Assessing the Management Strategies of Adolescent Patients with Breast Lesions

Background: Breast masses in children and adolescents are rare but can provoke significant concern in patients and their families. Children and adolescents with breast masses tend to have variable clinical presentations and are notably almost always found to be benign. While widely studied in the adult population with standardized assessments relying on the use of The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS), there is currently no standard of care regarding the evaluation and management of pediatric patients presenting with breast complaints. Physicians often resort to using adult based strategies to evaluate these patients despite the well-known differences in incidence of malignancy and lack of validation within this population. Our study aims to assess current management strategies of pediatric patients presenting with breast masses with a specific focus aimed at evaluating patients who were managed with observation in comparison to patients who elected to undergo surgical excision.

Methods: We conducted a retrospective study of 780 girls aged 21 years and younger who presented with a breast complaint over a 9-year period at our institution. Demographic data, clinical variables, imaging results, and surgical pathology were reviewed. Patients were stratified based on whether they underwent surgical excision in their management. Categorical variables were assessed using Fisher’s Exact Test and continuous variables were analyzed using 2 sample student t-tests.

Results: A total of 167 patients (21%) were found to have undergone a surgical excision or procedure compared to 613 (79%) managed with observation. Both groups were found to be similar in age at presentation, age at menarche, use of hormonal contraception, and laterality of lesions. Common presenting symptoms across both groups included pain (31%), growth of mass (18%), erythema (6%), and nipple discharge (5%). Among the patients who underwent surgical procedures, 61 patients (38%) identified size and 17 patients (11%) identified anxiety as indications for surgery. Ultrasound was performed in 148 patients who underwent surgical procedures and 447 in the observation group (92% vs 73% p<0.0001). Patients with BI-RADS1 (0.8% vs 27% p<0.0001) and BI-RADS2 (9% vs 28% p<0.0001) were more likely to be observed while patients with BI-RADS3 (51% vs 40% p =.029) and BI-RADS4a (38% vs 5% p<0.0001) were more likely to undergo surgical excision. Of the patients managed with surgery, the most common pathology was fibroadenoma with all but one patient returning with completely benign pathology

Conclusion: This study represents one of the largest cohorts evaluating the management of adolescent patients with breast masses and the role that imaging and reporting may play. Our data suggests that almost all children and adolescents can avoid a surgical procedure and supports the growing consensus that evaluation of these patients requires a new standardized protocol tailored towards the pediatric population.