Page. Objectives. Pediatric Breast Masses. Normal US Anatomy 5 Tanner stages. US Technique. Mature Breast (stage V)

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1 Pediatric Breast Masses Marilyn J. Siegel, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO Objectives Review normal breast development Recognize the sonographic features of common breast masses Understand unique clinical and pathologic features of these tumors US Technique High-resolution transducer (7-12 MHz) 5 MHz for deep or very fibrous tissue Gain settings optimized to allow differentiation of fluid-filled and solid Doppler may help in characterization Normal US Anatomy 5 Tanner stages I. Echogenic subareolar tissue II. Hypoechoic subareolar nodule III. Hypoechoic subareolar nodule with multiple ducts IV. Hypoechoic subareolar nodule, ducts less apparent & more echogenic glandular tissue V. Mature breast-more organized glandular tissue» subareolar nodule and radiating ducts no longer seen I III 3 layers Mature Breast (stage V) subcutaneous mammary» fibroglandular tissue II * IV *» ducts chest wall Subareolar nodule and radiating ducts not seen

2 Normal Breast Ducts, glandular tissue, fibrous stroma F G Common Variants Premature thelarche female breast development before 7 to 8 yrs Usually girls 1 to 3 years of age US--normal developing breast tissue without discrete lesion D Gynecomastia Gynecomastia Overdevelopment of the male breast Occurs at puberty, peak age years, resolves in 1-2 years Often bilateral Also can occur in the neonate US- increased subareolar tissue (Tanner stage I) Increased subareolar breast tissue similar to the appearance of early developing breast Breast Masses Differential Diagnosis Cystic Masses Solid masses Benign Malignant Cystic Masses Cystic Masses Mammary ductal ectasia Galactocele Fibrocystic disease

3 Mammary Duct Ectasia Duct Ectasia Hypoechoic, dilated subareolar ducts Refers to dilated subareolar ducts Clinical-bloody nipple discharge/ palpable mass Cause thought to be infection or inflammation Occurs in infants, prepubertal and pubertal boys and girls Resolves spontaneously Galactocele Seen in lactating females & infants of either gender Cause is an obstructed milk duct Clinical-painless mass Path: contain water and fat Galactocele Cystic, complex or echogenic depending on amount of water & fat clue is history (lactation) Fibrocystic Disease Seen in adolescent girls Patients present with tender breasts that are nodular on palpation Path-multiple cysts (dilated ducts), dense fibrous tissue Fibrocystic Disease US-cystic masses and dilated ducts health.allrefer.com

4 Differential Diagnosis-Hematoma Usually results from sports injury Complex cystic mass with internal echoes Acute-more echogenic Chronic-anechoic Differential Diagnosis-Abscess S. aureus most common pathogen Tender, indurated, red breast Hypoechoic complex mass, thick wall, peripheral flow Cellulitis Abscess-Mastitis Solid tumors Benign Masses Fibroadenoma Phyllodes tumor Hemangioma Lactating adenoma Granular cell tumor (Myoblastoma) Juvenile Papillomatosis Intraductal Papilloma Malignant Fibroadenoma Most common tumor (70% of masses) Affect adolescents (mean years) Commonly multiple and bilateral Clinical-slowly enlarging, painless mass Path-proliferation of periductal stroma, 2-5 cm diameter Fibroadenoma Smooth margins, oval, homogeneous, hypoechoic Avascular

5 Giant Fibroadenoma Refers to subtype > 5 cm Grow rapidly but are benign Path-more cellularity than typical FA US- look like typical FA, but may have large anechoic clefts Phyllodes 1% of breast lesions in children up to 25% are malignant Clinical-painless rapidly growing mass Large, 1 to 20 cm (mean 8-10 cm) Mimics fibroadenoma on ultrasound Differentiation based on histology greater cellularity, nuclear atypia / mitoses Benign Phyllodes Tumor US-homogeneous or heterogeneous, ovoid Hypoechoic, smooth or lobulated margins Can mimic fibroadenoma need biopsy Malignant Phyllodes Tumor Mimics fibroadenoma Ovoid hypoechoic mass, anechoic clefts Need biopsy Hemangioma Common breast mass in infancy Bluish discoloration of the overlying skin Undergo phase of initial growth, usually 1 st year of life, followed by slow involution over months to several years Path-ducts surrounded by vascular stroma Hemangioma Echogenic mass with anechoic areas representing dilated sinusoids Vascular channels D D

