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Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease
Maggie L Westfal1, Numa P Perez2, Ya-Ching Hung2
1Department of Surgery, Massachusetts General Hospital, 55 Fruit St., GRB-425, Boston, MA, 02114, USA. mwestfal@partners.org.
Insights
Half of pediatric patients with breast masses underwent unnecessary interventions, with 81.1% of procedures deemed inappropriate. Clinical observation is safe and recommended for benign breast disease in children.
Area of Science:
- Pediatric Surgery
- Oncology
- Radiology
Background:
- Pediatric breast masses are often managed like adult masses, despite differing pathology.
- Clinical observation is increasingly recognized as a safe management strategy for benign pediatric breast conditions.
Purpose of the Study:
- To quantify the clinical appropriateness of managing benign breast disease in pediatric patients.
- To evaluate the necessity of interventions versus observation for pediatric breast masses.
Main Methods:
- A multi-institutional retrospective cohort study analyzed 1,909 pediatric patients (≤19 years) with benign breast disease from 1995-2017.
- Interventions (ultrasound, biopsy, excision) and observation periods (≥90 days) were tracked.
- Pathologic concordance and positive predictive values (PPV) of clinical decisions were assessed.
Main Results:
- Only 54.3% of patients were observed for ≥90 days.
- 81.1% of interventions were unnecessary, with pathology confirming masses safe for observation.
- The PPV of ultrasound-guided decisions was 16.2%, similar to clinical suspicion alone (21.9%).
Conclusions:
- Despite evidence supporting observation, half of pediatric patients experienced interventions within three months.
- A significant majority of invasive procedures were unnecessary based on final pathology.
- A need exists for consensus clinical guidelines for pediatric benign breast disease management, emphasizing observation.
Purpose:
Breast masses in pediatric patients are often managed similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients.
Methods:
A multi-institutional retrospective cohort study was completed between 1995 and 2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions.
Results:
A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p < 0.25) for decisions made on clinical suspicion alone.
Conclusion:
Despite literature supporting an observation period for pediatric breast masses, half of patients had an intervention within three months with one out of ten patients undergoing an invasive procedure within this time frame. Furthermore, 81.1% of invasive interventions were unnecessary based on final pathologic findings. A formal consensus clinical guideline for the management of pediatric benign breast disease including a standardized clinical observation period is needed to decrease unnecessary procedures in pediatric patients with breast masses.
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