A Breast Mass in a 5-Month-Old Girl
A 5-month-old girl presented with her mother for a concern of a hard bump under the infant’s right breast. The girl had a past medical history of hydrocephalus with subsequent repair, as well as epilepsy, eczema, and gastrostomy tube placement. The patient’s mother stated that she had noticed this bump over the past 3 weeks. The mother denied fever in the girl or warmth at the bump site and had not seen any discharge from the breast. The mother does not believe that the girl has pain at the breast when it is touched.
Physical examination revealed a palpable mass at the right breast (Figures 1 and 2). The right breast felt harder than the left and was nontender to palpation. There was no warmth, discoloration, or redness at the site.
The patient underwent chest radiography and chest ultrasonography, the results of which are shown in Figures 3 and 4, respectively.
What’s causing this breast bump?
A. Thelarche
B. Fibroadenoma
C. Scoliosis
D. Hemorrhagic cyst
Answer: Scoliosis
A 5-month-old girl presented with her mother for a concern of a hard bump under the infant’s right breast. The girl had a past medical history of hydrocephalus with subsequent repair, as well as epilepsy, eczema, and gastrostomy tube placement. The patient’s mother stated that she had noticed this bump over the past 3 weeks. The mother denied fever in the girl or warmth at the bump site and had not seen any discharge from the breast. The mother does not believe that the girl has pain at the breast when it is touched.
Physical examination revealed a palpable mass at the right breast (Figures 1 and 2). The right breast felt harder than the left and was nontender to palpation. There was no warmth, discoloration, or redness at the site.
The patient underwent chest radiography and chest ultrasonography. Radiographs of the infant’s chest showed moderate S-shaped rotoscoliosis of the thoracolumbar spine related to segmentation-fusion anomalies in the lower thoracic spine (Figure 3). The radiographs also revealed a short right eighth rib, which accounted for the palpable prominence under the right breast. No acute abnormalities were visible in the chest.
Chest ultrasonography (Figure 4) showed that the palpable right breast mass appeared to be related to a prominence of the underlying rib, likely a result of the patients’ congenital spinal and rib deformities. No soft tissue mass was present in the breast.
The patient was referred to an orthopedic spine specialist, who recommended observation and delaying surgical intervention until the patient reached 5 years of age.
The differential diagnosis of a breast mass in a child includes unilateral thelarche, fibroadenoma, breast abscess, metastatic disease, and hemorrhagic cysts.1 Nonpathologically enlarged lymph node, galactocele, and mammary duct ectasia also are possible.2
The workup of a breast mass in a child begins with a full physical examination, looking for fluctuance and nipple discharge or drainage. The next step is breast ultrasonography, which typically is diagnostic. In our patient’s case, chest imaging revealed the cause of the bump under the breast to be a short eighth rib secondary to congenital scoliosis.
Congenital scoliosis with rib anomalies progresses most rapidly during the early infancy, followed by late infancy, and adolescence.3 Because of this pattern of growth, surgical intervention often is postponed until later in childhood. Surgical management of congenital scoliosis includes posterior hemivertebra resection, hemiepiphysiodesis/in situ fusion, or instrumented fusion without resection.4
Maryam Shambayati, DO, is a first-year pediatrics gastroenterology fellow at the University of Oklahoma at Oklahoma City.
Michelle S. Barratt, MD, MPH, is a professor of pediatrics at the University of Texas Health Science Center at Houston, Texas.
References
1. West KW, Rescorla FJ, Scherer LR III, Grosfeld JL. Diagnosis and treatment of symptomatic breast masses in the pediatric population. J Pediatr Surg. 1995;30(2):182-187.
2. Weinstein SP, Conant EF, Orel SG, Zuckerman JA, Bellah R. Spectrum of US findings in pediatric and adolescent patients with palpable breast masses. Radiographics. 2000;20(6):1613-1621.
3. Kawakami N, Tsuji T, Yanagida H, et al. Radiographic analysis of the progression of congenital scoliosis with rib anomalies during the growth period. ArgoSpine News J. 2012;24(1-2):55-61.
4. Yaszay B, O’Brien M, Shufflebarger HL, et al. Efficacy of hemivertebra resection for congenital scoliosis: a multicenter retrospective comparison of three surgical techniques. Spine (Phila Pa 1976). 2011;36(24):2052-2060.