Lumps & Bumps: Soft Tissue Masses and Lesions

And we are back. Uh, we are gonna now continue on with the rest of our session. I want to, um, uh, apologize and let everyone know, you know, we started this off as a very small operation with not so many people, and over the years we've really grown to the point where our existing system, it really, um, we've maxed it out to the point where all the bells and whistles we have with the polling and the chat and everything. Uh, we have, by November, we will have our brand new, uh, much more robust system that will be able to handle the volumes of people, uh, chats, social networking, all that good stuff, so people can continue the discussions even after the event and watching in the live archive. I mean, watching the footage and everything. So, Uh, I apologize that the polls aren't working perfect, but now you have an explanation. So without further delay, we're going to move right on to lumps and bumps. Uh, again, something very common that we all deal with, but we occasionally get faced with things that make us a little nervous and, and then we want to know what everyone else does with these difficult cases, so. Uh, I'm gonna turn this over to Danielle Walsh, who's coming to us from East Carolina, uh, and has, uh, is also representing, uh, SAGES, which is the Society for American Gastroendoscopic Surgeons, and they have a pediatric liaison committee, uh, which, uh, Danielle, uh, and Gretchen are the head of, and, uh, they're the ones that helped put this together. So thanks for joining us and thanks for representing SAGES. Thanks for having me, Todd. So, so this session, uh, is really about some of the things that you might see in the office and And, uh, many times the, the difficult stuff there's a lot of literature on, but some of the smaller stuff that we deal with commonly we don't know as much about. So let's take us through some of the things that we're probably gonna see in our offices and and how we take care of them. The first case is this 12 year old female, and she comes to see you for this red lesion that's on her shoulder. It's not caused any trouble yet. It's entirely asymptomatic, but it has been enlarging over the past couple of months. And so what do you want to do for this? What do you think it is? Little red lesion here. So, um, what. OK. So what's um let's ask some questions to the while we're waiting for the audience, um, anyone here, um, Oliver Witt, anyone from the audience wanna chime in and what they think this is? Well, this is one of the few things that I know the answer to. This is a pyogenic granuloma. So common things being common, this is a pyogenic granuloma, and most of them are those little solitary things, but you can see it has a few little satellite lesions on there which you can see. So, so how are you going to treat it? Come in your office, 12 years old. In the office, take him to the OR, send him to the plastic surgeon. What do you want to do? Before we get into that, while we're waiting, explain to us, so pyogenic granuloma, who does it occur? Are you going to go into this? Who does it occur? I am going to go into then I won't ask. Ask the question here and then we'll go through some of the literature, OK. So what are your thoughts? How would anyone, uh, handle this, uh, lesion? Anyone want to volunteer from the peanut gallery? Uh, sure, I would try tropical silver nitrate, try to cauterize it. I've excised them. Uh, flush with the skin and cauterize the base in the office. So I'm not sure, I'm not sure everyone heard that. So cauterization in the office with silver nitrate. We got a lot of head nodding going on. Dan von Almen agrees. Uh, who's that? Jose's there in the corner agreeing. Peter's not so sure he agrees. Well, I mean, I might try that once, but I, I'd be pretty quick to, I think, excise it. They tend to bleed and cause a lot of anxiety for the parents, and so I, I would excise also. It's not even try. Uh, anything in the, in the office. And when you excise it, negative margins, just gross margins? How, what kind? A very minimal margin. Millimeter. As little assly grossly negative. Yes. No margin at all. No, I would, I would excise it. I have not had good experience with topical silver nitrate for something that looks like that. OK. Um, and if you, if you just cut it off, uh, or you knock it off, it'll bleed. And to me, I've just gone on with, uh, An outpatient, uh, surgical exam. And Danielle, it looks like the audience was split almost 500/400 silver nitrates the surgical margins. So, so a little bit about this, yeah, this was a pyogenic granuloma. It's benign. Sometimes you get these stories of having trauma there, up to a quarter of them, most of the time not. I actually started seeing an increase in the teenage population. They get put on retinoids for their acne now and, and those actually are. Associated significantly with the development of them and it turns out just removal of the medication will often resolve that. Uh, pregnant patients see them, they can pop up in the midst of these vascular malformations and sometimes you'll get a history of a viral infection and they can have those satellite lesions. There are some cases of spontaneous regression, but a lot of times instead you get the story of it's bleeding and it's bleeding a lot and it really bothers the family. Um, so there are actually a few randomized controlled studies, but mostly it's cases in retrospective reviews, and the lowest recurrence rate is with the surgical resection, just gross negative margins. You do not need to take, um, a wider margin, so about a 3% recurrence rate with that. If you shave it off and curate it, it's got about a 9.5% recurrence rate. Some. People in the cosmetically sensitive areas are particularly prone to want to just cauterize it or treat it with laser. You can do that, but you need to warn the families that you may have about 10% that recur. Silver nitrate actually has the lowest success rate, 15% recurrence rate with it. So in select patients, you may want to try that in the office as long as the family is aware in advance that you, uh, you may need to do something else. The biggest problem with the silver nitrate is the bottom point there. You're not gonna get a path specimen, and it may require multiple treatments. So without that path specimen, let's say in this case you did take that kid to the OR and you resected it and you sent it off, and the pathology, much to your surprise, comes back spitz nevus with atypical features. What are you going to do next? Moving on. Oliver. Uh, I would excise it. OK. So you're gonna re-excise sorry excised it the first time that you're gonna excise it, uh, but I, I wouldn't miss. Oh no, no, no. So we have excised it already. You excised it. You sent it off. They came back and said, you know what, it's not a pyogenic granuloma. You got a Spitz nevus here, and it has a negative margin. It does have a, well, I'm OK. I, I'm happy if it has a negative margin. Negative margin, all done. Yeah, if the margin is negative on the first incision, I don't think you need to do anything else. Peanut gallery, agree, agree, agree, agree, agree, agree. margin's positive. Joy. We have Joy Collins on the phone from CHOP. What are your thoughts? Hi. Well, I, I guess I assumed that that perhaps the margin would be positive. Um, if it's atypical. I, I do, I do want it generally at least a few millimeters margin up to 5 millimeters. So, it does depend on the initial path. All right, comes back atypical, margins are positive. You're going to go back for a 5 millimeter reexcision. That's what I'm wondering. Others here, positive margin, go back on all of them? Um, I would get it, make sure a dermatopathologist looked at it first of all and make sure that's truly the, truly the diagnosis, then I would reexcise it. Yeah, because Spitz nevus is a really uncommon problem in children. Um, so, It's not something you see every day, and I would agree with getting perhaps a second opinion on the pathology specimen. OK. What about this same atypical one? You're going to go back and reexcise it. You're going to do a sentinel lymph node biopsy? OK. Atypical. No? No. OK. Anybody here ever done one? Sentinel node for the UK? Not for an atypical. Not for an atypical Spitz, OK. All right, well, let's look at a little, little literature there. So, uh, how you kind of want to divide some of these into whether they're classic spits, atypical spits, uh, because the management is a little bit different for them. Would you send them out for secondary review? We covered that. When are we going to re-excise it? So, so what do we got there? So it is considered benign, but the criteria distinguishing it from melanoma. It can be a little bit tough, you know. Some of the newer stains and and and typing and genetic studies may be helpful, but some people are theorizing that there's really a spectrum. It starts out as a classic spitz. It can move on, become an atypical Spitz, and then it may be in that spectrum that