E1262. Pediatric Breast Lesions: The Good, the Bad, and the Biopsy
The pediatric population routinely presents with breast findings on clinical evaluation. Imaging is often indicated and the first line modality for radiologic assessment is US. Many of these breast findings may represent normal or abnormal breast development, making it vital to be familiar with the imaging features of expected physiologic changes as well as abnormal variations. Most pediatric breast masses are benign including fibroadenomas, simple cysts, abscesses, or fat necrosis due to trauma. These lesions are usually conservatively managed due to the benign nature and risk of injury or deformity of the developing breast with intervention. Malignant lesions such as phyllodes tumor, carcinoma, or metastasis are rare in young patients, however, it is still important to identify their imaging features for timely management. If indeterminate or suspicious features are present on imaging and/or patient risk for malignancy is increased, biopsy may be indicated for pathologic correlation.
Educational Goals / Teaching Points
The goals are to examine the imaging approach to breast lesions in the pediatric population; review normal anatomy of the developing breast including physiologic changes in various Tanner stages; identify key imaging features of normal and abnormal breast development, non-neoplastic lesions, and benign and malignant masses; outline management approach and discuss specific scenarios where intervention is appropriate; and consider current management algorithms and potential pitfalls of adult BIRADs recommendations in a pediatric population.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Normal developing breast tissue demonstrates physiologic changes in various Tanner stages with distinct gross & sonographic appearances. Abnormal development such as unilateral premature thelarche may present as a palpable mass. In males, obesity may mimic gynecomastia. Benign entities have key sonographic features. Cysts are often retroareolar, anechoic, avascular, circumscribed masses, which may appear complex if infected. Fibroadenomas are usually solitary, homogeneously hypoechoic masses in adolescent females. Abscesses are hypoechoic with an echogenic vascular rim. Malignant breast lesions can be nonspecific and require intervention. Phyllodes tumors may be benign homogeneously hypoechoic, circumscribed masses with thin anechoic clefts versus malignant partially circumscribed hypoechoic masses with round anechoic foci. For definitive diagnosis, tissue sampling is needed.
US is the imaging of choice for the pediatric breast. Most breast lesions in this population are benign and can be managed conservatively. Some lesions exhibit indeterminate or suspicious features and may require further imaging or biopsy. Key imaging features distinguish between normal and abnormal development, cystic and solid lesions, and benign and suspicious masses. Identifying these details on initial imaging is essential for appropriate management and avoidance of unnecessary intervention. Current adult BIRADs recommendations are applied to pediatric cases, which may potentially lead to confusion among clinicians and radiologists in indeterminate cases.