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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 04-July-2008, Vol 121 No 1277

Accessory breast tissue presenting as a large pendulous mass in the axilla: a diagnostic dilemma
Rashesh Solanki, Dilip B Choksi, Dipesh D Duttaroy
Abstract
Accessory breasts are an uncommon entity. They may present as asymptomatic masses or cause symptoms such as pain or restriction of arm movements. They may prove to be a diagnostic challenge if found in locations along or outside the mammary line. We report a case of an ectopic accessory breast presenting as a large pendulous mass in the axilla which proved to be a diagnostic dilemma. Excision biopsy was diagnostic.

Ectopic mammary tissue appears in humans owing to an incomplete embryologic regression of the mammary ridges. They are thus located most frequently along the mammary line extending from axilla to pubic region. The same pathology that affects normally positioned breasts, including carcinoma, can occur in ectopic mammary tissue.
Enlargement of ectopic accessory breast tissue occurs commonly during hormonal stimulation as in pregnancy or lactation and they can then prove to be a diagnostic challenge.

Case report

A 30-year-old Asian Indian female presented with a large pendulous swelling in the left axilla (Figure 1) of 3 years duration; 2 weeks after delivering a stillborn child in her third pregnancy.. It had appeared during the first trimester of her second pregnancy but remained static in size until her third confinement, when the swelling grew to its present dimensions. During her second pregnancy the swelling decreased after each breastfeeding session.
Examination revealed a large pendulous swelling in the left axilla ,15×10 cm in size, that was firm, mobile, pigmented with skin free from the underlying tissue. Clinically, a diagnosis of an enlarged accessory breast was arrived at with an intent to rule out other pathologies of the normal breast.
Differential diagnosis included neurofibroma and galactocoele. The swelling was excised under general anaesthesia. Histopathology revealed accessory breast tissue with lactational changes. The postoperative course remained uneventful.

Figure 1. Accessory breast tissue: mass in the axilla


Discussion

Accessory breasts occur in 0.4–6% of women.1 They may present as asymptomatic masses or cause pain, restriction of arm movement, cosmetic problems, or anxiety.1 Commonly accessory breasts are bilateral. Aberrant breast tissue is usually present along the milk line above or below the normal breast location and result due to incomplete embryologic regression of mammary ridges. Occasionally, they are found in unusual locations, such as the axilla, scapula, thigh, and labia majora.2 Ectopic breast tissue usually becomes noticeable only after hormonal stimulation, usually during puberty, pregnancy, or lactation.
Accessory breast tissue, presenting as palpable thickenings in the axilla, can undergo monthly premenstrual changes, such as tenderness and swelling and irritation from clothing. Accessory tissue may range from a subcutaneous focus of breast tissue to a full accessory breast complete with areola and nipple. When nipple and areola are absent, the diagnosis becomes exceedingly challenging. It may also be a diagnostic challenge, as other benign and malignant lesions occur in this area.3 Interestingly, soft tissue sarcoma (malignant fibrous histiocytoma) have also been reported.4
Mammographic and sonographic findings include masslike density that is identical to that of the normal breast parenchyma in the axilla.5 Fine needle aspiration is a useful tool.
Ectopic breast tissue is subject to the same pathologic events that occur in normally positioned breasts. Indeed, there have been reports of fibroadenomas6 and even cancer developing in the accessory breast.7,8 Excision of ectopic axillary breast tissue may be required for diagnosis, treatment of symptoms, or cosmesis2 and is the definitive treatment for the above mentioned indications. However, according to a report, complications after removal of accessory breast are not uncommon. These include incomplete removal of the accessory breast, poor scar, and intercostobrachial nerve injury. Hence conservative treatment may be considered especially for asymptomatic cases.1 Liposuction may be a feasible alternative in selected cases.1

Conclusion

Accessory breast in the axilla may prove to be a diagnostic dilemma and this entity must be kept in mind while dealing with swellings in the axilla. The former enlarge upon hormonal stimulation during puberty, pregnancy or lactation. Excision is usually required for symptomatic cases but liposuction may be an alternative mode of therapy.
Author information: Rashesh Solanki, Senior Resident; Dilip Choksi, Associate Professor; Dipesh D Duttaroy, Associate Professor; Department of Surgery, Government Medical College & Sir Sayajirao General Hospital, Baroda, Gujarat, India
Correspondence: Dr Rashesh Solanki, Department of Surgery, Government Medical College & Sir Sayajirao General Hospital, Baroda, Gujarat, India 390001. Email: raseshsolanki@yahoo.co.in
References:
  1. Down S ,Barr L Baildam AD, Bundred N. Management of accessory breast tissue in the axilla. Br J Surg. 2003;90(10):1213–4.
  2. Lesavoy MA, Gomez-Garcia A, Nejdl R, et al. Axillary breast tissue: clinical presentation and surgical treatment. Ann Plast Surg. 1995;35(4):356–60.
  3. Velanovich V. Ectopic breast tissue, supernumerary breasts, and supernumerary nipples. South Med J. 1995;88(9):903–6.
  4. Son E, Park J, Jeon H, Cho S. Malignant fibrous histiocytoma (MFH) in axilla. Yonsei Med J. 2004;45:736.
  5. Kim HS, Cha ES, Kim HH, Yoo JY. Spectrum of sonographic findings in superficial breast masses. J Ultrasound Med. 2005;24(5):663–80.
  6. Conde DM, Torresan RZ, Kashimoto E, et al. Fibroadenoma in axillary supernumerary breast: case report. Sao Paulo Med J. 2005;123(5):253–5.
  7. Markopoulos C, Kouskos E, Kontzoglou K, et al. Breast cancer in ectopic breast tissue. Eur J Gynaecol Oncol. 2001;22(2):157–9.
  8. Aviles Izquierdo JA, Martinez Sanchez D, Suarez Fernandez R, et al. Pigmented axillary nodule: carcinoma of an ectopic axillary breast. Dermatol Surg. 2005;31(2): 237–9.
     
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