Macromastia of pregnancy: A unique presentation of this rare ...

Case Report
Macromastia of pregnancy: A unique presentation of this
rare clinicohistopathological entity
Sarda Anil K, Kulshreshta Vishal N, Bhalla Shweta A, Singh Lakhwinder, Chaturvedi Uma K
Departments of Surgery and Pathology, Maulana Azad Medical College and Lok Nayak Hospital, India.
Address for correspondence: Dr. A.K.Sarda, 27 RPS, Triveni-1, New Delhi - 110017, India. E-mail: aksarda@rediffmail.com
ABSTRACT
The present case is a unique presentation of a patient who developed a small lump in her breast
during her first pregnancy but it was only during her third pregnancy that it increased in size and
became a huge fungating mass. Although, gigantic sizes of this pathologic entity have been reported,
the present case had the involved breast hanging till below the inguinal ligament and required
sling to support the breast. Since the pre-operative diagnosis was suggestive of cystosarcoma
phylloides, no attempt at reconstructive surgery was contemplated.
KEY WORDS
Breast, benign tumour, macromastia
INTRODUCTION
feature of this rare disease was the massive size of the
breast-probably the biggest reported so far.
estational macromastia (syn. Gigantomastia) is
a rare disorder with disproportionate massive
CASE REPORT
Genlargement of one or both breasts that may
or may not undergo spontaneous regression after
A 28 year old pregnant lady presented in her ninth
parturition. Various criteria have been identified to
month of pregnancy with a huge fungating mass in her
differentiate macromastia from simple breast
left breast. On taking a detailed history the patient
enlargement: breast weight exceeding 600 grams and
revealed that she had noticed a small swelling in her
causing discomfort and stretching of the overlying skin
left breast three years previously, which appeared about
causing ulceration.1,2 We present a rare case of a 28
two months into her first pregnancy. There was no
year old patient presenting with a huge fungating mass
change in the size of the lump during the second
in her left breast in the ninth month of her pregnancy.
pregnancy or in between her three pregnancies. This
This patient had a small lump which developed during
swelling started increasing in size after the onset of
her first pregnancy. However, it was only during her
her current pregnancy and had reached its gigantic
third pregnancy that the lump increased in size to a
proportions over nine months. Two months prior to
huge fungating mass requiring surger y. The
admission the overlying skin developed ulcers in the
histopathology of the mastectomy specimen declared
most dependent part of the breast which rapidly
it to be macromastia of pregnancy. The interesting
increased in size. Thereafter the exposed tumour tissue
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Macromastia of pregnancy
underwent necrosis and started sloughing. Due to the
extreme discomfort to the patient because of the large
size and fungation of the large breast, the patient
reported to the hospital during the ninth month of her
pregnancy. The patient had two live issues the eldest
being three years old. She had no past or family history
of breast disease. On examination the patient was very
pale. She had a huge mass in the left breast with the
breast descending almost down to the inguinal region
(Figure 1). The breast measured 35 x 30 x 10 cm. She
required supporting the breast with a sling. There was
fungation on the lower aspect of the breast with
purulent discharge (Figure 2). The breast felt nodular
in consistency. The overlying overstetched skin had a
Figure 1: Photograph of the patient in the supine position demonstrating the
huge size, the large size of the ulcer and the tumour tissue which is seen
few small ulcers with a foul smelling discharge. The
sloughing off.
nipple and areola were oedematous, markedly
stretched out but essentially normal. The ipsilateral
axillar y lymph nodes were not enlarged. The
contralateral breast was normal. The patient’s blood
reports were Hb 7gm/dL with a PCV of 27%, TLC 10,800/
mm3, DLC P78L20 M1E2-1, Blood sugar 90 mg/dL, Blood
urea 20mg/dL, Serum Sodium 140 mmol/L, Serum
Potassium 3.7 mmol/L. Her ECG was within normal
limits and her chest X-ray showed a few patchy
opacities in the right lower zone suggestive of
pneumonitis. Fine Needle Aspiration Cytology of the
breast lump suggested a diagnosis of cystosarcoma
phylloides. With this diagnosis and in view of the
massive size and fungation of the mass, it was decided
to take up the patient for a total mastectomy. However,
the patient deferred surgery till after her delivery. After
delivery of a healthy male baby, the patient was
transfused three units of blood but her general
condition did not improve. She was also unable to get
anesthetic clearance due to a severe lower respiratory
chest infection. In view of the patient’s poor general
condition a decision was made to take up the patient
for a simple mastectomy under local anesthesia. The
simple mastectomy was undertaken with an intercostal
block and local infiltration of 1% lignocaine. During the
surgery there were large vascular channels which
required careful dissection. The blood loss was limited
to 400 ml. The patient developed mild post operative
wound infection which responded to local dressings.
Figure 2: (A) shows markedly expanded lobule due to pregnancy-lactational
Histopathology of the breast specimen showed
changes (H&E X100) while (B) demonstrates cytosol vacuolation indicative
lactational changes, adenosis and periductal as well as
of lactational changes (H&E X400).
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Sarda AK, et al.
diffuse fibrosis (Figure 2a). Acini showed vacuolated
mastectomy.14 Medical management of this condition
inner epithelium. Some lobules showed eosinophilic
has also been discussed extensively. Prolonged
secretions in the dilated lumina (Figure 2b). No features
bromocriptine therapy has been recommended after
of abscess, phylloides tumour or carcinoma were
delivery before planning a surgical reduction.11
present. The final diagnosis was macromastia of
pregnancy.
The present case of unilateral gigantomastia is a
diagnostic dilemma. It had other unusual features like
DISCUSSION
growth over a period of three pregnancies and the
abundant spindled out cells from the fibrous tissue
The incidence of gigantomastia of pregnancy is
which lead to a misdiagnosis of phylloides tumour on
approximately 1:100000 pregnant women.3 The
fine needle aspiration cytology, leaving no choice but
etiology of this condition remains a matter of
to offer mastectomy as the only treatment modality to
speculation with the most common theories supporting
the patient. Under different circumstances even such
hormonal imbalance or end organ hypersensitivity4.
large fungating breast masses may be amenable to
There are some case reports with documented
reduction mammoplasty leaving the patient with a
hyperprolactinemia.3,5 Other reports reveal no
cosmetically acceptable, albeit a nonfunctional breast.
endocrine abnormality6. The possibility of increased
number or increased sensitivity of prolactin receptors
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