CONGENITAL ANOMALIES OF BREAST

Question 1

Virginal mammary hypertrophy

Answer 1

Rare condition characterised by rapid, excessive and unyielding proliferation of one or both breasts in the adolescent years for at least 6 months.

Question 2

Difference between virginal hypertrophy and prepubertal hypertrophy

Answer 2

Virginal hypertrophy occurs a few months after puberty, prepubertal hypertrophy is before puberty and usually bilateral

Question 3

Symptoms of virginal mammary hypertrophy

Answer 3

1. Large breasts (13 to 23 kg)
2. Shoulder and neck pain
3. Bra strap grooving
4. Rashes

Question 4

Examination findings in virginal mammary hypertrophy

Answer 4

1. Breast hypertrophy
2. Tender parenchyma with thin skin and dilated veins.

Question 5

Etiology of virginal mammary hypertrophy

Answer 5

1. Excess local estrogen production
2. Estrogen end-organ sensitivity

Question 6

Differential diagnoses of virginal mammary hypertrophy

Answer 6

1. Fibroadenoma
2. Phyllodes tumor
3. Lymphedema
4. Endocrine conditions
5. Rheumatologic conditions
6. Lymphoma

Question 7

Management of virginal mammary hypertrophy

Answer 7

Medical management - Dydrogesterone, bromocriptine, medroxyprogesterone, tamoxifen
Surgical management - Reduction mammoplasty, mastectomy.

Question 8

Important preoperative counselling points to be made in a case of virginal mammary hypertrophy

Answer 8

1. Recurrence of breast tissue is sevenfold higher following reduction mammaplasty compared to mastectomy.
2. Lactation and aesthetic outcome can be preserved with reduction mammaplasty with preservation of NAC on a vascularised pedicle.
3. Defer reduction mammaplasty until later years of adolescence to reduce risk of recurrence and revision surgery.
4. Rates of breast feeding after careful preservation of subareolar gland with or without reduction mammaplasty - 60%.
5. Operated or non operated groups, 34-39% required supplementation of breast milk.
6. Tamoxifen administration for 4 months - shown to be most effective in retarding breast growth. Use is limited by side effects (hot flashes, venous thrombosis, osteoporosis, endometrial hyperplasia) in pediatric population.

Question 9

Clinical presentation of fibroadenomas

Answer 9

1. Common in adolescents, 75-95% of breast lesions are fibroadenomas
2. Well circumscribed, painless, rubbery, mobile masses of benign connective tissue and epithelial proliferation.

Question 10

What is giant fibroadenoma?

Answer 10

Refers to when tumor is larger than 5 cm in diameter and/or weighs more than 500 g.

Question 11

Features of giant fibroadenoma

Answer 11

1. Large breast mass - well circumscribed, painless, rubbery and mobile
2. Skin changes can occur - severe cases - skin ulceration of overlying tissue
3. Venous dilation

Question 12

Investigations required in giant fibroadenoma management

Answer 12

1. Breast ultrasound - may reveal well circumscribed Avascular mass
2. Fine needle aspiration cytology - confirmation of diagnosis

Question 13

Treatment of fibroadenoma

Answer 13

1. Surgical excision is the choice.
2. Early treatment is necessary to prevent distortion of existing tissue.
3. Remove lesion in the well demarcated plane.
4. To fill in the cavity, tissue rearrangement techniques are required with consideration to the pedicle and nipple perfusion.
5. If malignant phyllodes tumor is diagnosed pathologically, consult surgical oncology or pediatric surgery.

Question 14

Incidence of polythelia

Answer 14

5.6% of male and female patients along the milk lines.

Question 15

Important association of polythelia

Answer 15

Polythelia can be associated with nephrourologic abnormalities - so urinalysis and renal ultrasound is necessary.

Question 16

Treatment of polythelia

Answer 16

Surgical excision via elliptical excision, performed typically performed before puberty.
Delay in treatment - wider incisional pattern as glandular tissue may become involved.

Question 17

Prevalence of Polymastia

Answer 17

1-2% may occur along the embryonic mammary ridges, most commonly in axilla

Question 18

Important association of polymastia

Answer 18

Renal abnormalities

Question 19

What is the difference of polymastia and ectopic breast tissue?

Answer 19

Ectopic breast tissue lies outside the mammary ridges

Question 20

Diagnosis of polymastia

Answer 20

Usually identified after puberty, pregnancy, or lactation and when hormonal influences enlarge the breast tissue.

Question 21

Clinical features of polymastia

Answer 21

May present with discomfort during certain points of menstrual cycle.

Question 22

Treatment of polymastia

Answer 22

Excision of accessory breast tissue and primary closure over a drain as needed.

Question 23

Important consideration if polymastia is left untreated

Answer 23

If surgical excision is forgone, screen for malignancy as breast cancer can occur with the accessory tissue at an equal rate to the natural breast.