 Now these are the abnormal masses that arise from breast tissue so you may see cysts, simple cysts, fibrocystic breast disease in the peripubertal girls, you may see ductile ectasia, sometimes we see infection like mastitis or abscess, the fat tissue may give rise to lipoma or trauma related fat necrosis and you may see fibroidinoma in the adolescent girls. But just to again highlight that all these conditions are benign so pediatric age group has almost nil susceptibility for malignancy. So this is a case of an 11-year-old girl with nipple discharge as you can see that there are these dilapid glands below the nipple areola complex. You can see here that she is 11-year-old but her tanner stage has reached almost four of five there is a well-developed branching pattern so she is a pubertal girl and these dilated ducts are giving rise to the discharge so this was a ducteasia. Now this is a one-year-old girl with history of painful breast enlargement unfortunately I don't have ultrasound images but what we had seen on ultrasound was a very horrific looking mass which was tender and you can see on the which we followed up with MRI which you can see that there is restricted diffusion and low ADC values so this turned out to be a breast abscess but where does a breast abscess in a one-year-old girl come from and this is how these girls little girls develop breast abscesses because of the traditional method of oil massage in India. These dyes typically tend to press and squeeze the baby's nipples which introduces infection and hence they develop breast painful breast masses so this was her MRI which showed a breast abscess. Now this is a 15-year-old girl with a breast mass it's a fairly large well-defined hypoechoic lesion akin to many of the lesions that you all have seen today and this is nothing but a giant fibroidinoma. This is a 16-year-old girl with a soft palpable breast mass again you can see that this is a fibroidinoma but what is atypical about it is that it has these slightly irregular abnormal angular margins. See I want you to notice how this 16-year-old girl has got absolutely mature breast tissue like an adult she's obviously crossed her dana stage 5 and this raises the possibility of an atypical fibroidinoma or a phyloid's tumor and this may be a lesion that you can biopsy. So what is the radiological when you do find fibroidinomas in girls because of the precocious puberty because of the early onset of menar thilarp in our children nowadays we are seeing fibroidinomas even in young girls and it is simply because their breast tissue is already developed so if the fibroidinoma is less than three centimetres you can follow it up at imaging at six and twelve months if it is stable then nothing further needs to be done if it is growing beyond five centimetres or rapidly doubling consider doing a biopsy if the biopsy shows that it is a fibroidinoma then nothing further needs to be done however in the off chance that you think this is a phy that biopsy shows a phyloid's tumor then we must consider excision now this is a 13-year-old male with alstrom syndrome and this is a mass in his right axillary tail and I want you to notice the atypical appearance of this mass which looks somewhere between fatty tissue and glandular tissue so this is a lycogynacomastia and alstrom syndrome is a syndrome in which there is obesity and type 2 diabetes mellitus which gives because of the obesity and increased fat there is increased secretion of leptin which also causes increased estrogen secretion and causes abnormal breast development so in children antecedent history of their conditions their other associated comorbidities is equally important as it is in adults now coming to breast malignancy as I said it is extremely rare in girls less than 20 years and so it is truly out of the prerogative of a pediatric breast imaging even in genetically predisposed girls that is girls who have the BRCA 1 or 2 gene it is never really seen less than 20 years of age and we typically our patients at SRCC are not more than 18 years the only condition in which you may see it a little earlier is if there is a history of prior chest radiation for lymphoma particularly in girls between 10 to 16 years of age then the onset of malignancy would be a minimum of 8 to 10 years later so again they never present in the pediatric age group the only breast malignancy that you may see in pediatric age groups is metastasis from lymphomas, leukemias or neuroblastomas but that even in our pediatric setup where we see more than 1000 lymphomas, leukemias and neuroblastomas we are yet to come across one child with metastasis to the breast so just to sum up what did we learn today breast masses and children any child with a breast mass is 99.99% early breast development in females it is the normal glandular tissue which is developing abnormally early and when you see that quickly look at the pelvis and see whether this is just an isolated premature thelac or whether it is precocious puberty again if the child is between 1 to 3 years it would most likely be an isolated thelac and it would be self-limiting in male the three conditions of breast enlargement are gynacomastia which is glandular tissue, lipomastia which is adipose tissue or a combination of both if you see a mass other than normal breast tissue most likely it is infection or mastitis which will of course have the history of a painful mass or discharge or you will see a benign condition like fibro adenoma which may be a typical fibro adenoma and the only thing that you need to differentiate it from is a phyloids tumor and that is the be all and end all of pediatric breast masses and just to take you through what your breast pediatric breast report should look like so point number one mention the pre pictorial fat thickness point number two mention the tannous stage if any of you in the audience are residents or who are doing breast imaging please click a picture of this slide because it is absolutely the comprehensive what a pediatric breast report should look like then point number three or step three is you take the volume of the nipple subareolar glandular complex which typically is applicable in tannous stage two and beyond if it is a tannous stage one then you can barely see the nipple areola complex so you do not need to measure the volume you only need to measure the pre pictorial fat if it is a tannous stage two and beyond then you have to look for glandular breast tissue which is beyond the nipple complex or beyond the subareola complex and as I mentioned always measure it in three dimensions and write it as the volume in a table format look for any other lesion other than the glandular tissue and if you are seeing premature thelac you are seeing enlarged glandular tissue then even if it is not asked for just quickly screen the pelvis and you so you can give additional information is this an isolated thelac or is there a potential addition of precautious puberty and never ever you use biurads in a pediatric breast report because biurad gives the impression of there being a malignancy which is as I said very rare in pediatric so to conclude you know children are not small adults they need a different approach to diagnosis and treatment you must first know what is the normal imaging features at different stages of development as I showed you the tannous stages and that is the key to make the correct diagnosis in children there are some glands that enlarge in size there are some glands which shrink in size as they grow so we must know the normal development and anatomy of a growing child intervention is only required in limited cases surgery should definitely be avoided as it causes irreparable damage to the breast and hence there is such a strong role of regular radiologic surveillance and I would like to add one point to this never ever use a mammogram in a child only stick to ultrasound and Doppler