(Radiographics. 2000;20:1613-1621.)
© RSNA, 2000
Spectrum of US Findings in Pediatric and Adolescent Patients with Palpable Breast Masses1
Susan P. Weinstein, MD,
Emily F. Conant, MD,
Susan G. Orel, MD,
Julia A. Zuckerman, MD and
Richard Bellah, MD
1 From the Department of Radiology, Division of Breast Imaging, University of Pennsylvania Medical Center, 1 Silverstein Bldg, 3400 Spruce St, Philadelphia, PA 19104 (S.P.W., E.F.C., S.G.O., J.A.Z.); and the Department of Radiology, Children's Hospital of Philadelphia, Pa (R.B.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received March 21, 2000; revision requested April 14 and received May 31; accepted June 1. Address correspondence to S.P.W.
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Abstract
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Palpable breast masses arising in pediatric and adolescent patients are uncommon. A careful physical examination should be performed first, followed by an ultrasonographic evaluation when a suspect mass is present. In this study population, palpable findings were all due to benign causes, which is concordant with the literature. Benign causes included gynecomastia, cyst, fibroadenoma, lymph node, galactocele, duct ectasia, and infection. Though extremely rare, breast malignancies do occur in the pediatric and adolescent population.
Index Terms: Breast, abscess, 00.212 • Breast, cysts, 00.721 • Breast, diseases, 00.70 • Breast, ducts, 00.711, 00.714 • Breast, male • Breast, US, 00.1298 • Breast neoplasms, male, 00.30 • Breast neoplasms, US, 00.1298
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- List the stages of normal breast development.
- Describe the different entities in pediatric and adolescent patients that manifest as palpable breast masses.
- Recognize the imaging findings of both benign and suspect breast masses in this patient population.
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Introduction
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Palpable breast masses are uncommon in the pediatric and adolescent population. Because of heightened awareness of breast cancer in women, a breast lump in a child or adolescent may alarm both the parent and the child. Overwhelmingly, the cause is benign, with only 0.2% of primary breast cancers occurring in this age group (1,2). Although the cause may be benign, additional medical attention is needed in certain situations such as in cases of infections or rapidly enlarging masses.
In this article, we review normal breast development and provide the imaging findings from our retrospective review of cases of pediatric and adolescent patients with palpable breast findings, which include gynecomastia, cyst, fibroadenoma, lymph node, galactocele, duct ectasia, and infection.
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Pediatric and Adolescent Patients
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The radiology databases of a children's hospital and a large university teaching hospital were searched for pediatric and adolescent patients aged 019 years with palpable breast abnormalities seen from January 1996 through December 1998. We reviewed the medical records and images in all the cases. The breast masses in all patients were evaluated with directed ultrasonographic (US) examinations. We correlated the US findings and the pathologic results.
Sixty-four patients (four male and 60 female patients; age range, 7 months to 19 years; mean age, 15.6 years) presented with palpable breast masses. The findings at US examination are presented in the Table. Of the 24 solid masses (diameter range, 6 mm to 10 cm), 14 were treated with surgery and 10 were followed up. Clinical follow-up was also prescribed for the patients with negative US scans (no focal abnormality), changes due to normal breast development, gynecomastia, and benign findings such as cysts, lymph node, and duct ectasia. US-guided aspiration was performed in the case of galactocoele, and surgical debridement was performed for the breast abscess. None of the cases in our series was malignant.
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Breast Development
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The precursor to the human breast originates early in embryonic life at about 6 weeks. The "milk line" develops from ectodermal elements and extends from the axillary area to the groin region. Portions of the milk line atrophy except in the region of the fourth intercostal space, from which mammary tissue develops. When the appropriate portions of the milk line do not regress, accessory breast tissue or accessory nipples develop (3).
