|Year : 2015 | Volume
| Issue : 4 | Page : 235-238
Bilateral aberrant axillary breasts in puerperium
Karen G Minoza1, Habila U Na'aya1, Wadinga D Wadinga2, Bukar Bunu3
1 Department of Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
2 Department of Surgery, Federal Medical Center, Yola, Nigeria
3 Department of Orthopaedics and Trauma, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
|Date of Web Publication||21-Jan-2016|
Dr. Karen G Minoza
Department of Surgery, University of Maiduguri Teaching Hospital, PMB 1414, Maiduguri
Source of Support: None, Conflict of Interest: None
Ectopic breast tissue (EBT) is rare with a reported incidence of 0.4-6% worldwide, the commonest site being the axilla. It results from incomplete regression of the embryonic mammary ridges that extend bilaterally from the axillae to the groins, and may be associated with other clinical syndromes. EBT comprises accessory breasts, in which there is an accessory nipple, areola, or both, with or without glandular tissue, and aberrant breast tissue, in which the ectopic glandular tissue is without a nipple or areola. Aberrant breast tissue may remain asymptomatic until menarche, pregnancy, or lactation, when it responds to hormonal fluctuation. Diagnosis is important as EBT is subject to all pathologies of the normal breast, including cancer. We present the case of a 38-year-old multipara with bilateral aberrant axillary breasts noted only during her last pregnancy who had excision of the masses in the puerperium.
Keywords: Aberrant, accessory breasts, axilla, puerperium
|How to cite this article:|
Minoza KG, Na'aya HU, Wadinga WD, Bunu B. Bilateral aberrant axillary breasts in puerperium. Arch Int Surg 2015;5:235-8
| Introduction|| |
Ectopic breast tissue (EBT) is relatively rare, with a reported incidence of 0.4-6%,  resulting from the incomplete regression of the embryonic mammary ridges that extend bilaterally from the axillae to the groins. The commonest site is the axilla , but it may occur anywhere along this "milk line," and at sites as distant as the face, neck, vulva, perineum, and posterior thighs, , and can present diagnostic challenges. EBT responds to hormonal influences and its diagnosis is important as it is subject to all pathologies of the breasts, from mastitis, abscesses, fibroadenoma, fibrocystic disease, Phyllodes tumor, and cancer.
| Case Report|| |
A 38-year-old woman, para 7, 2 weeks postpartum presented with 6 months' history of painless bilateral axillary swellings, which gradually increased in size. There was spontaneous ulceration at the summit of the larger left-sided mass 2 months earlier. She had never noticed similar swellings in her previous pregnancies or during her menstrual period. There were no other similar swellings elsewhere and there was no family history of breast cancer. Physical examination revealed symmetrical pendulous lactating breasts, which were grossly normal. There were bilateral pear-shaped, axillary masses without a nipple or areola complex [Figure 1] and [Figure 2]. The left-sided mass was larger (30 × 20 × 8 cm), warm to touch, tender, soft and mobile with two ulcers inferiorly. The larger ulcer measured about 15 × 12 cm, with sloping edge, necrotic tissue on the floor, and no contact bleeding [Figure 3]. There was tender, firm, and discrete ipsilateral axillary lymphadenopathy. The smaller, right axillary mass was not warm, nontender, with intact skin, and no axillary lymphadenopathy. There were no significant findings on the review of the other systems. A clinical diagnosis of bilateral aberrant axillary breasts in puerperium, with septic focal ulceration of the left axillary breast was made.
|Figure 1: Preoperative photograph showing the pendulous lactating breasts and the bilateral axillary masses, with a dressing on the left axillary mass|
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|Figure 2: With the patient's arms raised, the right axillary breast is demonstrated to have no nipple or areola, thus called aberrant breast tissue. The left axillary mass is dressed|
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|Figure 3: Preoperative photograph showing the lactating breasts, the right axillary breast, and the ulcerated inferior aspect of the left axillary mass, just before redressing|
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Mammography, breast sonography, and fine-needle aspiration cytology (FNAC) of the right axillary mass could not be performed due to logistic reasons. Wound swab of the ulcer yielded Staphylococcus aureus. She had wound dressing, antibiotics, and subsequent excision biopsy of both axillary masses under general anesthesia. Histology of both masses showed proliferating breast lobules in keeping with lactation, with no features of malignancy [Figure 4] and [Figure 5]. Her postoperative period was uneventful. Unfortunately, she was lost to follow-up.
