Correspondence Clinical Letter
Clinical letter Axillary Accessory Breast Tissue – Case Report and Review of Literature
DOI: 10.1111/ddg.12285
Dear Editors, Polymastia is a rare condition of the breasts, affecting approximately 2–6% of all women and 1–3% of all men. Onethird of the affected individuals have more than one area of accessory breast tissue [1]. Two women presented to a dermatological outpatient clinic complaining about lumps in their axilla. The first patient was a 25-year-old woman who had noticed for 2 years a lump in her right axilla which restricted free motion. She assumed it was a lymph node. Clinical examination revealed a soft, movable 4 × 4 cm nodule. Sonographic examination revealed a soft tissue mass without increased perfusion. The second patient was a 40-year-old woman who complained of intermittent bilateral axillary pain, which had first o ccurred following bilateral subcutaneous curettage of the axillary sweat glands in 2009. The patient noticed menstrual-cycle-related swelling and discomfort. Small moveable subcutaneous soft tissue masses were palpable in both axillae (Figure 1). Sonographic examination suggested the nodules resembled orthotopic mammary tissue (Figure 2). Clinical differential diagnostic considerations included lipoma or lymphadenopathy. In the second patient, postoperative changes such as adipose tissue necrosis, foreign body granuloma or connective tissue fibrosis had to be considered. Sonographic examination led to the suspected diagnosis of ectopic mammary tissue. Because the nodules caused discomfort and to confirm the diagnosis, we recommended surgical removal in both cases. The affected tissue was excised in the first women. In the second, only a deep excisional biopsy was performed for diagnostic clarification. Histologically the specimens from both patients revealed multiple excretory ducts and acini of apocrine glands within a partially fibrotic connective tissue in a configuration typical of mammary tissue (Figure 3). Diagnosis of ectopic mammary tissue was confirmed. Acccessory breasts are an anomaly in which parts of the embryonic mammary ridge persist. The embryonic milk line arises ontogenetically, from epidermal thickenings during the first month of embryonic development; they condense at the beginning of the second embryonic month to form the mammary ridges. These extend bilaterally from the axilla to the groin. Initially a number of glands develop, all of which,
except for one located in the mid-thoracic region, degenerate at the beginning of the third embryonic month. The remaining gland forms the primordium of the latter mammary gland [2, 3]. Persistence of other parts of the mammary ridge may lead to polythelia (accessory nipple) or polymastia (accessory mammary gland). Polymastia may occur as glandular (mamma aberrata) or complete polymastia (mamma accessoria) [2]. Glandular polymastia or accessory mammary tissue features an isolated parenchymal mass without a mamilla, usually located in proximity of the breast, but potentially also in the axillary, vulvar, inguinal or other areas [2, 4, 5]. The ectopic mammary tissue is present from birth, and usually becomes symptomatic under the influence of the sexual hormones during puberty, pregnancy or lactation. Patients complain of a menstrual cycle-dependent tissue swelling, discomfort and restriction of movement, but also of cosmetic problems [4]. Sonographic examination is the key diagnostic method, showing hypoechoic septate tissue in analogy to orthotopic mammary tissue. Ultrasonographic examination serves to rule out differential diagnoses such as lymphadenopathy or lipoma [6]. In the literature, reports about familial incidence as well as a coincidence with cardiovascular or renal anomalies, kidney tumors or trisomia 21 are found [2, 4, 7]. Although those associations have not been proven, sonographic examination of the abdomen is recommended for diagnostic follow-up. Ectopic mammary tissue undergoes the same physiological and pathological changes as does the orthotopic mammary gland. Among those are benign (mastitis, fibroadenoma, hamartoma) as well as malignant (carcinoma) developments [1, 4, 8, 9]. The main complication is carcinoma, of the breast, which accounts for 0.3% of all mammary carcinomas [10]. Histologically, these are mostly not otherwise specified (NOS) carcinomas (72%), followed by
Figure 1 Clinical presentation: a slight swelling is noticeable in the right axilla.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014
1
Correspondence Clinical Letter
In conclusion, the differential diagnosis of subcutaneous soft tissue tumors of the axilla should include aberrant mammary tissue. Complete surgical excision of the aberrant tissue may be carried out to avoid a source of potential malignancy.
Marta Kogut, Mona Bidier, Alexander Enk, Jessica C. Hassel Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
Conflict of Interest None. Correspondence to Figure 2 Sonography: Hyperechoic gland tissue, analogous pattern as orthotopic mammary gland tissue.
