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Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease

  • Maggie L. WestfalEmail author
  • Numa P. Perez
  • Ya-Ching Hung
  • David C. Chang
  • Cassandra M. Kelleher
Preclinical study
  • 43 Downloads

Abstract

Purpose

Breast masses in pediatric patients are often managed similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients.

Methods

A multi-institutional retrospective cohort study was completed between 1995 and 2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions.

Results

A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p < 0.25) for decisions made on clinical suspicion alone.

Conclusion

Despite literature supporting an observation period for pediatric breast masses, half of patients had an intervention within three months with one out of ten patients undergoing an invasive procedure within this time frame. Furthermore, 81.1% of invasive interventions were unnecessary based on final pathologic findings. A formal consensus clinical guideline for the management of pediatric benign breast disease including a standardized clinical observation period is needed to decrease unnecessary procedures in pediatric patients with breast masses.

Keywords

Pediatric Benign Breast Observation Appropriateness 

Notes

Funding

ML Westfal is financially supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (Award Number: T32 DK007754) and by the Massachusetts General Hospital Department of Surgery Marshall K. Bartlett Fellowship. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with ethical standards

Conflict of interest

All authors declared that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

This study did not involve contact with any humans and therefor informed consent was not required. Informed consent was waived with approval of the Massachusetts General Hospital IRB.

Supplementary material

10549_2019_5224_MOESM1_ESM.doc (82 kb)
Supplementary material 1 (DOC 82 kb)

References

  1. 1.
    Knell J, Koning JL, Grabowski JE (2016) Analysis of surgically excised breast masses in 119 pediatric patients. Pediatr Surg Int 32(1):93–96CrossRefGoogle Scholar
  2. 2.
    Neinstein LS, Atkinson J, Diament M (1993) Prevalence and longitudinal study of breast masses in adolescents. J Adolescent Health 14(4):277–281CrossRefGoogle Scholar
  3. 3.
    Ezer SS, Oguzkurt P, Ince E, Temiz A, Bolat FA, Hicsonmez A (2013) Surgical treatment of the solid breast masses in female adolescents. J Pediatr Adolesc Gynecol 26(1):31–35CrossRefGoogle Scholar
  4. 4.
    Cerrato F, Labow BI (2013) Diagnosis and management of fibroadenomas in the adolescent breast. Semin Plast Surg 27(1):23–25CrossRefGoogle Scholar
  5. 5.
    Ciftci AO, Tanyel FC, Buyukpamukcu N, Hicsonmez A (1998) Female breast masses during childhood: a 25-year review. Eur J Pediatr Surg 8(2):67–70CrossRefGoogle Scholar
  6. 6.
    McLaughlin CM, Gonzalez-Hernandez J, Bennett M, Piper HG (2018) Pediatric breast masses: an argument for observation. J Surg Res 228:247–252CrossRefGoogle Scholar
  7. 7.
    West KW, Rescorla FJ, Scherer LR 3rd, Grosfeld JL (1995) Diagnosis and treatment of symptomatic breast masses in the pediatric population. J Pediatr Surg 30(2):182–187CrossRefGoogle Scholar
  8. 8.
    Valeur NS, Rahbar H, Chapman T (2015) Ultrasound of pediatric breast masses: what to do with lumps and bumps. Pediatr Radiol 45:1584–1599CrossRefGoogle Scholar
  9. 9.
    Gao Y, Saksena MA, Brachtel EF, Termeulen DC, Rafferty EA (2015) How to approach breast lesions in children and adolescents. Eur J Radiol 84(7):1350–1364CrossRefGoogle Scholar
  10. 10.
    Sanders LM, Sharma P, El Madany M, King AB, Goodman KS, Sanders AE (2018) Clinical breast concerns in low-risk pediatric patients: practice review with proposed recommendations. Pediatr Radiol 48(2):186–195CrossRefGoogle Scholar
  11. 11.
    Chung EM, Cube R, Hall GJ, Gonzalez C, Stocker JT, Glassman LM (2009) Breast masses in children and adolescents: radiologic-pathologic correlation. RadioGraphics 29(3):907–931CrossRefGoogle Scholar
  12. 12.
    Kaneda HJ, Mack J, Kasales CJ, Schetter S (2013) Pediatric and adolescent breast masses: a review of pathophysiology, imaging, diagnosis, and treatment. Am J Roentgenol 200(2):W204–W212CrossRefGoogle Scholar
  13. 13.
    Amin AL, Purdy AC, Mattingly JD, Kong AL, Termuhlen PM (2013) Benign breast disease. Surg Clin N Am 93:299–308CrossRefGoogle Scholar
  14. 14.
    Elsedfy H (2017) A clinical approach to benign breast lesions in female adolescents. Acta Biomed 88(2):214–221Google Scholar
  15. 15.
    Sonmez K, Turkyilmaz Z, Karabulut R et al (2006) Surgical breast lesions in adolescent patients and a review of the literature. Acta Chir Belg 106(4):400–404CrossRefGoogle Scholar
  16. 16.
    Diehl T, Kaplan DW (1985) Breast masses in adolescent females. J Adolesc Health Care 6(5):353–357CrossRefGoogle Scholar
  17. 17.
    Duflos C, Plu-Bureau G, Thibaud E, Kuttenn F (2004) Breast disease in adolescents. Endocr Dev 7:183–196CrossRefGoogle Scholar
  18. 18.
    Michala L, Tsigginou A, Zacharakis D, Dimitrakakis C (2015) Breast disorders in girls and adolescents. Is there a need for a specialized service? J Pediatr Adolesc Gynecol 28(2):91–94CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryMassachusetts General HospitalBostonUSA
  2. 2.Department of Pediatric SurgeryMassGeneral Hospital for ChildrenBostonUSA

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