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Sudden gigantism of breasts: Drug induced?
SUDDEN
GIGANTISM
OF BREASTS:
By S. N. DESAI, M.B.,
DRUG
INDUCED?
F.R.C.S.(Eng.)
Stoke Mandeville Hospital, Aylesbury, Bucks.
A 39 year old married woman had suffered from generalised rheumatoid arthritis for 9 years when, in 1966, she was put on Prednisolone 5 mg. daily at bed time. During 1967 and 1968 she had a right knee synovectomy and right lateral menisectomy, later manipulation of the right knee under general anaesthesia and a synovectomy of the left knee.
FIG. I. Gigantism of breasts which followed Prednisolone and penicillamine therapy for rheumatoid arthritis.
Her general condition deteriorated at the end of 1968. The Prednisolone was stopped and she started on ACTH, 40 units daily, gradually scaling down to IO units. In May 1970 she was put on penicillamine which was continued even when she developed thrombocytopenia with occasional spontaneous bruising, until May, 1971. In January 1971 she was again put on Prednisolone 5 mg. 6 hourly for 2 weeks, followed by Prednisolone 5 mg. 8 hourly and towards the end of the month she noticed that her breasts were enlarging. The Prednisolone was stopped altogether at the end of February, 1971. Her previous bust measurement had been 36 inches and by the end of June, 1971 it was 48 inches (Fig. I). Both breasts felt heavy and tender, more so during menstrual periods, with marked dilatation of the superficial veins. She lost 7 lbs. in weight in July 1971 but there was no apparent reduction in breast size. At this time she was off all drugs. Because of a possible risk of recurrence if breast tissue was retained (Ship and 371
372
BRITISH
JOURNAL OF PLASTIC
SURGERY
Shulman, 1971) a bilateral total mastectomy was then carried out through Strombeck (1960) skin incisions with free nipple transplants and insertion of Cronin Silastic breast implants of “small” size. The breast tissue removed weighed 8 lbs. from the left and IO lbs. from the right side and histologically showed some increased fibrosis and duct dilatation but no malignancy. Eight months later her general condition had again deteriorated and she was quite ill. The scar of the vertical skin incision below the left nipple parted and the implant protruded. There was no evidence of infection and the exposed implant was therefore removed and replaced by a smaller one. This healed well. DISCUSSION Gigantism of breasts is not uncommon in puberty and during pregnancy when it is presumably hormone related. In our patient rapid hypertrophy of the breasts followed There was no evidence of moderately high doses of Prednisolone and penicillamine. pregnancy during this episode and no obvious other cause was found. Penicillamine is a metabolite of penicillin with an SH group. It is a chelating agent which breaks down large protein molecules into smaller ones. Many circulating hormones are tacked to carrier proteins. Penicillamine might break down this carrier protein, thus releasing more available free hormone, and it is postulated that this might be the cause of the sudden hypertrophy. My grateful thanks are due to Mr. B. N. Bailey, F.R.C.S., Consultant Plastic Surgeon, to Dr. A. G. S. Hill, M.C., M.B., Ch.B.(Ed.), F.R.C.P., Director Rheumatism Research Centre, Stoke Mandeville Hospital, Aylesbuy, and to Mr. Standon the clinical photographer. REFERENCES SHIP,A. G. and SHULMAN,J. (1971). Virginal and gravid mammary gigantism-recurrence after reduction mammaplasty. British~ournd of Plastic Surgery, 24, 396-401. STROMBECK, J. 0. (1960). Mammaplasty: report of a new technique based on the two pedicle procedure. BritishJournal of Plastic Surgery, 13,7g-go.
GIGANTISM
OF BREASTS:
By S. N. DESAI, M.B.,
DRUG
INDUCED?
F.R.C.S.(Eng.)
Stoke Mandeville Hospital, Aylesbury, Bucks.
A 39 year old married woman had suffered from generalised rheumatoid arthritis for 9 years when, in 1966, she was put on Prednisolone 5 mg. daily at bed time. During 1967 and 1968 she had a right knee synovectomy and right lateral menisectomy, later manipulation of the right knee under general anaesthesia and a synovectomy of the left knee.
FIG. I. Gigantism of breasts which followed Prednisolone and penicillamine therapy for rheumatoid arthritis.
Her general condition deteriorated at the end of 1968. The Prednisolone was stopped and she started on ACTH, 40 units daily, gradually scaling down to IO units. In May 1970 she was put on penicillamine which was continued even when she developed thrombocytopenia with occasional spontaneous bruising, until May, 1971. In January 1971 she was again put on Prednisolone 5 mg. 6 hourly for 2 weeks, followed by Prednisolone 5 mg. 8 hourly and towards the end of the month she noticed that her breasts were enlarging. The Prednisolone was stopped altogether at the end of February, 1971. Her previous bust measurement had been 36 inches and by the end of June, 1971 it was 48 inches (Fig. I). Both breasts felt heavy and tender, more so during menstrual periods, with marked dilatation of the superficial veins. She lost 7 lbs. in weight in July 1971 but there was no apparent reduction in breast size. At this time she was off all drugs. Because of a possible risk of recurrence if breast tissue was retained (Ship and 371
372
BRITISH
JOURNAL OF PLASTIC
SURGERY
Shulman, 1971) a bilateral total mastectomy was then carried out through Strombeck (1960) skin incisions with free nipple transplants and insertion of Cronin Silastic breast implants of “small” size. The breast tissue removed weighed 8 lbs. from the left and IO lbs. from the right side and histologically showed some increased fibrosis and duct dilatation but no malignancy. Eight months later her general condition had again deteriorated and she was quite ill. The scar of the vertical skin incision below the left nipple parted and the implant protruded. There was no evidence of infection and the exposed implant was therefore removed and replaced by a smaller one. This healed well. DISCUSSION Gigantism of breasts is not uncommon in puberty and during pregnancy when it is presumably hormone related. In our patient rapid hypertrophy of the breasts followed There was no evidence of moderately high doses of Prednisolone and penicillamine. pregnancy during this episode and no obvious other cause was found. Penicillamine is a metabolite of penicillin with an SH group. It is a chelating agent which breaks down large protein molecules into smaller ones. Many circulating hormones are tacked to carrier proteins. Penicillamine might break down this carrier protein, thus releasing more available free hormone, and it is postulated that this might be the cause of the sudden hypertrophy. My grateful thanks are due to Mr. B. N. Bailey, F.R.C.S., Consultant Plastic Surgeon, to Dr. A. G. S. Hill, M.C., M.B., Ch.B.(Ed.), F.R.C.P., Director Rheumatism Research Centre, Stoke Mandeville Hospital, Aylesbuy, and to Mr. Standon the clinical photographer. REFERENCES SHIP,A. G. and SHULMAN,J. (1971). Virginal and gravid mammary gigantism-recurrence after reduction mammaplasty. British~ournd of Plastic Surgery, 24, 396-401. STROMBECK, J. 0. (1960). Mammaplasty: report of a new technique based on the two pedicle procedure. BritishJournal of Plastic Surgery, 13,7g-go.