goes on to melanoma with with some spitzoid features. Uh, the largest study of the lesions, 80% of these characteristic Spitz nevi actually involuted on their own. And so if you, there was actually a good study, a very big study of pediatric dermatologists that was just published this year, and they asked pediatric dermatologists if. They looked at those lesions and they really believed it was a classic Spitz nevus. What would they do? And half of them wouldn't even operate on them. They wouldn't even take them off. They actually observe them and wait for them to spontaneously resolve, which is different than us as surgeons. Usually when they're sent to us, we want to take them off, but, but I thought it interesting that almost half of pediatric dermatologists actually would leave them alone. Uh, and most of those, those dermatologists did report seeing some of them resolve spontaneously. Uh, they did recommend biopsies for patients who were postpubertal, so that not young population, if they were larger than 6 millimeters or so, uh, if they had rapidly grown, if they were asymmetric or had any ulceration. When they surveyed that same population, if there was a Spitz nevus excised and it had an incomplete removal, not all of them would go back and re-excise it, unlike us, where we were pretty uniform about that. Uh, and if they did re-excise it, they usually had 1 to 2 millimeter margins. There was a. A series of 30 patients that had incompletely removed Spitz nevi, 24 were observed and none of them recurred. 6 of them were re-excised, and of those 6, only 1 actually had residual stuff in the in the re-excision area. So does that change anybody? The dermatologist wouldn't do it, and if you go back, chances are you're not going to have anything left in the specimen, even if you had a grossly positive margin initially. We're all going back anyhow. Can't sleep, it fails the sleep test, you know. Uh, I mean, the data may say that, that you could get away with it, but you don't really feel real good about it, do you? Got it. Um, there was a retrospective, uh, study where they did excision with narrow margins, the 1 to 3 millimeters, and 20% of them were positive. So Doctor Collins' comment about going back and doing a little bit wider margin, the 5 millimeters, probably has some value. If you're going to go back and you're still going to miss 20% of them histologically, that 5 millimeter margin may have some value. Um, and some people have, have sort of, uh, estimated what kind of margin they're going to take based on that atypia or not. So Barnhill published saying classic spits do 3 to 5 millimeters, atypical spits 1 centimeter if you're able to, and then if it's a severely atypical, treat it like a melanoma based on your depth. Doctor Collins, is that, is that what you're doing? You, you have any more comments on that? Yeah, I think that's typically what I've done. I should mention that I also do have these reviewed by a dermatopathologist, and I talked to our pathologists here, so I have the luxury of those opinions, and I generally haven't taken more than 5 millimeters because I've frequently re-excised somebody's prior scar. To be honest with you, so I, I think, you know, in general, I, I tend to do 5 millimeters instead of 1 centimeter, and sometimes I've had to go a little smaller, like if it's on the, the dorsum of the foot or a difficult area, and so far have not, uh, found residual disease much of the time and have had negative margins and good results with that. Now, do you, have you done any sentinel lymph node biopsies for these patients? Not for these, just for melanomas. OK. So, there are some, there is some literature looking at doing the sentinel lymph node biopsies, and about a third of cases that have Spitz nevi did have nodal and micrometastases. Now, I have to qualify that, that most of these studies are a combination of adult and PS, and there are many that believe the adult and the PES don't act quite the same. So, take some of this with a grain of salt. Um, there was a, there were 8 series of adults and pes, that 3rd bullet point there, and 39% of the Spitz and Nevis where they did a sentinel lymph node biopsy were positive. But when they followed those patients without doing anything more than the sentinel lymph node biopsy, at the 3 year follow up, all of them remained disease free. So your sentinel node biopsy may be positive, but that doesn't necessarily mean that you need to do a lymph node dissection. On the other hand, there are some rare deaths reported of Spitz nevi that make people question that benign nature of them. Anybody, uh, does that change anything for anybody? Nope, no, no sentinel lymph node biopsy takers today. All right, very good. Well, if anybody out there in our audience listening has done those and, uh, has used that to change their management, we'd love to hear from you. No, before you go on, so rapid fire quick summary of what we just discussed. So number one for a pyo, uh, for a pyogenic granuloma. Um, I think that most people here would go straight to the operating room. There were some people that would try cautery, but it seems to not work. The literature shows that has the lowest recurrence rate. Lowest recurrence rate is surgery, but if you want to try it, you can do it. Just warn them it's about 15% recurrence rate, right? So you unnecessarily operate on 85% at the worst, but you also don't get fat because you also don't get back if it recurs. That's what I've done. OK. Um, and then Spitz nevi, your top three points that you want to make about re-excision, about sentinel lymph node is you do need to and you don't need to. Yeah. So, yeah, if they're atypical, watch out, probably send it out and get that secondary review of it by a dermatopathologist, making sure that you don't actually have a small melanoma. Got it. If it's got positive margins, Most of us are re-excising, but the literature says you might be able to just watch. 24 patients. Uh, well, small studies. We got not a lot of these in kids, all right, but we see them. We see it. We've, I, I suspect all of us have seen at least a few, uh, and then, uh, sentinel lymph node biopsies have been done. People describe it, but there isn't any good literature to support that you need to do. It and if it's positive, it doesn't necessarily mean it's going to cause trouble later on. So probably not a role for doing that at this time. All right, next question. Unfortunately, the pathologist calls you back. You sent it out for that external dermatopathologist review and the external reviewer atH calls you and says it's actually a melanoma. What are you going to do now? Observe, reexcise with wider margins. If it's positive, reexcise and do a sentinel biopsy, reexcise and do a lymphadenectomy. Is the, is the, uh, audience. So, I think it depends on the thickness of the lesion. Oh. OK. Um-hum. So, do you have that data? I have that. Jonah, you're putting these poles out, right? Uh. OK, good. Let's say you're a two millimeter thickness. OK, so that's a thick melanoma. That, so that needs a, a wide, uh, margin of excision, 2 or 3 centimeters depending upon where it is. So doesn't it depend on, yeah, the depth dictates the distance of the margin, but it's a thick, it's a very thick 2 millimeters is a thick melanoma, so it needs a wide, wide excision. All right, before. I show you some of the data, where's the poll, do we have poll results up yet? Um-hum. Yeah, we're, uh, why don't we post those stuff and can we show those? I'm trying. Oh, all right. As soon as we get those. It's usually about a minute. The system gives about a minute, so. Now, the, uh, also the question of sentinel lymph node biopsy comes up. I won't steal your thunder, but. All right. You can. But that's a thick, well, that's a thick melanoma, yes. All right. So, you're going to do it. Anybody ever, do you, do you guys, do you do your own? Uh, sentinel lymph node, I have in the past. I have. You have in the past. All right. How about the peanut gallery here? How many are doing their own sentinel lymph node biopsies? We got 22 doing it, three I haven't had it yet, but I will. You will do your own. Uh, I think you need the infrastructure. Uh-huh. Uh, if you're going to use a radio labeled, uh, albumin, uh, to, uh, um, And uh a centigraphy agent, you have to have it in your hospital because these problems don't come up very frequently freestanding children's hospital, you may not have access to a neoprobe and those kinds of things, whereas if you're affiliated with an adult center where there's a lot of melanoma, you're gonna have all of that infrastructure ready ready. I think that's a very good point. And looking at our audience, at our faculty here, there's a mix of some who are freestanding children versus associated with adult, and I, I would wonder if we, I mean, I don't know, maybe the plastic surgeons have used it. I have never used it here. I don't know. John, you've been here. No, we have not used it here. We don't have it. OK. You