Objective: There are a limited and inadequate data for breast diseases in children. This may be because of low importance expectations of practitioners' for clinical breast problems in which laboratory tools are rarely used. However, breast issues of children may possibly remain missing as a consequence of insufficient data. In this article, we encourage the authors to share their experiences and publish procedures.
Settings and Methods: Pediatric surgery documents between 2005 and 2011 were evaluated to demonstrate breast disorders. Diagnosis, gender, age, ultrasonography, treatment modalities and follow-up procedures were studied in this study. Literature data is compared with the study findings. What could be the lack of practice due to lack of data in the literature are presented.
Results: Seventy-two patients were diagnosed with breast diseases among 9958 patients. Twenty-eight patients were male and 44 patients were female. Median ages of the male and female patients were 12.5 and 14 respectively. Physical examination was the only practice used for most patients. Ultrasonography was used for 27 patients. Laboratory examinations were not used. Only one patient was operated. Male and female patients were followed for 2 and 3 years, respectively.
Conclusion: Although literature data is present for breast disorders, clinical documents published by paediatric surgery on this subject is rare. Simple treatment modalities, necessity of long follow-up periods and clinically unimportant disorders may be the reason of very little published information. Different managements and experiences for breast diseases must be published to add value to a lacking and neglected issue. The only mission of this study is to invite authors all over the world to add their data about breast disorders.
Paediatricians must pay attention to breast disorders that may be seen at any paediatric age group. (1). Although most of the diseases are benign as a fact, the possibility of malignancy can never be ignored (1-3). The major problem to form a confident treatment protocol is very little published data for breast diseases of adolescence (2,3). Underestimation of the breast disorders often by clinicians may be the reason of publication deficiencies (4). On contrary to this, breast disorders of children and adolescent must be important topics for physicians and gynecologist (4). Parents anxiety and patients’ fear about progressive breast disorders are the main reason of this suggestion (4).
More data is needed to make decisions on breast diseases. For data expansion, we aim to add 6-year experience for breast diseases to literature.
In Kecioren Education Hospital, documents of pediatric surgery between 2005 and 2011 were evaluated for breast diseases. Some of the authors contributing to this study previously worked in the hospital. Some authors are still working. In this study, spectrum of breast disorders, gender, age, ultrasonography, treatment modalities, and follow-up periods are presented. Diseases were evaluated with International Classification of Diseases Code-10 (ICD-10). Authors had agreed on similar codes for diagnosis of unknown lesions like masses. Most of undefined masses were diagnosed as “Benign Breast Dysplasia”.
Seventy-two patients were diagnosed with breast disease in 9958 cases. Twenty-eight patients were male and 44 patients were female. Median ages of the male and female patients were 12.5 and 14 respectively. Accessory breast (1 patient, 1.4%), benign breast dysplasia (51 patients, 70.8%), gynecomastia (6 patients, 8.4%), breast hypertrophy (4 patients, 5.5 %), non-puerperal infective mastitis (4 patients, 5.5 %), non-puerperal breast abscess (3 patients, 4.2%), nipple fissure (2 patients, 2.8%), and diffuse breast cyst (1 patient, 1.4%) was the result of the study. Breast ultrasonography was used for 27 patients. Very few patients had blood samples and other laboratory tests were performed. Therefore, laboratory studies are not included in article. Physical examination has been the main assessment and management tool. Only one patient was operated. Male and female patients were followed-up for 3 and 2 years respectively. Results were demonstrated in Table-1.
Breast disorders can be diagnosed also in children (3,5). Although most breast disorders of this age are benign, parents are always fear of malignancy (1). Parents' concerns are the most effective factor for the treatment of breast disorders. Sometimes, these concerns may force physicians for surgical intervention. Physicians must know the process of these diseases at adolescence to do the right thing for the child and to convince parents. In contrast, the literature contains adolescence diseases is limited, and physicians have often overlooked the diseases.
Breast problems are rarely examined in pediatric surgery clinics. Therefore, collections of the patients' data at any number will be meaningful. Total number of our patients is 72. Nevertheless, we share our experience for accessory breast, benign breast dysplasia, gynecomastia, breast hypertrophy, non-puerperal infective mastitis, non-puerperal breast abscess, nipple fissure and diffuse breast cyst.
