Breast Masses in Adolescents: Clinical Pearls in the Diagnostic Evaluation

In adults, 11 percent of breast masses represent breast cancer.1 In adolescents, only 0.02 percent of surgically removed masses represent a breast malignancy, whereas fibroadenomas account for up to 95 percent of breast masses.2-4 The prevalence of breast masses among teenage girls is approximately 3.2 percent.5 Common causes include fibroadenoma, cysts, hamartoma, fat necrosis, or abscess. Because the diagnosis of a primary breast carcinoma is rare, the differential diagnosis includes rare metastatic disease from malignant tumors, including rhabdomyosarcoma, lymphoma, and neuroblastoma.6 Evaluation begins with eliciting a detailed history on duration, change in mass size, nipple discharge, precipitating factors, and constitutional symptoms. The preferred imaging modality in adolescents is breast ultrasonography, which can better characterize and delineate breast masses, differentiate cystic from solid masses, and increase sensitivity while avoiding radiation exposure.9 Indications include an irregular, firm mass; skin erythema or tethering; bloody nipple discharge or retraction; an enlarging mass; or a persistent mass without regression after three to four months.2 A solid, suspicious lesion detected on ultrasonography requires a percutaneous biopsy preoperatively to guide surgical intervention. Literature on the use of minimally invasive procedures, such as cryoablation of masses in adolescents, is limited.12 In patients who do not accept surveillance of multiple or small masses (less than 2 cm) and who are concerned about surgical scarring, management with vacuum-assisted, ultrasound-guided percutaneous excision can be an alternative to surgery.13 The discovery of a breast mass can be disconcerting and can provoke anxiety and fear for the patient, her family, and her physician.