Supernumerary breasts

SUPERNUMERARY WITH SPECIAL REFERENCE CAPTAIN

LEOR.

WEINSHEL,

M.C. AND

BREASTS*

TO THE PSEUDOMAMMA

FIRSTLIEUT.

NICHOLAS

TYPE

DEMAKOPOULOS,

M.C.

MOODY FIELD, GEORGIA

C

supernumerary breasts are not uncommon, but a supernumerary breast of the pseudomamma type, as cIassified by Kajava, is a reIativeIy rare phenomenon. This belief is further substantiated by Deaver and McFarIand, especiaIIy so if the supernumerary breast is found in the inguina1 region, for, in reviewing over 10,000 cases of poIymastism, they found onIy tweIve cases in which this anomaIy occurred in the inguina1 region. It is interesting to note that a study of the literature on supernumerary breasts discIoses the fact that this cIinica1 anomaIy has been overIooked somewhat by medica authors, and that detaiIed descriptions or accurate case records are diffIcuIt to find. It may be that what is written in this paper but it is hoped that may be repetitious, those of the medica profession who have seen supernumerary breasts of the pseudomamma type in the past wiI1 be stimuIated to the point of submitting cases, photographs, and other pertinent data. ONGENITAL

EMBRYOLOGY

Traced from its embryona1 origin, the human breast arises from an epiderma1 ridge or primitive “miIk Iine,” which extends between the upper and Iower Iimb buds on either side of the midline. In the second month of intrauterine life, breast anIage appear. These breast anIage appear in the embryos of a11 mammaIs, to be deveIoped or suppressed according to phyIogenesis. In man the anIage appear in the form of an evagination on each side in the pectora1 region at the site of the normal breast, and the remaining anIage are suppressed and disappear. When suppression of any of the rudimentary anIage faiIs, and

when the so-caIIed “miIk spots” deveIop unduIy, supernumerary breasts appear at different points aIong the course of the epiderma1 ridge. AIthough there are no records to aid and enIighten us in the study of the historica1 aspects of the subject, certain concIusions may be surmised from the facts that the Phoenician goddess, Astarte, was frequentIy portrayed as having an accessory number of mammary gIands, and that the we11 known goddess Diana was usuaIIy represented with her trunk covered with Iarge and we11 formed mammae. Geoffroy-Saint HiIaire, in 1836, suggested that man was descended from animaIs having muItipIe breasts. Darwin (1871) in his “Descent of Man” caIIed attention to the fact that supernumerary breasts shouId be considered an atavistic manifestation. Champney beIieves that supernumerary mammary gIands are enIarged sweat gIands and not true breasts, a theory which was supported byTandIaus’ observation of a patient in whom there was compIete faiIure of deveIopment of the breast and nippIe, together with tota absence of sweat gIands a11 over the body and partia1 absence of the sebaceous gIands. CLASSIFICATION CompIete supernumerary breasts are exceptiona1. UsuaIIy supernumerary breasts appear as poIytheIia or pseudomamma. Kajava cIassif?ed congenita1 supernumerary breasts as shown in TabIe I. INCIDENCE AND LOCATION Supernumerary mammary poIymastia, and supernumerary poIytheIia, are said to occur

* From the SurgicaI Service of the Station HospitaI, Moody Field, Georgia. 76

gIands, or nipples, or rather more

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frequentIy in the maIe than in the femaIe. De ChoInoky, in 1939, in an exceIIent review of the Iiterature on supernumerary breasts, reported that one additiona breast TABLE I KAJAVA'S CLASSIFICATION OF SUPERNUMERARY

Nipple

Type of Breast

Fat TiSSUe

Are0la

I Colnplcte

Present Present NOM NOlIe Present Present

Supernumerary Supernumerary Aberrant. Pseudomammu Polythelia Polythelia areolis Polythelia pilusa