Breast development begins during adolescence, with the surge of coordinated interactions of many hormones. Estrogen is the hormone primarily responsible for ductal development. The influence of progesterone is needed for lobuloalveolar development (3). Thelarche, the appearance of the breast bud, begins with the onset of puberty (mean age, 9.8 years). Premature breast development is defined as breast development before the age of 8 years. The lack of development before age 13 years is considered delayed (4). The Tanner grading system (3) is commonly used to describe the stages of breast development (Fig 1).
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Figure 1a. Tanner stages of breast development. (a) Stage I, preadolescent, the nipple elevates. (b) Stage II, the breast bud develops. The breast tissue and nipple arise as a single mound of tissue. (c) Stage III, the single mound enlarges. (d) Stage IV, a secondary mound develops, with the nipple and areola projecting above the breast tissue. (e) Stage V, the areola regresses to form a smooth contour with the rest of the breast tissue.
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Figure 1b. Tanner stages of breast development. (a) Stage I, preadolescent, the nipple elevates. (b) Stage II, the breast bud develops. The breast tissue and nipple arise as a single mound of tissue. (c) Stage III, the single mound enlarges. (d) Stage IV, a secondary mound develops, with the nipple and areola projecting above the breast tissue. (e) Stage V, the areola regresses to form a smooth contour with the rest of the breast tissue.
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Figure 1c. Tanner stages of breast development. (a) Stage I, preadolescent, the nipple elevates. (b) Stage II, the breast bud develops. The breast tissue and nipple arise as a single mound of tissue. (c) Stage III, the single mound enlarges. (d) Stage IV, a secondary mound develops, with the nipple and areola projecting above the breast tissue. (e) Stage V, the areola regresses to form a smooth contour with the rest of the breast tissue.
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Figure 1d. Tanner stages of breast development. (a) Stage I, preadolescent, the nipple elevates. (b) Stage II, the breast bud develops. The breast tissue and nipple arise as a single mound of tissue. (c) Stage III, the single mound enlarges. (d) Stage IV, a secondary mound develops, with the nipple and areola projecting above the breast tissue. (e) Stage V, the areola regresses to form a smooth contour with the rest of the breast tissue.
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Figure 1e. Tanner stages of breast development. (a) Stage I, preadolescent, the nipple elevates. (b) Stage II, the breast bud develops. The breast tissue and nipple arise as a single mound of tissue. (c) Stage III, the single mound enlarges. (d) Stage IV, a secondary mound develops, with the nipple and areola projecting above the breast tissue. (e) Stage V, the areola regresses to form a smooth contour with the rest of the breast tissue.
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Adolescent patients may have a "breast mass" that represents the normal developing breast bud. Confounding the situation, breast development may be asymmetric, and the more developed side may be perceived as a "lump." US interrogation over the palpable area shows normal tissue without a discrete mass lesion (Figs 2, 3). Surgical excision must be avoided in these patients because iatrogenic amastia results if the breast bud is excised.
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Figure 2. Developing breast bud mistaken for a right breast mass in an 8-year-old girl. US scan shows breast tissue in the subareolar location (*) that is hypoechoic relative to the fat (straight arrow). The pectoralis muscle (curved arrow) lies posterior to the fat.
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Figure 3a. Premature thelarche in a 7-month-old female infant. US scans of the right (a) and left (b) breasts show tissue in the subareolar regions. Development of the breast buds is asymmetric, greater in a than in b. In a, * indicates the pectoralis muscle, and the arrow indicates a rib. Premature thelarche is a benign condition that usually manifests in the first 2 years of life. There should be no other associated signs of secondary sexual characteristics.
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Figure 3b. Premature thelarche in a 7-month-old female infant. US scans of the right (a) and left (b) breasts show tissue in the subareolar regions. Development of the breast buds is asymmetric, greater in a than in b. In a, * indicates the pectoralis muscle, and the arrow indicates a rib. Premature thelarche is a benign condition that usually manifests in the first 2 years of life. There should be no other associated signs of secondary sexual characteristics.
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To optimize visualization of the breast tissue, a linear-array high-megahertz transducer should be used. For evaluation of superficial lesions, use of a standoff pad or a generous mound of acoustic coupling gel to substitute for a standoff pad is helpful.
