What is the Differential Diagnosis of a Breast Mass?

Patient Presentation
A 15-year-old female came to adolescent clinic with a lump in her left breast that she noticed 2-3 weeks previously.
It was painless and not changing in size. A soccer ball had hit her 1 week ago in that area and she said that she was bruised but the bruise had resolved.
She denies other trauma, skin changes, nipple discharge and had no fever or weight changes. She had normal menses and currently was having her period.
The family history was positive for diabetes but no cancer or breast disease.
The social history showed her to be good student who was not sexually active in the past or currently, and had no body piercings.
The review of systems was negative.
The pertinent physical exam showed a well-appearing female. She had a 1 x 2 cm ovoid, non-tender mass that was freely mobile, with regular margins that was located at ~11 o’clock next to the areola.
The rest of the breast tissue showed uniform, very finely thickened “cord-like” texture on palpation consistent with patient age and nulliparity. There were no other masses or axillary or other adenopathy.
The physicians felt that this was most likely due to a fibrocystic cyst, fibroadenoma, mammary ductal ectasia or trauma.
They considered abscess but the lack of historical or physical evidence made this less likely, and malignancy was also considered but because of her age and physical findings felt to be also less likely.
The physician instructed the girl return to clinic in two weeks for re-examination and to monitor and report any changes during the interval, especially if the skin was changing color, the mass increased in size or there was fever.
The patient’s clinical course continued as she returned to clinic two weeks later and reported that 10 days after the her previous visit she had some increase in mass size, and the skin broke down with discharge of yellowish fluid. She still had no fever. On examination she had a 4 x 3 cm mass with a punctum near the areola. The mass felt regular and no discharge could be obtained with palpation.
There was overlying skin redness, but no extension and some tenderness of the mass. The diagnosis of a breast abscess was made and she was placed on Cephalexin (Keflex®). She was to told to use warm packs. The radiologic evaluation of an ultrasound of the breast showed fluid and blood within the mass consistent with an abscess/hematoma.
She was also referred to a surgeon who saw her 7 days later. On examination at that time she had minimal discoloration of the area, a healed punctum and no definitive mass palpable.
The surgeon thought that maybe she had an initial fibrocystic cyst that because of trauma ruptured causing local irritation and hematoma. This later became infected producing the abscess.
This would be consistent because she had draining at the areolar margin which is classic for a subareolar process. She was to return to her primary care physician in another two weeks to confirm complete resolution.


Figure 49 – Sagittal ultrasound image of the upper outer quadrant of the left breast demonstrates skin thickening and a 4 cm mass-like area of disorganized breast tissue and edema with a small adjacent fluid collection. The constellation of findings was felt to represent an abscess.

Discussion

Thelarche is the onset of breast development and is usually the first sign of puberty in girls. It occurs at an average age of 11-11.5 years with a range of between 8 and 13 years.
The breasts grow over the next 2-4 years as classified by Tanner staging. If no breast development occurs by 13 years of age then this is delayed and an evaluation is warranted.

All adolescents should be examined and taught self-examination particularly adolescents with a family history of breast cancer or other malignancies. Risk factors for breast cancer include chest wall radiation and girls with a family history of breast cancer.

Most breast masses in children and adolescents thankfully are benign in nature.
Evaluation and management of breast masses depends on the history and examination. Ultrasonography is most helpful to characterize the lesion and can be performed serially. Mammography is not helpful because of the dense breast tissue of adolescents.
Aspiration and/or excision of the mass may be necessary.

Learning Point
The differential diagnosis of breast masses includes:

