Frequency of breast lesions in pubertal children with ultrasound evaluation

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Barrera, Valeria Peña-Trujillo, Isabella M. DeGregorio, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6771168/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND : Breast masses in the puberal children are uncommon. Ultrasound is the first modality of choice to evaluate for breast masses in children. OBJECTIVE: To evaluate the frequency and etiology of breast masses in puberal children with ultrasound. METHODS: A single institution, institutional review board–approved, retrospective study was performed including 13- to 18-year-old patients who had a breast ultrasound from January 1990 to December 2024. Clinical information and the ultrasound results were collected. Ultrasound were considered positive or negative if it explained the patients concern. Tissue sample was determined by the patient and ordering physician. Pathology results and follow-up ultrasounds were recorded as well. Descriptive analysis was performed. RESULTS : 240 patients (237 girls) were included with a mean age of 13 years. The most common indication was a palpable mass (65%). 237 ultrasounds were positive (99%), 193 patients had a biopsy (80%). The most common diagnoses were fibroadenoma (69%), hamartoma (13%), and phyllodes tumor (7%). No primary or secondary breast malignancies were identified. 26 patients with a positive ultrasound and without a biopsy underwent sonographic surveillance, 20 patient had unchanged findings and 5 had decreased/resolved findings. CONCLUSION : The prevalence of malignant pediatric breast masses is exceedingly low. Lesions with the potential to be malignant are uncommon, and diagnosis should be suspected based on the clinical presentation and ultrasound appearance. Sonographic surveillance and patient education are feasible and safe management approaches in most adolescent breast mass cases. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Breast tissue abnormalities in the child may occur at any age, from the neonate through adolescence [ 1 ]. Given the high prevalence of breast cancer in adults, a palpable area of concern in the breast of a child can be concerning to parents and family. Diagnostic imaging of breast tissue in the child, therefore, plays a key role in patient management. Normal breast development is influenced by hormones that peak at the time of puberty[ 1 ]. Variations such as asymmetric breast development and accessory breast tissue can be diagnosed during this time[ 2 ]. Acquired disorders such as breast infections and vascular masses may occur in neonates and infants, whereas solid and cystic lesions are typically diagnosed in preadolescents and adolescents[ 2 ]. In adults above 17 years of age, breast radiologists use the Breast Imaging Reporting and Data System (BI-RADS) to standardize reporting of breast imaging, clarify the level of concern for malignancy, and guide clinical recommendations[ 3 ]. However, this system has not been validated in children given the low prevalence of breast cancer in children and the lack of large-scale studies in this area. Ultrasound is the primary imaging modality of choice to evaluate the breast in children and in patients younger than 30 years of age according to the American College of Radiology appropriateness criteria[ 4 ]. The widespread use of ultrasound, lack of ionizing radiation, great sensitivity in soft tissue, and no need for sedation makes it a great imaging modality in children[ 2 ]. At some institutions, the evaluation of a breast mass in a pubertal child may be the responsibility of a pediatric radiologist instead of a breast radiologist. This variation may raise concerns about the possibility of missing a malignancy given the lack of a standardized reporting system in children, such as BI-RADS. The purpose of this study is to evaluate the prevalence of the different breast masses seen in puberal children based on imaging findings and clinical concerns. MATERIALS AND METHODS This retrospective study was approved by the institutional review board at the XXX. The requirements for written informed consent were waived. A computer search of our institution’s radiology department database between January 1990 and December 2024 was performed and included children, boys and girls, between 13 and 18 years of age who had a breast ultrasound. The age of 13 years old was chosen as at this age there is an increased incidence of solid breast masses occurs. Patients without ultrasound images available for review were excluded from the sample. Clinical information and study indication were collected, if available. Breast ultrasounds were categorized as positive or negative depending on whether they showed a finding that could explain the patient’s complaint. The number of masses or other relevant findings, as well as the greatest dimension of each mass, were recorded. Findings that were considered cysts or intraductal based on ultrasound findings were recorded, in addition to solid and parenchymal masses, which were further sub stratified based on pathology information. The decision to perform a needle biopsy, an excisional biopsy, or a needle biopsy followed by an excisional biopsy depended on the clinical symptoms, suspicion for malignancy, patient’s preference, or the breast surgeon assessment. The pathology result was collected. For patients who had a needle biopsy followed by an excisional biopsy, the concordance or discrepancy of both results was recorded as the excisional biopsy results were considered to supersede the results of the needle biopsy and the imaging findings. Final diagnosis was determined based on the assessment with the highest diagnostic accuracy available (i.e., excisional biopsy > needle biopsy > breast ultrasound). In patients with a pathology-proven Phyllodes tumor, the histologic grade in the pathology report was recorded as benign, borderline, or malignant. Patients who had follow-up imaging without a biopsy were recorded. Descriptive statistics were performed using SPSS (version 25; IBM, Armonk, NY). Continuous variables are presented as mean ± range and median. Categorical variables are presented as percentages and counts. RESULTS A total of 584 breast ultrasounds were performed between January 1990 and December 2024 in children. 