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5 August, 2019 00:00 00 AM

Breast anomalies –an experience

Prof. Dr. Hafizuddin Ahmed
Breast anomalies –an experience

Mammals are provided with mammary glands. Breast exist in the female as well as male (though in rudimentary state). It secret milk and is an accessory gland of the reproductive system. In fact it is a modified sweat gland lying in superficial fascia (except the axillary tail of Spence which pierces deep fascia) extending vertically from second to sixth rib in mid axillary line (i.e almost opposite to scapula which extends vertically from second to seventh rib on the back) and transversely as level of fourth costal cartilage from side of sternum to almost mid axillary line (anterior axillary line).

It is separated from pectoral fascia by retro-mammary space and remains anchored to fascia by suspensory ligaments of Astley Cooper.

The main purpose of breast is to provide nutrition in the form of milk to new born but the modern female use this organ as a sex symbol to attract the opposite sex. But if a woman possesses more than two breasts does she become more attractive? Definitely not.

The goat, sheep, cow, elephant and mare have an udder surmounted by teats. Lower mammals give birth to many offspring in a litter have five to six pairs of breasts. Lioness, sea-cow, whales and apes like human have one pair only. Possessing more than two breasts or polymazia is a very rare congenital anomaly and an interesting clinical curiosity. Usually when it occurs there are accessory nipples only.

The following reports described in case no. 1 and no. 2 are of women one of whom had six breasts and the other had three breasts like lower mammals. In the first case one of the four extra breasts was fully developed and functioning. This was first time I saw a case with anomaly like this in my long clinical life. Case reports no. 3 and 4 depict other anomalies of breast.

Breast develop from ectodermal thickening called Milk Ridge, Mammary Ridge or line of Schultz at sixth week of intrauterine life. The Milk Ridge or line extends from axilla to groin and sometimes even thigh i.e from base of forelimb to the region hind limb as a band like thickening of epidermis.

Except a small portion in thoracic region major part of milk line disappears shortly afterwards. Here it penetrates underlying mesoderm and form 16-24 epithelial sprouts which in turn give rise to solid out budding. They are canalized. Sprouts form lactiferous ducts and out buddings form small ducts and alveoli.

Lactiferous ducts open into epithelial pit which later forms nipple (15 ducts open at the summit of the nipple) i.e nipple is everted by the growth of the underlying mesenchyme. If there is disturbance of growth it may give rise to retracted nipple. The gland is ectodermal and the stroma is mesodermal.

It has already been told that normally only a small portion of Milk Ridge persists in the mid thoracic region and the rest disappears. If whole Milk Ridge disappears it leads to amastia or amazia. Sometimes other fragments persist giving rise usually to polythelia or accessory nipples and rare cases fully developed accessory mammary glands.

Case No. 1

A 22 year old wife of a Libyan solder presented in May 1987 complaining of progressive swelling in the right axilla which produced a discharge that caused her need to change her blouse frequently.

On examination she was apparently in good health, well nourished and lactating. Her breasts were slightly engorged. She was found to have four cystic swellings – two on each side – in a line starting from the upper and outer quadrant of the both breasts to the floor of the axilla of the respective sides.

The lower one on the right side was fully developed breast with areola and nipple and was discharging milk on expression. The others were small, of the size of the nuts and looked like enlarged lymph glands except the skin covering them was dark.

On inquiry it was learned that the larger one produced milk when suckled (reflex oxytocin release) and all the swellings increased in size during her pregnancy. No other abnormalities were found.

The patient – a conservative Muslim Arab woman – very naturally refused to be photographed, and also refused any surgery. As she wished breast feed her baby, she was given Stilboesterol 10 mg, followed by 5 mg TDS for five days which reduced tension in the extra breast tissues and stopped the milk ejection but did not inhibit her normal lactation. The patient was very happy to have extra mammary swellings significantly reduced within a week.

Case No. 2

While working as a Surgical Specialist in HQ. Bangladesh Rifles Hospital, a 22 year old wife of sepoy presented in September 1992 with complains of ugly swelling in the left axilla.