Accessory breast is a true polymastia containing all components of mammary but the disease forms a small percentage of the polymastia disorders. (5). Polythelia, the existence of accessory nipple and areolae, is the most seen anomaly of this issue. (5). In literature, enough data about the demography, characteristics and statistics for accessory breast disorders has not been collected. In our clinics, only one case was present and the disease was at the axillary region. Ultrasonography was used for the confirmation of disease. At the same time, she was the only patient who underwent surgery for breast disorder. In our series, the incidence of accessory breast was 1.4%. To our knowledge, predictors like incidence and age for the operations of accessory breast in literature is not clear. Also, evaluation mechanisms for pathogenesis of the disease are not sufficient. Therefore, we performed a randomized treatment. We invite authors to share their experience in this regard. Otherwise, the disease can’t be formulated for better decision-making.
Breast masses have usually been diagnosed as benign physiologic enlargements or developmental changes (6). Fibroadenoma is the most seen benign dysplasia of female (1-3). Fibroadenoma could be 72-75% of the breast masses (4). In our series, 70.8% patients (n=51/72) were diagnosed with benign breast dysplasia. In International coding system for diseases is limited on breast problems. Seeing this, “Benign Breast Dysplasia” was preferred for the description of breast masses in our practice. Thirty patients (30/72, 41.6%) in this group were female and all female patients had fibroadenoma. Fibroadenomas are estrogen-sensitive tumors. Due to this sensitivity, fibroadenomas can be seen in patients premenarchal and 20 years old (4). Patients, in our study, are found to be premenarchal or older, as mentioned in literature. Ultrasound (US) is important for the diagnosis of breast disorders especially masses (1,2). Only 13 ultrasonography examinations were performed for female patients in this group and therefore, the number of evaluations for diagnosis may be accepted insufficient. Typical physical examination findings of breast masses may be one of the reasons. Low expectations for USG findings about the masses of patients may be another important reason. Also, follow-up decisions of the authors may interrupt ultrasonography evaluations.
Breast masses, particularly fibroadenoma, due to the menstrual cycle can be treated with hormones. For this purpose, to monitor two or three menstrual cycles, may be sufficient to decide (1). However, to our knowledge, management schedule of these problems is not present, yet. In this section; the breast masses variations, ultrasound necessity, sufficiency of ultrasound, or predicting factors are still unknown. In fact, we realize that our data was also defective for all these factors. Therefore, practices in our clinic will also be revised.
On the other hand, twenty-one male patients (21/72, 29%) were diagnosed with benign breast dysplasia. Median age of these patients was 12 and only 6 were evaluated with ultrasonography (U.S.). Ultrasound examinations were normal in 3 patients, 2 patients had cystic lesions, and there was a fibroadenoma. The data is also limited in male patients suffering from breast masses. These masses may be breast tissue of premature thelarche, cysts, or fibroadenomas. (3). The literature is not sufficient for the evaluation of the subject. So, age characteristics, determinant factors, reasons for the existence, management procedures and control criteria are not satisfactory in the literature after a thorough evaluation.
Exact diagnosis breast masses with physical examination and ultrasound is difficult sometimes. Therefore, “Benign Breast Dyplasia” is our preference as a code for breast masses. International coding system of diseases (ICD-10) is restricted for breast diseases. Therefore, descriptions with “Breast disorders, undefined”, “Breast masses, undefined” and “Breast, undefined” are not useful for breast problems. According to us, “Benign Breast Dyplasia” is the most effective description in the coding system. This name can be used for different problems including fibroadenoma, hypertrophy, and cysts. It is hard to find benign dysplasia classification in literature. Nevertheless, benign dysplasia is a pre-diagnosis that forms the largest group in our series. For more descriptive definitions, evaluations procedures must be developed.
Gynecomastia is glandular enlargement of one or two breast of male gender (4,7). Subaerolar growth of breast tissue is characteristic feature in gynecomastia and it may reach up to 3 cm in diameter. (4). Unfortunately, a measurement schedule is not present to diagnose gynecomastia. Therefore, we had only used physical examinations as diagnostic tool. Gynecomastia is separate from the general obesity or breast hypertrophy (3). When it appears in male newborn, it is named as neonatal breast hypertrophy (4). Among our patients we have no neonatal hypertrophy. Gynecomastia, generates 60% of all male breast diseases (7). Our findings are different from the literature. In our series, incidence of gynecomastia was 21.4 % (6/28 male patients) and the disease is the second most seen problem. Gynecomastia may be unilateral or bilateral (4). Bilateral gynecomastia is common especially in the neonatal and prepubertal periods (7). Our patients’ median age was 16 years and this finding is correlated with the literature. All patients had bilateral gynecomastia and none of them were operated. Resolving spontaneously in 2 years follow-up periods is the reason of conservative treatment (4). A specific cause of gynecomastia is difficult to find and the reason for 90% of them are unknown (7). Testicular calcifications may be the sign of aromatase hyperactivity of testicle and stimulate gynecomastia formation (8). To our knowledge, this is the only etiological theory of gynecomastia. This is not enough to decide about gynecomastia. Other possible etiologic factors, predictor parameters and management schedules have to be evaluated in the future.