273 (47%) were patients between 13 and 18 years of age, 240 patients had ultrasound images available (41%). Out of 240 patients (237 girls, 3 boys), 193 (80%) had medical records available for review ( Figure 1 ). The mean age was 13 years old (range 13 – 18). The most common indication ( Table 1 ) was a palpable breast mass (65%), followed by pain and palpable mass (10%). 193 (80%) patients had clinical information reported by the breast surgeon in their medical records. Two patients had a history of malignancy (0.8%), 24 patients had a family history of primary breast cancer (10%), three patients had a known genetic mutation that predisposes to breast cancer (1%), and one patient was pregnant at the time of evaluation (0.4%). No patients had a history of radiotherapy to the chest. 237 (99%) breast ultrasounds were deemed positive for a finding that could explain the patient’s complaint. Laterality of findings were evenly distributed between the right (49%) and the left (43%) breasts, with only 18 (8%) patients having bilateral findings. The mean number of findings was one (median 1, range 1 – 11). The mean size of the largest dimension of the largest finding was 2.9 cm (range 0.6 – 11.3 cm). Five (2%) patients had a cyst(s) and four (2%) had an intraductal mass ( Figure 2 ). 193 (82%) patients underwent a biopsy based on the ultrasound findings, 82 (43%) had only a needle biopsy, 62 (32%) had only an excisional biopsy, and 49 (25%) had a needle biopsy followed by an excisional biopsy. Out of 49 patients with both needle and excisional biopsy, 22 (45%) had a discordant biopsy result with seven patients upgraded from a fibroadenoma to a Phyllodes tumor and one upgraded from a Pseudoangiomatous stromal hyperplasia (PASH) to a papilloma (8/49, 16%). Out of 14 patients with a Phyllodes tumor, 10 (71%) had a benign lesion and 4 (29%) had a borderline lesion. No malignant Phyllodes lesions were found in our sample ( Figure 3 ). Out of 193 biopsies, the most common final pathologic diagnosis was a fibroadenoma (69%), followed by hamartoma (13%), and Phyllodes tumor (7%) ( Table 2 ). There were no detected cases of primary or secondary malignancy in the breast. Out of 47 breast ultrasounds without a subsequent biopsy, the most common diagnosis was a fibroadenoma (75%) ( Table 2 ). Two patients had a breast ultrasound with findings suspicious for malignancy, however, they were lost on follow-up. Out of 44 patients with positive breast ultrasound and without a subsequent biopsy, 26 (59%) had a follow-up breast ultrasound to assess for stability. 20 (77%) did not show a significant change and 5 (19%) had decreased or resolved findings. One (4%) 18-year-old patient had a mass that increased in size after a two-year follow-up and underwent a needle biopsy that was positive for a fibroadenoma – the patient was 20 years old at the time of the procedure. DISCUSSION Malignant breast masses in post puberal children are exceedingly rare, with no cases of primary or secondary breast malignancy reported in the current sample. Multiple studies have reported a low prevalence of malignant breast masses in children and adolescents ranging between 0–1% [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ]. However, the incidence of primary breast malignancy in patients younger than 25 years has been reported to be 3.2 per million, with four cases of primary breast cancer in the 20–24-year age group[ 6 ], [ 10 ]. Similarly, Surveillance Epidemiology and End Results (SEER) data from 2006 to 2010 report an incidence rate of < 0.2/100,000 in patient younger than 19 years of age[ 11 ]. Thelarche is the onset of pubertal breast development between 8 to 13 years of age[ 1 ]. The hormones estrogen and progesterone stimulate ductal and lobular growth in the breast, which leads to an increased incidence of estrogen-sensitive lesions such as fibroadenomas and, in theory, primary breast cancer[ 12 ]. However, the prevalence of primary breast malignancies remains extremely low and is limited to children with inherited genetic mutations, such as BRCA 1 and 2, and secondary to treatment of childhood malignancies, such as high-dose mantle radiation for Hodgkin lymphoma[ 13 ], [ 14 ]. Metastasis is a rare cause of malignant breast lesions in children, seen mostly with rhabdomyosarcomas, non-Hodgkin lymphoma, and leukemia [ 14 ], [ 15 ], [ 16 ]. However, out of two patients with history of childhood malignancy in our sample, no patients presented with findings of a breast metastasis. Fibroadenomas are the most common solid breast lesions in children, accounting for 70% of the lesions in this sample. Fibroadenomas are estrogen-sensitive and may grow rapidly during puberty and pregnancy with a reported prevalence up to 94% of breast masses in adolescents[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 17 ], [ 18 ]. These lesions have a typical sonographic appearance as an oval or round circumscribed mass with variable posterior acoustic enhancement, and vascularity, and can be multiple due to hormonal influence[ 13 ], [ 14 ], [ 15 ], [ 19 ], [ 20 ]. The management of fibroadenomas depends on the growth rate and sonographic appearance. Findings with a typical clinical and sonographic appearance may prefer ultrasound surveillance instead of biopsy, given the risk of iatrogenic injury to the developing breast [ 13 ], [ 20 ]. However, surgical excision can be considered if the lesion is symptomatic or if there are concerning features (namely, size > 2.5–5 cm, rapid growth) [ 8 ], [ 21 ]. Although fibroadenomas are benign, a complex fibroadenoma variant has been suggested to increase the risk for developing breast cancer[ 17 ], [ 18 ]. Phyllodes tumors (6%) and papilloma (2%) are the only lesions found in this study sample with the potential to be malignant. Although Phyllodes tumor has been reported as less that 1% of all pediatric breast masses, it constitutes the most common primary breast malignancy in children [ 12 ], [ 13 ], [ 20 ]. Phyllodes tumors present as a painless, rapidly enlarging breast mass with a sonographic appearance indistinguishable from a fibroadenoma. Some authors recommend obtaining a core biopsy for a lesion with a typical appearance for a fibroadenoma if it measures between 3–5 cm and referral to a surgeon for excision if it measures > 5 cm [ 8 ], [ 20 ], [ 22 ]. Phyllodes tumors can be classified