There was no discharge or pain. On examination the swellings had the size of a big potato, non tender, freely mobile and soft in inconsistency. From the out door G.D.M.O. diagnosed it as a case of lipoma. But on the operation table it was suspected as a case of polymazia and confirmed after operative removal by me and Lt. Col. Badar Ahmed. The patient happily returned home with normal axilla.

Case No. 3

A 8 year old healthy girl reported to me in 2005 along with her worried father who was an engineer by profession with the complains of “tumour” on the chest. It was not accompanied by any pain or discomfort.

On examination the girl was apparently healthy with average height for her age and yet to develop pubic hair or menarche. There was a soft non tender swelling on the right pectoral region at the site of breast. On the left side the nipple and areola were very rudimentary. She had no palpable glands or fever.

The swelling was diagnosed as breast. The guardian was assured and counseling was done. He was asked to wait and report when the other breast develops. She was prescribed no medicine or hormones except vitamins. After 7 months the guardian happily reported the growth of the other breast. This was a unique case of psudomonomazia.

Case No. 4

While working in Libyan Armed Forces, a wife of a Libyan army officer aged 27 years reported to me with complains of inverted nipple on the right side which she noticed since her puberty. She had issues who suckled the normal breast. She tried many local remedies and even underwent surgical treatment in Garynus University Teaching Hospital, Benghazi, Libya but her problem did not solved.

On examination she was a young lady in good health and well nourished. Her both breasts were normal in size and contour except she had retracted nipple on the left side. She had no other problems.

As the retraction of the nipple was since her puberty, so question of malignancy was omitted. Retraction is of cardinal importance only if it recent when it indicates there is fibrosis due to malignancy (or inflammatory). Sometimes it is due to chronic abcess with a blocked duct having a lump in the breast.

 A lump in the breast with a long standing retraction also points towards carcinoma. In this case this was a congenital anomaly. Since all possible treatments (common surgery done is Ashford’s operation) failed so the author designed a hand made pump by two 10 cc plastic syringes in the following manner:

The piston of one of the syringe was removed and the open end of the body of the syringe was put over the retracted nipple. The nozzle of the syringe was connected to the nozzle of the other syringe by a piece of rubber tubing (collected from infusion set) and suction was applied by the second syringe.

The nipple which failed to evert even after surgery suddenly propt up but again went inside when the suction was stopped. The patient was taught to repeat the endeavor twice a day at home. After six months the nipple became almost normal. This type of treatment is first of its kind and not mentioned in any medical textbook.

Studies of the above cases shows that breast anomalies are not rare in our society. Many women hide it till their marriage have been arranged or sometimes still later when they face problems during lactation as in our first case. Amazia or complete absence of breast seldom occurs.

Sometimes only one breast may be present. Scanzoni has observed absence of left mamma with absence of left ovary. Our third case was not real case of monomazia although she presented with one breast thinking it as a tumour.

We must remember the sequence of breast development i. e Thelerche (beginning of breast development)          Puberche (development of pubic hair: in 60% after 8 years)         Menerche (onset of menstruation). Micromazia is not rare and associated with genital problems.

In some indigenous negroes and bushman tribe breasts generally become so abnormally large and pendulous that these can be easily folded over shoulder. Polymazia or more than two breasts though rare Anne Boleyn, the wife of Henry VIII of England suffered from it. She had three breasts with six toes and six fingers.

Leichtenstern, who collected 70 cases of polymazia in females and 22 males, thinks that accessory breast or nipples are due to atavism and that our most remote inferiorly organized ancestors had many breasts, but that by constantly bearing but one child, from being polymastic, females have gradually become bimastic. Greatest number of accessory breasts reported is that of Neugebauer in 1886 who found ten in one person. However my first case of six breasts with one functioning seems to be unique in nature.

It should be remember that polymazia must be distinguished from lipoma or other tumours of the milk line region.

Besides self examination of the breast with the pulp of the fingers (not palm of the hand) during bath the girls should be taught regarding normal growth of the breast in the school so that they can themselves detect any anomalies which help them to get treatment at an earlier stage. (Reprint)

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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