When breast overgrowth is present for female gender, it is called breast hypertrophy (1,5). Hypertrophy may be unilateral or bilateral (5). Breast hypertrophy is named as premature thelarche before the 7 years old (1, 5). However, ethnic differences must be taken into account because of hormonal influence on breast development activities (9). Hypertrophy may be seen as an over-response of breast tissue to estrogen activities (1, 4). In our series, patients with hypertrophy were in prepubertal period but none of them had premature thelarche. Median age is 11 and incidence of hypertrophy in our series is 5.5%. They had all bilateral hypertrophy. There was no laboratory algorithm for this topic. Therefore, our recommendations did not inform about the etiologic factors in detail. Also, treatment modalities are not definitive on this subject. So far, the only thing that can be done, is to inform the patient about a possible surgery after puberty (1).
Breast infections and abscesses may also occur in childhood (1, 4, 5). Inflammation consists of 4% of breast diseases (1). Also, infection incidence with an abscess was 7% (4). In our series, mastitis was 5.5% and abscess formation was 4.2%. Inflammation of the tissues around the breast before thelarche referred to as cellulite. (5). If present in neonate, mastitis can be seen with different clinical presentations including septicemia (4). In our series, mastitis and abscesses presented with mean age of patients, respectively, 14.5 and 14. Breast infections may occur by foreign bodies, epidermoid cysts, trauma, nipple piercing, folliculitis after shaving periareolar hair, sexual trauma, acne lesion, duct abnormality, inverted nipple, and altered immune defence (1,4). Mastitis, abscess, hematoma and fat necrosis especially occurs due to nipple trauma. (5). The trauma related to underwear clothes may be the reason of mastitis and abscess in our patients. There were not anatomical deformities of the breasts and nipples. Unfortunately, patients’ histories were not definite for some other factors, and certain parameters, like sexual activity, were not appropriate for the research in our social life. Cystic lesions were present in two patients who had mastitis and abscess. In addition, we could not demonstrate what causes cysts, mastitis and abscess.
Fissure of nipple was found in two patients in our series. One patient was 8 years old male and other was 14 years old female. The disorder incidence in our series was 2.8%. There is little information about nipple fissure in the literature. The most plausible reason seems to be accused of trauma. Nevertheless, mastitis and abscess reasons that were mentioned above may also be the reason of fissure.
In the literature, cystic breast disease incidence was 6-10 % (4). In our series, the incidence is 1.4 %. Only one female patient was diagnosed as a benign cyst. The patient was 7 years old. We have followed up the patient for 2 years without surgery. As usual, the cause of cyst formation was not detected. Breast cysts may be benign cysts, sclerosing adenosis, parenchymal fibrosis, and duct ectasia (5). Cysts may also be fibrocystic (5). Under all circumstances, cystic masses usually resolve spontaneously in time. (5).
Radiographic studies, especially ultrasonography (US), are important for breast evaluations (1,3). US is useful for palpable masses, and solid masses can be differentiate from cystic lesions by US but it is a poor evaluation tool (1,2). Umanah et al reported that only 41% of the breast tumors can be diagnosed with US and only 3.8% of them are treated with biopsy and excision (2). In our series, 27 (37.5%) of 72 patients were evaluated with ultrasonography. In the literature, to find a similar study is not easy. Therefore, we can’t compare our findings with another study. Also, criteria of necessity, and reliability for ultrasonography is lacking in the literature.
There are some other problems for the evaluation of the breast disorders for clinicians because of weak database. First, breast problems have usually been evaluated in surgical clinics (2). Subsequently, pediatric clinics are not interested in the diseases in details. Second, surgical evaluations have usually been underestimated because surgeons suggest that many of the disorders can be managed only by clinical examinations or by reassurance of the patient and/or parents (1). Third, surgical procedures for breast disorders at pediatric age group are thought to be limited because of the possibility of breast deformity in later periods (3). This limitation altered surgeons’ interest in breast disorders.
In conclusion, we realized that our patients for breast disorders had not been evaluated in details. However, when we evaluated the literature to structure a clinical algorithm, we could not find out data revealing pediatric managements in detail. We think that branches from internal and surgical medicine concerning on breast disorders may work together to structure evaluation charts of breast disorders for children. Also, by this article, we want to invite authors to share their experiences to strengthen the database of the task.
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