histologically as benign, borderline, and malignant, with a reported 5–24% prevalence of malignant phyllodes tumors in children[ 19 ]. However, the current study population did not report any cases of malignant phyllodes. There were only benign (71%) and borderline (29%) variants. Papilloma is a benign proliferation of ductal epithelium that is treated with surgical excision due to its risk of subsequent carcinoma[ 13 ], [ 14 ]. These lesions typically present clinically with clear or bloody nipple discharge. Ultrasound shows a solid intraductal mass with increased vascularity[ 13 ], [ 14 ], [ 19 ]. Sonographic surveillance for solid breast lesions is a feasible and safe management option, in the absence of rapid growth, large size approaching or above 5 cm, or suspicious imaging features for invasive carcinoma. Patients with a classic appearing benign lesion on ultrasound or a biopsy-proven benign lesions should be educated to seek re-evaluation in case of rapid growth of the known lesion or development of new symptoms, such as nipple discharge. Our sample showed that in patients who had a needle biopsy followed by an excisional biopsy, 8 patients were upgraded from a benign diagnosis to one with the potential to be malignant (7 from fibroadenoma to Phyllodes tumor, and 1 from PASH to papilloma). Rapid growth or unilateral nipple discharge are clinical presentations that should raise concern for a malignant entity, regardless of the sonographic appearance or the needle biopsy result. Of note, our cohort showed that most discordant pathology results between a needle and excisional biopsy are benign (84%). Similarly, most findings assessed by sonographic surveillance either remained unchanged (77%) or resolved/decreased (19%). Based on the results of the current study and those in the recent literature, the authors advocate for increased use of ultrasound not only in the initial review of breast complaints in the pediatric population but also in the follow-up and surveillance of imaging given the low likelihood of malignancy[ 20 ]. Ultrasound guided biopsy may provide definitive diagnosis, whenever indicated. However, education of patients and family, appropriate reassurance, and clear communication between providers may ultimately reduce the use of image guided procedures and surgical interventions in this age group. The current study has several limitations. First, this is a retrospective study and confounders, such as the decision to undergo biopsy or sonographic surveillance, were not controlled for. Second, our sample was limited to a non-pediatric tertiary hospital. Given the rarity of primary and secondary malignant breast lesions, a larger sample from different institutions may be needed to further characterize the variety of possible breast masses that can be seen in children. For example, a sample from a pediatric hospital with a large pediatric oncology clinic may report a higher percentage of malignant breast masses. Third, 80% of the study sample population had complete medical records by the breast clinic. For the remaining 20%, some clinical information, such as indication or risk factor assessment for breast cancer, was not available. Finally, our sample only included postpubescent patients based on age. CONCLUSION In conclusion, the prevalence of malignant pediatric breast masses is exceedingly low. Lesions with the potential to be malignant are uncommon, and diagnosis should be suspected based on the clinical presentation and ultrasound appearance. Sonographic surveillance and patient education are feasible and safe management approaches in most adolescent breast mass cases. Declarations Author Contribution CAB collected the data, analyzed the data, and prepared the manuscriptVPT collected the dataIDG revised and edited the manuscriptPG revised and edited the manuscriptTC revised and edited the manuscriptSH revised and edited the manuscriptTV revised and edited the manuscript References Restrepo R, Cervantes LF, Swirsky AM, Diaz A Breast development in pediatric patients from birth to puberty: physiology, pathology and imaging correlation, 10.1007/s00247-021-05099-4/Published Harper LK, Simmons CL, Woodard GA, Solanki MH, Bhatt AA (Jan. 2023) Pictorial Review of Common and Uncommon Pediatric Breast Lesions. Radiographics 43(1). 10.1148/rg.220117 D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA (2014) 2013 ACR BI-RADS Atlas: Breast Imaging Reporting and Data System . American College of Radiology, [Online]. Available: https://books.google.com/books?id=nhWSjwEACAAJ Harvey JA et al (Nov. 2016) ACR Appropriateness Criteria Palpable Breast Masses. J Am Coll Radiol 13(11):e31–e42. 10.1016/j.jacr.2016.09.022 McLaughlin CM, Gonzalez-Hernandez J, Bennett M, Piper HG (Aug. 2018) Pediatric breast masses: an argument for observation. J Surg Res 228:247–252. 10.1016/j.jss.2018.03.056 Richards MK et al (Jun. 2017) Breast Malignancies in Children: Presentation, Management, and Survival. Ann Surg Oncol 24(6):1482–1491. 10.1245/s10434-016-5747-5 Mareti E et al (2021) Breast Disorders in Adolescence: A Review of the Literature, Breast Care , vol. 16, no. 2, pp. 149–155, Apr. 10.1159/000511924 Valeur NS, Rahbar H, Chapman T (2015) Ultrasound of pediatric breast masses: what to do with lumps and bumps, Oct. 26, Springer Verlag . 10.1007/s00247-015-3402-0 Kaneda HJ, Mack J, Kasales CJ, Schetter S (2013) Pediatric and adolescent breast masses: A review of pathophysiology, imaging, diagnosis, and treatment. Feb. 10.2214/AJR.12.9560 Simmons PS, Jayasinghe YL, Wold LE, Melton LJ (Sep. 2011) Breast carcinoma in young women. Obstet Gynecol 118(3):529–536. 10.1097/AOG.0b013e31822a69db Browse the Tables and Figures - SEER Cancer Statistics Review (CSR) 1975–2010. Accessed: Apr. 29, 2025. [Online]. Available: https://seer.cancer.gov/archive/csr/1975_2010/browse_csr.php?sectionSEL=4&pageSEL=sect_04_table.12.html García CJ et al Breast US in Children and Adolescents 1. [Online]. Available: www.rsna.org Gao Y, Saksena MA, Brachtel EF, Termeulen DC, Rafferty EA (2015) How to approach breast lesions in children and adolescents, Jul. 01, Elsevier Ireland Ltd . 10.1016/j.ejrad.2015.04.011 Chung EM, Cube R, Hall GJ, González C, Stocker JT, Glassman LM (May 2009) From the archives of the AFIP: Breast masses in children and adolescents: Radiologic-pathologic correlation. Radiographics 29(3):907–931. 