Dr. med. Jessica Hassel Universitäts-Hautklinik Heidelberg Ruprecht-Karls-Universität Heidelberg Im Neuenheimer Feld 440 69115 Heidelberg E-mail: [email protected]
References 1
Figure 3 Histology: multiple acini of apocrine glands in a configuration that is typical for mammary tissue (hematoxylin-eosin staining, 5× magnification).
lobular-invasive and medullary carcinomas. Their prognosis is the same as that of the equivalent carcinomas of orthotopic mammary tissue. Some reports suggest potentially higher rates of lymph node metastasis at the initial diagnosis [10]. Therefore, some authors recommend a prophylactic total excision of the affected tissue [2, 5, 6], while others recommend biopsy to rule out malignancy for patients >40 years of age [1]. The decision regarding surgical removal should consider all potential risks [4].
2
Gentile P, Izzo V, Cervelli V. Fibroadenoma in the bilateral ccessory axillary breast. Aesthetic Plast Surg 2010; 34: 657–9. a 2 Giggel S, Schier F. Axilläre Mamma aberrata – eine Fallbeschreibung und Literaturübersicht. Klin Pädiatr 1999; 211: 473–5. 3 Sadler T. Medizinische Embryologie. Die normale menschliche Entwicklung und ihre Fehlbildungen, 10. Auflage, Thieme-Verlag, Stuttgart, 2003: 385–6. 4 Alghamdi H, Abdelhadi M. Accessory breasts: when to excise? Breast J 2005; 11(2): 155–7. 5 Patel PP, Ibramim AHS, Zhang J et al : Accessory breast tissue. Eplasty 2012; 12: ic5. 6 Ritter L, Sorge I, Till H, Hirsch W. Accessory breast tissue (mamma aberrata) as a rare differential diagnosis of soft tissue swelling in the axilla. Rofo 2013; 185(1): 74–5. 7 Aughsteen AA, Almasad JK, Al-Muhtaseb MH. Fibroadenoma of the supernumerary breast of the axilla. Saudi Med J 2000; 21(6): 587–9. 8 Madej B, Balak B, Winkler I, Burdan F. Cancer of the accessory breast – a case report. Adv Med Sci 2009; 54(2): 308–10. 9 Mukhopadhyay M, Saha AK, Sarkar A. Fibroadenoma of the ectopic breast of the axilla. Indian J Surg 2010; 72(2): 143–5. 10 Visconti G, Eltahir Y, Van Ginkel RJ et al. Approach and management of primary ectopic breast carcinoma in the axilla: where are we? A comprehensive historical literature review. J Plast Reconstr Aesthet Surg 2011; 64(1): e1–11.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014
Clinical letter Axillary Accessory Breast Tissue – Case Report and Review of Literature
DOI: 10.1111/ddg.12285
Dear Editors, Polymastia is a rare condition of the breasts, affecting approximately 2–6% of all women and 1–3% of all men. Onethird of the affected individuals have more than one area of accessory breast tissue [1]. Two women presented to a dermatological outpatient clinic complaining about lumps in their axilla. The first patient was a 25-year-old woman who had noticed for 2 years a lump in her right axilla which restricted free motion. She assumed it was a lymph node. Clinical examination revealed a soft, movable 4 × 4 cm nodule. Sonographic examination revealed a soft tissue mass without increased perfusion. The second patient was a 40-year-old woman who complained of intermittent bilateral axillary pain, which had first o ccurred following bilateral subcutaneous curettage of the axillary sweat glands in 2009. The patient noticed menstrual-cycle-related swelling and discomfort. Small moveable subcutaneous soft tissue masses were palpable in both axillae (Figure 1). Sonographic examination suggested the nodules resembled orthotopic mammary tissue (Figure 2). Clinical differential diagnostic considerations included lipoma or lymphadenopathy. In the second patient, postoperative changes such as adipose tissue necrosis, foreign body granuloma or connective tissue fibrosis had to be considered. Sonographic examination led to the suspected diagnosis of ectopic mammary tissue. Because the nodules caused discomfort and to confirm the diagnosis, we recommended surgical removal in both cases. The affected tissue was excised in the first women. In the second, only a deep excisional biopsy was performed for diagnostic clarification. Histologically the specimens from both patients revealed multiple excretory ducts and acini of apocrine glands within a partially fibrotic connective tissue in a configuration typical of mammary tissue (Figure 3). Diagnosis of ectopic mammary tissue was confirmed. Acccessory breasts are an anomaly in which parts of the embryonic mammary ridge persist. The embryonic milk line arises ontogenetically, from epidermal thickenings during the first month of embryonic development; they condense at the beginning of the second embryonic month to form the mammary ridges. These extend bilaterally from the axilla to the groin. Initially a number of glands develop, all of which,
