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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 13  |  Issue : 4  |  Page : 206-208

Bilateral axillary accessory breast with ductal ectasia: Ultrasonography and elastographic appearance


Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi, Wardha, Maharashtra, India

Date of Web Publication16-Apr-2019

Correspondence Address:
Dr. Samida A Samad
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_54_18

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  Abstract 


Ectopic breast tissue can present in any part of the body except normal breast region. Ectasia of the breast is a condition where the lactiferous ducts are dilated and blocked by secretions. Both accessory breast tissue and duct ectasia are common entities presenting separately, but the coexistence is rare with a normal breast finding. Here, we report a case of a 28-year-old lactating female presented with firm bilateral painful axillary lump of 6-month duration. This case is reported for its rarity and to give an overview of simultaneous coexistence of bilateral axillary accessory breast with duct ectasia, in a lactating normal breast.

Keywords: Accessory breast, axilla, duct ectasia


How to cite this article:
Samad SA, Phatak SV. Bilateral axillary accessory breast with ductal ectasia: Ultrasonography and elastographic appearance. J Datta Meghe Inst Med Sci Univ 2018;13:206-8

How to cite this URL:
Samad SA, Phatak SV. Bilateral axillary accessory breast with ductal ectasia: Ultrasonography and elastographic appearance. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 Jul 20];13:206-8. Available from: http://www.journaldmims.com/text.asp?2018/13/4/206/256211




  Introduction Top


Polymastia or supernumerary or accessory breast are frequently used terms for ectopic breast tissue which can present anywhere along the milk line, which extends from the axilla to groin. The incidence of the accessory breast in females is about 0.4%–6%, of which the axilla is the most common location.[1] The supernumerary breast tissue is subject to the same alterations and diseases, whether benign or malignant, that affect normal breast tissue.[2],[3],[4] However, the incidence remains very low. Duct ectasia is dilatation in one or more of the larger lactiferous duct filled with a stagnant brown or green secretion, which may or may not discharge through the nipple. This material acts as an irritant and leads to periductal mastitis. Surgical options are microdochectomy or cone excision of major ducts.


  Case Report Top


A 28-year-old lactating female presented at our hospital with the complaint of painful mass in the bilateral axilla for 6 months, which was gradually increasing in size and associated with pain and discomfort. There was no history of discharge from the lump. On examination, there was a well-defined firm, nonmobile, tender swelling in the bilateral axillary region of approximate size 4 cm × 3 cm [Figure 1] and [Figure 2]. The mass did not seem to be adherent to chest wall. Examination of both the breast was normal. Ultrasonography revealed the presence of fibroglandular tissue with duct ectasia and particulate material with bilateral small reactive axillary lymphadenopathy suggestive of ductal ectasia in bilateral accessory breast tissue in the axilla. Strain elastography revealed a typical blue-green-red (BGR) pattern indicating cystic nature of the lesion [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 1: Accessory breast tissue in the right axilla seen as axillary swelling

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Figure 2: Accessory breast tissue in the left axilla seen as axillary swelling

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Figure 3: Ultrasonography right axilla showing hyperechoic accessory breast tissue with dilated ducts and some debris within. No solid component seen

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Figure 4: Ultrasonography left axilla showing hyperechoic accessory breast tissue with dilated ducts and some debris within. No solid component seen

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Figure 5: Strain elastography right axilla showing blue-green-red appearance in dilated ducts a typical feature of cystic lesion

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Figure 6: Strain elastography left axilla showing blue-green-red appearance in dilated ducts a typical feature of cystic lesion

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  Discussion Top


Mammary ridge develops during 5th or 6th week of embryogenesis and extends from axilla to the groin. In normal development, most of the embryologic mammary ridges resolve, except for two segments in the pectoral region, which later become breasts. Failure of any portion of the mammary ridge to involute can lead to ectopic breast tissue with or without a nipple-areolar complex.[1] Although it appears on milk line, yet rarely can appear on atypical locations such as the face, vulva, perineum, posterior neck, thigh, shoulder, and upper extremities.[2] The presence of ectopic breast tissue at sites other than milk line is supported by two hypotheses; one is that it represents a migratory arrest of the breast primordium during chest wall development and the other is that it develops from the modified apocrine sweat glands.[1] In most cases, accessory breasts are asymptomatic and cause nothing more than a visible distension which may resemble a tumor. Sometimes, it could cause psychological disturbances in adolescence and it may give pain and discomfort, especially during menstruation, pregnancy, and lactation.[2] Apart from the psychological and cosmetic impact, it develops the same pathological changes as the normally located breast tissue such as duct ectasia, inflammation, fibrosis, fibroadenoma, cystosarcoma phyllodes, and carcinoma.[1],[3] Fine-needle aspiration cytology is an important initial investigation for differentiating these conditions, and final confirmation can be done on histopathological examination of excised tissue. Extramammary breast tissue may be associated with supernumerary kidneys, renal agenesis, renal malignancies, and other congenital anomalies such as pyloric stenosis, epilepsy, and cardiac abnormalities due to the corresponding development of mammary tissue and the genitourinary system.[4],[5] Excision is done for cosmetic, psychological, and therapeutic reasons.

