Breast anomalies

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—Most breast lesions in children and adolescents are benign and self limiting. However, it is important not to overlook the impact that abnormal breast development can have on an adolescent’s self-esteem and self-confidence. Here Catherine Boorer (Plastic and Reconstructive Surgeon) discusses the spectrum of presentations.


Polythelia (accessory nipples)

polythelia

  • —Can occur anywhere along the mammary ridge
  • —Occurs in 2% of the population
  • —Treatment is by simple excision

Polymastia

polymastia

  • —Commonly in axilla
  • —Can be associated with polythelia
  • —Treatment is by direct excision +/- liposuction
  • (Note that you can get breast cancer in the accessory parts)

Nipple inversion

nipple inversion

 

  • —This is a normal variant but new onset may represent malignancy or infection
  • —Can be corrected for cosmetic purposes however this may lead to the inability to breast feed

Amastia

  • —Rare
  • —If unilateral – consider Poland’s syndrome
  • —Bilateral with normal pubertal development – normal (bilateral hypomastia– not considered an anomaly)
  • —Bilateral with delayed puberty – work up for ovarian failure (gonadal dysgenesis, androgen insensitivity syndrome, or congenital adrenal hyperplasia; or other disorders including hypothyroidism or poly- cystic ovary syndrome)

Poland’s syndrome

poland

—Occurs in 1 in 20 000 – causes is possibly a vascular accident

—Individuals have a range of anomalies

  • —Amastia
  • —Athelia
  • —Absent chest wall and shoulder girdle muscles
  • —Bony chest wall anomalies
  • —Shortened radius/ulna
  • —Symbrachydactyly

Treatment aims to reconstruct the breast mound (in females) or pectoralis contour (in males). Other procedures may include reconstruction of the anterior axillary fold, nipple reconstruction and contralateral breast lift/reduction. 


Premature breast development

  • —Breast development prior to age of around 7 years
  • —Usually benign and possibly familial
  • —Consider investigating for precocious puberty

Adolescent hypertrophy

hypertrophy

  • —Sustained progressive breast growth >2.5 kg
  • —Multifactorial – familial, related to obesity, hormone imbalances
  • —Significant social, psychological and physical discomfort
  • —In the past, breast reduction was offered at >18 years but this is now offered earlier if significant distress is present
  • If the patient has unilateral hypertrophy, exclude tumours e.g. giant fibroadenoma, lymphoma

Virginal or juvenile breast hypertrophy

juvenile

 

  • —Rare condition where there is extremely rapid breast growth during puberty
  • —Possible end organ sensitivity to gonadal hormones
  • —Can recur immediately after breast reduction
  • —Pharmacological agents are being used to control growth e.g. tamoxifen, danazol, or bromocriptine

Tuberous breasts

tuberous breast

—Congenital anomaly of breast shape

  • —Constricted base
  • —Herniation breast tissue under an enlarged areolar
  • —High IMF
  • —Asymmetry

—Surgery

  • —Breast expansion
  • —Prosthetic augmentation
  • —Areolar reduction
  • —Breast lift

Breast asymmetry

breast asymmetry

—Relatively common presentation at commencement of thelarche

—Likely to be permanent if no catch up growth in the first 1-2 years

—Surgery is indicated for psychosocial distress

  • —Reduction
  • —Breast lift
  • —Augmentation

Breast infections

  • —Abscesses and mastitis can occur at any age
  • —Usually S. Aureus
  • ——Rx antibiotics +/- careful surgical drainage

Breast pain

  • —In the absence of infection or mass usually secondary to hormonal stimulation
  • ——Consider OCP if problematic

Benign breast lumps

  • —>70% fibroadenomas
  • ——Smooth, rubbery, discreet and non-tender (2cm-15cm)
  • ——Diagnose on US

Breast metastases

—Secondary breast metastases more common than primary malignancy

  • —Rhabdomyosarcoma
  • —Lymphoma
  • —Melanoma
  • —Neuroblastoma

Primary breast cancer

  • —Ductal carcinoma, secretory carcinoma, phylloides tumous
  • —Extremely rare (1 in 1m breast cancers occur <20 years)
  • —Usually present as hard, nontender, poorly circumscribed masses
  • —Diagnosis: US, needle or excisional biopsy

BRCA Genes

  • —BRCA 1 & BRCA 2 genes responsible for 7-9% breast cancer
  • —BRCA 1 – 55-65% breast Ca, 39% ovarian Ca risk by age 70
  • —BRCA 2 – 45% breast Ca, 11-17% ovarian Ca risk by age 70

—Screening for BRCA not typically recommended in children of affected families due to lack of consensus of the benefit of medical interventions

—Current guideline: start screening 10 years younger than youngest affected individual but no later than 35 years


Gynaecomastia

gynaec

  • —Increase in the size of male breast tissue
  • —70% boys will develop gynaecomastia in adolescence
  • —75% will have resolution in 2 years
  • —Imbalance in the estrogen/androgen ratios

—Secondary causes

  • —Medications (TCAs, metronidazole, anabolic steroids, ketoconazole, spironolactone….)
  • —Street drugs (ETOH, marijuana)
  • —Herbal products (tea tree oils, lavender oils)
  • —Medical conditions (hypogonadism, liver or kidney disease, Klinefelter syndrome, thyroid disorders)

—Management

  • ——Address underlying conditions
  • —If persistent and causing concern consider surgery
  • —Liposuction
  • —Open excision
  • —Skin resection
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3 Responses to "Breast anomalies"

  1. Dr Rolanda Baars, pediatrician, The Netherlands
    Dr Rolanda Baars, pediatrician, The Netherlands 2 years ago .Reply

    Have you got any information on benign mammary duct ectasie in babies under 1 years old?
    I have 2 children with this symptom under my care. Have found some literature but no colleagues with experience in this area.

  2. Abe Khan
    Abe Khan 1 year ago .Reply

    Dr Baars

    This week’s New England Journal of Medicine actually has a case report of an 8 year old Boy with an Enlarging Mass in the Right Breast. http://www.nejm.org/doi/full/10.1056/NEJMcpc1503831 They actually have a very good flow chart of how to work up nonphysiolgic gynecomastia and a pertinent discussion. I think it complements this post really well.

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