Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease

Abstract

Purpose: Breast masses in pediatric patients are often managed in a similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients.Methods: A multi-institutional retrospective cohort study was completed between 1995-2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions.Results: A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p<0.25) for decisions made on clinical suspicion alone.Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. https://www.springer.com/aamterms-v1

Bloody nipple discharge due to intraductal papilloma in an adolescent girl

“…Breast masses in childhood and adolescence are uncommon, occurring with an estimated incidence of 3% 1. Fibroadenoma represents the most common breast lesion in the adolescent population, accounting for 44%–94% of cases 6 8–10 14. Fibrocystic change, a normal variant of female physiology, is the second most common breast lesion in adolescents 15.…”

“…Ultrasound may show a solid intraductal mass within a dilated duct filled with anechoic fluid 4. Intraductal papilloma is a rare breast lesion during adolescence, with intraductal papillomas and juvenile papillomatosis combined representing only 1.1% of paediatric breast masses in a recent large case series 9…”

“…The differential diagnosis for paediatric breast masses is summarised in box 1. Fibroadenoma is the most commonly diagnosed breast pathology in childhood and adolescence, representing 44%–94% of cases 6–10. Intraductal papillomas in adolescence have only been reported in case reports and a small number of patients in larger case series 7–9 11 12.…”

“…Fibroadenoma is the most commonly diagnosed breast pathology in childhood and adolescence, representing 44%–94% of cases 6–10. Intraductal papillomas in adolescence have only been reported in case reports and a small number of patients in larger case series 7–9 11 12. Further, while bloody nipple discharge is a well-described symptom in adults with clearly defined diagnostic and management approaches, this clinical sign is very uncommon in the paediatric age group 7 13.…”

Clinicopathological profile of breast lesions and their management in paediatric patients seen in a tertiary health facility in Southern Nigeria

“…[13] The cases of gynaecomastia we encountered were mostly managed by counseling and reassurance to enable them overcome the embarrassment and psychosocial disorders which are recognized problems in that condition. [14][15][16] Subcutaneous mastectomy was performed only in one case of gynaecomastia secondary to intersex disorder. There was no case of ductal atresia in our series.…”