Present None Present NolIe Present None

BREASTS

Present Present Present Present None None

Present Present Present Present Present NOtlIZ

i

occurs in from 60 to 65 per cent of the cases, two in 30 to 35 per cent, three in 3.5 to 4 per cent, and four in 1.5 to 2 per cent. It seems, therefore, that the relative incidence of supernumerary breasts diminishes with the increase in the number of those organs observed in one person. In generaI, more accessory mammae are noted on the Ieft side of the body than on the right, and a great many more are observed below the normaI breasts than above them. Those situated below the norma1 breast are usuaIIy medial to the norma breast, whereas those above the normaI site are usuaIIy found IateraI to the normaI breast region. However, cases have been reported in which supernumerary breasts have occurred on the cheek, neck, ear, tragus and heIix, upper part of Ieft arm, thorax and abdomen, shouIder, back, Iumbar region, pubic and inguina1 regions, Aank and hip, thigh and Scarpa’s triangIe, thigh and dorsoIatera1 aspect, buttock, vulva, Iabia majus and minus. Supernumerary breasts located in these atypicaI regions are said to be rare and usually asymmetrical when they do occur. In most cases, these abnorma1 organs are very rudimentary and suppressed in their development, and are often represented by a minute nipple or pigmented areoIa. Deaver and McFarIand compiled a series of cases of atypica1 Iocations of super-

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numerary breasts, and among those noted were tweIve cases of pubic and inguina1 accessory mammae. Four of these cases occurred in maIes, six in femaIes, and two in sex unknown. It was our fortune to see a case of an extremeIy Large supernumerary breast of the pseudomamma type located in the Ieft inguina1 region of an otherwise normaI, coIored, aduIt maIe. In reviewing the Iiterature, we found such IittIe mention of this type of congenita1 anomaly that we are reporting this case at this time, together with those cases of Deaver and McFarIand in which supernumerary breasts occurred in the inguinal region of the maIe. CASE

REPORTS

(DEAvER

AND

MCFARLAND)

and Mosig. Miincb. med. I. Steinborn W’cbnscbr. Vol. 471, 1900. The subject was a man forty-seven years old. In Scarpa’s triangle on the inner aspect of the left thigh there is a hemispherica enlargement like the mammary gland of a virgin, about puberty, surmounted by a well formed but long nipple surrounded by a dark areola in which grew a number of dark hairs. There was no secretion. 2. Knox. Reported from Dr. D. N. Knox’s notes by Dr. Wm. Sneddon, GIasgow MedicaI JournaI, 1879, n. s., XI, 92. The patient, a fullgrown man, came to consuIt about a tumor in his groin which he said had aIways been there but which had, of Iate, been growing rather larger, and had given him both bodiIy and mental uneasiness. On examining the tumor it proved to be an extra mamma with we11 formed nipple situated upon the inner side of the right thigh cIose below the externa1 inguinal ring. It was about 2 inches Iong and I $5 inches broad, but was evidently tumilied at the time I saw it, probabIy from some irritation. 3. Dietscby. Correspondenzbl. f, scbweiz. Aerzte, Basle, 43: 366, 1913. The subject was a man twenty years of age suffering from puImonary tuberculosis. On the inner side of the Ieft thigh, 12 cm. from the upper border of the symphysis pubis there is a typical IittIe mammary gland. It is somewhat ova1 in shape and is surrounded by an areola 12 cm. Long and 0.8 cm. broad. The papilla is 0.4 cm. in diameter and its height 0.2 cm. It was a IittIe smaIler by actual measurement than his Ieft pectoral mamma and more deeply pigmented. It also

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has a few dark hairs which the pectoral mamma Iacks. 4. Hoepfner. InauguraI Dissertation, Jena, 1899. The subject was a man of about thirty

FIG. I. LateraI view showing nippIe, areola and gtand.