do. You have it. Yeah. Tim says no. We used to, uh, years ago borrow the equipment when we needed it from the adults. And we've since developed our own protocols and have our own expertise. So, and we bought our own Geiger counter. You did? Yeah. OK. So, without the equipment here, Todd Akron Children's Hospital, you're going to do your own reexcision or, Gonna let them re-excise and do the sentinel at the same time. Uh, my initial answer was yes, I would do my own re-excision, but I guess the, the point is if I, I, I would talk, I probably, if I think that I was not able to do a sentinel lymph node biopsy, I probably would transfer it to someone who could do the entire package. Yeah. I got a lot of nods. All right. So, what kind of margins do we want? Uh, we'll get to that rule for sentinel. Do, when do you do the lymphadenectomy? Grossly positive nodes. You can palpate the nose. You're going to do your sentinel or you're going to just take it out? Anyone? Anyone? Joy, how about you? It's part of your sign. Um, I have not done a complete lymphadenectomy yet. Um, I haven't had any grossly positive nodes or positive path on a sentinel yet. OK. So I don't know if I can answer that. All right. By the way, if you want the results, 77% did re-excision with sentinel lymph node biopsy. Good. Um, 20% re-excision with wider margins, but not, no mention of lymph node biopsy. All right, so unfortunately, pediatric melanoma is something that we're starting to see a little bit more and, uh, with our, uh, our sunbathing, uh, children, we may continue to see it. Uh, so a lot of times you're trying to preoperatively evaluate for that A, B, C, DE criteria, but when they did a study looking at kids, it was published recently, looking at kids, only 40%. 60 % of the kids under 10 met that ABCDE criteria and then 60% uh over uh age 11 met that criteria so it's not nearly as good as it in the adults. So those adult ABCDE criteria asymmetry, the irregularity of the border, color variation, diameter greater than 6 millimeters in evolut and, uh, whether it's changing, evolevolving. But if you add in some additional criteria for children, a melanoic melanoma, a big problem in our population, whether it has a history of bleeding or is an external bump, whether the color uniformity is there, whether it developed de novo in a in a fresh area of skin, no other lesions, and it can be any diameter, then you'll capture more of that pediatric population. As far as looking at the guidelines, the US tends to use the NCCN guidelines. There are guidelines published by different countries, so Germany's are a little bit different. UK is a little bit different, but a lot of it is in agreement. So in situ lesions, 5 millimeters, 11 millimeter thick or less, 1 centimeter between 1 point. 1 and 2 you're going to get up between a 1 and 2 centimeter thickness as you get into the thicker lesions, 2 centimeters. There was recently the Cochrane review where they evaluated the benefits of 2 centimeter versus 4 centimeter lesion, and at this time, the data, although not perfect, uh, suggests that the 2 centimeter lesion is adequate for you. Sometimes we're seeing these in these giant, uh, congenital nevi's, uh, so giant congenital nevis are, are real, a real problem. They can be real large, these greater than 20 centimeter ones, and they have this elevated melanoma risk, 8% in the regular ones, and if they're hairy, it can be even higher than that. Uh, 60% of them will get their melanoma in the first decade, and it's been reported as young as 3 years of age. So some recommendations are to, to get those out before they get melanoma. Looking at the sentinel lymph node biopsies though, higher metastatic rate to lymph nodes in kids than in adults. About 25% of them are going to be metastatic, and it seems to be in the small studies out there, the more in the kids that are younger than 10 and the thicker lesions, not surprising. as you pointed out, thicker lesion, uh, definitely probably needs that, that biopsy, the, uh, sentinel node biopsy. Survival is fortunately a little bit better, uh, in kids than in adults. If the sentinel node is negative, the probability of a subsequent recurrence is real low, only about 5%. If the sentinel is negative, the probability of a non-sentinel node being positive is also low, although not zero, so you probably can follow these kids clinically. Prognostic significance of sentinel nodes and melanoma is still very unknown, and it's controversial still in some of the adult literature, let alone in the pediatric literature. So, just to review, for melanoma here, thicker lesions, you probably should be doing the sentinel lymph node biopsy. There's a good, good 25% chance that it's going to be positive. Your margins continue to be dependent on the depth. There's probably not a role for the bigger than 2 centimeter margins in most of these patients. Anybody want to add anything in? Well then, if your sentinel lymph node biopsy is positive, are we, are we, I think it's still controversial whether we should proceed with, uh, with a lymph node dissection. Um, we, we haven't done any that I can recall lately, but, uh, it seems like there's more and more literature to suggest that it might be. Uh, a good idea. Might be worth the risk, I guess I should say. I think it's going to go back to that sleep test. I don't think too many of us are going to sleep very well on a positive sentinel node without doing a completion lymphadenectomy. Uh, recognizing that it comes with a, a fair amount of morbidity and, and lymphadenitis. All right. So, let's move on to some other kind of bumps. Question 4, a six year old kid is sent to your office for a one month history of an enlarged cervical lymph node. No evaluation or treatment has been performed, and there's no other symptoms. You palpate a single 1.8 by 2. 1.5 rubbery lymph node. On the posterior border of the sternocleidomastoid at the level of the angle of the mandible, and there are no skin changes. What do you want to do next? Is there a history of infections or? Head and neck infections? Not that they can think of. OK. How many people are going to operate on these right away? Not a person. All right. Antibiotics? Are you going to give him a course of antibiotics? Antibiotics? No. They've usually had one by now, but, no. And if they hadn't, John, would you? No. Yeah. Would you. About a month. Would anyone here get x-rays, get, uh, blood workup, any blood tests, anything other than just come back and I'll see you in a month? OK. So, everybody's going to come back in a month. Is it a month? Would anyone do different than a month? I would think about the antibiotics, um OK. At this point. If it's been a month. You'd, OK, so, what antibiotics would you put on? It depends a little on what your exposure in your community is, but, uh, so what your risk of MRSA or, but you're going to try and cover group. A strep at least. So, clindamycin's a good choice. Other people use Augmentin, uh, depending on what, what you think you're. Is there anyone else that would, that would start antibiotics? OK. Um, how, how long do you see him back? Just 1 month? Anybody else? 3 or 4 weeks. 3 or 4 weeks. Joy, you had a comment? Well, I was just going to say if it's already been there for 1 month and there's nothing, no other arrows pointing to anything else, I'd, uh, I'd probably do a course of antibiotics and see him back in, in 2 or 3 weeks, a little on the shorter side. OK. All right. So, John, you're nodding your head now. Yeah, I would agree that two or three weeks, but I still don't think antibiotics at this point are going to add much, but I don't think they probably hurt. So, I'm curious, because at 2 weeks, and now it's 4 weeks, you wouldn't do anything, but at 6 weeks, you would? Um, I, if it hasn't changed, and it's under 2 centimeters, I think there's literature to suggest you, unless it's supraclavicular, which is a high risk area, you can still just watch it. So, you're bringing them back just to make sure it's not getting bigger. Reassure the family, see him back. If you're not sure what it is, follow it till you cut it out or it improves. OK. All right? All right, let's say in this patient you went ahead and gave him that course of antibiotics. It's been going on. You finally gave in, gave him a course of antibiotics, and it's unchanged again. Nothing more. Nothing's changed. Still there. Parents are getting anxious. Been there for a while. I'm sorry, how long is it now? It's been two months, well, Two months. You waited a month. Right. So, it's now been there for two months and you gave him a course of antibiotics and it didn't get better. I think unfortunately we all think it's probably benign, but I think there are many of us would want to just do a little outpatient biopsy of it. This is a great question. So is that true, uh, Jose, I'm gonna leave you alone this time. I'm gonna start with, uh, Peter. Yeah, I think I would probably have to cave to the pressure that's undoubtedly present from the