  • Prepubertal breast masses (almost all are non-malignant)
    • Breast buds at birth secondary to maternal hormones
    • Premature thelarche
    • Supernumerary breast tissue including accessory nipples and accessory breast tissue
    • Breast assymmetry – one side larger than the other, often because of initial thelarche
    • Mammary duct ectasia – benign dilatation of the subareolar duct resulting in inflammation and fibrosis, that usually has a bloody nipple discharge
    • Abscess
    • Mastitis
    • Hemangioma
    • Lymphangioma
  • Adolescent benign breast masses
    • Fibroadenomas – is the most common cause of adolescent breast pathology (67-94% of all causes). There is a localized exaggerated response to estrogen where the lesion increases in size usually over 6-12 months and then becomes stable. Most are 2-3 cm in size.
    • Fibrocystic breast disease – breast will have thickened, cord-like lesions that are diffuse and often because larger and tender with menses. Occurs in 50% of reproductive age women.
    • Juvenile hypertrophy – extremely rapid breast growth that occurs shortly after thelarche
    • Juvenile papillomatosis – localized, proliferative lesion that is similar to a fibroadenoma on examination
    • Retroareolar cysts – also known as Cysts of Montgomery that serve in lactation – are small raised projections at the edge of the areola which can obstruct and cause inflammation or a mass
    • Mammary duct ectasia – benign dilatation of the subareolar duct resulting in inflammation and fibrosis, that usually has a bloody nipple discharge
    • Mastitis
    • Abscess
    • Trauma – can cause a hematoma or fat necrosis.
  • Adolescent malignant breast masses
    • Phyllodes tumors – these may be benign, intermediate or malignant. They are usually seen around 45 years of age, but have been reported in girls as young as 10.
    • Primary breast carcinoma – has been reported in 39 children ages 3-19 years of age
    • Sarcoma
    • Cancer metastatic to the breast – common tumors include Hodgkin’s lymphoma, Non-Hodgkin’s lymphoma, primary hepatocellular carcinoma, neuroblastoma, and rhabdomyosarcoma.

Questions for Further Discussion
1. What is the current age that most women should receive a screening mammogram?
2. What are the Tanner stages of breast development?
3. Describe the major pubertal changes in males and females in the proper order of appearance?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Breast Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

De Silva NK, Brandt ML.
Disorders of the breast in children and adolescents, Part 1: Disorders of growth and infections of the breast.
J Pediatr Adolesc Gynecol. 2006 Oct;19(5):345-9.

De Silva NK, Brandt ML.
Disorders of the breast in children and adolescents, Part 2: breast masses.
J Pediatr Adolesc Gynecol. 2006 Dec;19(6):415-8.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 7, 2007

  • What is Polymorphous Light Eruption?

    Patient Presentation
    A 17-year-old female came to clinic because of a pruritic skin rash for 3 days.
    She was on a spring break vacation to a beach and noticed the rash on her arms and top of her legs.
    She said she felt her skin become ‘tingly’ towards the end of one afternoon that increased in intensity. She noticed that her skin looked liked a sunburn in that it was ‘bumpy’ and seemed to itch more than be painful.
    She used some moisturizing lotion on the rash but she said that didn’t seem to make a difference. Over the evening she said that the intensity of the itchiness gradually faded.
    In the morning of the second day, the bumpiness was still there and it would itch if she accidentally bumped the areas. When she went outside the itchiness increased almost immediately. She put on long-sleeved shirt and a long pair of shorts that covered the rashes which seemed to help some.
    She had been using the same sunscreen during this vacation that she had used previously. She denies any new soaps, lotions, deodorants, clothing, detergents, etc.
    The past medical history was non-contributory.
    The review of systems was negative including fever, joint complaints, difficulty breathing or swallowing.
    The pertinent physical exam showed a well-appearing female with mild sunburn to her face, back of neck and ears. On the extensor surfaces of her forearms, upper arms and top-front of her legs bilaterally, she has an intensely red, blanching rash that has fine confluent papules, some of which look like they may be vesicular.
    Palpation causes her to have a mildly painful pruritus.
    The diagnosis of polymorphous light eruption was made. The patient was instructed to avoid the sun as much as possible and to use protective clothing and sunscreen. For her comfort she was told that she could use diphenhydramine. She was also told that this could improve within a few days to two weeks but could recur.

