Emergency Medicine is very complex, but it also can be rather straight forward. If there is a fish hook in there, then take it out. If there is is bead in the nose, then get it out. If there is a laceration, then repair it. If there is an abscess, then drain it! Of course, none of those seemingly simple decisions are really that easy. Those fish hooks are treacherous, beads are slippery, laceration repairs often require Ketamine, and abscesses may do better with Loop drainage rather than packing! Furthermore, location obviously matters. Let us take a minute to consider Pediatric Breast Mass and Abscess Management:

Pediatric Breast Mass

• Normal Breast Development needs to be considered. [Valeur, 2015]
  • Breasts develop in 2 stages: 1) during fetal life, 2) during puberty.
    • Initial phase:
      • Occurs in both males and females.
      • In the 5-6th week of fetal development.
      • Neonates often have sub-areolar nodules, that enlarge in response to maternal hormones.
    • 2nd phase / Thelarche:
      • Occurs as breast bud develops during puberty.
      • Mean age of onset is ~9.8 years.
      • Considered premature if occurring in those < 8 years.

• In pediatric patients, primary breast malignancy is rare. [Omar, 2019; McLaughlin, 2018; Durmaz, 2017; Kaneda, 2013]
  • Estimated incidence = < 1 case per 100,000.
  • 0.1% of all primary breast cancers are in children/adolescents.
  • While rare, it is often the primary concern that families will have.
    • Malignancy can occur, and still warrants our awareness. [McLaughlin, 2018; Gutierrez, 2008]
    • Challenge is to balance the rarity of malignancy with the potential complications of biopsy. [Omar, 2019]

• The developing breast is relatively delicate. [Omar, 2019]
  • Surgery or biopsy can result in lasting deformity.
  • Hypoplasia, asymmetry, and scarring can occur.
  • Tumors themselves, can cause breast tissue deformity.

• The vast majority of pediatric breast masses are benign! [Omar, 2019; McLaughlin, 2018; Valeur, 2015]
  • Solid:
    • Fibroadenoma (a benign fibroepithelial tumor) is the most common – ~95% of the reported excised pediatric breast masses.
      • Some fibroadenomas can be more locally aggressive than others.
      • Some can become very large as well (some can be >10 cm).
      • Despite being benign, these may still cause concern and/or deformity.
    • Phyllodes tumors also occur. [Omar, 2019]
      • Usually benign, but can become malignant.
      • Appear similar to Fibroadenomas on ultrasound.
    • Juvenile Papillomatosis [Valeur, 2015]
      • Fibrotic mass with many small cysts and dilated ducts.
    • Skin Mass
  • Cystic: [Valeur, 2015]
    • Simple cysts
      • In adolescents, tend to be near the nipple.
      • May present with nipple discharge and signs of inflammation also.
    • Duct ectasia
    • Fat necrosis
      • Often related to recent trauma.
    • Galactocele
    • Hematoma

Breast Abscess

• Overall, breast abscesses are uncommon in children. [Valeur, 2015]
  • Can occur in infants < 2 months – related to maternal hormones.
  • Also seen in pre-adolescence and adolescence (8-17 years) – related to skin breaks from piercings… or breastfeeding…

• Most often occur in lactating / breastfeeding women (which, yes, does include some of our pediatric patients). [Lam, 2014; Trop, 2011]
  • Breast abscess is the most common “benign” breast problem during pregnancy.
  • When occurring in non-lactating patients, they are typically older / toward end of reproductive period.
  • Periareolar abscess formation in a non-lactating female primarily affect your women, particularly those who smoke. [Trop, 2011]

• Lactational abscesses usually are a progression of mastitis. [Lam, 2014; Trop, 2011]
  • Milk stasis leads to culture media collecting in breast tissues.
  • Bacteria enter through the terminal ducts of the nipple.
  • Bacterial proliferation first creates mastitis, which can then progress to abscess formation.
  • Staph species and strep species are most prevalent culprits.

• Presentation: [Lam, 2014; Trop, 2011]
  • Pain
  • Malaise, Chills. Fever may not be as common.
  • Palpable mass (although, this may not be evident for deeper abscesses / larger breasts)
  • Erythema (also may not be apparent).

• Evaluation / Management
  • There are few high qualities studies pertaining to management in general, and even more limited when addressing just pediatric cohorts. [Lam, 2014]
  • Current recommendations include: [Valeur, 201; 5Lam, 2014; Trop, 2011]
    • Low threshold for imaging with Ultrasound, as it can distinguish other abscess from mastitis as well as other masses.
    • Empiric antibiotics.
    • Drainage of purulent material:
      • Surgical team comfortable with breast abscess management should be consulted… may elect to refer to interventional radiology. [Trop, 2011]
      • 1st line = Needle aspiration (ideally with ultrasound guidance).
        • May require repeated aspiration sessions.
      • Surgical drainage may be required if:
        • Needle aspiration is not successful and/or infection worsens.
        • Abscess is large (> 5cm) or multi-loculated.

Breast Mass Evaluation

• Unlike with adults, there are no well established, evidence-based guidelines on the management of the pediatric breast mass. [Omar, 2019]

• General principles, though, to exist: [Omar, 2019; McLaughlin, 2018; Englert, 2018]
  • Have a low threshold for obtaining ultrasound (U/S).
    • U/S is good at determining size and characteristics.
    • Size, however, does not reliably predict the pathology. [McLaughlin, 2018]
  • More conservative approach to the pediatric breast mass is reasonable.
    • If exam concerning for abscess, U/S guided needle aspiration may be 1st step.
    • If U/S shows features typical of fibroadenoma, and it is < 5 cm, close follow-up with repeat U/S (in ~12 months) is recommended.
  • Closer observation and/or surgical intervention may be appropriate for masses that are:
    • > 5 cm.
    • Causing more symptoms.
    • Associated with personal or family history of malignancy.
    • Demonstrating significant growth.

Moral of the Morsels

• Get the U/S! It will be useful to help determine the size and characteristics.
• Don’t cut it! Contact your friendly pediatric surgeon and discuss needle aspiration as 1st line option for breast abscesses.
• Appreciate the concern. While most will be benign, ensure appropriate and timely follow-up.

References