Breast anomalies

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)

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

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

• This is a normal variant, but new onset may represent malignancy or infection.
• This can be corrected for cosmetic purposes however, this may lead to the inability to breastfeed

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

—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 the age of around 7 years
• Usually benign and possibly familial
• Consider investigating for precocious puberty

Adolescent 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

• 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

—Congenital anomaly of breast shape

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

—Surgery

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

Breast asymmetry

—Relatively common presentation at the commencement of thelarche

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

—Surgery is indicated for psychosocial distress

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, phyllodes tumous
• Extremely rare (1 in 1m breast cancers occur <20 years)
• Usually present as hard, non-tender, poorly circumscribed masses
• Diagnosis: US, needle or excisional biopsy

BRCA Genes

• BRCA 1 and BRCA 2 genes responsible for 7-9% of breast cancers
• 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 is not typically recommended in children of affected families due to a lack of consensus on the benefit of medical interventions

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

Gynaecomastia

• Increase in the size of male breast tissue
• 70% of boys will develop gynaecomastia in adolescence
• 75% will resolve 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)