Normal US findings in children prior to thelarche are subcutaneous tissue with linear planes of the pectoralis muscle posteriorly. Subcutaneous fat demonstrates heterogeneous echotexture in a healthy 5-month-old female infant (Fig 4). The ribs may also be seen as hypoechoic masses with associated shadowing, but they should not be mistaken for breast masses because they lie posterior to the pectoralis muscle. When breast development starts, the breast bud appears as retroareolar tissue that is hypoechoic relative to the fat (Fig 5). In a healthy 11-year-old girl (Fig 6), fat is hypoechoic with linear echogenic planes of connective tissue through the breast. In a healthy 17-year-old girl (Fig 7), the glandular tissue is echogenic relative to the hypoechoic fat. This appearance mimics the breast tissue in an adult.
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Figure 5. Asymmetric breast development in a 9-year-old girl. US scans of both breasts show tissue in the subareolar regions bilaterally, more prominent on the left side (L) than on the right side (R). Asymmetric development was mistaken for a left breast mass at clinical examination.
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Breast Masses
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Gynecomastia
US findings suggestive of gynecomastia were seen in three male adolescents, who underwent US owing to clinical concern based on physical examination. Gynecomastia has peak frequencies at three times: in the neonatal period, during adolescence, and in elderly men (5). In the neonatal period, gynecomastia is due to influences from maternal estrogens across the placenta. During puberty, the peak frequency occurs at about age 13–14 years and as many as 60% of male adolescents are affected (5). US findings in patients with gynecomastia demonstrate breast tissue in the subareolar palpable area (Fig 8). This appearance mimics the US findings of early breast development in female adolescents. Once a careful clinical evaluation has excluded a pathologic cause, gynecomastia in a male adolescent typically resolves within months to 2 years (4). Reassurance should be provided for these patients.
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Figure 8a. Gynecomastia in an 11-year-old boy. (a) US scan directly over the palpable area in the left breast shows hypoechoic tissue in the subareolar region. (b) US scan of the right breast shows a similar appearance, although the hypoechoic tissue is less prominent. Findings are suggestive of bilateral gynecomastia.
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Figure 8b. Gynecomastia in an 11-year-old boy. (a) US scan directly over the palpable area in the left breast shows hypoechoic tissue in the subareolar region. (b) US scan of the right breast shows a similar appearance, although the hypoechoic tissue is less prominent. Findings are suggestive of bilateral gynecomastia.
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Cyst
Cysts may occur in any age group, although they most commonly occur between the ages of 30 and 50 years (6). US is an ideal noninvasive method for differentiating solid from cystic masses. Cysts arise from the lobule caused by dilation of the lobular acini, which is believed to result either from obstruction of the duct leading to the lobule or an imbalance of fluid secretion and resorption (6). As in the adult population, cysts in pediatric and adolescent patients may be simple or complex and vary widely in size (Fig 9).
Fibroadenoma
Fibroadenomas are the most common solid breast masses excised in the pediatric and adolescent population (4) (Figs 10, 11). Classically, fibroadenomas are mobile nontender breast masses (4). US scans show the classic benign features of a fibroadenoma: a well-circumscribed hypoechoic mass that may be oval, round, or macrolobulated. Other features of benign solid masses at US include three or fewer circumscribed lobulations, well-circumscribed margins, and horizontal growth greater than vertical growth (7). The diameter commonly ranges from 2 to 3 cm or less, although some may grow considerably larger (1). The term "giant fibroadenoma" is reserved for fibroadenomas that are 10 cm or more in diameter (6).
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Figure 10. Fibroadenoma in an 18-year-old woman who presented with a newly palpable breast mass in the right breast. US scan reveals a well-circumscribed oval hypoechoic mass. Diagnosis was made with core needle biopsy.
