(Radiographics. 2000;20:1605-1612.)
© RSNA, 2000
Breast US in Children and Adolescents1
Cristián J. García, MD,
Aníbal Espinoza, MD,
Víctor Dinamarca, MD,
Oscar Navarro, MD,
Alan Daneman, MD,
Hernán García, MD and
Andreina Cattani, MD
1 From the Department of Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile (C.J.G., V.D., A.C.); the Departments of Radiology and Pediatrics, Hospital San Borja-Arriaran, University of Chile, Santiago (A.E., H.G.); and the Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada (O.N., A.D.). Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received April 25, 2000; revision requested May 19; revision received and accepted July 10. Address correspondence to C.J.G. (e-mail: famgarc@entelchile.net).
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Abstract
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Ultrasonography (US) is of value in the evaluation and characterization of breast masses in children. Most masses represent either normal breast tissue, cysts, or fibroadenomas. Premature thelarche may be unilateral, and normal breast tissue is found at US. Cysts are commonly retroareolar; when they become infected, they appear sonographically as a complex mass. Fibroadenoma is the most frequent breast tumor in adolescent girls, and it is usually solitary, homogeneous, and hypoechoic. Malignant breast lesions are very rare in children; most are due to metastatic disease secondary to rhabdomyosarcoma, leukemia, lymphoma, and neuroblastoma, and their US appearance is nonspecific. Gynecomastia in boys can be mimicked by general obesity and pectoral hypertrophy; US is helpful in the diagnosis, especially when gynecomastia is asymmetric. Most breast lesions in children and adolescents are benign, and surgery should be avoided to prevent later deformity. US is the ideal imaging modality to evaluate breast lesions and may be used to guide a fine-needle aspiration biopsy. Color Doppler US evaluation is helpful; cysts are avascular, fibroadenomas may be avascular or hypovascular, and abscesses show peripheral increased flow. Bloody nipple discharge is more common in prepubertal patients, may occur in infants, and may be secondary to mammary ductal ectasia. Discharge commonly resolves spontaneously, and findings at US are frequently normal.
Index Terms: Breast, male, 00.30 • Breast, US, 00.1298 • Breast neoplasms, 00.30 • Breast neoplasms, male, 00.30 • Breast neoplasms, US, 00.1298, 00.311, 00.3119 • Fibroadenoma, 00.311, 00.3119 • Neoplasms, in infants and children, 00.30
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Identify the US features of normal breast development.
- Describe the role of US in the study of breast lesions in children.
- Discuss the limitations of US in the differential diagnosis of breast masses in children.
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Introduction
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Pathologic breast conditions are rare in childhood and adolescence. The spectrum of breast disease in the pediatric age group is different from that in adults, and most lesions are benign.
In contrast to treatment of adults, mammography is contraindicated in children because of the extremely low risk of breast cancer (1), the increased risk of radiation-induced malignant changes in the young glandular breast (2), and poor image quality due to dense fibroglandular breasts.
US is the ideal imaging modality to study the pediatric breast and can be useful in all cases in identifying and characterizing the abnormality and guiding further investigation (3,4). US has been shown to be useful in characterizing palpable masses in children (3,5) and may be clear enough to allow fine-needle aspiration biopsy of solid lesions. Biopsy and surgery should be avoided, however, because of the risks of deformity to the developing breast (6).
Knowledge of the US appearance of normal breast development and specific lesions is essential for successful use of breast US. The highest quality US images of the breast are obtained with 512-MHz linear transducers, depending on the degree of breast development. At US, the fat in normal breast parenchyma is hypoechoic, fibrous tissue is echogenic, and glandular tissue is intermediate in echogenicity (7).
This article describes the US characteristics of the following breast conditions in children and adolescents: normal breast development and normal variations, as well as the pathologic conditions of premature thelarche, congenital anomalies, gynecomastia, inflammatory lesions, benign neoplastic masses, nonneoplastic benign lesions, primary and secondary malignant tumors, and bloody nipple discharge.
