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prescribed only for fibrocystic disease in adolescence. Follow-up and subsequent
evaluation by a primary care physician is recommended; referral to a surgeon for
needle aspiration or core biopsy is indicated for painful, large, solitary lesions.
Nipple masses represent another group of generally benign breast lesions.
Benign intraductal papillomatosis is the most common etiology and can be seen
in prepubertal or pubertal boys and girls, often coming to attention because of
bleeding from the nipple. Occasionally, the lesion may obstruct the nipple and
causing pain and possibly infection. In extremely rare instances, a nipple mass
can represent an intraductal carcinoma. In these cases, cytologic examination of
the bloody nipple discharge can be of diagnostic value. Therefore, expedient
referral to a breast surgeon or pediatric surgeon is indicated after detection of
nipple mass with bloody discharge. In cases of benign nipple masses, careful
observation for several weeks by an experienced primary care physician or
surgical specialist is indicated. If the nipple mass or bleeding persists, excision is
the treatment of choice.
Trauma to the breast can lead to hematomas and fat necrosis, both of which are
palpated as firm, lumpy, well-circumscribed breast masses. Initially, these lesions
may be tender. If left untreated, they may develop into areas of scar tissue that are
affixed to the skin. Fat necrosis is relatively common, but the differentiation from
other more serious lesions may be difficult, requiring consultation with a surgeon
or use of serial ultrasounds in cases of uncertainty.

Malignant Masses
Primary cancers of the breast have been reported in children, but are exceedingly
rare, with an incidence of 1 in 1,000,000 females less than age 20 years. In
children, breast tumors accounting for less than 1% of all malignancies and less
than 0.1% of all breast cancers occur in the pediatric age group. Metastatic
disease is far more common than primary breast tumors, and may be secondary to
Hodgkin and non-Hodgkin lymphoma, neuroblastoma, and leukemia, and
rhabdomyosarcoma. Adolescent or childhood breast tumors are often classified as
secretory carcinomas that behave more benignly than breast cancers in adults.

Other histologic classifications of breast malignancies reported in children and
adolescents include carcinomas, sarcomas, and cystosarcoma phyllodes, which
can have both benign and malignant features. Physical examination
characteristics suggestive of malignancy include a hard, nontender, solitary mass
with ambiguous margins. The mass may be fixed to surrounding tissues, and
overlying skin changes such as edema, warmth, skin dimpling, and/or nipple
retraction may be present. Other signs include bleeding from the nipple and local
lymphadenopathy may be present. The appropriate treatment for suspected