|Figure 4: Photomicrograph of accessory breast tissue showing inactive areas exhibiting apocrine and cystic changes in a fibroelastic stroma. There is no evidence of malignancy. H and E ×100|
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|Figure 5: Photomicrograph of breast tissue with active areas showing glands lined by double-layered epithelium with apical snout, consistent with lactational change. There is no evidence of malignancy. H and E ×200|
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| Discussion|| |
Accessory breast tissue is defined as "residual breast tissue that persists from normal embryological development."  Also known as EBT, it has been found in up to 6% of the population ,, and is commoner in women.  By the fifth week of gestation, bilateral ectodermal thickenings, the mammary ridges, extend from the axillae to the groins, forming the "milk line." These normally regress but for those in the pectoral region, which become the breasts. Failure of any portion of the mammary ridge to involute results in EBT, varying in its components of nipple, areola and glandular tissue.  Most occur sporadically but there have been reports of autosomal dominant inheritance with incomplete penetrance. , Accessory breasts may be indicators of other congenital anomalies, particularly of the urinary system. , It is commoner in Asians, with a high incidence in the Japanese compared to Caucasians. ,
Terminology has not been standardized in the literature as of yet.  EBT is an umbrella term referring to both supernumerary breasts and aberrant breast tissue. In 1915, Kajava  classified supernumerary breasts into eight classes. , Class 1 is called "polymastia," consisting of a complete breast with nipple, areola, and glandular tissue. Class 2 has glandular tissue, nipple but no areola. Class 3 has glandular tissue with an areola. Class 4 is glandular tissue only. Class 5 contains a nipple and areola only and is termed "pseudomamma." Class 6 consists of just a nipple (polythelia) and Class 7 has just an areola. Class 8 consists of just a patch of hair, and is called "polyethelia pilosa." In the classification of EBT by Copeland and Geschickter,  accessory nipple or areola formation, or both, with or without glandular tissue, is termed supernumerary or accessory breasts as opposed to aberrant breast tissue, which refers to ectopic glandular tissue without a nipple or areola complex. In contrast to supernumerary breasts, aberrant breast tissue lacks the organized secretory systems. ,,,
The commonest clinical manifestation is class 4, which is fibroglandular tissue, commonly seen in the axilla. ,, However, EBT can occur anywhere along the milk line, and has been reported at sites as distant as the face, neck, vulva, perineum, and posterior thighs. ,, Aberrant axillary breast tissue is frequently bilateral,  and is distinct from the axillary tail.  EBT may present as a small, asymptomatic subcutaneous mass, or may cause symptoms of heaviness, pain, or restriction of arm movements. Aberrant breast tissue may become more evident only during menarche, pregnancy, or lactation as it responds to hormonal fluctuations, and can present a diagnostic challenge. Various diagnoses include excess axillary fat, lipoma, lymphatic malformation, lymphadenitis, hidradenitis suppuritiva, and sebaceous cysts. ,, It is commonly mistaken for a lipoma and diagnosis is made only after excision biopsy, as was the case reported by Dauda.  Our patient only noticed the enlarging axillary masses in her last pregnancy, and presented in the puerperium after the left side had ulcerated and had gotten infected, which is most likely the reason she eventually sought medical treatment. Lakkawar  reported a similar case of a small axillary breast noted in puerperium, which regressed spontaneously.
Primary ectopic breast carcinoma is uncommon, with more than 70% occurring at the axilla.  While conflicting reports remain on whether aberrant tissue is at more risk for malignant change compared to normal breasts, ,, the close proximity of axillary breast tissue to the axillary lymph nodes, its unpredictable lymphatic drainage  as well as the delay in its diagnosis is considered contributory to a worse prognosis. Ductal carcinoma is the most frequent (79%) subtype of primary ectopic breast cancer ,, followed by medullary and lobular carcinomas.  Cystosarcoma phyllodes and extramammary Paget's disease have also been reported. , These malignancies are diagnosed by triple assessment in the same manner as breast cancer, using mammography and sonography, and pathologically using FNAC and excision biopsy. Sentinel lymph node biopsy also has a role, especially for those in the axilla.
Most presentations are for cosmetic reasons, and treatment is by surgical excision or liposuction in benign conditions. Liposuction is particularly more suitable for small, subcutaneous masses, with less scar formation. Excision of large axillary masses may result in unsightly scars and even alteration in lymphatic drainage. Although our patient did not develop postoperative seroma, it would have been curious to monitor her subsequently had she not been lost to follow-up.
Malignant lesions require surgical management and lymph node evaluation, in line with current treatment recommendations for tumor, node, and metastasis (TNM)-classified breast cancers.  As EBT is at risk of developing any benign or malignant condition that can develop in the normal breast, a high index of suspicion, early diagnosis, and treatment are pertinent to reduce the chances of misdiagnosis, especially of cancer.
We acknowledge Dr. Abba Bukar Zarami of the Department of Histopathology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria for providing assistance with the photomicrographs.
Financial support and sponsorship
Conflicts of interest
We also declare no conflicts of interest for this manuscript.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]