pediatrician and from the family. I, I hate to say it like that. I mean, I do talk to the families about the fact that we don't have an in-between step like they do in adults. We don't fine needle aspiration hasn't really caught on in kids and may not be very useful. And so it's a difference between a procedure under a general anesthetic that leaves them with a scar and the anxiety. The the parents' inability to sleep at night. I'm going to make it harder for you. The make it harder for you. The parental anxiety may be the main thing driving you to do something. So, so let me make it harder. I admit the parents aren't anxious. The parents aren't anxious. They say, no, I, I'm, I trust you, doc. I trust you. If you tell me it's OK, I'm OK. Do we want to operate now? It's 2 months. Two months makes it difficult, doesn't it? Yeah, and then they, they often ask the question, what would you do with your own, own child? And I, and I think I probably would wait it out even a couple, even a couple more weeks. But I, I, I because I'm not sure there's much of a downside to waiting if, if it's lymphoma or if it's something, so that's very expensive actually, take to the operating room to do this. I mean, I, I would probably, if particularly if the parents are, are, are not super anxious, I'd get a chest x-ray and a CBC. We know that if it's lymphoma, it grows extremely. Fast. So, if you have a lymph node that hasn't changed in two months and it's a solitary node, OK. They probably don't have lymphoma. So, in the, uh, and, you know, it's basically exposing them to an anesthetic and spending a lot of money. I'm going to go to Jack in a second, who just joined us. We'll introduce Jack in a second, but before we get to Jack, when would you go for a biopsy? Uh 4 months, 6 months, 12 months? Never? Uh, it, if I, so the simple question to that is, and the simple answer, There's, uh, do I think it's malignant or not? It's staying the same. And if I think it, then I don't feel a, a, a pressure to biopsy a solitary node that's not enlarging in size with no systemic symptoms. OK, cause if you're going to make it easy if we say, if there's malignant features. Well, then I think we would all go to the OR. Right. So, but the, so the questions that would make it more difficult to me, so there, there's data that if you have multiple sites of enlarged lymph nodes, the likelihood of malignancy is far higher. So, if I, I find nodes in the groin, And nodes in the neck, I'd be much more likely to biopsy, uh, it. And the other thing I, I always think of is growth. Is it growing quickly because melanoma grows. OK. I mean, uh, lymphoma grows very quickly. Jack, you wanted Jack Langer coming to us from Toronto. Sick Kids. Welcome. Thank you. What comments did you want to make? So I, I would, I would not operate on this. I, I would do a CBC and a chest X-ray, and the main reason for doing those is because they're virtually always normal and it helps to reassure the family. And I would just follow it. If it's not growing, a 6 year old with a single node in the neck that's not growing, I think the chance of lymphoma is almost zero. So I would, uh, I would, and I've followed some of these for years. OK, so you're gonna, you're gonna have them come back how often? Every, I'd bring them back for in this scenario, I'd bring them back probably in a month, and then I'd probably bring them back in another month. And then if it hadn't grown at all, I'd just bring them back whenever they got. Anxious about it. All right, so 67, which happens from time to time, 6 or 7 doctors visits plus uh CBC and a chest X-ray. CBC, chest x-ray, and, and, uh, 3 visits. Dan. I agree with Jack. If the parents are not nervous, I'm not nervous. I think a chest X-ray and some labs is, is low cost and reassuring, and I would do. What is the sensitivity of a CBC for lymphoma? I don't, I don't know how reassured are you low? What's that? I think it's probably pretty low. I mean, even, even if you add in a smear, I think it's still pretty low. Yeah. Any other comments? I, I'll sometimes add an ultrasound because if you get two small lymph nodes side by side, you then have your 2 centimeters and you're really dealing with a couple small nodes stuck together. It also reassures the family, and it also rules out a different type of problem, either a, uh, epidermoid cyst or something that I would resect. OK. That, that's, uh, actually a good point, even with the anxious parents, because if the architecture of the lymph node is preserved, it, it's more likely to be a reactive lymph node. Um-hum. That's a good sign. So, so, actually, that can be a relatively low cost intermediate step. OK? All right. So, I, I've pulled, so, so, when you're looking through the workup of the, the cervical lymphadenopathy, I got this list a mile long of all the different labs you could do. Um. So, so, some, some little inputs there. Everybody here going to do a CBC? Show of hands, CBCs? Not initially, but I'm. Not initially. All right. Um. Follow up. Continuing on most, no, I got some yes, some no. How about sed rates and CRPs? OK? We got a couple of votes for sed rates and CRPs. LDH, poor man's, poor man's test for cell breakdown. All right. Add the LDH in there for some, OK? How many are going to check uric acids? No. A lot of nos. Thyroid function tests could be a thyroid nodule. No? Not, not going there. HIV test? PPD, before you go to the OR, PPD? I got one or two nods on PPD. Yeah. And then how about some serologies? We've got a lot of different serologies we can send here EBV, CMV, Bartonella, and just for the viewing audience, no one is saying anything. That's what the silence means. So the silence is, you know, there really isn't good data, OK? If who you ask, where you live in the country, where you live in the world, what you see commonly may, may predicate this. Um, I found one author who kind of broke it into. Some categories that seem to help me a little bit and maybe some of you will find that that helpful so they broke it into whether it's acute or chronic and subacute and whether it's unilateral and bilateral so acute unilateral they felt was mostly bacterial and it's probably gonna be that that strep and the staph. Uh, that you're, you're talking about, and antibiotics probably has a pretty good role there. Acute bilateral they thought was usually viral, um, but it could be other, other bacterial infections often associated with either oral lesions or, or pharyngitis. And then you get into that chronic subacute unilateral, and this is where you start to see the atypical mycobacteria or Bartonella and even tuberculosis toxoplasmosis might hit that category and then the chronic subacute bilateral is where they. Seeing the EBV CMV, HIV and so you might use sightedness and the duration of it to help you choose which of those tests there are, but there is no right answer or wrong answer for which of those if you do decide it's in that acute category and you're going on to antibiotic choice, uh, some have recommended if it's bilateral, it's usually viral and no antibiotics are needed, and much of our audience here seem to agree with that. Unilateral, go ahead and cover for your MRSA and strep with clindamycin. There's, uh, a few that recommended not using Bactrim or, or backup to clindamycin because it doesn't cover the group. A strep as well. Uh, if you have a low, uh, incidence of MRSA in your, in your community, uh, Keflex may be enough. If they have significant periodontal disease that may be causing their lymphadenitis augment so you cover some neo might be a little better. A history of exposure to cat scratch that'll change you into the Zithromax and revamping categories. Typical courses they were recommending were anywhere from 10 to 14 days, but recognizing your lymphadenopathy may persist for 6 to 8 weeks later on. Moving past those tests, some people are doing the ultrasound, look at the characteristics of it. Doppler may be helpful for you. Some have advocated doing a thyroid ultrasound that they're picking up thyroid nodules and especially in a unilateral, that may be part of it. Chest x-ray was pretty routine. Routinely done before surgery in a lot of the recommended series and then CT or MRI if you think there may be something more extensive in the malignancy category. Let me stop you just for one second. So, first of all, some results, to give you before you move on. Um, you asked about, uh, after the, there was no change, it was completely divided among everybody. So there was no, the, the majority said proceed with excisional biopsy, but you had people saying additional labs and imaging, you have people saying a second course of antibiotics, 21% said that. 14% did a needle biopsy of the node, which is surprising to me. Um, the other thing I, there's a lot of comments about ultrasound echoing what Oliver had said about looking at the, um, the architecture architecture of the, of the node. Um, and there was a question that I'll let you decide when you get to from Doctor