years. He had a supernumerary mammary gIand upon the inner aspect of the Ieft thigh I I cm. beIow the symphysis pubis. It appeared as a darkIy pigmented wart. 4. Romiti. Anatomia deII’Uomo, VoI. II. Is said by Fiori (Bull. d. r. Acad. Med. di Genovo, 20: 369, 1905, to have described a mammary gIand in Scarpa’s triangIe. 6. Sacasa, Roberto. (Thkse de Paris, 1867.) This report says that in 1863 a man appeared in Velpeau’s cIinic with a mamma-like formation surmounted by a kind of nippIe, in the upper inner aspect of the Ieft thigh. The great surgeon caIIed it a Iipoma, and discussed its resembIance to a mammary gIand. The man refused to be operated upon, so the true nature of the enIargement is not known. Since there are so few cases of supernumerary breasts in the inguina1 region of the maIe reported in the Iiterature, it therefore appears warranted to add another case in detaiI. A. M., a twenty-eight year oId colored maie, Case No. 531, entered the surgicaI service of the station hospita1 on ApriI 13, 1942, because of a tumor mass of the left inguina1 region which had been present for many years. His primary reason for seeking hospitaIization was that this tumor mass resembIed a normaI, ad&, femaIe breast, fuIIy deveIoped with nippIe and areoIa, and because of this,

APRIL, 1943

he was subjected frequently to ridicuIe and embarrassment whenever he exposed his body in the soldiers’ barracks whiIe dressing and bathing. The patient does not recaI1 just how

FIG. 2. TangentiaI view of su~ernumerarv breast, left inguina1 rkgion. I

Iong he had this anomaIy, but he beIieved that it came on at puberty and it had not changed in size or shape for the past six years. There had never been any discharge from the nippIe, pain, or any other abnorma1 symptom referabIe to the tumor mass. The past history was noncontributory, in that he had onIy the usuaI.chiIdhood diseases, and no injuries or surgica1 operations. There was no famiIia1 history of supernumerary breasts or other congenita1 anomaIies. The famiIy history was negative for organic disease and the history by systems was Iikewise essentiaIIy negative. PhysicaI examination reveaIed a coIored male, age twenty-eight, who was norma in a11 respects except for the presence of a Iarge accessory breast in the Ieft inguina1 region, inferior to Poupart’s Iigament and lying between the anterior superior iliac spine and the pubic tubercIe. (Figs. I and 2.) This accessory breast resembIed a normaI, fuIIy deveIoped, femaIe breast, with a normaIIy deveIoped nippIe and areoIa. The nippIe was directIy in the Iine of the embryonal milk ridge. The breast tissue feIt firmer than female breast tissue, but other than that, it grossIy resembIed a normal femaIe breast in a11 respects. Measurements were noted as foIIows: Length, 12.7 cm; width, 7.6 cm.; height, 4.5 cm. The areoIa measured 3.2 cm. in diameter. The urinaIysis, seroIogy, and the compIete bIood counts were essentiaIIy negative. A

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WeinsheI-PoIymastia

roentgenoIogica1 examination of the tumor mass revealed that the mass contained no caIcified bodies and was not attached to any underIying bony framework. (Fig. 3.)

79

no evidence of breast tissue. Sections through the noduIe resembling a nipple reveaIed no evidence of ductal eIements. A diagnosis of benign Iipoma was made.

FIG. 4. Gross specimen. DIFFERENTIAL

This case, of congenita1

FIG. 3. Photograph of roentgenogram soft tissue structure.

outIining

A diagnosis of supernumerary breast of the Ieft inguinal region, congenital in origin, was made. On ApriI 13, 1942, the patient was taken to surgery, and under IocaI infiltration with I per cent procaine hydrochIoride, a simpIe mastectomy was performed. The patient had an uneventfu1 postoperative course and was discharged from the hospita1 on May 4, 1942. Fig.

4.)

The specimen was forwarded to Lawson Genera1 HospitaI, Atlanta, Georgia for path0IogicaI examination. The gross examination reveaied a specimen consisting of a piece of skin IO by 6 cm., with an eIevated nodule resembIing a nippIe, 1.5 cm. in height and 3 cm. in diameter at its base, covering 150 Gm.

of yeIIowish IobuIated tissue. Microscopic examination revealed benign fatty tissue with

