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Managing Adolescent Breast Masses


 

NEW YORK — When evaluating a breast mass in an adolescent, keep in mind that breast cancer is rare in this population and imaging should be limited, Dr. Patricia Simmons advised physicians at a gynecology conference sponsored by Mount Sinai School of Medicine.

Studies of the histopathology of young patients who have had surgery for a breast mass show that the most consistent finding is fibroadenoma, though some had fibrocystic changes, abscess, and infection, and in very rare cases, malignant diseases, said Dr. Simmons, professor of pediatrics at the Mayo Clinic in Rochester, Minn.

In the rare case of a malignant mass, it is likely to be the type of tumor found more commonly in young patients, such as primary or metastatic rhabdomyosarcoma, metastatic neuroblastoma, or lymphoma, she said.

In those cases, patients did not discover the masses through self-breast exam but generally presented with constitutional symptoms such as fever, night sweats, and weight loss.

The clinical experience in breast masses in adolescents is largely anecdotal, and the surgical experience is limited, Dr. Simmons said. But for the most part, breast masses in adolescent women are benign, cancer is rare, and when cancer occurs, it is generally not carcinoma, she said.

When looking at a breast mass in adolescents, physicians should consider the duration, the constitutional symptoms, and the risk factors for malignancy. Keep in mind that in young women, the risk factors are different, because the patient hasn't lived long enough to develop most of the factors considered in adults, Dr. Simmons said. The risk factors in adolescents are generally cancer history and whether the patient has had chest radiation.

During the physical exam, the mass size and character, breast skin changes, nodes, and organomegaly should be assessed.

In cases in which the diagnosis is uncertain, imaging will be necessary. However, while a mammogram is the go-to test in adults, this type of imaging is ineffective in adolescents because the young breast is denser and firmer, Dr. Simmons said. An ultrasound will be much more sensitive, she said.

Surgery may be indicated in cases such as a recurring cyst that is symptomatic; a growing, disfiguring mass; suspected cystosarcoma phyllodes; suspected papilloma; suspected papillomatosis; or an abscess.

When considering surgery for a fibroadenoma, physicians should assess the course, the certainty of the diagnosis, any worrisome features, size and distortion, and tolerance, Dr. Simmons said. In a case in which the mass is distorting the breast, surgery is probably the right choice, because it is interfering with normal life, she said. However, she cautioned physicians not to opt for surgery just because the mass is worrisome to the mother.

“I think we need to arm our patients with the facts, and we should be able to alleviate anxiety if that anxiety is misplaced and not take [the fibroadenoma] out just because it's there,” she said.

In many cases, it is fine to watch a fibroadenoma in an adolescent patient since most will be benign and not progressive, Dr. Simmons said. “We should be conservative with this population to preserve breast architecture and breast-feeding to the extent we can,” she said.

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