Zannati and Amadeo, I believe it's Paraguay that you're from, so correct me if I'm wrong, but, uh, he wants to know, is there any tumor marker that would help guide, guide us in our, uh, decision making. So if I had an elevated LDH or a uric acid, I'd probably be more prone to do an excisional biopsy to figure out what's going on. If those were normal, I don't, it doesn't help me one way or the other, but if they are elevated, I think it would push me toward a biopsy. OK. So, uh, some people, uh, are more prone to do it as some of our, our people, uh, pointed out here, if it's greater than 3 centimeters, if it's harder fixed, if it's in that supraclavicular or epitrochlear location, if more than one nodal group is involved. If there's a history of symptoms like night sweats and weight loss, if they clinically had hepatosplenomegaly, if there were significantly abnormal labs, now that's open to interpretation or abnormal imaging also open to interpretation that might push them more toward that biopsy. Uh, we did have some people who would do FNA. FNA is a little better than I thought. Um, its sensitivity and specificity was about 90%, but 10% are wrong. And unfortunately, that higher false negative rate is in your Hodgkin's lymphoma. Um, many of us have gone to the open biopsy because if we do think it might be a malignancy, we want to be able to do our flow studies, our chromosomal analysis, and, and potentially EM on it, and the needle biopsy just doesn't allow us enough tissue to do that. Uh, and in the, some of our smaller patients, especially if we're gonna have to put them to sleep or sedate them to do an FNA, you kind of lose the benefit of the, of doing the FNA without going to the OR. And then there are a few that have worried about seating of the site. Malignancy is about 10 to 25% of patients overall, but it depends on whose study you look at and what their referral patterns are. So if you look at a group that's primarily oncologic, they'll report that 80% of their cervical lymph node biopsies had something malignant in there, whereas if you go to a dermatologist or, I mean, an ENT, you might get as low as 12% malignancy rate. So your location and how the referrals come to either ENT or to surgery may in fact determine what your malignancy rate really is. So that's still a big unknown as to what percentage really are. All right. Uh, another kid here. We got a 3 year old girl who comes in and she has a large swelling under the mandible. It's measuring about 15 by, by 10 centimeters in size. Big thing. Initially they thought it might be the mumps, but then the skin became red and they started developing a drainage of some clear yellow material on the skin. A fluid from that was sent for culture and remarkably, it did grow, uh, an atypical mycobacteria. What are you going to do next? Let's see. OK. What, what are you going to do? Uh atypical mycobacteria. Yeah, I would, uh, probably try to treat with antibiotics initially, but at some point you're, you're going to have to excise the mass. OK. Cause it's not going to, uh, resolve on its own. Hopes of shrinking. Don't think it's going to resolve with antibiotics alone, OK? Same thing? Do the same. I think it may be super infected, so I would, uh, give antibiotics to try and settle that down, but the treatment for atypical mycobacteria is excision. OK. It's really one of the true absolute indications for a lymphadenectomy is, uh, atypical disease, so. Um-hum. OK. All right. We got a lot of nodding. I'll be interested to see what the poll comes through, whether some of our colleagues in other countries have, uh, are doing antibiotics alone. So Joy, you want to weigh in on that one? 3, 38% said treat with antibiotics alone. 23% plan wide, excision of the skin and underlying nodes and involve a plastic surgeon. 46% do a limited excision of the skin fistula and underlying lymph nodes. So, a lot more split than the panel here. So, the panel here is nodding all to short term antibiotics and then go to the OR. Um, but there were a good number there that were doing it alone. So atypical, uh, mycobacteria is, uh, normally a local problem in the immunocompetent kids. It's usually in the younger population, the 1 to 5 years old. It usually enters through the oropharynx and remarkably, it's not considered contagious. So these are not kids you need to keep out of school just because of the, or daycare because of it necessarily. Um, people have talked a lot about using clarithromycin and rifampin, and surprisingly it has been it has been subjected to a randomized multi-center trial. So on the bottom there, in that randomized multi-center trial, surgery had a 96% cure rate, so you're gonna get them all. But the group that had antibiotics alone had a 66% cure rate. So not unlike our pyogenic granuloma, you might cure 85% of them without surgery in that pyogenic 2/3 of them here, you could cure with antibiotics alone, only a third of them going on to need something surgical done about it. So this is a little different than what we've been taught. Uh, another study where they had 55 patients that had mycobacteria, all with a confirm on a needle biopsy, 10 went straight to surgery but were treated with antibiotics afterwards. 45 were started on the antibiotics, and of those, 30 resolved without any surgery, antibiotics alone, so same thing, um, but some of them did need to go on to get, uh, to get surgical therapy. So has anybody here done antibiotics alone? No. No. No. No. No. That's interesting that there's such a discrepancy in the viewing audience and the, and the studio audience. Well, I, I will tell you that oftentimes, at least, uh, in my experience, these, uh, the, um, aggregation of the lymph node, uh, complex will be really not too far from the facial nerve and you're. You're, you give them the, uh, antibiotics to try to resolve an underlying infection. And frankly, you're hoping it's going to solve the problem because you're, you're delaying because you're concerned about a, an injury to the marginal mandibular branch. And so. Sure. But at least I can't remember a time that I thought it actually resolved on its own. So, you've been pressed to go in and do an operation, do the lymphadenectomy. Um. But have you used those antibiotics? I never have. I mean, I'm, I'm delighted to see that. I did. So I, I learned something already. This is, this is the actual patient here. This was a patient of mine and, and it was a 3 year old and she had a huge involvement all the way down to almost her chin and up through her earlobe there. And I did treat her with three months of, uh, of clarithromycin and it shrunk down to this little fistula site here. She had two fistulas eventually, one. Of them did close and this was the secondary one and I um was able to do a little limited excision there and take out a big granuloma and and node underneath there and, and it cosmetically was a much easier and smaller operation than if I hadn't pre-treated her so I have to admit I will put them all on there uh and and hope that some of them I might get away with reserving my right for surgery later on. So, the antibiotics review what the antibiotic choice would be. Uh, clarithromycin and rifampin are the two that have been used pretty widely. One or the other? Uh, some have done both. I've actually had patients that ID put on both and then I've had ones that were just on one or the other. Um-hum. How. This kid was. How do you make the diagnosis if you're going to pretreat him with antibiotics? Is it clinical or do you do a biopsy? Um, in, in, uh, in most of the ones I've had, they've actually had drainage and I've been able to get drainage that tested positive. Uh, and a couple of the ones that were sent to me by ID, they did an FNA of it, ultrasound guided FNA, and, and the fluid was positive. I just need a tech person to come because I'm the slide advancer and the computer battery is about to die. Oh, You can. All righty. All right, moving on. So, uh, another lump here. We got a, we got a, a young, uh, infant here who's got a, uh, a swelling underneath their breast there. Female infant, 2 centimeter area of breast mastitis with a 1 centimeter area of fluctuance. Your next step in the management of this patient, so we're gonna do antibiotics. We're gonna needle it. We're gonna do IND. We're gonna do IND and antibiotics. Let's take a poll on that one. That's probably too soon. We'll refresh that they change it. We'll keep refreshing that as it goes. All right. So, 60% are going to do, so far, we got 60% antibiotics and a warm compress only. 33. All right, now, here it comes in. Drop down to a third. So, a third antibiotics and compresses. A third of them are going to do that needle aspiration, and a third of them are going to do IND plus antibiotics. Nobody's going to do drainage alone. It's exactly, it's exactly the same right now between. A, B and B. All right. So a third, a third and a third. A third and a third. So, so antibiotics alone, what's the rationale for that? You got some