6 Lactating adenoma Benign tumor occurring late in pregnancy or during lactation in response to the physiological changes of pregnancy Located in anterior breast Clinical--firm, mobile and non-tender Resolve at delivery or upon cessation of lactation Lactating adenoma Ovoid, smooth margins, hypoechoic or echogenic, homogeneous echotexture Posterior acoustic enhancement Lactating Adenoma Can contain hyperechoic foci, related to fat in the milk produced by the tumor Granular Cell Tumor Benign tumor of neural origin Ethnic propensity women of African American origin Palpable, firm superficial mass, occasionally associated with skin retraction Granular Cell Tumor Solid, ill defined margins, posterior shadowing (71%) mimicking cancer Or more benign-appearing well-circumscribed solid mass (Yang et al J Clin Ultrasound 2006; 34:153) Juvenile Papillomatosis Adolescents & young women (mean age 19 yrs) Presents as firm, mobile mass, in the periphery of the breast Benign but marker for familial breast cancer 33-58% have family history of breast cancer 5% to 15% have concurrent breast cancer Treatment is excision

7 Juvenile Papillomatosis Complex mass with multiple small cysts Juvenile Papillomatosis Multiple cysts Intraductal Papilloma Intraductal Papilloma Benign proliferation of ductal epithelium Patients present with serous or serosanguinous nipple discharge Bilateral 25% of cases Treatment is excision Dilated duct with intraductal mass Can contain calcifications May be vascular on Doppler imaging Solid tumors Benign Masses Fibroadenoma Hemangioma Lactating adenoma Granular Cell (Myoblastoma) Tumor Juvenile Papillomatosis Intraductal Papilloma Intramammary Lymph Nodes Malignant Phyllodes (some cases) Carcinoma Metastases Malignant Tumors Extremely rare < 5% of breast masses Risk factors--history of familial breast cancer, other malignancies, or radiation to neck and chest Metastasis is more common than primary breast cancer

8 Carcinoma < 1% of breast lesions Painless, firm mass < 3 cm in diameter US features (98% sensitivity) spiculation angular margins shadowing calcification Starvos Radiology 1995; 196:123 Carcinoma Solid hypoechoic mass Irregular or spiculated margins Mass is suspicious because it has irregular margins don t mistake for complicated cyst Invasive Ductal Carcinoma Metastases Metastatic tumors include lymphoma, leukemia, rhabdomyosarcoma, neuroblastoma and renal carcinoma More common in girls but can occur in boys Present as mobile, rapidly enlarging masses that may be painful Round not oval Metastases-Melanoma Irregular or lobulated margins Heterogeneous, hypoechoic, matrix Lack acoustic enhancement Lymphoma Hypoechoic, heterogeneous masses

9 Summary US Characteristics of Masses Summary: Cystic Masses Characteristics Anechoic Smooth or lobulated margins, round or oval Hypo-or isoechoic Smooth margins, round or oval Smooth margins, lobulated Irregular, ill-defined margins Homogeneous, echogenic Diagnosis Cyst, duct ectasia, galactocele, old hematoma Complex cyst, fibroadenoma, other benign tumors Fibroadenoma, other benign tumors Abscess, malignancy, mets, granular cell tumor Fibroadenoma, hemangioma, galactocele, adenoma Remember hematoma and abscess Hypoechoic, Smooth Margins Hypoechoic, Irregular Margins *GCT can have spiculated margins Just biopsy!!!! Pediatric Breast Tumors Palpable mass is most common indication for breast US in children Most breast tumors are benign Clinical history helpful in diagnosis