10.1148/rg.293095010 Weinstein SP, Conant EF, Orel SG, Zuckerman JA, Bellah R (2000) Spectrum of US Find-ings in Pediatric and Adolescent Patients with Palpable Breast Masses 1, [Online]. Available: www.rsna.org J.-F. Chateil Florence Arboucalot Yves PØrel Muriel Brun Martine Boisserie-Lacroix François Diard, J. F. Chateií Arboucalot, M. Brun, and F. Diard, Breast metastases in adolescent girls: US findings, Springer-Verlag, (1998) Kaneda HJ, Mack J, Kasales CJ, Schetter S (2013) Pediatric and adolescent breast masses: A review of pathophysiology, imaging, diagnosis, and treatment. Feb. 10.2214/AJR.12.9560 Sanchez R, Ladino-Torres MF, Bernat JA, Joe A, Dipietro MA (2010) Breast fibroadenomas in the pediatric population: Common and uncommon sonographic findings, Pediatr Radiol , vol. 40, no. 10, pp. 1681–1689, Oct. 10.1007/s00247-010-1678-7 Jones KN (2013) Imaging of the adolescent breast. Semin Plast Surg 27(1):29–35. 10.1055/s-0033-1343994 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 , vol. 48, no. 2, pp. 186–195, Feb. 10.1007/s00247-017-4007-6 Kopkash K, Yao K (2020) The surgeon’s guide to fibroadenomas, Annals of Breast Surgery , vol. 4, no. 0, pp. 25–25, Dec. 10.21037/ABS-20-100 Jacklin RK, Ridgway PF, Ziprin P, Healy V, Hadjiminas D, Darzi A (May 2006) Optimising preoperative diagnosis in phyllodes tumour of the breast. 10.1136/jcp.2005.025866 Tables Table 1. Demographics and sonographic findings Parameters (N = 240) Value Age (mean and range) 17 (13 – 17) Sex 237 girls (99%) Indication Palpable mass Pain and palpable mass Pain Nipple discharge Pain and skin changes Unavailable 159 (65%) 22 (9%) 6 (3%) 5 (2%) 1 (1%) 47 (20%) History of malignancy 2 (0.8%) 1 Retinoblastoma/osteosarcoma 1 Anaplastic astrocytoma Family history of breast cancer 24 (10%) Genetic mutation/syndrome 3 (1%) 1 BRCA 1 2 Cowden syndrome Pregnancy 1 (0.4%) Positive ultrasound 237 (99%) Laterality Right Left Bilateral 117 (49%) 102 (43%) 18 (8%) Number of masses (mean and range) 1 (1 – 11) Size in cm (mean and range) 2.9 cm (0.6 – 11.3) Cyst 5 (2%) Intraductal 4 (2%) Biopsy 193 (82%) Table 2 . Frequency and percentage of final diagnosis with and without a biopsy Final diagnosis Biopsy Total Yes No Fibroadenoma 133 (69%) 35 (74%) 168 (70%) Hamartoma 25 (13%) 25 (10%) Phyllodes tumor 14 (7%) 14 (6%) Papilloma 4 (2%) 4 (2%) Normal 3 (6%) 3 (1%) Complicated cyst 3 (6%) 3 (1%) Nodular adenosis 2 (1%) 2 (1%) Axillary mammary tissue 2 (1%) 2 (1%) PASH 2 (1%) 2 (1%) Fibroepithelial lesion 2 (1%) 2 (1%) Gynecomastia 1 (1%) 1 (2%) 2 (1%) Suspicious mass † 2 (4%) 2 (1%) Accessory breast tissue 1 (2%) 1 (<1%) Ruptured epidermal inclusion cyst 1 (1%) 1 (<1%) Benign fibroadipose tissue vs hamartoma 1 (1%) 1 (<1%) Nodular fasciitis 1 (1%) 1 (<1%) PASH and fibrocystic changes 1 (1%) 1 (<1%) Non-diagnostic ‡ 1 (1%) 1 (<1%) Ruptured cyst 1 (1%) 1 (<1%) Fat Necrosis 1 (1%) 1 (<1%) Hematoma 1 (2%) 1 (<1%) Inflamed fibrocystic tissue 1 (2%) 1 (<1%) Lactating adenoma 1 (1%) 1 (<1%) TOTAL 193 (100%) 47 (100%) 240 (100%) Note: PASH = Pseudoangiomatous stromal hyperplasia, † Two patients had suspicious masses on the ultrasound, however, they were lost on follow-up. ‡ Biopsy was not diagnostic, and the patient had clinical follow-up instead. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6771168","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466489490,"identity":"c45f5761-75f1-46b1-a6a4-8b3fff65600a","order_by":0,"name":"Christian A. Barrera","email":"data:image/png;base64,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","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Christian","middleName":"A.","lastName":"Barrera","suffix":""},{"id":466489491,"identity":"8d81a694-6a5a-42eb-abd6-c95286aec635","order_by":1,"name":"Valeria Peña-Trujillo","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Valeria","middleName":"","lastName":"Peña-Trujillo","suffix":""},{"id":466489492,"identity":"79434ad8-b9d9-46a5-bf58-b5a2277ac54c","order_by":2,"name":"Isabella M. 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Harrington","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"G.","lastName":"Harrington","suffix":""},{"id":466489496,"identity":"f18ee16c-8739-46d7-b216-de6210818a17","order_by":6,"name":"Teresa Victoria","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Victoria","suffix":""}],"badges":[],"createdAt":"2025-05-28 21:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6771168/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6771168/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84214601,"identity":"387ad361-fa19-468b-9db5-5c3daa2b6d4b","added_by":"auto","created_at":"2025-06-09 10:32:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":151245,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart shows the inclusion and exclusion criteria used to reach the final sample and the distribution of patient in each category.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6771168/v1/e575476d91e7fe0485b78c85.png"},{"id":84214602,"identity":"1ae688b5-bfe4-4f7c-ad20-6c4cdc9109d2","added_by":"auto","created_at":"2025-06-09 10:32:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":275259,"visible":true,"origin":"","legend":"\u003cp\u003e17-year-old girl presents with nipple discharge in the right breast. Targeted ultrasound shows (\u003cstrong\u003ea\u003c/strong\u003e) an intraductal mass measuring up to 2.6 cm with (\u003cstrong\u003eb\u003c/strong\u003e) internal flow on Doppler color. These imaging features are consistent with a papilloma, which was subsequently confirmed with an excisional biopsy.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6771168/v1/ffcfc7754518be47f875e6ea.png"},{"id":84216169,"identity":"55db18c5-9eeb-4536-bd73-4c8402f78189","added_by":"auto","created_at":"2025-06-09 10:40:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":200080,"visible":true,"origin":"","legend":"\u003cp\u003eThree examples of the most common breast lesions in our sample. (\u003cstrong\u003ea\u003c/strong\u003e) 18-year-old girl with a painful palpable mass in the right breast. A breast ultrasound showed a 11.3 cm oval hypoechoic circumscribed mass, parallel to the chest wall. An excisional biopsy was consistent with a fibroadenoma (\u003cstrong\u003eb\u003c/strong\u003e) 16-year-old girl with a palpable mass in the left breast. A breast ultrasound showed a 10.4 cm oval hypoechoic circumscribed mass, parallel to the chest wall and with posterior acoustic enhancement. An excisional biopsy was positive for a hamartoma. (\u003cstrong\u003ec\u003c/strong\u003e) 14-year-old girl with palpable mass in the right breast. Ultrasound shows a 5.4 cm oval heterogeneous circumscribed mass. Needle biopsy was positive for a fibroepithelial lesion and a subsequent excisional biopsy positive for a phyllodes tumor with borderline histopathology grade.