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Breast Masses
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The normal anatomy of the breast is shown in Figure 77-1. A variety of benign breast lesions occur in the female adolescent. The most typical presentation is a self-detected, asymptomatic mass. Complaints such as bloody discharge, nipple retraction, or skin dimpling are rare.
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ANATOMIC CHANGES AND CONGENITAL ABNORMALITIES
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Breast asymmetry, a common condition in which one breast develops earlier or grows more rapidly than the other, usually occurs between sexual maturity rating (SMR) 2 and 4 and persists into adulthood in 25% of women. It is important to consider the age of the patient when assessing the etiology of a breast mass or enlargement. Normal thelarche usually occurs between 8 and 13 years of age. Rare congenital abnormalities of the breast include amastia (absent breast, associated with chest wall deformities such as pectus excavatum or Poland syndrome) and athelia (absent nipple). Polymastia (accessory breast tissue) and polythelia (accessory nipples) occur along the mammalian nipple line in 1% to 2% of girls and may be inheritable conditions. Breast atrophy developing after thelarche can be one sign of an eating disorder or other chronic illness such as scleroderma. The associated loss of both fat and glandular tissue in the breast results from significant weight loss. Virginal (juvenile) hypertrophy, the massive enlargement of one or both breasts caused by either increased tissue sensitivity to pubertal hormones or endogenous production of hormones from within breast cells, can be associated with a variety of problems, including headache, neck and back pain, dermatitis, embarrassment, and psychological difficulties. Reduction mammoplasty after completion of breast maturation may be indicated in female adolescents with severe virginal hypertrophy.
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CYSTS, FIBROCYSTIC CHANGE, AND FIBROADENOMAS
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The most common breast masses in adolescents are solitary cysts, fibrocystic change, and fibroadenomas. Masses resulting from inflammation or trauma occur less frequently. Cancer is rare among female adolescents. A solitary cyst contains sterile fluid. Over half resolve spontaneously within 2 to 3 months, so fine-needle aspiration or biopsy is often unnecessary. Recurrent or multiple cysts in the adolescent may represent early fibrocystic change.
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Fibrocystic change (benign proliferative breast change) is a physiological response of breast tissue to cyclic hormonal activity. The result is a dilation and proliferation of duct epithelium to form gross cysts. A benign condition more common during the third and fourth decades, fibrocystic change may occur during adolescence. Bilateral breast pain in the upper outer quadrants beginning in the premenstrual phase of the menstrual cycle and subsiding thereafter is the typical presentation. Adolescents tend to have dense breast tissue. Physical examination reveals areas of diffuse, cordlike thickening as well as discrete mobile lesions, which often increase in size during the premenstrual period. Supportive care, including nonsteroidal anti-inflammatory agents for pain and a ...