Breast Enlargement
Abnormal breast enlargement can occur atany age in girls and boys.
Principal Causes of Breast Enlargement
- Infectious
- Cellulitis/abscess
- Noninfectious
- Infancy
- Physiologic hypertrophy
- Childhood
- Premature thelarche
- Precocious puberty
- Gynecomastia (male)
- Neoplasm (rare)
- Adolescence
- Girls
- Cysts
- Trauma
- Macromastia
- Juvenile hypertrophy
- Fibrocystic disease
- Neoplasm
- Boys
- Physiologic gynecomastia
- Drugs
- Klinefelter syndrome
- Neoplasm
- Other
Clinical Features and Diagnosis
Infectious
Cellulitis/Abscess
Cellulitisor breast abscess can occur in the newborn.Breast infections are unusual in adolescentgirls except for postpartum mastitis. Most common pathogen is S.aureus.Breast is inflamed, painful, and tender.Fluctuance is usually found with abscess. Noninfectious
Infancy
Physiologic Hypertrophy
Transplacentalpassage of estrogen from mother to fetus causes unilateral or bilateral breasthypertrophy in the newborn, which is usually apparent during firstweek of life.Hypertrophy usually resolves withina few months but sometimes persists until 1 or 2 yrs of age.If breast enlargement does not progressand growth velocity remains normal, no other investigation is necessary. Childhood
Premature Thelarche
Definedas breast enlargement (unilateral or bilateral) that occurs withoutother pubertal changes.Resolution occurs in a few months ormay persist until puberty.See Chap.48, Precocious Puberty. Precocious Puberty
Exists whensigns of sexual development besides breast development occur, includingdevelopment of axillary and pubic hair, accelerated growth, andonset of menses.See Chap.48, Precocious Puberty. Gynecomastia
Male breastenlargement is uncommon before puberty.Cause in most cases is idiopathic.Unusual causes include exogenous estrogen exposure and tumors (adrenal,testicular).Obese boys often appear to have breastenlargement, but no breast tissue is palpable. Adolescence
Girls
Cysts
Single ormultiple breast cysts may cause mild pain and tenderness.U/S can confirm diagnosis. Trauma
Contusionto the breast may produce firm, tender, diffuse mass, whereas hematoma ismore sharply defined.Fat necrosis may develop after traumaas firm, superficial mass that does not enlarge but resolves slowlywith time. Macromastia
Defined as development of large but histologicallynormal breasts.
Juvenile Hypertrophy
Definedas breast enlargement secondary to marked increase in fibrous connective tissueand ductal proliferation.Breasts are firm and may be nodular. Fibrocystic Disease
Fibrocysticchanges of one or both breasts are physiologic response to cyclichormonal stimulation.Pain and tenderness usually occur justbefore menstrual period as cysts enlarge. Cordlike thickenings andcystic masses may be palpable. Nonbloody nipple discharge also maybe seen.Usually diagnosed clinically; however,U/S can confirm cystic nature of masses. Neoplasm
Benign
Most commonbreast mass found in girls is fibroadenoma, which usually occursin adolescence and can be multiple and bilateral.Discrete, mobile, nontender, firm massesare usually 2–3 cm in diameter. Larger ones that are 10–15cm in diameter may need excision. Otherwise, these tumors can befollowed clinically.Besides fibroadenoma, breast tumorsare rare in childhood and adolescence. Ductal papilloma usuallyappears as nodule beneath areola, and firm pressure may producebrown or bloody fluid. Lipomas and lymphangiomas appear as soft,painless breast masses.Cystosarcoma phyllodes is firm, circumscribedmass with occasional nipple discharge. Often benign but may be malignant. Malignant
Rare inpediatric population.Primary tumors include carcinomas,lymphomas, and sarcomas.Carcinoma of breast usually appears as unilateral,firm mass that adheres to skin and sometimes produces dischargeor bleeding from nipple.Sarcomas also present as firm, unilateral,breast masses. Metastatic lesions from leukemia, lymphoma,rhabdomyosarcoma, and neuroblastoma also occur.Malignancy should be suspected wheneverunilateral, hard, fixed, rapidly growing breast mass is noted.Only way to make definitive diagnosisis by biopsy. Boys
Physiologic Gynecomastia
Any growthof breast tissue in males is called gynecomastia, a common occurrence inadolescence.Mechanism of enlargement is thoughtto be increased ratio of estrogens to androgens or change in sensitivityof breast tissue receptors during puberty.Palpable breast tissue involving 1or both breasts is 1–2 cm in diameter.Enlargement usually lasts for 1–2years and gradually recedes. Drugs
Drugs that have been implicated in causingbreast enlargement in girls before puberty and in boys include