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Normal Breast Development: US Characteristics
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The human female breast undergoes two separate phases of growth and differentiation. The first occurs during fetal development and results in the formation of a rudimentary organ consisting of simple branched ducts, which are able to respond to the secretory stimuli of maternal origin (8). The second period of growth occurs at puberty, when the ducts elongate, divide, and form terminal duct lobular units (8–10). At the end of the pubertal development phase, the breast consists of a ductal system lined by epithelial cells (the epithelial parenchyma), terminating in terminal duct lobular units.
The prepubertal breast consists of simple branched ducts. The rapid growth of the mammary tree results from the elongation and branching of these ducts (8). Lobular differentiation is seen first in the peripheral regions of the breast and then extends centrally (8).
The first clinical sign of puberty is usually breast development (thelarche) but may be pubic hair development (pubarche).
The normal progression of breast development under the influence of pubertal hormones has been classified into five Tanner stages (11,12) that can be correlated with characteristic US appearances (13), which also correlate with characteristic histologic findings (8):
Tanner stage I is prepubertal, and in most cases US shows ill-defined hyperechoic retroareolar tissue (Fig 1).
Tanner stage II is clinically appreciated as a palpable subareolar bud before it can be seen as an elevation. At US, it appears as a hyperechoic retroareolar nodule with a central star-shaped or linear hypoechoic area that represents mostly simple branched ducts (Fig 2).
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Figure 2. Tanner stage II. In a 10-year-old healthy girl, US scan shows a hyperechoic retroareolar nodule (arrows) with a central hypoechoic area (*) that represents mostly simple branched ducts.
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Tanner stage III is obvious enlargement and elevation of the entire breast. At US, hyperechoic glandular tissue is seen extending away from the retroareolar area, and a central spider-shaped hypoechoic region is noted (Fig 3).
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Figure 3. Tanner stage III. In a 13-year-old healthy girl, US scan shows hyperechoic glandular tissue extending away from the retroareolar area (arrows) and a central spider-shaped hypoechoic retroareolar region (*).
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Tanner stage IV is the phase of areolar mounding; it is very transient and may not necessarily appear. At US, in most cases, hyperechoic, mostly periareolar fibroglandular tissue is seen (Fig 4), showing a prominent hypoechoic nodule in the central region. Subcutaneous adipose tissue is identified in some cases.
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Figure 4. Tanner stage IV. In a 14-year-old healthy girl, US scan shows hyperechoic fibroglandular periareolar tissue (arrows), with a prominent central retroareolar hypoechoic nodule (*). Subcutaneous adipose tissue is also depicted.
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Tanner stage V describes the attainment of mature breast contour. At US, hyperechoic glandular tissue is found, with increased subcutaneous adipose tissue anteriorly and without the hypoechoic central nodule seen in Tanner stages II, III, and IV (Fig 5).
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Figure 5. Tanner stage V. In a 14-year-old healthy girl, US scan shows hyperechoic glandular tissue, with increased subcutaneous adipose tissue anteriorly and without the hypoechoic central nodule seen in previous Tanner stages.
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Normal Variations in Breast Development
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A common normal variant is the unilateral onset of breast development that can be clinically misdiagnosed as a tumor. Unilateral breast development may exist as long as 2 years before the other breast becomes palpable. US shows normal breast tissue in these cases and obviates surgery or biopsy.
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Premature Thelarche
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Breast development that begins before the age of 7
years is considered precocious or premature. Premature thelarche, either isolated or associated with central precocious puberty, may be unilateral or bilateral, and normal breast tissue is found at US (Fig 6).
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Figure 6a. In a 7-year-old girl with unilateral thelarche, US scans show Tanner stage II development (arrows) in the right breast (a) and a small hyperechoic retroareolar area (arrows) in the left breast region (Tanner stage I) (b).