DIAGNOSIS

in our opinion, supernumerary

is truIy breast,

a case

pseudomammatous in type as given by Kajava. (Table I.) We have here a normaI coIored maIe who at the age of puberty deveIoped this abnorma1 breast. GrossIy it resembIed a femaIe breast having a fuIIy deveIoped nippIe, areoIa, and what appeared to be gIanduIar tissue on paIpation, except for a somewhat firmer consistency. OnIy the microscopic examination reveaIed the true condition, nameIy, a repIacement of the gIanduIar tissue by fatty tissue. According to De ChoInoky, supernumerary breasts are frequentIy diagnosed as Iipomas, for in four of his eleven cases cIinicaIIy diagnosed as Iipomas, microscopical examination estabhshed the presence of breast tissue. Thus, one can make, cIinicaIIy, an undifferentiated diagnosis of supernumerary breast without regard to its specificity. It remains for the pathoIogist to determine the presence or absence of gIanduIar tissue. Deaver and McFarIand stated that in men having supernumerary breasts, unIess microscopic examination was made, it wouId be impossible to determine whether supernumerary breasts have gIanduIar tissue or not; whereas in women the presence of gIanduIar tissue can be determined with

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certainty if the subject becomes pregnant and Iactates. Accessory mammae are aIso to be differentiated from hypertrophied sudariparous and sebaceous gIands, Iymphadenitis, chronic Iymphadenopathy caused by syphilis, tubercuIosis, Hodgkin’s disease, Iymphsarcoma, or metastatic carcinoma.

the fifth case of reported supernumerary breasts in the inguina1 region of the maIe. The authors are indebted to Major CharIes A. Pigford, M.c., Commanding Officer of the Station HospitaI, Moody FieId, VaIdosta, Georgia; Captain Arthur A. Nadler, M.c., Executive Oficer, and Mr. John Bridges, RoentgenoIogicaI Technician, for their technica assistance in the preparation of this manuscript.

TREATMENT

The harmIess existence of the supernumerary breast requires no medical or surgica1 treatment. It is onIy when the accessory breast has an abnorma1 discharge or Iocation that surgica1 remova may be requested by the patient. In our case, the unusua1 size of the breast and its resembIance to a normaI femaIe breast caused him no end of embarrassment and shame. Thus, for cosmetic and psychoIogica1 reasons it was deemed best to remove the breast. The operation itseIf is usuaIIy a simpIe procedure, and recovery is rapid and uneventfu1. The patient goes on to Iead a fuII and happy Iife, satisfied with the knowIedge that he or she is the equa1 of a11 other men or women. CONCLUSIONS

PoIymastia is a common congenita1 maIformation of which the Iiterature shows the reported occurrence of upward of 10,000 cases, but the deveIopment of a supernumerary breast in the Ieft inguina1 region in the maIe is a very rare phenomenon. The embryoIogy, cIassification, incidence, Iocation, differentia1 diagnosis, and treatment of supernumerary breasts are discussed. There are definite, indications for surgica1 intervention in poIymastism and they are as foIIows: painfuI or disfiguring supernumerary breasts, and the presence of a mahgnancy in these aberrant gIands. A case is reported, wherein a supernumerary breast, pseudomamma type, was removed from the Ieft inguina1 region of a coIored, ad& male. Insofar as we have been abIe to ascertain by a review of the Iiterature, this reported case constitutes

REFERENCES

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99: 743, -1934.

MASON. L. W. PoIvmastia. Colorado Med., 31: 141, 1934. MCFARLAND, J. Case of mammary gIand-tissue -in-t-he axiha. Am. J. Path., 5: 23, 1929. MCFARLAND, J. Mammary gIand situated on Iabium majus: report of case. Arch. Patb., I I : 236, 1931. MOURADIAN, A. H. BiIateraI lactating supernumerary mammary gIands. Med. Rec., pp. I 13-114, 1935. NORONHA, A. J. Cystic disease in supernumerary breasts. Brit. J. Surg., 24: 143, 1936. PANKOW, L. J. Accessory extra, supernumerary muItipIe breasts: case report. Lancet, 49: 539, 1929. RIBEIRO, E. B. Sobre mamma supranumeraria. Bol. Sot. de med. e cir. de .S?lo Paulo, 15: 333, 1931. STOREY, C. F. PoIymastia, with specia1 reference to supernumerary axillary breasts: brief review with case report. U. S. N. Med. Bull., 34: 362, 1936. WHITE, R. J. Fibroadenoma in an accessory breast. Am. J. Surg., 8: 830, 1930.