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6771168/v1/c5d89723d9fad12fc4c0a78b.png"},{"id":90467337,"identity":"6c57a332-ff38-415d-85d7-7c99964d76ff","added_by":"auto","created_at":"2025-09-03 05:47:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1094643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6771168/v1/4885c995-9283-4fdc-ae0a-6004a5dc1944.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frequency of breast lesions in pubertal children with ultrasound evaluation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreast tissue abnormalities in the child may occur at any age, from the neonate through adolescence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Given the high prevalence of breast cancer in adults, a palpable area of concern in the breast of a child can be concerning to parents and family. Diagnostic imaging of breast tissue in the child, therefore, plays a key role in patient management. Normal breast development is influenced by hormones that peak at the time of puberty[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Variations such as asymmetric breast development and accessory breast tissue can be diagnosed during this time[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Acquired disorders such as breast infections and vascular masses may occur in neonates and infants, whereas solid and cystic lesions are typically diagnosed in preadolescents and adolescents[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn adults above 17 years of age, breast radiologists use the Breast Imaging Reporting and Data System (BI-RADS) to standardize reporting of breast imaging, clarify the level of concern for malignancy, and guide clinical recommendations[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this system has not been validated in children given the low prevalence of breast cancer in children and the lack of large-scale studies in this area. Ultrasound is the primary imaging modality of choice to evaluate the breast in children and in patients younger than 30 years of age according to the American College of Radiology appropriateness criteria[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The widespread use of ultrasound, lack of ionizing radiation, great sensitivity in soft tissue, and no need for sedation makes it a great imaging modality in children[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. At some institutions, the evaluation of a breast mass in a pubertal child may be the responsibility of a pediatric radiologist instead of a breast radiologist. This variation may raise concerns about the possibility of missing a malignancy given the lack of a standardized reporting system in children, such as BI-RADS. The purpose of this study is to evaluate the prevalence of the different breast masses seen in puberal children based on imaging findings and clinical concerns.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e This retrospective study was approved by the institutional review board at the XXX. The requirements for written informed consent were waived. A computer search of our institution\u0026rsquo;s radiology department database between January 1990 and December 2024 was performed and included children, boys and girls, between 13 and 18 years of age who had a breast ultrasound. The age of 13 years old was chosen as at this age there is an increased incidence of solid breast masses occurs. Patients without ultrasound images available for review were excluded from the sample. Clinical information and study indication were collected, if available.\u003c/p\u003e \u003cp\u003eBreast ultrasounds were categorized as positive or negative depending on whether they showed a finding that could explain the patient\u0026rsquo;s complaint. The number of masses or other relevant findings, as well as the greatest dimension of each mass, were recorded. Findings that were considered cysts or intraductal based on ultrasound findings were recorded, in addition to solid and parenchymal masses, which were further sub stratified based on pathology information. The decision to perform a needle biopsy, an excisional biopsy, or a needle biopsy followed by an excisional biopsy depended on the clinical symptoms, suspicion for malignancy, patient\u0026rsquo;s preference, or the breast surgeon assessment. The pathology result was collected. For patients who had a needle biopsy followed by an excisional biopsy, the concordance or discrepancy of both results was recorded as the excisional biopsy results were considered to supersede the results of the needle biopsy and the imaging findings. Final diagnosis was determined based on the assessment with the highest diagnostic accuracy available (i.e., excisional biopsy\u0026thinsp;\u0026gt;\u0026thinsp;needle biopsy\u0026thinsp;\u0026gt;\u0026thinsp;breast ultrasound). In patients with a pathology-proven Phyllodes tumor, the histologic grade in the pathology report was recorded as benign, borderline, or malignant. Patients who had follow-up imaging without a biopsy were recorded. Descriptive statistics were performed using SPSS (version 25; IBM, Armonk, NY). Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;range and median. Categorical variables are presented as percentages and counts.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 584 breast ultrasounds were performed between January 1990 and December 2024 in children. 273 (47%) were patients between 13 and 18 years of age, 240 patients had ultrasound images available (41%). Out of 240 patients (237 girls, 3 boys), 193 (80%) had medical records available for review (\u003cstrong\u003eFigure 1\u003c/strong\u003e). The mean age was 13 years old (range 13 – 18). The most common indication (\u003cstrong\u003eTable 1\u003c/strong\u003e) was a palpable breast mass (65%), followed by pain and palpable mass (10%). 