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Figure 6b. In a 7-year-old girl with unilateral thelarche, US scans show Tanner stage II development (arrows) in the right breast (a) and a small hyperechoic retroareolar area (arrows) in the left breast region (Tanner stage I) (b).
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Most cases of idiopathic premature thelarche are due to subtle overfunction of the pituitary-ovarian axis. A growth spurt does not occur, the bone age does not advance abnormally, and menses do not appear until the usual age. Pelvic US is useful in the early differentiation between isolated premature thelarche and central precocious puberty by allowing measurements of the uterus and ovaries (14).
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Congenital Anomalies
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Polythelia (more than the normal number of nipples), polymastia (more than the normal number of breasts), and congenital amastia (absence of mammary glands) are the most common congenital breast anomalies. The diagnosis of these conditions is usually made clinically (6,15), and in most cases no imaging studies are needed.
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Gynecomastia
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Physiologic pubertal gynecomastia (excessive development of the breast in the male) is well recognized and can be asymmetric or unilateral (Fig 7). Breast enlargement begins approximately 1 year after the onset of puberty and subsides in 1—2 years (4,16,17). Enlargement may occur in as many as 75% of healthy boys. Gynecomastia can be caused by drugs (eg, anabolic steroids, digitalis, isoniazid, tricyclic antidepressants, marijuana) (6). Enlargement can be managed nonsurgically, but mastectomy may eventually be indicated.
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Figure 7a. Asymmetric pubertal gynecomastia in a 16-year-old boy with a clinically suspected right breast mass. US scan shows bilateral breast development (arrows) that is much more pronounced on the right side (a) than on the left (b).
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Figure 7b. Asymmetric pubertal gynecomastia in a 16-year-old boy with a clinically suspected right breast mass. US scan shows bilateral breast development (arrows) that is much more pronounced on the right side (a) than on the left (b).
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General obesity may cause pseudogynecomastia due to adipose tissue accumulation in the breasts. In these cases, US is diagnostic and permits differentiation from other breast masses (Fig 8).
Gynecomastia may also occur in pathologic conditions (eg, Klinefelter syndrome, anorchism or acquired testicular failure, androgen receptor defects).
In an extreme form, there may be juvenile or virginal hypertrophy or gigantomastia. This is associated with massive breast hypertrophy and is thought to be due to an abnormal local reaction to normal hormone levels (3).
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Inflammatory Lesions
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Inflammatory breast lesions can occur in the neonate (18) and also in children and adolescents (19). Breast abscesses manifest as tender, indurated, or fluctuant erythematous masses (4). They may result from obstruction of a mammary duct, infection of a retroareolar cyst, irritation or abrasion of a nipple, or cellulitis of the surrounding chest wall area (4). Staphylococcus aureus is the major causative agent in documented series (4,20,21). These lesions appear at US as cystic or complex masses (22) (Fig 9). US is not only diagnostic but also helps guide therapeutic needle aspiration (15).
Mastitis may appear as a complex or solid mass at US (22). At Doppler US, abscesses show only peripheral flow, whereas mastitis shows central flow (22).
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Benign Neoplastic Masses
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Fibroadenoma is the most common benign neoplastic lesion in children and composes 50%—60% of all breast lesions in adolescents (15,23). At US, fibroadenoma manifests as a well-defined hypoechoic homogeneous mass (24–26) (Fig 10), 1—20 cm in diameter, and may appear as multiple masses in 10%—15% of patients (15). At Doppler US, 67% may be avascular and 33% may show central vessels (22).
Other benign neoplastic lesions include hemangiomas, papillomas, lymphangiomas, and lipomas.
