Breast Masses Rapid Fire Session: Update Course 2015

Yep, blue. Great. Uh, so we're going to start with a case study of a breast lump, 16-year-old female, 2 centimeter, uh, a 2 month history of a 3 centimeter solitary mass, mid left breast, no size change, discharge, tenderness, or other symptoms. Um, maternal grandmother had mastectomy for breast cancer. Um, breast development, as you know, begins in utero. Uh, Telarchy is considered normal at 9. 10 years of age, premature is 7 to 8, delayed 12, that becomes important. Uh, later, um, normal anatomic structures that are seen as breast masses that come to the office include lymph nodes, uh, breast bud, um, which is due to the effect of maternal hormones in infants and is considered normal, um, asymmetric breast development, uh, seen in older children, um. You know, one breast starts developing sooner than the other, pediatrician and the parents panic, um, but again, that's normal, and you can also see bony structures as a normal, um, ah, ah, process that appears to be a breast lump. Um, Developmental issues include ectopic tissue, ectopic breast tissue, gynecomas. um, which is due to circulating estrogens in males. It can be associated with medications, uh, illegal drugs, uh, herbal, uh, uh, supplements, um, and as we know, gynecomastia is usually self-limited. Um, also there are, uh, tumors that can occur. Um, the non-neoplastic tumors include a cyst. Hematoma that usually associated with a history of um chest wall trauma, uh, an abscess of course can occur uh pretty much at any time, and a galactocele uh collection, uh basically another collection, fluid collection. Benign masses, the most common is, of course, fibroadenoma. Hematomas can be seen, intraductal papillomas, juvenile papillomatosis, and fibrous nodules are all benign masses found on pathologic examinations. Malignant, here's a whole host of malignant. Probably the most common is going to be some type of metastatic disease, um, uh, phyloides, tumors and primary chest wall malignancies are certainly less common. So what is the management of fibroadenoma in children? Um, generally the most important thing that we can do for these children is to get a good history and physical examination, and then we say, your lump appears to be a fibroadenoma. They have the characteristic, ah, features that we've all learned about. They're small, smooth, lobular, movable. They, ah, may be tender during, um, ah, different types of time periods during the periods. Um, not associated with overlying skin changes. They have those type of, ah, typical, ah, appearances. Um, if there is imaging that needs to be performed or someone orders imaging, we want to avoid, ah, mam mammography for all kinds of reasons, not just because of the, ah, radiation dose to the breast, but it's not going to be helpful at all. If there's any type of imaging that's going to be, ah, considered, it should be an ultrasound. And the ultrasound examination of a fibroadenoma is considered to be very diagnostic with a high degree of specificity and sensitivity. And the question is, uh, the controversy is what do we do about these. Um, the standard, at least in my practice, is that all breast lumps, fibroadenomas, no matter the size, they get excised. However, there is a recent paper, uh, especially in countries that may not have as many, um, facilities available to perform surgery. Uh, is that these can be observed because the risk of malignant transformation, especially in a small tumor, if it's watched, are very, very small. However, as part of the original case presentation, I mentioned the maternal history of the maternal grandmother's history of breast cancer, and I think that one of the things that drives what we're going to do with these patients is going to be the. Family's consideration and in this particular case, the family, there was no consideration at all. If there's a lump in the breast that had to come out, um, and the concern being that if you leave it there, will it grow or will eventually something grow behind it that the patient is not going to be able to see. OK, so who here, who here, uh, routinely takes out those that fibro, uh, fibroadenoma that's 2 centimeters. Who routinely takes them out, that one was 3 centimeters. Those 3 centimeters or, but I think it depends on the context. If it's not visible and it's not bothering the patient completely asymptomatic, I, I would watch it. How long, how often do you follow them? I, I, I don't even think they really need to be. I mean, you can follow them up. You always follow them up once for, for reassurance after 3 months or something. So what breast lesion would you be more concerned about if it's, so I think these fibroadenomas are always benign, but they can grow and then they can. Start to become symptomatic. So what I explained to the families is that if it's getting bigger and if we, if we, you know, if it starts to grow and you take it out when it's bigger, you're going to have a bigger scar. Start calling it fibroadenoma right now because we're assuming it's a fibroadenoma. So if someone comes to you and they have a 2 centimeter lesion in their breast. Do you ever biopsy it? Do you ever, if there were, if there was discharge, if there was skin dimpling over it, anything to make it look like it's malignant, but there are exceedingly rare case reports of breast cancer in teenagers. OK, teenage girls who want it out. What's that? But there are many teenage girls who want it out. I found. They usually want it out even though we, and, and that's a consideration. I'm not gonna say it's not a consideration. It's not a diagnostic ultrasound. Fibroadenomas, it's a patient preference issue because they want it out. But if they want to, if they're not concerned about it, are you OK watching it and leaving it? You don't follow them up. That's a great question. I think I don't follow them up. I leave it, you know, I, I, they're very usually very concerned, and I tell them if it's growing, then we need to see them back. OK, yeah. I don't know. Any comments? I don't think they usually come back if you don't follow them up. The parents, the patients will come back anyways, right, right. I'll just take my time.