lactiferous ducts or due to lack of oxytocin stimulus in the newborn  stagnation of milk, • Superimposed infection may result in complications such as and breast 5

2 wk old female with breast enlargement

J Neonatal Surg. 2013 Jul-Sep; 2(3): 31. Published online 2013 Jul 1. Neonatal Mastauxe (Breast Enlargement of the Newborn) V Raveenthiran Neonatal Mastitis • Common in full term female neonates during 3rd and 4th week of life

• Bilateral involvement rare (<10%)

• Maternal endocrinopathy in 0-14% of cases

• Staph commonest isolate - >60% of cases

• With or without pre-treatment  50-70% progress to breast abscess requiring drainage

• 30-60% of neonates require IV abx; 8-28% serious life threatening systemic complications6

• No long term follow-up 2 week old male with left breast cellulitis

LFT BREAST TRAN 2 week old male with left breast cellulitis

LFT BREAST TRAN and Imaging Findings

• First phase of breast development as fetus – Results in formation of rudimentary organ consisting of simple branched ducts – Ducts respond to the secretory stimuli of maternal origin 7

• Normal US finding of the breast prior to – Subcutaneous tissue and fat that appear heterogeneous in echotexture – Linear planes of the pectoralis muscle posteriorly – Ribs lie posteriorly and result in posterior acoustic shadowing, should not be mistaken for mass 4 month old female, reported palpable mass however no longer 4 month old female, reported palpable mass however no longer a.k.a breast bud

• Breast development that begins before the age of 7.5 yrs, considered precocious or premature – Normally thelarache or breast bud happens at Tanner stage II breast development

• Subtle overfunction of the pituitary-ovarian axis – Not associated with growth spurt, advanced , and menses – Must differentiate between isolated premature thelarche and central precocious – Unilateral or bilateral7 19 month old female with question of left subareolar breast lesion

RT BREAST SUBAREOLAR LFT BREAST 19 month old female with question of left subareolar breast lesion

LFT BREAST SUBAREOLAR 7 y.o. female evaluate for

RT BREAST SUBAREOLAR LFT BREAST 1 year old female with persistent bump underneath right nipple

RT BREAST SUBAREOLAR LFT BREAST 1 year old female with persistent bump underneath right nipple

RT BREAST SUBAREOLAR Duct Ectasia

• Most commonly affects the subareolar ducts but may also involve the smaller peripheral ducts  cause unclear

• US demonstrates tubular anechoic structures or ducts filled with echogenic debris, usually behind the nipple.

• +/- nipple discharge

• Sx vary: • Painful and/or palpable area • Asymptomatic , only seen on imaging7 1 month old male with bilateral breast swelling 1 month old male with bilateral breast swelling 29 day old male with 2 days of bilateral mobile breast masses 29 day old male with 2 days of bilateral mobile breast masses 29 day old male with 2 days of bilateral mobile breast masses Congenital Breast Anomalies

• No imaging required

• Polythelia  more than the normal number of

• Polymastia  more than the normal number of

• Congenital  absence of mammary glands Interesting Cases in Pre-Pubertal Population 6 month old male with right chest wall mass 6 month old male with right chest wall mass 8 y.o. male w/ 8 y.o. male w/ gynecomastia 5 yr. old male with left 5 yr. old male with left breast mass 5 yr. old male with left breast mass 5 yr. old male with left breast mass 5 yr. old male with left breast mass References

• 1. Amer A, Fischer H. Neonatal breast enlargement. N Engl J Med. 2009; 360: 1445. 2. Jayasinghe Y, Cha R, Horn-Ommen J, O'Brien P, Simmons PS. Establishment of normative data for the amount of breast tissue present in healthy children up to two years of age. J Pediatr Adolesc Gynecol. 2010; 23: 305-11. • 3. McKiernan JF, Hull D. Prolactin, maternal oestrogens, and breast development in the newborn. Arch Dis Child. 1981; 56: 770-4. • 4. Madlon-Kay DJ. Witch’s milk: in the newborn. Am J Dis Child. 1986; 140: 5. Rudoy RC, Nelson JD. Breast abscess during the neonatal period. A review. Am J Dis Child. 1975; 129: 1031 - 1034. \ • 6. V Raveenthiran. J Neonatal Surg. 2013 Jul-Sep; 2(3): 31. Published online 2013 Jul 1. Neonatal Mastauxe (Breast Enlargement of the Newborn) • 7. Weinstein SP. Spectrum of US Findings in Pediatric and Adolescent Patients with Palpable Breast Masses. Radiographics. 2000 Nov. 20(6)