193 (80%) patients had clinical information reported by the breast surgeon in their medical records. Two patients had a history of malignancy (0.8%), 24 patients had a family history of primary breast cancer (10%), three patients had a known genetic mutation that predisposes to breast cancer (1%), and one patient was pregnant at the time of evaluation (0.4%). No patients had a history of radiotherapy to the chest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e237 (99%) breast ultrasounds were deemed positive for a finding that could explain the patient’s complaint. Laterality of findings were evenly distributed between the right (49%) and the left (43%) breasts, with only 18 (8%) patients having bilateral findings. The mean number of findings was one (median 1, range 1 – 11). The mean size of the largest dimension of the largest finding was 2.9 cm (range 0.6 – 11.3 cm). Five (2%) patients had a cyst(s) and four (2%) had an intraductal mass (\u003cstrong\u003eFigure 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e193 (82%) patients underwent a biopsy based on the ultrasound findings, 82 (43%) had only a needle biopsy, 62 (32%) had only an excisional biopsy, and 49 (25%) had a needle biopsy followed by an excisional biopsy. Out of 49 patients with both needle and excisional biopsy, 22 (45%) had a discordant biopsy result with seven patients upgraded from a fibroadenoma to a Phyllodes tumor and one upgraded from a Pseudoangiomatous stromal hyperplasia (PASH) to a papilloma (8/49, 16%). Out of 14 patients with a Phyllodes tumor, 10 (71%) had a benign lesion and 4 (29%) had a borderline lesion. No malignant Phyllodes lesions were found in our sample (\u003cstrong\u003eFigure 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eOut of 193 biopsies, the most common final pathologic diagnosis was a fibroadenoma (69%), followed by hamartoma (13%), and Phyllodes tumor (7%) (\u003cstrong\u003eTable 2\u003c/strong\u003e). There were no detected cases of primary or secondary malignancy in the breast. Out of 47 breast ultrasounds without a subsequent biopsy, the most common diagnosis was a fibroadenoma (75%) (\u003cstrong\u003eTable 2\u003c/strong\u003e). Two patients had a breast ultrasound with findings suspicious for malignancy, however, they were lost on follow-up. Out of 44 patients with positive breast ultrasound and without a subsequent biopsy, 26 (59%) had a follow-up breast ultrasound to assess for stability. 20 (77%) did not show a significant change and 5 (19%) had decreased or resolved findings. One (4%) 18-year-old patient had a mass that increased in size after a two-year follow-up and underwent a needle biopsy that was positive for a fibroadenoma – the patient was 20 years old at the time of the procedure. \u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMalignant breast masses in post puberal children are exceedingly rare, with no cases of primary or secondary breast malignancy reported in the current sample. Multiple studies have reported a low prevalence of malignant breast masses in children and adolescents ranging between 0\u0026ndash;1% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the incidence of primary breast malignancy in patients younger than 25 years has been reported to be 3.2 per million, with four cases of primary breast cancer in the 20\u0026ndash;24-year age group[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similarly, Surveillance Epidemiology and End Results (SEER) data from 2006 to 2010 report an incidence rate of \u0026lt;\u0026thinsp;0.2/100,000 in patient younger than 19 years of age[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThelarche is the onset of pubertal breast development between 8 to 13 years of age[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The hormones estrogen and progesterone stimulate ductal and lobular growth in the breast, which leads to an increased incidence of estrogen-sensitive lesions such as fibroadenomas and, in theory, primary breast cancer[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the prevalence of primary breast malignancies remains extremely low and is limited to children with inherited genetic mutations, such as BRCA 1 and 2, and secondary to treatment of childhood malignancies, such as high-dose mantle radiation for Hodgkin lymphoma[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Metastasis is a rare cause of malignant breast lesions in children, seen mostly with rhabdomyosarcomas, non-Hodgkin lymphoma, and leukemia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, out of two patients with history of childhood malignancy in our sample, no patients presented with findings of a breast metastasis.\u003c/p\u003e \u003cp\u003eFibroadenomas are the most common solid breast lesions in children, accounting for 70% of the lesions in this sample. Fibroadenomas are estrogen-sensitive and may grow rapidly during puberty and pregnancy with a reported prevalence up to 94% of breast masses in adolescents[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These lesions have a typical sonographic appearance as an oval or round circumscribed mass with variable posterior acoustic enhancement, and vascularity, and can be multiple due to hormonal influence[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The management of fibroadenomas depends on the growth rate and sonographic appearance. Findings with a typical clinical and sonographic appearance may prefer ultrasound surveillance instead of biopsy, given the risk of iatrogenic injury to the developing breast [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, surgical excision can be considered if the lesion is symptomatic or if there are concerning features (namely, size\u0026thinsp;\u0026gt;\u0026thinsp;2.5\u0026ndash;5 cm, rapid growth) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although fibroadenomas are benign, a complex fibroadenoma variant has been suggested to increase the risk for developing breast cancer[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePhyllodes tumors (6%) and papilloma (2%) are the only lesions found in this study sample with the potential to be malignant. Although Phyllodes tumor has been reported as less that 1% of all pediatric breast masses, it constitutes the most common primary breast malignancy in children [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Phyllodes tumors present as a