Breast pathology
Key points
Breast development starts Week 5 gestation
Endodermal mammary ridges
Modified sweat gland comprises of adipose and glandular tissues.
15-25 Lobes and lactiferous ducts draining acini
Progesterone acts on acini and oestrogen acts on ducts and stroma
Thelarche 8-13 years
Average 11 years
Once breast is developed, can get any adult pathology - however cancer is very rare in children
Athelia - Absence of nipple
Amastia - Absence of breast
Amazia- Absence of glands
Polythelia - accessory nipples - look along 'milk line'. Do renal USS as may be associated with duplication and renal agenesis
BRCA1 - Chromosome 17
BRCA 2 - Chromosome 13
Should not screen adolescents as no treatment shown to affect disease course
Li Fraumeni - TP53 mutation - risk for breast and other types of cancer
Anatomy
Blood supply:
Internal mammaries
Axillary - lateral thoracic, thoracoacromial
intercostals
Veins: Intercostal, internal thoracic, axillary
Level I nodes - lateral to the pectoralis minor, level II - deep to pectoralis minor, level III lymph medial to the medial border of pectoralis minor
Benign lesions
Neonatal Galactorrhoea: a condition where milk or milky discharge is secreted from the breasts of newborns, not related to breastfeeding
Acute decease of maternal and placental oestrogens and progesterone
Increased prolactin and oxytocin
Spontaneous resolution
Reassurance
Do NOT express or squeeze: Makes it worse or introduce infection
Blood discharge: Duct ectasia or Duct papilloma, usually self-limiting
Fibroadenomas
Lobular
Malignant trasnformation extremely rare
Indications for operation: Size >5cm, if distorting breast anatomy
Mammary duct ectasia
Distension of subareolar ducts
Sticky discharge
Can happen in male infants
Bluish mass
Needs USS
Resolves spontaneously
Juvenile papillomatosis
Swiss cheese disease
Rare and benign disorder
Females < 30 years
Often misdiagnosed as fibroadenoma
Family history of breast cancer in around half of patients Increased risk of development of breast carcinoma
Excise lesion
Breast abscesses
In neonates - due to staph aureus infection of immature ducts
Often responsive to antibiotics, if not - should be aspirated, not incised as it can destroy breast tissue
Fat necrosis
Following trauma
Calcifications over time
Mimics malignancy
Phases:
Acute - Oedema, Sub acute - cyst, Late - walled off calcification/complex cyst
Underwire bras should not be worn while breast are developing
Asymmetry
Trauma, surgery, infection
Could be chest wall/scoliosis
No surgical management in children as breasts not fully developed
Malignant lesions
Epithelial tumours - ductal and secretory
Phyllodes
Sarcomas
Metastases are most common malignant breast lesion in children e.g. rhabdomyosarcoma, lymphoma, melanoma
Ductal carcinoma
Arise in ducts and lobules
Lumpectomy or mastectomy
Adjuvant chemo recommended
Secretory carcinoma
Rare in adults, more common in children
Slow growing
Thick walled capsule
Excision alone usually sufficeient
Phyllodes tumour
Fibroepithelial
Stromal in origin
Difficult to distinguish from fibroadenoma, and less common (1:40)
Can be benign, borderline or malignant (cystosarcoma)
Excise
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. June 2025
Page edited by Mrs Charnjit Seehra BSc. June 2025
References
Gayther SA, Ponder BA. Mutations of the BRCA1 and BRCA2 genes and the possibilities for predictive testing. Mol Med Today. 1997 Apr;3(4):168-74. doi: 10.1016/S1357-4310(97)01017-4. PMID: 9134530.
Rivard AB, Galarza-Paez L, Peterson DC. Anatomy, Thorax, Breast. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519575/
Brindle, Mary, and Carmen T Ramos-Irizarry. "Breast Disorders." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829149/all/Breast_Disorders.
Vandeweerd V, Keupers M, Hoste G, Langenaeken T, Neven P. Juvenile Papillomatosis: A Case Report. Eur J Breast Health. 2019 Feb 15;15(2):130-134. doi: 10.5152/ejbh.2019.4362. PMID: 31001616; PMCID: PMC6456279.