Mammary duct ectasia is a benign condition characterized by dilatation of the mammary ducts. It is an inflammatory condition of unknown genesis. Nipple retraction and discharge may be present, mimicking carcinoma clinically.[2] Mammary duct ectasia has also been referred to as varicocele tumor, comedomastitis, periductal mastitis, stale milk mastitis, chemical mastitis, granulomatous mastitis, or mastitis obliterans. Most of the cases probably represent a localized response to different components of stagnant colostrums. The most common presentation is a palpable periareolar mass, which is ill defined and frequently associated with nipple discharge and skin retraction. Pain and erythema are uncommon.[6] The mechanism of duct ectasia begins with dilatation of the terminal collecting ducts beneath the nipple and areola. They become distended with cellular debris and lipoid-containing material. The process ordinarily begins after menopause, although it is occasionally seen in younger women. The initial phase of duct ectasia is usually asymptomatic. The material distending the ducts irritates and causes thickening of the duct walls by fibrosis and by an inflammatory infiltration of lymphocytes. The duct epithelium is not stimulated to proliferate. This absence of epithelial proliferation is one of the basic features of mammary duct ectasia. In due course, fibrosis produces skin and nipple retraction. Squamous metaplasia of nipple ducts is normally absent.[7]

Itoh et al. described Tsukuba scoring system.

Tsukuba scoring system

A score of 1 indicated even strain for the entire hypoechoic lesion (i.e., the entire lesion was evenly shaded in green). A score of 2 means strain in most of the hypoechoic lesion, with some areas of no strain (i.e., the hypoechoic lesion had a mosaic pattern of green and blue). A score of 3 implies that strain at the periphery of the hypoechoic lesion, with sparing of the center of the lesion (i.e., the peripheral part of lesion was green and the central part was blue). A score of 4 shows no strain in the entire hypoechoic lesion (i.e., the entire lesion was blue, but its surrounding area was not included). A score of 5 indicated no strain in the entire hypoechoic lesion or in the surrounding area (i.e., both the entire hypoechoic lesion and its surrounding area were blue). BGR represents typical artifactual three-layered aspect (BGR) encountered with cystic lesions.[8]


  Conclusion Top


This case report emphasizes the importance of considering the ectopic breast and its associated pathology in the differential diagnosis of axillary mass and also stresses the importance of evaluating the patients to rule out renal anomalies or urological malignancies as it is an important association.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coras B, Landthaler M, Hofstaedter F, Meisel C, Hohenleutner U. Fibroadenoma of the axilla. Dermatol Surg 2005;31:1152-4.  Back to cited text no. 1
    
2.
Rizvi G, Pandey H, Gupta MK. Fibroadenoma of ectopic breast tissue in axilla. J Case Rep 2012;2:36-8.  Back to cited text no. 2
    
3.
Dixon JM, Mansel RE. ABC of breast diseases. Congenital problems and aberrations of normal breast development and involution. BMJ 1994;309:797-800.  Back to cited text no. 3
    
4.
Grossl NA. Supernumerary breast tissue: Historical perspectives and clinical features. South Med J 2000;93:29-32.  Back to cited text no. 4
    
5.
Goyal S, Bawa R, Sangwan S, Singh P. Fibroadenoma of axillary ectopic breast tissue: A rare clinical entity. Clin Cancer Invest J 2014;3:242-4.  Back to cited text no. 5
    
6.
Giron GL, Friedman I, Feldman S. Lobular carcinoma in ectopic axillary breast tissue. Am Surg 2004;70:312-5.  Back to cited text no. 6
    
7.
Rahal RM, de Freitas-Júnior R, Paulinelli RR. Risk factors for duct ectasia. Breast J 2005;11:262-5.  Back to cited text no. 7
    
8.
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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