fluctuance there. You want to wait for it to try and drain on its own? Well, I think sometimes it'll, it'll actually just resolve. It doesn't necessarily drain. OK. I would start with just antibiotics. OK. What would change you? So, you started out on that antibiotic course. What would you have to see to make you switch over? I think if the antibiotics don't work. OK. So no improvement in 24, 48 hours? No, I'd, I'd probably give it 5 to 7 days. OK. And how are you going to give those antibiotics, oral? IV? I would probably give oral antibiotics unless the child had a fever and was sick. OK. So, toxic, bring them in, IV, nontoxic, Leave them at home, oral antibiotics. Right. I got a lot of nodding over on the Peanut gallery over here. I, I would, I would actually try to do. A and B together. So, I, I would like to do the antibiotics and aspirate the, uh OK. That would be the combination I would use. Is, is the age of the infant going to change it for you? Let's say this baby's, uh, three weeks old as opposed to a year old, and, and they I thought the baby was a month old. This is an infant. Uh, let's say they're a month old. I thought, I thought you'd say yes, yeah, I think it did a year, but would, would age change, change it? Let's say in, in our local region, these are all MRSA or 99% of them. So is that gonna change it if you have a very young baby versus an older infant? For me it would, it would change how I manage it, not only from an antibiotic perspective but from what I would do to them, um, and there's literature to support both ways, so let's, let's take a peek at some, some of the literature that's there and so I just want to clarify, when you say incision and drainage. Um, for those of you who would, who would do incision and drainage here so I can ask someone. I've done incision and drainage. Uh, I just do a little stab wound. That's what I was wondering. You use a knife. You use a knife. Yeah, a little 11 blade submar or, uh, circummarla right circummarla right over the flexion. All right. I, cause I, this is the one time that I would probably use a, a big needle, like an 18 gauge or something, and flick it up a little bit so you don't get a huge hole, but I guess the tip of an 11 blade right on the areola. Yeah, it's almost the same. Yeah. Packing in there. Uh, not unless it's huge, no. Try not to drain. Uh, the reason I like to drain them is cause I want to. What's that, John? Well, I, the infection can destroy the breast bud just like the surgery can. So I'd like to get the pus out and get them better and get them on their way. So, you know, if it's just a little phlegmon in the office, I'd treat it orally. Otherwise, if it's really that flexion, I'd drain it. All right. Uh. All right. So let's, let's do this now. Um, and can I, is it OK with you, Danielle, you tell me to shut up. Cause you've never had a problem telling me that in the past, but, um, is it OK if we broaden this for a second and take it away from breast? OK, uh, poll here, Jonah, new poll, uh, for a typical buttock abscess in a diaper age child. OK, we're gonna spend one minute on this. We're gonna do rapid fire. Uh, uh, packing, vessel loop or nothing after you've done your drainage. So, you've done your drainage. Do you pack it? Do you vessel loop or do you leave nothing? Uh, let's put the pole up there. Let's go this way around the room. Uh, I actually like to pack it. Packing? Vesi loop. Vesi loop. Vessi loop. Vessi loop. Nothing. Nothing. Vessel loop or nothing, depending on the size, but never packing. OK. I've used all three techniques. OK. Uh, nothing. Nothing or Vessel loop again, in size. Packing for hemostasis. OK, so it's completely varied. So, um, uh, and I, you know, there are a couple of things there was a study level 7 evidence. There's a lot. Well, there is, there is level 3 data that was presented at APSA this past year with the whole Star Wars montage, uh, where they did no, nothing compared to packing, and they saw no difference, um, but those patients. Did get treated with antibiotics, um, and I think we have to clarify packing. Some people take the entire jar of packing and shove it in. Some put a tiny little wick in and it falls out on its own. Um, what about, and so I'm curious to see what the poll results are. We'll pull that up in a minute. Well, I, I think the point is for packing or the vest loop, what you're trying to do is, is really keep the incision open. Yeah. So you promote further drainage. Yeah. As opposed to the pack. itself. There's no magic about that. It's just keeping the incision open, keeping the the, the hole open. The hole open for right so wicked open somehow, it doesn't close on its own, right. Um, I, I, um, anecdotally, I found that if it's an infected lymph node, um, especially the ones in the neck, those, if I don't put anything in, tend to have a higher recurrence than the typical buttock ones because the source is still there. So those I'll leave either a vessel loop or packing in, um. Uh, there we go. Packing 30% vessel loop 20%, leave nothing, 50%, uh, it's changing 30, 20%. I gotta wait. I'll always wait 2 minutes. That's what I, I can't get too excited. So it looks like it's very you all can in the audience can see the results there. What about, does anyone do this is important because we're doing a prospective study and our IRB was debating on whether or not we're practicing standard of care. Does anyone after they drain? In a non-sick kid, just drain with no postoperative antibiotics. Does anyone do that? Is there anyone here? Do you, would you ever do no postoperative antibiotics after you drain them? Yes. If there's no cellulitis, yes, no, outside of the abscess, you mean, right, right outside of that. OK. I have not, but I would like to. OK, Jack, I, I usually keep them on some antibiotics. They're usually on antibiotics, and so you just continue the course. You do continue them afterwards. Yeah. OK. All right. I often will avoid antibiotics unless, but there's often a lot of pressure also to keep them off from the parents. I'm loving this. OK, so you, it's not out of, it's not out of the realm of normal to not put them on antibiotics. After you do a drain is minimal cellulitis. Um, I use them, but I've had, uh, quite a few patients who've not ever given them cause they've either come back in and they just don't ever fill the prescriptions, so OK. They're all on antibiotics. You've done both. For afterwards, yeah. Variable. For I don't, I don't need it. I don't put them on, but they're already on it. For 10 days, 5 days? 5 days. 5 days max. 5 days we're hearing. Till the redness is gone. And then, OK. Um, so, and then the last question is, I know the answer because I think it's very institution dependent because I'm doing the study with you guys. I don't know if you even knew that, but we're, what I'm the last one we leave you out of the loop. But what, one thing that fascinated me by coming here from my previous institution. Is that they all got admitted afterwards. Here we send them all home immediately from the recovery room unless they are systemic, unless there's a huge abscess or they're febrile or something. But if they're healthy kids with a small 5, I mean less than 5 centimeter buttock abscess, drain and home from the recovery room. Does anyone do that? You don't because you do them on the floor, right? We do. In the ED or the floor or something, which would be great. Yeah, well, if we can sedate him in the ED or you'll send him home with the sin. Interesting. I know what you do. We do, yeah, emergency department and home. Wow, we're hearing a lot of ER you know, I know what you do, Dan Cincinnati. Wow. Tim, I'm, they're usually inpatients with us. It's that's what I'm usually. That's where I trained, yeah, yeah, they're often inpatients or become inpatients. OK, so there we go. That was a, that was a quick summary of buttock abscess. I think the summary there was variability in what everyone's doing. We still don't have an answer. It's in need of a prospective randomized trial which we're starting, and anyone who wants to join us in the audience, please let us know. More centers, the better. Um, sorry. Not much different issues, same issues we got this breast kid here, so we've, we've covered some of them, but, but what do we find out there? So neonatal breasts, we all know why it's there. They've had estrogen exposure. It's mostly in term or near-term infants because the estrogen levels don't go up, so it's very uncommon to get this mastitis issue in some of the preemie kids. Females a little bit more than males. Most of the time you don't see it after a year of age. The peak age for this is really young though, it's that 2 to 4 week um uh age group there and the majority of them are staff, but there are reports of gram negatives in there. Um, management is really based on very sparse literature and what's out there is very old, like 1960s, there's one from the 1950s that's cited in all these series and it's really old data, um, but a lot of