Hormones(estrogens, estrogen agonists, androgens, anabolic steroids, chorionicgonadotropin)Psychoactive agents (tricyclic antidepressants,diazepam, phenothiazines, haloperidol)Cardiovascular drugs (captopril, enalapril,verapamil, nifedipine, digitoxin)Diuretics (thiazides, spironolactone)Antibiotics (isoniazid, ketoconazole,metronidazole)Cytotoxic drugs (vincristine, cyclophosphamide,methotrexate)Gastric acid inhibitors (ranitidine,cimetidine, omeprazole)Drugs of abuse (alcohol, heroin, methadone,marijuana, amphetamines)Others (phenytoin, penicillamine) Klinefelter Syndrome
Adolescentboys with Klinefelter syndrome are tall and have small testes. Gynecomastiamay occur but is not evident until puberty.Serum concentrations of follicle-stimulatinghormone (FSH) and luteinizing hormone (LH) are elevated.Most common karyotype is 47,XXY. Neoplasm
Althoughprimary breast tumors in boys are rare, they may be benign (hemangioma, lipoma,lymphangioma, neurofibroma) or malignant (carcinoma). Malignanttumor should be suspected with irregular, hard, fixed mass; bloodynipple discharge; and axillary adenopathy.Leydig cell testicular tumors secreteestrogen and can present with gynecomastia and precocious puberty.Testicular mass is usually palpable.Adrenal estrogen-producing tumors (adenoma,carcinoma) are rare but may cause gynecomastia. Abdominal U/Sand CT are useful in locating tumor mass.hCG-secreting germ cell tumors stimulateandrogen and estrogen production in testes and may present withgynecomastia and precocious puberty. Other
Gynecomastia also may be associated withcystic fibrosis, ulcerative colitis, chronic liver disease, hypothyroidism,hyperthyroidism, and HIV infection.
Diagnostic Approach
Historyand physical exam are diagnostic in many cases of breast enlargement.Important features are gender, ageof onset, history of drug ingestion, signs of infection, whetherphysical and sexual development are normal, stage of sexual development,and presence of breast mass. Girls
Before puberty,except for the newborn, premature thelarche and precocious puberty aremost common causes of breast enlargement.Girls with unilateral subareolar massesin early puberty usually have normal enlarging breast bud, and excisionalbiopsy should be avoided.In pubertal girl suspected of havingfibrocystic disease, clinical observation for 3 menstrual cyclesis appropriate.Nature of discrete palpable mass (solidvs cystic) can be determined by U/S. Needle aspirationcan be considered if mass persists.Palpable mass that cannot be delineatedby imaging should be followed and excisional biopsy should be considered. Boys
Before puberty,breast enlargement is rare.In obese boys, breasts seem to be enlargedbut no breast tissue is palpable.In pubertal boys, most common causeof breast enlargement is physiologic.Body habitus and testicular size shouldbe noted. If testes are small and serum concentrations of FSH andLH are elevated, diagnosis is almost certainly Klinefelter syndrome.Chromosomal karyotype confirms diagnosis.Drugs, chronic liver disease, and neoplasmsare rare causes of breast enlargement in boys during childhood andadolescence. References
- Baren JM. Breast lesion. In: FleisherGR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4thed. Philadelphia: Lippincott Williams & Wilkins, 2000,157–163.
- Beach RK. Breast disorders. In: McAnarney ER, et al.,eds. Textbook of adolescent medicine. Philadelphia: WB Saunders,1992:720–728.
- Biro FM. Gynecomastia. In: Dershewitz RA, ed. Ambulatorypediatric care, 3rd ed. Philadelphia: Lippincott-Raven, 1999:516–517.
- Braunstein GD. Gynecomastia. N Engl J Med 1993;328:490–495.
- Davis AJ, Kulig JW. Adolescent breast disorders. Adolescenthealth update. Elk Grove Village, IL: American Academy of Pediatrics1996:1–7.
- Emans SJH, et al. Pediatric and adolescent gynecology,4th ed. Philadelphia: Lippincott-Raven, 1998.
- Herman-Giddens ME, et al. Secondary sexual characteristicsand menses in young girls seen in office practice: a study fromthe Pediatric Research in Office Settings Network. Pediatrics 1997;99:505–512.
- Kaplowitz PB, Oberfield SE, and the Drug and Therapeuticsand Executive Committees of the Lawson Wilkins Pediatric EndocrineSociety. Reexamination of the age limit for defining when pubertyis precocious in girls in the United States: implications for evaluationand treatment. Pediatrics 1999;104:936–941.
- Mahoney CP. Adolescent gynecomastia. Pediatr Clin NorthAm 1990;37:1389–1404.
- Rogers DA, et al. Breast malignancy in children. JPediatr Surg 1995;29:48–51.
- Seashore JH. Disorders of the breast. In: O'NeillJA Jr, et al., eds. Pediatric surgery, 5th ed. St. Louis: Mosby-YearBook, 1998:779–785.
- Simmons PS. Diagnostic considerations in breast disordersof children and adolescents. Obstet Gynecol Clin North Am 1992;19:91–103.
- West KW, et al. Diagnosis and treatment of symptomaticbreast masses in the pediatric population. J Pediatr Surg 1995;30:182–187.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.
More About Causes of Breast symptoms
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