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A worrisome, increasingly painful breast mass in an adolescent female

A breast mass in a young woman presents a challenge to clinicians. The differential diagnosis and diagnostic studies of choice may differ from those used for an adult patient.

Valerie J. Schaffer, MHS, PA-C; David Coniglio, MPA, PA-C

Valerie Schaffer is a clinical associate in the Duke University PA program, Durham, North Carolina. David Coniglio is an assistant professor in the program. The authors have indicated no relationships to disclose relating to the content of this article.

CASE

A 16-year old female presented to a family medicine clinic for evaluation of increasing right breast pain associated with a right breast mass. The patient had a 2-day history of right breast pain associated with a breast mass that had been present for approximately 8 months. The mass first appeared after she was hit in the right breast during a fight at school. At that time, she did not see any bruising of the breast, nor did she feel significant pain. The mass had grown in size over the preceding 8 months. The patient did not report associated skin erythema or dimpling, nor was there nipple discharge.

The patient's medical history was significant for allergic rhinitis, gastroesophageal reflux, and obesity. Medications included omeprazole, 20 mg twice daily; and fexofenadine (Allegra), 180 mg daily. The patient had no known drug allergies. Her last menstrual period had started 2 weeks earlier, and she denied being sexually active. She admitted to smoking a few cigarettes daily, but she denied the use of alcohol or street drugs. She drank approximately 3 cans of caffeinated soda daily. There was no personal or family history of breast cancer.

The patient was 66.5 in tall and weighed 178 lb. Temperature was 98.3°F; pulse, 93 beats per minute; respirations, 18 breaths per minute; and BP, 144/79 mm Hg. The patient was alert and oriented to person, place, and time. She was well-developed, was well-nourished, and appeared her stated age.

The heart rate and rhythm were regular, without murmurs, rubs, or gallops. There was no deformity of the chest wall. Chest expansion was full and equal bilaterally, with vesicular breath sounds throughout. There was no palpable cervical or axillary adenopathy. Breasts were at Tanner stage V, with the right breast slightly larger than left breast. No skin erythema or retraction and no nipple inversion or discharge were noted. The left breast was without palpable masses. Palpation of the right breast revealed a subareolar 9 3 10-cm firm, smooth, freely mobile mass.

To further evaluate the breast mass, ultrasound of the right breast was obtained. Ultrasound demonstrated a predominantly solid, circumscribed mass with an anechoic cystic component, likely representing a juvenile fibroadenoma (see Figure 1). The final radiology report described the mass as BI-RADS (Breast Imaging Reporting and Data System) 4a, a suspicious abnormality with low probability of malignancy. The patient was given a probable diagnosis of a juvenile (giant) fibroadenoma, and the diagnosis was discussed with the patient and her mother.

Although the ultrasound suggested a benign process, biopsy was recommended for definitive diagnosis. After discussing the options, which included watchful waiting with monitoring for stability, core biopsy, or excisional biopsy; both the patient and her mother were in favor of biopsy. They elected excisional biopsy because of the size of the mass and the patient's degree of breast pain. The patient was referred for surgical consultation. She underwent wide lumpectomy of the right breast. The pathology report confirmed an 8.5 × 7 × 6-cm fibroadenoma with extensive necrosis. The patient had a normal postoperative course and has returned to routine primary care follow-up.

DISCUSSION

The differential diagnosis of a breast mass in an adolescent female may include fibroadenoma, juvenile fibroadenoma, cystosarcoma phyllodes, cyst, fat necrosis, and malignancy, as well as adenopathy, galactocele, duct ectasia, infection, and, in the setting of trauma, hematoma. The most common cause of breast mass in this patient population is fibroadenoma.^1-4 Giant fibroadenoma is distinguished from fibroadenoma by virtue of size; a mass greater than 5 to 10 cm is classified as a giant fibroadenoma.^1,2,5 Phyllodes tumors are rare, occurring in less than 1% of all adolescent breast masses.³ The majority of phyllodes tumors are benign, although some have malignant potential. Generally painless and slow growing, phyllodes tumors may become as large as 20 cm.