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Figure 11a. Fibroadenoma in a 10-year-old girl. (a) US scan of the left breast shows a solid homogeneous mass. (b) Gadolinium-enhanced MR image of the same breast reveals a mass with internal septations consistent with a giant fibroadenoma, which was confirmed at excisional biopsy. A second smaller fibroadenoma is located inferior to the palpable one. Given the size of the first mass, the differential diagnosis would include juvenile fibroadenoma and cystosarcoma phyllodes.
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Figure 11b. Fibroadenoma in a 10-year-old girl. (a) US scan of the left breast shows a solid homogeneous mass. (b) Gadolinium-enhanced MR image of the same breast reveals a mass with internal septations consistent with a giant fibroadenoma, which was confirmed at excisional biopsy. A second smaller fibroadenoma is located inferior to the palpable one. Given the size of the first mass, the differential diagnosis would include juvenile fibroadenoma and cystosarcoma phyllodes.
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Lymph Node
Lymph nodes are most commonly located in the lateral breast, primarily in the upper outer quadrant (8). A hilar notch or a fatty hilum should be visible to make the diagnosis (Fig 12). Normal intramammary lymph nodes are usually less than 1 cm in diameter (9). A nonpathologically enlarged lymph node in the axilla may vary in size depending on the size of the fatty hilum.
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Figure 12. Small palpable lymph node in the left breast in a 15-year-old girl. US scan obtained directly over the palpable area shows an 8-mm-long hypoechoic mass with an echogenic center. Although the lymph node is small, its superficial location made it easy to palpate.
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Galactocele
Galactoceles, which occur during lactation or shortly after breast-feeding is stopped, are usually caused by an obstructed milk duct. At mammography, galactoceles may appear as an indeterminate mass, unless the classic fat-fluid level is seen. Even if the fat-fluid level is not seen, a benign finding can be determined if the fat can be identified with the mass. US may show a complex mass. The case in our study involved a young woman with a palpable breast mass who had recently given birth (Fig 13). The diagnosis was made on the basis of the clinical history and aspiration, which yielded a milky substance.
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Figure 13a. Palpable galactocele in a 19-year-old woman 4 months after giving birth. US scans of the left breast show a complex mass spanning 5.5 cm. There also were multiple dilated tubular structures filled with echogenic material representing dilated milk-filled ducts. Given the clinical history and imaging findings, the complex mass was believed to be a galactocoele. The patient subsequently underwent aspiration, which yielded milky fluid.
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Figure 13b. Palpable galactocele in a 19-year-old woman 4 months after giving birth. US scans of the left breast show a complex mass spanning 5.5 cm. There also were multiple dilated tubular structures filled with echogenic material representing dilated milk-filled ducts. Given the clinical history and imaging findings, the complex mass was believed to be a galactocoele. The patient subsequently underwent aspiration, which yielded milky fluid.
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Duct Ectasia
Duct ectasia most commonly affects the subareolar ducts but may also involve the smaller peripheral ducts. US shows tubular anechoic structures or ducts filled with debris (Fig 14), and there may be associated nipple discharge. Duct ectasia may manifest as a painful and/or palpable area, or the process may be asymptomatic and apparent only at imaging evaluation. The cause is not clear.
Infection
Mastitis may occur in the puerperal or nonpuerperal state. The two most common organisms are staphylococci and streptococci (10). Infections are believed to arise from breaks in the skin surface that allow the bacteria to enter the breast tissue. Puerperal or lactational mastitis may occur in the epidemic or sporadic pattern. The epidemic pattern typically occurs in the hospital setting in nursing mothers. If an abscess occurs in the subareolar location, incision and drainage with appropriate antibiotic therapy usually eradicate the infection without sequellae (10).
Nonpuerperal mastitis may occur in the subareolar location or peripherally in the breast. The nonpuerperal subareolar infection is difficult to eradicate and may be indolent with recurrence, but the peripheral infection is not as resistant to treatment (10). Patients at risk for peripheral infections may have predisposing conditions such as steroid use or diabetes (10).
Clinically, patients may present with a focal area of tenderness with associated erythema and induration. US should be performed in such patients to help identify a potential abscess collection that needs to be drained (Fig 15).
