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Background
Breast masses in pediatric patients are uncommon and comprise a very small portion of cases encountered in breast imaging practice, contributing to a lack of familiarity and confidence in their evaluation and diagnosis. The spectrum of findings in the pediatric breast range broadly from physiologic processes to infectious pathologies to primarily benign neoplasms, with rare cases of malignancy, most commonly metastasis.

Educational Goals / Teaching Points
The goal of this presentation is to provide a case-based review of the spectrum of common and uncommon pediatric breast diagnoses with their associated clinical histories and primarily sonographic findings. It is intended to improve diagnostic confidence in classic benign cases and provide a variety of differential diagnoses in other cases which may require additional follow up or histopathologic correlation for accurate diagnosis.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Initial workup should always begin with complete clinical history and exam to inform imaging interpretation before final assessment and recommendations. When the clinical presentation correlates with classically benign imaging findings, a BIRADS (Breast Imaging Reporting and Data System) 2, benign category assessment and reassurance is indicated. Case illustrations in this category will include premature thelarche, gynecomastia in males, simple or mildly complicated cysts, and sebaceous cyst. Diagnosis of benign fat necrosis or abscess can be challenging without classical imaging findings and supportive history. Such atypical presentations and more complex pathologies will be reviewed, with cases including infectious etiologies such as cat scratch disease and toxoplasma lymphadenitis, vascular or lymphatic abnormalities, benign masses of pseudoangiomatous stromal hyperplasia (PASH) and fibroadenoma, borderline masses with malignant potential such as phyllodes tumor, and breast metastasis. Primary breast cancer in childhood is a true zebra.

Conclusion
The diagnostic evaluation of pediatric breast masses remains a challenge for many radiologists given the relative paucity of cases in a typical breast imaging center. This educational exhibit intends to familiarize radiologists with classic and atypical presentations of benign, borderline, and malignant breast disease in this population.