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Milk-rejection sign of breast cancer
Milk-Rejection Sign of Breast Cancer
Harry S. Goldsmith,
MD, FACS, Philadelphia,
Pennsylvania
In 1966, I [I] reported on a small number of nursing mothers in whom a malignant tumor of the breast had developed. These patients were of interest because in each case the nursing mother reported the abrupt refusal of the infant to take milk from the breast that subsequently revealed the malignant tumor. The purpose of this paper is to further substantiate this clinical observation. In the mid 1950’s, a lactating mother was seen who reported that her infant had suddenly refused milk from one of the breasts. Subsequently, she detected a mass in the rejected breast which, after a period of patient and doctor delay, was biopsied and proved to be malignant. In the early 1960’s, another lactating mother was seen with the same clinical history, but no connection between these two patients was made until 1964 when a third nursing mother was seen with a clinical history identical to that of the other two patients. It was at this time that the idea first arose of a possible link between an infant’s rejection of breast milk and the presence of a malignant breast tumor. Approximately one year later a fourth woman was seen whose clinical history strongly strengthened the concept of milk rejection and breast cancer and was the basis for the initial report of this clinical observation. The patient was a thirtyeight year old Russian immigrant who had nursed her twenty month old daughter from both breasts From the Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania. Reprint requests should be addressed to Dr Goldsmith, Department of Surgery, Jefferson Medical College, 1025 Walnut Street, Philadelphia. Pennsylvania 19107.
280
since birth. The mother claimed that her child, who had a limited vocabulary, had objected vocally to the palatability of the milk. The patient stated that the infant complained that milk from the rejected breast was “kaka.” At that time I did not understand the meaning of this word and assumed that the child used it as a general term for something that was no good. However, it has subsequently been learned that the term is commonly used in eastern European languages to specify something as being highly objectionable, up to and even including something “fecal in nature.” The mother stated that when the child became drowsy while being nursed, she would attempt to place the nipple of the rejected breast in the child’s mouth, only to have the child awaken and complain of the milk. The mother prevented painful accumulation of milk in the rejected breast by hand pumping. After six weeks of this activity, the patient discovered a mass in the rejected breast which proved to be a malignant tumor when biopsied. Recently, a fifth patient with the milk-rejection sign of breast cancer was seen. The patient was a twenty-two year old gestating woman who noted a mass in the left breast approximately two months before delivery; the obstetrician had felt that it was associated with the pregnancy. After the infant’s birth, the mother nursed the child for two weeks. During this period she noted that the baby objected vigorously to nursing from the left breast. The mother claimed she was aware that the baby sensed something different about the milk that
The American
Journal of Surgery
Milk-Relemon
came from this breast. Believing it might be the nipple of this breast which the infant found distasteful, the mother began to use a breast shield which allowed milk to pass but eliminated nipple exposure to the infant. However, the child continued to refuse milk from this breast. The patient, after two weeks of breast feeding, noted that the mass in the breast had enlarged. This mass proved to be a carcinoma when it was finally biopsied. The factors present that make the milk from a breast containing carcinoma objectionable to the infant remain speculative. The addition of tumor or its breakdown products may influence the milk’s characteristics. Perhaps the tumor blocks milk ducts, causing stasis and localized infection; yet infants can nurse from caked breasts caused by stasis of the ducts. Infection is also difficult to incriminate, since infants are known to nurse from abscessed breasts. If there is unilateral nursing in the presence of an infected breast, it is usually the mother who withholds the involved breast from the infant to prevent painful manipulation. Cancer of the breast in lactating women is relatively rare. The survival rate of women with this tumor is equivalent to that of nonlactating patients, if the malignant lesion has been confined to the breast [2]. Unfortunately, metastatic spread to adjacent axillary lymph nodes has usually occurred by the time of treatment, because of delay. This delay, which Haagensen [3] reports to be four months longer than that of nonlactating patients with breast tumors, is frequently caused by the assumption that a breast mass that develops during pregnancy and lactation is physiologic. It is hoped that awareness of the milk-rejection sign in a nursing mother will alert the physician more quickly to the possibility that neoplastic changes have occurred in a lactating breast, a consideration that could lead to earlier diagnosis and treatment. The presence of a mass in a lactating breast requires the immediate attention of a physician who must determine whether biopsy is indicated. If a lactating mother reports a mass in the breast in the presence of the milk-rejection sign, immediate biopsy appears indicated. Mammography may be
Volume
127.