painless, rapidly enlarging breast mass with a sonographic appearance indistinguishable from a fibroadenoma. Some authors recommend obtaining a core biopsy for a lesion with a typical appearance for a fibroadenoma if it measures between 3\u0026ndash;5 cm and referral to a surgeon for excision if it measures\u0026thinsp;\u0026gt;\u0026thinsp;5 cm [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Phyllodes tumors can be classified histologically as benign, borderline, and malignant, with a reported 5\u0026ndash;24% prevalence of malignant phyllodes tumors in children[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, the current study population did not report any cases of malignant phyllodes. There were only benign (71%) and borderline (29%) variants. Papilloma is a benign proliferation of ductal epithelium that is treated with surgical excision due to its risk of subsequent carcinoma[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These lesions typically present clinically with clear or bloody nipple discharge. Ultrasound shows a solid intraductal mass with increased vascularity[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSonographic surveillance for solid breast lesions is a feasible and safe management option, in the absence of rapid growth, large size approaching or above 5 cm, or suspicious imaging features for invasive carcinoma. Patients with a classic appearing benign lesion on ultrasound or a biopsy-proven benign lesions should be educated to seek re-evaluation in case of rapid growth of the known lesion or development of new symptoms, such as nipple discharge. Our sample showed that in patients who had a needle biopsy followed by an excisional biopsy, 8 patients were upgraded from a benign diagnosis to one with the potential to be malignant (7 from fibroadenoma to Phyllodes tumor, and 1 from PASH to papilloma). Rapid growth or unilateral nipple discharge are clinical presentations that should raise concern for a malignant entity, regardless of the sonographic appearance or the needle biopsy result. Of note, our cohort showed that most discordant pathology results between a needle and excisional biopsy are benign (84%). Similarly, most findings assessed by sonographic surveillance either remained unchanged (77%) or resolved/decreased (19%).\u003c/p\u003e \u003cp\u003eBased on the results of the current study and those in the recent literature, the authors advocate for increased use of ultrasound not only in the initial review of breast complaints in the pediatric population but also in the follow-up and surveillance of imaging given the low likelihood of malignancy[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Ultrasound guided biopsy may provide definitive diagnosis, whenever indicated. However, education of patients and family, appropriate reassurance, and clear communication between providers may ultimately reduce the use of image guided procedures and surgical interventions in this age group. The current study has several limitations. First, this is a retrospective study and confounders, such as the decision to undergo biopsy or sonographic surveillance, were not controlled for. Second, our sample was limited to a non-pediatric tertiary hospital. Given the rarity of primary and secondary malignant breast lesions, a larger sample from different institutions may be needed to further characterize the variety of possible breast masses that can be seen in children. For example, a sample from a pediatric hospital with a large pediatric oncology clinic may report a higher percentage of malignant breast masses. Third, 80% of the study sample population had complete medical records by the breast clinic. For the remaining 20%, some clinical information, such as indication or risk factor assessment for breast cancer, was not available. Finally, our sample only included postpubescent patients based on age.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, the prevalence of malignant pediatric breast masses is exceedingly low. Lesions with the potential to be malignant are uncommon, and diagnosis should be suspected based on the clinical presentation and ultrasound appearance. Sonographic surveillance and patient education are feasible and safe management approaches in most adolescent breast mass cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCAB collected the data, analyzed the data, and prepared the manuscriptVPT collected the dataIDG revised and edited the manuscriptPG revised and edited the manuscriptTC revised and edited the manuscriptSH revised and edited the manuscriptTV revised and edited the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRestrepo R, Cervantes LF, Swirsky AM, Diaz A Breast development in pediatric patients from birth to puberty: physiology, pathology and imaging correlation, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00247-021-05099-4/Published\u003c/span\u003e\u003cspan address=\"10.1007/s00247-021-05099-4/Published\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarper LK, Simmons CL, Woodard GA, Solanki MH, Bhatt AA (Jan. 2023) Pictorial Review of Common and Uncommon Pediatric Breast Lesions. 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17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e237 girls (99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eIndication\u003c/p\u003e\n \u003cp\u003ePalpable mass\u003c/p\u003e\n \u003cp\u003ePain and palpable mass\u003c/p\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003cp\u003eNipple discharge\u003c/p\u003e\n \u003cp\u003ePain and skin changes\u003c/p\u003e\n \u003cp\u003eUnavailable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e159 (65%)\u003c/p\u003e\n \u003cp\u003e22 (9%)\u003c/p\u003e\n \u003cp\u003e6 (3%)\u003c/p\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003cp\u003e47 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHistory of malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 Retinoblastoma/osteosarcoma\u003c/p\u003e\n \u003cp\u003e1 Anaplastic astrocytoma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFamily history of breast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e24 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eGenetic mutation/syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e3 (1%)\u003c/p\u003e\n \u003cp\u003e1 BRCA 1\u003c/p\u003e\n \u003cp\u003e2 Cowden syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePositive ultrasound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e237 (99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eLaterality\u003c/p\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e117 (49%)\u003c/p\u003e\n \u003cp\u003e102 (43%)\u003c/p\u003e\n \u003cp\u003e18 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eNumber of masses (mean and range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e1 (1 \u0026ndash; 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSize in cm (mean and range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e2.9 cm (0.6 \u0026ndash; 11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eIntraductal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e4 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eBiopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e193 (82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Frequency and percentage of final diagnosis with and without a biopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 287px;\"\u003e\n \u003cp\u003eFinal diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 229px;\"\u003e\n \u003cp\u003eBiopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 108px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eFibroadenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e133 (69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e35 (74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e168 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eHamartoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e25 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e25 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003ePhyllodes tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e14 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e14 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003ePapilloma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e4 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eComplicated cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eNodular adenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eAxillary mammary tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003ePASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eFibroepithelial lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eGynecomastia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eSuspicious mass\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eAccessory breast tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eRuptured epidermal inclusion cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eBenign fibroadipose tissue vs hamartoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eNodular fasciitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003ePASH and fibrocystic changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eNon-diagnostic\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eRuptured cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eFat Necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eInflamed fibrocystic tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eLactating adenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (\u0026lt;1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e193 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e47 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e240 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 624px;\"\u003e\n \u003cp\u003eNote: PASH = Pseudoangiomatous stromal hyperplasia, \u0026dagger; Two patients had suspicious masses on the ultrasound, however, they were lost on follow-up. \u0026Dagger; Biopsy was not diagnostic, and the patient had clinical follow-up instead.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6771168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6771168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e: Breast masses in the puberal children are uncommon. Ultrasound is the first modality of choice to evaluate for breast masses in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOBJECTIVE:\u003c/strong\u003e To evaluate the frequency and etiology of breast masses in puberal children with ultrasound.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS:\u003c/strong\u003e A single institution, institutional review board–approved, retrospective study was performed including 13- to 18-year-old patients who had a breast ultrasound from January 1990 to December 2024. Clinical information and the ultrasound results were collected. Ultrasound were considered positive or negative if it explained the patients concern. Tissue sample was determined by the patient and ordering physician. Pathology results and follow-up ultrasounds were recorded as well. Descriptive analysis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e: 240 patients (237 girls) were included with a mean age of 13 years. The most common indication was a palpable mass (65%). 237 ultrasounds were positive (99%), 193 patients had a biopsy (80%). The most common diagnoses were fibroadenoma (69%), hamartoma (13%), and phyllodes tumor (7%). No primary or secondary breast malignancies were identified. 26 patients with a positive ultrasound and without a biopsy underwent sonographic surveillance, 20 patient had unchanged findings and 5 had decreased/resolved findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e: The prevalence of malignant pediatric breast masses is exceedingly low. Lesions with the potential to be malignant are uncommon, and diagnosis should be suspected based on the clinical presentation and ultrasound appearance. Sonographic surveillance and patient education are feasible and safe management approaches in most adolescent breast mass cases.\u003c/p\u003e","manuscriptTitle":"Frequency of breast lesions in pubertal children with ultrasound evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 10:24:42","doi":"10.21203/rs.3.rs-6771168/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3046f67c-9632-4e23-8d67-c5b7a7f51ce9","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-03T05:38:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 10:24:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6771168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6771168","identity":"rs-6771168","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}