    Discussion
    Photodermatosis is any dermatosis caused by exposure to light. These photodermatoses can be normal responses to excessive sunlight or could be a photosensitivity. Photosensitivity is a general term describing an abnormal reactivity to sunlight by the skin.
    Idiopathic photosensitivity reactions include:

    • Actinic Prurigo – is also called hydroa aestivale and Hutchinson’s summer prurigo. It is commonly seen in Indians and mixed ancestry people of Mexico, Central American and South America. Intensely pruritic papules, plaques and nodes occur with excoriations and scars. It generally affects exposed areas but can also be seen in covered areas particularly the lower back and buttocks. It can be seen year round but is worse in the spring and summer with improvement in the fall.
    • Juvenile spring eruption – is a photosensitivity where there are edematous, red papules mainly on the helix of the ears that can become vesicular and crusted. Dorsum of the hands and the trunk can also be involved. It is third more common in boys than girls and usually resolves within 1 week.
    • Polymorphous light eruption – see below
    • Solar urticaria – is a Type 1 IgE-mediated hypersensitivity reaction that causes localized urticarial flare reaction during or within 30 minute of light exposure. The skin returns to normal after a few hours and will not recur within 12-24 hours even with more sunlight exposure. It occurs often in females in the 3rd to 4th decade but can be seen as early as age 2 years.

    Learning Point
    Polymorphous light eruption is the most common idiopathic photosensitivity reaction. It is sometimes referred to as “sun poisoning” or “sun allergy”. It is most often found in females in the second or third decade of life and occurs in 10-15% of the U.S. population.
    An autosomal-dominant form has been described in North and South American natives. It appears to be an immune-mediated, delayed type hypersensitivity reaction to UV rays in the 290-480 nm range papules but its exact etiology is unknown.

    The skin is described a having pleo- or poly-morphic lesions that range from small papular, urticarial, vesicular or eczematous lesions to large papules and plaques that can look like erythema multiforme. The lesions generally occur 1-2 days after intense sunlight.
    They are located on sun exposed areas such as the face, arms, hands and sides of the neck. The pruritus can be quite severe and the lesions resolve within 1-2 weeks if no additional sunlight exposure occurs. For some people the lesions can occur in the spring and persist, but improve as the skin gets used to the sun exposure over the summer.

    The diagnosis is made clinically, but phototesting can be done. With phototesting, the expected reaction occurs in hours, lasts days and is not urticarial. Sometime systemic lupus erythematosus may present with similar lesions and serological testing is necessary.

    Images of polymorphic light eruption can be found in the eMedicine and Google Image references below in To Learn More.

    Questions for Further Discussion
    1. What medications commonly cause photosensitivity?
    2. What is phytophotodermatitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Sun Exposure

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Scheinfeld NS, Shirin S, DelRosario R, Winkielman A. MDPolymorphous Light Eruption. eMedicine.
    Available from the Internet at http://www.emedicine.com/derm/topic342.htm (rev. 3/9/06, cited 4/9/07).

    Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology. Elsevier Inc. 2006;505-507.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 30, 2007

  • Can Lyme Disease be Transmitted by Breast Milk?

    A 9-month-old female came to clinic for her health supervision visit.
    The mother had just been diagnosed with Lyme disease after having fatigue, mild headache, muscle aches, and joint aches that were initially attributed to being a new mother. She did not remember having a rash.
    She had been started on antibiotics a few days ago, and wanted to know if she could pass the infection to her daughter because she was breastfeeding.
    The child herself did not have a history of a tick bite or rash, but did have a couple of colds in the past. She was doing well per her mother.
    The pertinent physical exam showed a smiling, interactive female. Growth parameters were between 5th and 25th percentiles, and her examination was normal.
    The diagnosis of a healthy infant was made. The physician reviewed Lyme disease in the American Academy of Pediatrics RedBook Online® which said that Lyme disease is not transmitted by breast milk.
    The mother was reassured with this information.

    Discussion
    Lyme disease, also referred to as Lyme borreliosis, is caused by the spirochete Borrelia burgdorferi. It is spread by the tick Ixodes scapularis which is about the size of a pencil point.
    In the United States it occurs mainly in the New England states, upper Midwest especially in Wisconsin and Minnesota, and in northern California. Cases occur during warm months (April-October) with ~ 50% of the cases occurring in June and July.
    All ages can be affected but incidence is highest in 5-9 year olds and 45-54 year olds.

    For children, the most common symptoms are erythema migrans, arthritis, facial nerve palsy, aseptic meningitis, and carditis. Symptoms depend on the timing though.