March
1974
Sgn
of Breast
of value if the milk-rejection sign is seen in a iactating woman who has either multiple or no palpable breast masses. The frequent practice of assuming that all breast masses in a nursing mother are due to the lactational process and :require only watchful waiting for resolution should be condemned. Summary A clinical observation has been made in nursing mothers whose infants rejected milk from a breast in which a malignant mass was subsequently discovered. Addendum Doctor Chester M. Southam. Professor of Medicine and Chief of Medical Oncology at the Jefferson Medical School, recently treated a patient who clearly demonstrates the milk-rejection sign. The patient was a twenty-five year old woman who breast fed her infant from the time of delivery until six weeks postpartum when the infant abruptly refused milk from the left breast. All efforts to induce the child to take milk from this breast failed. One of the methods used by the mother was the application of honey to the nipple of the rejected breast; however, the child merely licked the honey off the nipple and continued to reject the breast. At fifteen weeks postpartum and while the mother was continuing to nurse the infant from the right breast only, she noted a mass in the rejected breast, which prompted her to consult her family physician. Several opinions as to the cause of the breast mass were given by various physicians and the consensus was that the mass was secondary to “plugged ducts.” A consulting surgeon suggested biopsy, which showed infiltrating ductal carcinoma requiring radical mastectomy.
References 19: 1185. sign. Cance/ 1. Goldsmith HS: MilK-rejection 1966. 2. White TT: Prognosis of breast cancer for pregnant and nursing women. Sorg Gynecol Obstet 100: 661, 1955. 3. tiaagensen CD: Diseases of the Breast. Philadelphia. Saunders, 1956.
Harry S. Goldsmith,
MD, FACS, Philadelphia,
Pennsylvania
In 1966, I [I] reported on a small number of nursing mothers in whom a malignant tumor of the breast had developed. These patients were of interest because in each case the nursing mother reported the abrupt refusal of the infant to take milk from the breast that subsequently revealed the malignant tumor. The purpose of this paper is to further substantiate this clinical observation. In the mid 1950’s, a lactating mother was seen who reported that her infant had suddenly refused milk from one of the breasts. Subsequently, she detected a mass in the rejected breast which, after a period of patient and doctor delay, was biopsied and proved to be malignant. In the early 1960’s, another lactating mother was seen with the same clinical history, but no connection between these two patients was made until 1964 when a third nursing mother was seen with a clinical history identical to that of the other two patients. It was at this time that the idea first arose of a possible link between an infant’s rejection of breast milk and the presence of a malignant breast tumor. Approximately one year later a fourth woman was seen whose clinical history strongly strengthened the concept of milk rejection and breast cancer and was the basis for the initial report of this clinical observation. The patient was a thirtyeight year old Russian immigrant who had nursed her twenty month old daughter from both breasts From the Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania. Reprint requests should be addressed to Dr Goldsmith, Department of Surgery, Jefferson Medical College, 1025 Walnut Street, Philadelphia. Pennsylvania 19107.