the rest of it is based on these isolated cases with gram negatives. There were really only two retrospective studies that were recent. One had 21 infants and one had 18 infants. And their recommendations actually in many of these kids was to do parenteral. So, some of them would do Augmentin or, or coverage for MRSA, the clindamycin, and plus or minus gram negative if they were sick. But a lot of them went on to comment that the the parenteral antibiotics for 7 to 14 days might be needed, largely because, uh, they don't absorb the antibiotic as well internally at that age group. So you have a delay in absorption and a delay in, in antibiotic efficacy. Um, treatment of the abscess is an intervention. So in the, um, uh, adult literature, breast abscesses are primarily treated by needle aspiration. There are no studies that I could find looking at specifically, uh, needle aspiration for infant, uh, uh, mastitis. So there's another study right there waiting to be done. Uh, in, in the adult literature, sometimes you needed to aspirate more than once, and sometimes the ultrasound guided was done, particularly if it wasn't right there at the surface. And then for surgical drainage, less is more, um, so minimizing the size of your incision, minimizing the amount of trauma and dissection that you're doing, and just try and get, uh, the fluid out in order to maximize healing. Uh, breast deformation is really a big issue in these patients. There's occasional case reports of it, and I could find two series that had, uh, uh, evaluation of patients that had I&D of their abscess 10 to 15 years out. One had 6 patients that had mastitis. 5 had an IND. 1 did not. 2 of those patients with an IND did develop a deformity. That's, that's a pretty significant rate. That's more than a third, less than half. And then a second study had 8 patients that had mastitis, 7 of them had an I&D. 2 of them had a deformity. Those patients actually had an ultrasound done, and the ultrasounds also showed abnormalities, uh, calcifications and fibrous elements at the site of it. Um, so, uh, you know, numbers are very low, but it's not an insignificant portion of these that had INDs that went on to develop deformities. Um, but again, no, no studies on outcomes with needle aspiration and unknown risk if your breast distortion rate will go down with needle, go down with, uh, antibiotics. Alone, so, uh, uh, again, uh, an area I hope that somebody will take on and study so we really know how to treat it for, for again for buttock, for typical abscesses, how many times has the culture that we all spend and spend $250 to $300 on ever changed your management? How long, how often have you gone back to look at your culture results? I don't usually a culture. You don't culture. We don't. You don't culture. I'm the only one who cultures in this entire studio. Is there anyone else that culture culture in immunosuppressed kids. I have culture in diabetics, OK, but I don't culture routinely. Well, the big question for us has been MRSA. I mean, uh, and MRSA, that's not sensitive to clindamycin, so I, I used to, for a while I stopped culturing, and now I'm culturing again. Two questions for you. One, well, A statement. One is I don't think it matters because once you drain it, I don't think you need antibiotics. That's the study I'm trying to show. The, the other question is, um, don't you assume that it's MRSA and treat with usually Bactrim, or do you use Clina as your primary? Well, that's the thing, I mean, not all of our MRSA, at least in our, in our, in, in our part of the country, is sensitive to Bactrim or Clia, and so there's this, maybe we're just gathering data, uh, maybe we're not helping the individual patient, but, uh, it seems like more and more we're trying to culture and get that information. So for those of you that you that use antibiotics, clindamycin tastes awful, awful. So the young kids will not take it. So that's another reason if you, if you're gonna use antibiotics, use Bactrim receptor. OK. Sorry, Danielle. All right, you ready to move on? We are. All right. 16 year old noticed a lump in her right breast. History is absolutely unremarkable. She's never been pregnant. She's not on birth control pills. Exam reveals a non-tender 2.5 centimeter smooth walled mass without adenopathy anywhere. An ultrasound was already done and it's consistent with a fibroadenoma. How are you gonna manage this? Reassurance and see you again in 6 months. Core biopsy, send to somebody else for a core biopsy, excisional biopsy. This one's probably pretty straightforward. If you want to talk about parenteral pressure. Yeah. That is the definition. This is right. This is one where we sleep well, but they don't. Right. We feel pretty good about it. All right, while we're waiting for that, so, let's say you went on and you did your observation. Well, so what was the general feeling in the studio while we're waiting for the, for the virtual audience? Excisional biopsy is what I was talking about. Would anyone watch and wait? I would watch. Yeah, I would, I would try to talk them into waiting. OK, let's just fly through. Watch, watch and wait. Watch and wait. Watching. I would excise, excise, excise, excise, watch and wait, excise. So it's. OK, so just so for all of you who couldn't hear, it was watch, excise, watch, excise. So I think I can say it's about 50. Well, let me ask you, I'm surprised, so I'm a watch and wait. Uh, we feel like this 16 year old has a fibroadenoma. What am I missing? Why do we need to, um, in case, cause I guess you can't be sure is, I guess the concern that everyone has. So if you can't be sure, why not just the risk of a, of a malignancy in a 16 year old with a, with a, The ultrasound, you know, the ultrasound is very specific for, uh, for fibroadenoma. So, so I think the, uh, I agree with Witt. I mean, what do you, what's the rationale other than parental or child anxiety about lumps in the breast, which is not trivial, but, but from a risk standpoint, I think there's very little risk to watching. Did we post the uh audience results yet? I'm curious while we're waiting, um, Dan, uh, or Tim, I, I, yeah, I think they, I, I take them out. I think they can get bigger, and I, I just don't know how long to follow them. I don't want to see. That's what my next question was. How long do you and how often do you, how long and how often, Dan? Yeah, and, so, I agree, that's a challenge and I would probably see him back in, you know, two or three months or something like that. And if, if it's unchanged, then it would be the same plan and you have to get the family to agree to. Redo the ultrasound? Repeat the? No, I would not repeat the ultrasound. OK. Unless I thought it had changed. From a, from a practical perspective, when they start to see an adult provider, they're, they're going to, their PCP is going to say you're a 20 year old woman with a breast mass that needs a biopsy today. You know, so, you know, for a practical perspective. I don't know. Is that true? I mean. But are they excising them? They're, they'recoring them. They would do a core biopsy. I think a lot of them are resolved too. I. So, we, we're not doing cores because we don't know how to do them, that we weren't trained to do them. So either we cut them all the way out or we do nothing. We watch them. Sure. But if we were trained on core, we would probably do that. I have to tell you, this is the one that gives me angst. Peter, what were you gonna say? No, I'm just gonna say that I, I follow them, and you do have to follow them frequently because of the anxiety and sometimes you, you know, it might also depend on the location because the, the cosmetic implications of the surgical excision might vary. You know, it might be different. So in other words, if it's, uh, subareolar and you can, you know, you can get it through a small incision that's cosmetically acceptable, that's, uh, that might change your, your, your calculus a little bit. But I try to follow them if I can, and sometimes you have to do ultrasounds just to prove to them that the, the, the size hasn't changed. Um, and I kind of feel like that, uh, some of them resolve, and maybe it's the ones that I've seen who've had multiple fibroadenomas that seem to resolve if you watch them longer. Well, what's the, the thinking used to be about there was some relationship to caffeine or caffeine containing drinks, and so I used to have them suggest sure I had some. And, and so I actually have had a few that seem to have gone away if they took, uh, took that out of their diet. Uh, I think the, the other question is how uncomfortable, if they're uncomfortable. Right. Well, this is nontender. So, if it's, if it remains uncomfortable, then I'm I'm comfortable watching it. All right, so that's what actually, I'm going to go ahead and interrupt you. So, so now she, she did observation, all right, and you come back in 6 months later and it hasn't changed. There's another lesion now in the other breast that's real small, and that