      Early localized disease

      • Erythema migrans at site of lesion – red macule or papule that appears to migrate over time forming a painless, non-pruritic, annular, erythematous lesion sometimes with central clearing.
        The spreading occurs over days to weeks. This can appear 1-55 days after the tick bite, with a median of 11 days.

      • Arthralgia
      • Fever
      • Headache
      • Lymphadenopathy, regional
      • Malaise
      • Neck stiffness, mild
      • Myalgia

        Recommended treatment:
        Doxycycline 100 mg orally, twice a day for 14-21 days is recommended for all children 8 years or older. Alternatively for all ages, Amoxicillin 50 mg/kg/day orally, divided three times per day for 14-21 days (maximum dose is 1.5 g/day)
        or Cefuroxime 30 mg/kg/day orally, divided twice per day for 14-21 days (maximum dose 1000 mg/day) or Cefuroxime 1.0 g/day orally for 14-21 days.

      Early disseminated disease

      • Erythema migrans, multiple lesions
      • Arthralgia
      • Arthritis
      • Carditis
      • Conjunctivitis
      • Cranial nerve palsies, especially cranial nerve VII
      • Encephalitis
      • Fever
      • Headache
      • Lymphadenopathy, regional
      • Meningitis, aseptic
      • Myalgia
      • Neuritis

        In untreated children, 50% will develop arthritis, 10% will develop central nervous system involvement, and 5% will develop cardiac involvement.

        Recommended treatment depends on symptomatology:

      • For multiple erythema migrans, follow early localized disease treatment for 21 days
      • For Isolated facial palsy follow early localized disease treatment for 21-28 days
      • For arthritis, follow early localized disease treatment for 28 days
      • For arthritis that is persistent or recurrent, Ceftriaxone sodium 75-100 mg/kg intravenously or intramuscularly, once per day for 14-28 days (maximum dose 2 g/day)
        or Penicillin 300,000 Units/kg/day intravenously, given in divided doses every 4 hours for 14-28 days (maximum 20 million Units/day)
        or same regimen as early localized disease

      • For carditis, follow persistent or recurrent arthritis treatment
      • For encephalitis or meningitis, follow persistent or recurrent arthritis treatment for 14-28 days

      Late disease – can occur months to years later

      • Arthritis, particularly large joints and is recurrent
      • Peripheral neuropathy

    Treatment usually prevents development of later stages but successfully treated patients may have persistent symptoms for weeks.

    The diagnosis is made by history and physical examination, particularly the characteristic erythema migrans rash.
    A step-wise approach to laboratory testing is recommended. The first step is screening by an enzyme immunoassay or immunofluorescent antibody assay. Positive or equivocal results should then be confirmed by Western immunoblot for IgG and IgM if confirming early disease and for IgG for late disease.
    Other testing can be done but can be complex or is not necessarily better than the step-wise approach.

    The risk of developing Lyme disease after a tick bite even in an endemic area is low enough that prophylactic antibiotics are not indicated for most people.
    Some experts recommend treatment after 72 hours of suspected attachment to the skin by the tick using Doxycycline 200 mg orally once or 4.4 mg/kg for body weight <45 kg in people older than 12 years of age. A vaccine was licensed by the FDA from 1998-2002, but is not currently available.

    Learning Point
    Lyme disease is not transmitted by breast milk. The American Academy of Pediatrics RedBook® states that no causal relationship between maternal Lyme disease and pregnancy complications or congenital abnormalities has been conclusively documented.

    Questions for Further Discussion
    1. What are other tick-borne diseases?
    2. Why is it called Lyme Disease?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Lyme Disease and Tick Bites
    and at Pediatric Common Questions, Quick Answers for this topic: Lyme Disease

    To view current news articles on this topic check Google News.

    DePietropaolo DL,
    Powers JH,
    Gill JM,
    Foy AJ. Diagnosis of lyme disease. Am Fam Physician. 2005;72(2):297-304. Available from the Internet at http://www.aafp.org/afp/20050715/297.html (rev. 7/15/2006, cited 3/8/07).

    American Academy of Pediatrics. Lyme Disease, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;428-433.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 23, 2007