280
since birth. The mother claimed that her child, who had a limited vocabulary, had objected vocally to the palatability of the milk. The patient stated that the infant complained that milk from the rejected breast was “kaka.” At that time I did not understand the meaning of this word and assumed that the child used it as a general term for something that was no good. However, it has subsequently been learned that the term is commonly used in eastern European languages to specify something as being highly objectionable, up to and even including something “fecal in nature.” The mother stated that when the child became drowsy while being nursed, she would attempt to place the nipple of the rejected breast in the child’s mouth, only to have the child awaken and complain of the milk. The mother prevented painful accumulation of milk in the rejected breast by hand pumping. After six weeks of this activity, the patient discovered a mass in the rejected breast which proved to be a malignant tumor when biopsied. Recently, a fifth patient with the milk-rejection sign of breast cancer was seen. The patient was a twenty-two year old gestating woman who noted a mass in the left breast approximately two months before delivery; the obstetrician had felt that it was associated with the pregnancy. After the infant’s birth, the mother nursed the child for two weeks. During this period she noted that the baby objected vigorously to nursing from the left breast. The mother claimed she was aware that the baby sensed something different about the milk that
The American
Journal of Surgery
Milk-Relemon
came from this breast. Believing it might be the nipple of this breast which the infant found distasteful, the mother began to use a breast shield which allowed milk to pass but eliminated nipple exposure to the infant. However, the child continued to refuse milk from this breast. The patient, after two weeks of breast feeding, noted that the mass in the breast had enlarged. This mass proved to be a carcinoma when it was finally biopsied. The factors present that make the milk from a breast containing carcinoma objectionable to the infant remain speculative. The addition of tumor or its breakdown products may influence the milk’s characteristics. Perhaps the tumor blocks milk ducts, causing stasis and localized infection; yet infants can nurse from caked breasts caused by stasis of the ducts. Infection is also difficult to incriminate, since infants are known to nurse from abscessed breasts. If there is unilateral nursing in the presence of an infected breast, it is usually the mother who withholds the involved breast from the infant to prevent painful manipulation. Cancer of the breast in lactating women is relatively rare. The survival rate of women with this tumor is equivalent to that of nonlactating patients, if the malignant lesion has been confined to the breast [2]. Unfortunately, metastatic spread to adjacent axillary lymph nodes has usually occurred by the time of treatment, because of delay. This delay, which Haagensen [3] reports to be four months longer than that of nonlactating patients with breast tumors, is frequently caused by the assumption that a breast mass that develops during pregnancy and lactation is physiologic. It is hoped that awareness of the milk-rejection sign in a nursing mother will alert the physician more quickly to the possibility that neoplastic changes have occurred in a lactating breast, a consideration that could lead to earlier diagnosis and treatment. The presence of a mass in a lactating breast requires the immediate attention of a physician who must determine whether biopsy is indicated. If a lactating mother reports a mass in the breast in the presence of the milk-rejection sign, immediate biopsy appears indicated. Mammography may be
Volume
127.
March
1974
Sgn
of Breast
of value if the milk-rejection sign is seen in a iactating woman who has either multiple or no palpable breast masses. The frequent practice of assuming that all breast masses in a nursing mother are due to the lactational process and :require only watchful waiting for resolution should be condemned. Summary A clinical observation has been made in nursing mothers whose infants rejected milk from a breast in which a malignant mass was subsequently discovered. Addendum Doctor Chester M. Southam. Professor of Medicine and Chief of Medical Oncology at the Jefferson Medical School, recently treated a patient who clearly demonstrates the milk-rejection sign. The patient was a twenty-five year old woman who breast fed her infant from the time of delivery until six weeks postpartum when the infant abruptly refused milk from the left breast. All efforts to induce the child to take milk from this breast failed. One of the methods used by the mother was the application of honey to the nipple of the rejected breast; however, the child merely licked the honey off the nipple and continued to reject the breast. At fifteen weeks postpartum and while the mother was continuing to nurse the infant from the right breast only, she noted a mass in the rejected breast, which prompted her to consult her family physician. Several opinions as to the cause of the breast mass were given by various physicians and the consensus was that the mass was secondary to “plugged ducts.” A consulting surgeon suggested biopsy, which showed infiltrating ductal carcinoma requiring radical mastectomy.
References 19: 1185. sign. Cance/ 1. Goldsmith HS: MilK-rejection 1966. 2. White TT: Prognosis of breast cancer for pregnant and nursing women. Sorg Gynecol Obstet 100: 661, 1955. 3. tiaagensen CD: Diseases of the Breast. Philadelphia. Saunders, 1956.