one's causing her discomfort. All right? So you got a 2.5 centimeter one that hasn't changed in 6 months on one side and you got a 1.5 centimeter one on the other side that still feels like a fibroadenoma, and I'll even give you, let's say you ultrasound it, and it is, it looks like a fibroadenoma, but it causes her discomfort. Now what are you gonna do? I'd probably operate for the second time on this. On the other breast. Well, I think the pain is probably an indication for, uh, for doing something. I mean, you, you, you have a symptom now, not because I'm more worried about it, but just because you're, you want to relieve her pain. But, so, I think I would excise the symptomatic one and hope that it confirms that it's a fibroadenoma and, and add to the reassurance about the first one. Well, I think, uh, an issue though, is she's now, what, 17 years old or something, and she's going to have this problem the rest of her life. So, I think you need to talk to her about, you know, You, you don't want to be doing one or two operations at 17 thinking that she's going to live another 50 years or 60 years and how many more operations is she going to get. All right. And then when she graduates and goes to the adult surgeon. Right. They're going to either take it out or, or core biopsy it, right? She graduates out of pieces. So, I think this is a discussion you need to have with the patient and with the, with the parents about. But I just want to make sure, is that true that that's what the adult guys would do, they would, These? Most of the ones that I've, I've seen, the adults had to do that. But more important than the adult surgeon that they see is the adult radiologist that they see because if we get a report from a center that deals mostly with adults, they almost invariably say, well, we believe, you know, we, we, we believe it's a fibroadenoma, but we definitely recommend a biopsy. I mean, they always add that at the end. I think to cover themselves, and that puts us really in a tough spot because once the radiologist says you have to do a biopsy, it's hard to ignore that. Right. OK. We're already a half an hour over, but I, I know that this is hot for everyone. So why don't we just. We'll skip the last case. But let's finish up this one here then. All right. So, mom asked for a mammogram and an MRI. No and no, all right? Is there a role for it? Let's, uh, what are the chances it's cancer? And then, then the the classic one, well, grandmother died of breast breast cancer and so she's got a lump now and she wants her tested for the gene. You're gonna send your patient for genetic testing, BRAC testing. Anyone going to send them? Why or why not? Well, wait a second. So there was a is there a history of BRCA in the family? No, they just know that grandmother died of breast cancer. My daughter has a lump. I probably would. I mean, I, I would say you don't, you know, really, you have one, associated person in the family. You don't have a, a very strong family history. I don't think that's an indication for sending off BRCA, but I don't know. I guess if they ask for it, I don't know. I think at our institution, it hasn't come up frequently, but I don't think we can just order the test. We have to put, plug them into the genetic genetic counseling system, and they often will, you know, weigh the odds for them and, and basically talk to the I was the buck. Genetics is I don't want to know. Don't, don't make me answer that question. That's right. That's why God made geneticist. Reassurance. All right, so in your evaluation, sorry, the, the, the formatting is a little bit off there, but, so ultrasound is, of course, the standard of care. Coppler, the Doppler ultrasound may help you a little bit. MRI, uh, with gadolinium studies are limited. We don't really know what to do with it. People are. Doing it, but not generally for a benign fibroadenoma. Some people have advocated if you, if you have a malignancy that doesn't look like a fibroadenoma, that perhaps there's a role for surgical planning in there. Most of these are in uh under the 20 age group. Uh, it's the most common lesion that we'll see. Um, it's an exaggerated response to estrogen. About 10 to 15% of them will be multiple, as this patient is, and 10% of them are bilateral, as this patient is. Most of these lesions are going to be 1 to 3 centimeters, and they do have a normal history. Their natural history is they're going to increase in size over 6 to 12 months, but they usually stabilize and they can regress, and they can regress in their entirety. So observation with ultrasound and uh exam every 6 months until stabilized and then yearly is a common recommendation, but nobody cites any literature to support it, OK? If they are having rapid growth or it's earlier, many people have advocated. Just seeing them back in one or two menstrual cycles as, as Dan Von Almen suggested, or an earlier follow-up in the beginning and then moving on if it's stabilized to a longer follow-up of the 6 months, um, FNA is rarely needed. FNA in breast lesions in pediatric patients isn't really as definitive as it is in adults. Um, some have advocated that if you do do it in a pediatric patients, it should be ultrasound guided because you have a lot of developing breast tissue there and you wanna minimize trauma to that. Uh, excisional biopsies, um, uh, are generally recommended if it's continuing to grow, if it's changing, if it's over, some say 3 centimeters, most say 5 centimeters, if it's symptomatic or if it appears complex on ultrasound, and what does that mean? I'll get to that in a second, or if the family is just unable to do reliable follow-up, they're not gonna make their appointments and you're worried about it, go ahead and take it out, or if the family really just can't sleep on it because of family history experience or just overall anxiety. There is that subpopulation where it's really a juvenile fibroadenoma. It's a much larger lesion than usual. They usually have a rapid growth. They're greater than 5 centimeters. They can become very large, but it's only about 10% that are going to get that big. The other 90% of them are generally the smaller kind. Um, and juvenile fibroadenomas, especially those bigger than 5 centimeters, can be very difficult to distinguish from cystosarcoma phyloides. Uh, even on, uh, percutaneous biopsies, it can be very difficult for the pathologist to distinguish. So, in those cases where you have greater than 5 centimeters, there's very good consensus that excision needs to be done. Uh, that cystosarcoma phyloides could be benign, could be borderline, could be malignant. All depends on the histotype, and you're not going to know until you get it out. There is a local recurrence and a metastatic rate that comes with that lesion. Um, fibroadenomas, so controversy over whether these have a risk of malignancy in the future, and you kinda need to divide it then into whether you have a simple or a complex one. So in a simple one, it's that isolated, well demarcated, solid lesion that we're classically seeing on ultrasound, and in those patients there is no increased risk as long as there is no family history of breast cancer and there's no evidence of abnormality in the adjacent breast tissue. However, there is a different. Category there's the fibroadenoma that has complex lesions. It has cysts. It might have calcifications. It might have abnormal breast tissue around it. In those patients, there is a very slight increased risk of future breast cancer up to 20 years after the initial diagnosis. So that may account for in the earlier literature, discrepancy as to whether there was an increased risk. If you divide it into the simple and complex, it seems to become less controversial. Um, malignant breast disease does occur in our pediatric population, but it's very rare. It's more common to be metastatic from some other type of lesion than it is a primary breast tumor. Uh, so sarcomas and lymphomas, particularly our lymphoma patients who at young ages were treated with chest radiation, they have a high incidence of malignant breast disease. Some have said as much as 25% higher. Um, as far as the genetic testing issue, there is a, a published recommendation from the American Society of Clinical Oncology that discourages genetic testing for the BRAC genes before age 20 because they won't have a timely medical benefit from it. You're generally not going to consider mastectomies or operations until they've completed their breast development and the psychosocial risks of setting a patient up for believing that they could have cancer and making life decisions based on that. So at this time that is not a recommendation. And we're out of time. Yeah, we're out of time, but, uh, Um, I think people can still continue the discussions that we didn't quite get to everything, but pretty much we did a pretty good job there. I think this was, uh, pretty high yield stuff that we all see every day. So Danielle, thank you for that. That was awesome. All right.