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Figure 15. Breast abscess in a 19-year-old woman with a tender palpable area in the right breast and clinical signs and symptoms of an infection. US scan shows a superficial fluid collection with debris. Surgical incision and drainage were performed.
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Malignancies
Malignancies in the pediatric and adolescent population are extremely rare. Potential malignancies in such patients may be either primary breast cancers or metastatic disease from another primary lesion. Primary breast cancer in patients younger than 25 years is exceedingly rare (1). Metastatic disease to the breast occurs late in the course of a malignancy. Rhabdomyosarcoma, nonHodgkin lymphoma, and leukemia are the most common primary tumors to metastasize to the breast in young patients (11). A malignant breast mass in this age group is more likely to be metastatic from a nonbreast origin than a primary breast cancer (12).
As in the adult population, masses should be considered suspect if they have irregular, angular, or microlobulated margins; demonstrate posterior acoustic shadowing; or exhibit vertical growth that is greater than horizontal growth (7). A rapidly enlarging mass should also be clinically suspect, although benign masses such as fibroadenomas may also grow over time. In a child or adolescent, especially those with a known history of a primary malignancy other than breast, enlargement of even a circumscribed solid mass should be viewed with caution because metastasis to the breast may manifest in this fashion (1). Chateil et al (11) describe a variety of appearances for metastatic disease. Some lesions are well circumscribed, but others exhibit more suspect features, such as posterior acoustic shadowing and vertical growth greater than horizontal growth. Among metastatic lesions, the most common US feature is heterogeneous echotexture (11).
None of the patients in our population had a malignant mass.
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Conclusions
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In the pediatric and adolescent population, the literature and our results show that benign findings are overwhelmingly the most common cause of symptomatic breast abnormalities. A careful physical examination with clinical follow-up and US help the evaluation of patient symptoms. Reassurance should be provided for both the patients and parents in cases of benign findings at both clinical examination and US. When US scans are negative, however, the level of clinical concern should guide management. Given the overwhelmingly benign causes, surgery should be the last resort and reserved for only lesions that enlarge or have highly suspect features.
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Footnotes
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See also the article by Garcia et al (pp 1605–1612)
in this issue.
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References
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Simmons PS. Diagnostic considerations in breast disorders of children and adolescents. Obstet Gynecol Clin North Am 1992; 19:91-102.[Medline]
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Bower R, Bell MJ, Ternberg JL. Management of breast lesions in children and adolescents. J Pediatr Surg 1976; 11:337-346.[Medline]
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Osborne M. Breast development and anatomy. In: Harris JR, Lippman ME, Morrow M, Hellman S, eds. Diseases of the breast. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1996; 1-14.
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Davis AJ, Kulig JW. Adolescent health update: adolescent breast disorders. Am Acad Pediatr 1996; 9:1-8.
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Braunstein G. Gynecomastia. In: Harris JR, Lippman ME, Morrow M, Hellman S, eds. Diseases of the breast. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1996; 54-60.
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Kopans D. Pathologic, mammographic, and sonographic correlation In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 511-615.
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Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196:123-134.[Abstract/Free Full Text]
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Kopans D. Anatomy, histology, physiology, pathology In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 3-24.
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Kopans D. Imaging analysis of breast lesions. In: Harris JR, Lippman ME, Morrow M, Hellman S, eds. Diseases of the breast. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1996; 71-83.
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Tanabe K. Duct ectasia, periductal mastitis, and infections. In: Harris JR, Lippman ME, Morrow M, Hellman S, eds. Diseases of the breast. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1996; 49-53.
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Chateil JF, Arboucalot F, Perel Y, et al. Breast metastasis in adolescent girls: US findings. Pediatr Radiol 1998; 28:832-835.[Medline]
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Boothroyd A, Carty H. Breast masses in childhood and adolescence: a presentation of 17 cases and a review of the literature. Pediatr Radiol 1994; 24:81-84.[Medline]
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Abstract
LEARNING OBJECTIVES