A fibroadenoma frequently manifests as a slowly growing mass, increasing in size over weeks to months. Physical examination will reveal an oval or round, rubbery lump, averaging 2 to 3 cm in size. Although fibroadenomas are frequently found in the upper outer quadrant of the breast, they may occur anywhere within the breast tissue. They are not usually associated with nipple discharge. Juvenile fibroadenomas may grow rapidly to between 10 cm and 20 cm. On physical examination, a giant fibroadenoma may feel softer than the typical fibroadenoma.² Attention should be paid to a patient complaining of breast asymmetry, as the underlying cause may be macromastia from a giant fibroadenoma.⁶ The growth pattern of phyllodes tumors, and their clinical presentation, may make them undistinguishable from fibroadenomas without biopsy.¹

Primary breast malignancy is rare in adolescents.^1-3 The majority of cancers detected in the adolescent breast are metastatic from other malignancies, including sarcoma, rhabdomyosarcoma, lymphoma, non-Hodgkin's lymphoma, leukemia, and neuroblastoma.^1,2 Cysts and other manifestations of proliferative changes in breast tissue, often called fibrocystic disease, are common and may include a nodular character. These may be more pronounced in the menstruating female immediately before and at the start of the menstrual cycle.^1,3 Fat necrosis, which may occur after direct trauma to the breast, may mimic a breast mass.¹ The solid characteristic of palpable fat necrosis renders it indistinguishable from malignancy or fibroadenoma.

Radiologic imaging Mammography is often unrevealing and is not indicated in the adolescent because of the density of the female breast in this age group. Ultrasound is a reliable method of imaging for adolescent breast masses. On ultrasound, a fibroadenoma will appear as a solid mass, usually with distinct borders. There may be few well-circumscribed lobulations. Growth in the horizontal plane may be greater than that in the vertical.⁵ Giant fibroadenomas will have the same characteristics except for size. Phyllodes tumors also appear on ultrasound as well-circumscribed, hypoechoic, ovoid or lobulated masses.⁷ Characteristics of fat necrosis on ultrasound may vary depending on the lesion; fat necrosis may look like a simple cyst or anechoic mass with solid components.⁸

Management In addition to the fears of malignancy faced by all women with a breast mass, adolescent females present with unique issues. As children progress through puberty, they may have anxiety about their development as it compares to that of peers. Any perceived abnormality, such as a breast mass, may be associated with a great deal of stress. It is important for the clinician to address openly and honestly any fears or questions the patient may have. Depending on developmental stage, the patient will have differing needs and concerns. The clinician must be aware of the patient's developmental stage and provide appropriate education. Clinicians also should include parents in the decision-making process as they are likely to have significant concerns regarding the diagnosis, evaluation, and treatment of a breast mass in their child. Communication with the patient and parents is an essential component in the care of the adolescent patient.

Simple fibroadenomas, particularly small lesions, may be managed initially with observation through multiple menstrual cycles. No further therapy may be necessary, as some fibroadenomas resolve spontaneously, often over years.¹ Patient preference for removal is often motivated by concern about malignant potential of the fibroadenoma. Although there are no data linking fibroadenomas to breast cancer, patients and their families may prefer a definitive procedure. In the case of a growing fibroadenoma, surgical excision should be undertaken when the lesion is small, so as to minimize the extent of the surgical wound.¹ A giant fibroadenoma may be associated with physical discomfort and alteration of cosmetic appearance; rapid growth may also present a concern for the patient or family. In this case surgical excision is warranted.

Phyllodes tumors require a complete surgical excision with clean margins. These lesions, whether benign or malignant, may recur. In the setting of pathologic confirmation of malignant features such as cellular atypia, anaplasia, and high mitotic activity in the cells, patients may require adjunctive therapy including chemotherapy or radiation.² Fat necrosis poses a unique problem as it is not readily classifiable as a benign lesion based on physical examination and breast ultrasound. In the setting of a young woman in whom cancer is less likely—and with a history of trauma, as in this case—careful observation and short follow-up may be warranted because these lesions may slowly resolve over an extended period of time. If close observation reveals a growing mass, or if the patient experiences continued pain or has other concerns regarding the lesion, she should be referred for surgical evaluation and excision.⁹

CONCLUSION

Fibroadenoma is the most common breast mass in the adolescent female. These are benign lesions that may require no intervention. Giant fibroadenomas, given their size, generally require surgical excision. Ultrasound is a useful procedure for defining the lesion, but mammography is likely to be unhelpful. Differentiating a giant fibroadenoma from a phyllodes tumor requires surgical excision with pathologic confirmation. Management of phyllodes tumor depends on its malignant potential.

Being sensitive to the unique circumstances of the adolescent patient is important. Although, breast masses in this population are typically benign, they are likely to cause significant distress to the patient and family. Including the parents and patient in discussions and decision making is critical. Clinicians should be aware of the developmental stages of adolescence and how these might affect the patient's emotional and cognitive responses to having a breast mass. Body image issues are particularly important in this age group. By directly addressing fears, encouraging questions, and providing age-appropriate education, the PA can help relieve anxiety. Finally, referral to a surgeon with experience treating patients of this age group will increase the chances of a good outcome for patients. JAAPA

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