except for one located in the mid-thoracic region, degenerate at the beginning of the third embryonic month. The remaining gland forms the primordium of the latter mammary gland [2, 3]. Persistence of other parts of the mammary ridge may lead to polythelia (accessory nipple) or polymastia (accessory mammary gland). Polymastia may occur as glandular (mamma aberrata) or complete polymastia (mamma accessoria) [2]. Glandular polymastia or accessory mammary tissue features an isolated parenchymal mass without a mamilla, usually located in proximity of the breast, but potentially also in the axillary, vulvar, inguinal or other areas [2, 4, 5]. The ectopic mammary tissue is present from birth, and usually becomes symptomatic under the influence of the sexual hormones during puberty, pregnancy or lactation. Patients complain of a menstrual cycle-dependent tissue swelling, discomfort and restriction of movement, but also of cosmetic problems [4]. Sonographic examination is the key diagnostic method, showing hypoechoic septate tissue in analogy to orthotopic mammary tissue. Ultrasonographic examination serves to rule out differential diagnoses such as lymphadenopathy or lipoma [6]. In the literature, reports about familial incidence as well as a coincidence with cardiovascular or renal anomalies, kidney tumors or trisomia 21 are found [2, 4, 7]. Although those associations have not been proven, sonographic examination of the abdomen is recommended for diagnostic follow-up. Ectopic mammary tissue undergoes the same physiological and pathological changes as does the orthotopic mammary gland. Among those are benign (mastitis, fibroadenoma, hamartoma) as well as malignant (carcinoma) developments [1, 4, 8, 9]. The main complication is carcinoma, of the breast, which accounts for 0.3% of all mammary carcinomas [10]. Histologically, these are mostly not otherwise specified (NOS) carcinomas (72%), followed by
Figure 1 Clinical presentation: a slight swelling is noticeable in the right axilla.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014
1
Correspondence Clinical Letter
In conclusion, the differential diagnosis of subcutaneous soft tissue tumors of the axilla should include aberrant mammary tissue. Complete surgical excision of the aberrant tissue may be carried out to avoid a source of potential malignancy.
Marta Kogut, Mona Bidier, Alexander Enk, Jessica C. Hassel Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
Conflict of Interest None. Correspondence to Figure 2 Sonography: Hyperechoic gland tissue, analogous pattern as orthotopic mammary gland tissue.
Dr. med. Jessica Hassel Universitäts-Hautklinik Heidelberg Ruprecht-Karls-Universität Heidelberg Im Neuenheimer Feld 440 69115 Heidelberg E-mail: [email protected]
References 1
Figure 3 Histology: multiple acini of apocrine glands in a configuration that is typical for mammary tissue (hematoxylin-eosin staining, 5× magnification).
lobular-invasive and medullary carcinomas. Their prognosis is the same as that of the equivalent carcinomas of orthotopic mammary tissue. Some reports suggest potentially higher rates of lymph node metastasis at the initial diagnosis [10]. Therefore, some authors recommend a prophylactic total excision of the affected tissue [2, 5, 6], while others recommend biopsy to rule out malignancy for patients >40 years of age [1]. The decision regarding surgical removal should consider all potential risks [4].
2
Gentile P, Izzo V, Cervelli V. Fibroadenoma in the bilateral ccessory axillary breast. Aesthetic Plast Surg 2010; 34: 657–9. a 2 Giggel S, Schier F. Axilläre Mamma aberrata – eine Fallbeschreibung und Literaturübersicht. Klin Pädiatr 1999; 211: 473–5. 3 Sadler T. Medizinische Embryologie. Die normale menschliche Entwicklung und ihre Fehlbildungen, 10. Auflage, Thieme-Verlag, Stuttgart, 2003: 385–6. 4 Alghamdi H, Abdelhadi M. Accessory breasts: when to excise? Breast J 2005; 11(2): 155–7. 5 Patel PP, Ibramim AHS, Zhang J et al : Accessory breast tissue. Eplasty 2012; 12: ic5. 6 Ritter L, Sorge I, Till H, Hirsch W. Accessory breast tissue (mamma aberrata) as a rare differential diagnosis of soft tissue swelling in the axilla. Rofo 2013; 185(1): 74–5. 7 Aughsteen AA, Almasad JK, Al-Muhtaseb MH. Fibroadenoma of the supernumerary breast of the axilla. Saudi Med J 2000; 21(6): 587–9. 8 Madej B, Balak B, Winkler I, Burdan F. Cancer of the accessory breast – a case report. Adv Med Sci 2009; 54(2): 308–10. 9 Mukhopadhyay M, Saha AK, Sarkar A. Fibroadenoma of the ectopic breast of the axilla. Indian J Surg 2010; 72(2): 143–5. 10 Visconti G, Eltahir Y, Van Ginkel RJ et al. Approach and management of primary ectopic breast carcinoma in the axilla: where are we? A comprehensive historical literature review. J Plast Reconstr Aesthet Surg 2011; 64(1): e1–11.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014