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Nonneoplastic Benign Lesions
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Breast cysts are solitary or multiple, unassociated with fibrocystic disease, 1—5 cm in diameter, and most commonly located near the nipple and areola. Cysts can manifest as a palpable mass or as a result of secondary infection. Uninfected cysts appear as anechoic masses in the breast tissue. Uninfected cysts may be multiple in number, round or lobular in shape, contain internal septations or isolated echoes (Fig 11), and be avascular at Doppler US (22). When infected, the cysts may contain echogenic debris, septations, or fluid-fluid levels, and increased vascularity is noted peripherally (Fig 12).
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Figure 12. Infected retroareolar cyst in an 11-year-old girl with a breast mass and fever. Doppler US scan shows a predominantly cystic lesion (arrowheads), with increased peripheral flow.
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Fibrocystic disease or mammary dysplasia is a group of benign cystic and proliferative lesions with some potential for development of breast carcinoma that are almost exclusively confined to the adult breast, although they may be seen in late adolescence (19,21). US is nonspecific and may show solid or cystic masses (7).
Other benign lesions include galactocele, postsurgical fibrosis, fat necrosis, hematoma (Fig 13), and extramedullary hematopoiesis.
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Primary Malignant Tumors
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There is no clinical or radiologic difference between benign and malignant tumors, and histologic differentiation may be also difficult (3).
Cystosarcoma phyllodes may arise from a preexisting fibroadenoma, and although usually benign, it may show evidence of malignancy in 5% of cases (27). It probably develops de novo from breast tissue and is characterized by exuberant stromal cellularity. Although rare in adolescents, it is the most common malignant breast mass in this age group (4,23,28). At US, phyllodes tumors are described as well-defined oval or lobulated masses with a smooth margin and may contain fluid-filled cysts or clefts (7,29,30).
Adenocarcinoma of the breast is extremely rare in children, accounting for less than 1% of breast masses in this age group (21), and may be less aggressive than in adults (31). It usually manifests in the 1st decade with a painless mass (1), and the histopathologic results are similar to those of adult adenocarcinoma (1). The US appearance is variable and nonspecific; it manifests most commonly as a hypoechoic mass with inhomogeneous internal echoes, irregular margins, and variable acoustic shadowing (7).
Other primary malignant breast tumors include lymphoma, rhabdomyosarcoma, and angiosarcoma (3,21).
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Secondary Malignant Tumors
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Malignant breast lesions are more likely to be secondary to metastatic or disseminated tumor in children and are described in lymphoma, leukemia, rhabdomyosarcoma, and neuroblastoma (3). Their appearance at US is nonspecific. In leukemia, they may manifest as a solid, well-defined, and relatively hypoechoic mass (Fig 14) that is sometimes bilateral. In metastatic neuroblastoma, US may reveal multiple hypoechoic breast lesions (3).
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Bloody Nipple Discharge
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Bloody nipple discharge may occur in neonates or infants and has been attributed to infantile mammary ectasia, chronic cystic mastitis, intraductal cysts, and intraductal papillomas in the prepubertal age groups (4,32,33). This can also be related to the fact that the breasts are actively hematopoietic in the embryo, and hematopoietic tissue is readily detected in the newborn (9). In our experience (three infants), Doppler US has shown no abnormalities.
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Summary
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Pathologic breast conditions are rare in childhood and adolescence. The spectrum of breast disease in this age group is different from that in adults; most lesions are benign and represent either normal breast tissue, cysts, or fibroadenomas.
US can help evaluate breast masses in children. It is the ideal imaging modality to study the pediatric breast and can be useful in all cases in identifying and characterizing the abnormality and guiding further investigation. Knowledge of the US appearance of normal breast development and specific lesions is essential for successful use of breast US.
Malignant breast lesions are very rare in children; most are due to metastatic disease, and their US appearance is nonspecific. Gynecomastia in boys can be mimicked by other conditions, and US is helpful in the diagnosis. Color Doppler US evaluation is helpful in the diagnosis of cysts, fibroadenomas, and inflammatory processes.
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Footnotes
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See also the article by Weinstein et al (pp 1613–1621)
in this issue.
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Abstract
LEARNING OBJECTIVES 
