Abnormal Case of Breast Hypertrophy - ePlasty

Interesting Case Series
Abnormal Case of Breast Hypertrophy
Ian Hoppe, BA a , and David Bleich, MD b
a Department of Surgery, Division of Plastic Surgery, New Jersey Medical School—UMDNJ,
Newark; and b Department of Medicine, Division of Endocrinology, New Jersey Medical
School—UMDNJ, Newark
Correspondence: hoppeic@umdnj.edu
DESCRIPTION
A 26-year-old nulligravid woman presents with massive, rapidly enlarging
breasts in a 10-month period. She has increased from a small C cup
size to approximately a 50 FFF, as well as developing hypertrophy of
the left axillary breast tissue (growth coinciding with menstrual cycle).
She is not using contraceptives and is not pregnant.
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QUESTIONS
1. What is the differential diagnosis of this condition?
2. What test(s) is appropriate?
3. What surgical approach is appropriate?
4. How should this patient be managed postoperatively?
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DISCUSSION
Differential diagnoses for this case include juvenile fibroadenoma,
virginal hypertrophy, fibrocystic disease, and cystosarcoma phylloides.
This patient had no palpable masses and both breasts as well as the
axillary tail of the breast were massively hypertrophic suggesting
virginal hypertrophy.
A very rare condition, virginal hypertrophy, is thought to be due
to end-organ (breast) hypersensitivity to gonadal hormones. Virginal
hypertrophy is a differential diagnosis. A serum estrogen and gonadotrophin
assay should be conducted as well as a measurement of
urinary 17-keto and hydroxysteroid levels. These tests will give normal
results in virginal hypertrophy, ruling out malignancy of adrenal,
pituitary, or ovarian origin. A mammogram will not demonstrate malignancy.
On the basis of these findings, along with the timing of the
breast growth (coinciding with menstrual cycle) and the presence of
the axillary breast tail, a diagnosis of virginal hypertrophy is strongly
supported.
In this patient a keyhole pattern breast reduction and free nipple areola
graft was most appropriate. Because of the large size of the breasts any
of the pedicled options could not adequately reduce the breast size. The
axillary breast was directly excised.
There have been reports of breast regrowth after reduction,
necessitating a second reduction surgery. Hormone therapy is a possible
postoperative option to prevent recurrent breast growth. Medroxyprogesterone
inhibits luteinizing hormone as well as exerts some
antiestrogen activity. Possible disadvantages of this treatment include
amenorrhea and interruption of ovulation. Tamoxifen is a selective estrogen
receptor modulator that has been shown to arrest breast growth
and to reduce breast size in some instances. It can be used postoperatively
to prevent breast growth in cases of virginal hypertrophy.
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REFERENCES
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