Case Report

Gestational Gigantomastia: Case Report and Review of Treatment Options

by Versha Pleasant1*, Ellen Chapel2, Adeyiza Momoh3, Amanda Manorot1, Alissa Carver4

1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA

2Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA

3Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA

4Wilmington Maternal-Fetal Medicine, Wilmington, North Carolina, USA

*Corresponding author: Versha Pleasant, Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA

Received Date: 08 March 2024

Accepted Date: 13 March 2024

Published Date: 15 March 2024

Citation: Pleasant V, Chapel E, Momoh A, Manorot A, Carver A (2024) Gestational Gigantomastia: Case Report and Review of Treatment Options. Ann Case Report. 9: 1700. https://doi.org/10.29011/2574-7754.101700

Abstract

Gestational gigantomastia is a rare and devastating condition involving rapid and excessive enlargement of the breast tissue during pregnancy or postpartum. We review the workup, assessment, and care of a patient with gestational gigantomastia with superimposed mastitis. Conservative treatment, medical management, and surgical options should be explored with patients. It is also important for providers to be cognizant of the psychological impact of this condition.

Keywords: Gigantomastia; Gestational; Pregnancy; Breast; Macromastia

Introduction

Gigantomastia (also called macromastia or mammary gigantism) is a rare and devastating condition which involves rapid and excessive enlargement of the mammary tissue. While there have been cases of gigantomastia that occur spontaneously, there are reports of pregnancy-associated gigantomastia (called gestational gigantomastia, gestational macromastia, pregnancyinduced gigantomastia, or gravid macromastia). With gestational gigantomastia, the underlying cause is unclear [1]. While there are some options for conservative management as well as medical therapy, the literature suggests that surgery is the most effective and definitive treatment for many patients [1]. This article discusses a case of gestational gigantomastia with superimposed mastitis and explores various options for clinical management as outlined in Figure 1.

Case Presentation

A 21-year-old African American gravida 1 para 1 was admitted for severely painful, enlarged breasts on postpartum day 5 after an uncomplicated spontaneous vaginal delivery at 39 weeks and 3 days. The patient stated that breast enlargement began approximately 5 months into her pregnancy, with increasing breast size from her baseline D cup and progressive pain. These symptoms significantly worsened one day after vaginal delivery, with areas of the breasts becoming hard and nodular. There was delayed milk let down and minimal output in attempts to breastfeed. She also noted fever and chills at home. Her medical history was significant for major depressive disorder diagnosed several years prior in which she was started on escitalopram. Family history was significant for a maternal great-aunt with breast cancer at an unknown age and a remote maternal relative with lymphoma at an unknown age. At time of admission, the patient was taking ibuprofen and acetaminophen as needed, topical dapsone and clindamycin for acne, and a daily prenatal vitamin. She had no known drug allergies. On exam, the patient was tachycardic to 112 beats per minute, blood pressure was 135/81, and temperature was to 101.1 Fahrenheit. BMI was 29 kg/m2. Breasts were notably enlarged with mild bilateral erythema. There was edema and skin dimpling in the dependent inferior areas of both breasts, with the left breast slightly larger than the right. The skin was intact with no ulceration, skin breakdown, or necrosis noted. There was minimal lactation from the right nipple. Physical exam was otherwise unremarkable. Regarding lab work and imaging, the patient had a leukocytosis of 14.0 x 109/L and a lactate of 0.6 mmol/L. Sepsis workup was performed which included negative blood cultures and negative urine culture. Chest X-ray was performed, which was challenging to interpret due to “large body habitus and soft tissues of the chest wall” that obscured view and created increased opacity. The patient was diagnosed with gestational gigantomastia with superimposed mastitis. She was treated initially with cephalexin, then subsequently switched to vancomycin and piperacillin/ tazobactam. The concern for malignancy was low due multiple factors including bilateral presentation of symptoms, age, lack of strong family history, and absence of other risk factors. However, bilateral breast ultrasound was performed for further assessment. Breast ultrasound was notable for probably benign findings, specifically bilateral fluid collections posteriorly in the upper central breasts for which there was consideration of therapeutic and diagnostic aspiration. There was severe bilateral skin thickening measuring up to 1.2 cm on the left and superficial hypoechoic masses in the left upper central breast. However, there was no definite drainable fluid pocket. Diffuse heterogeneous echogenicity with dense vascular breast tissue was observed bilaterally, with areas of prominent palpable nodularity. The decision was made to proceed with core needle biopsy of representative target tissue of the left breast to rule out underlying pathology. Ultrasound-guided core biopsy demonstrated benign breast tissue with lactational change (negative for atypia and malignancy).

A Gynecologic Breast Specialist was consulted who recommended skin punch biopsy, breast compression, and consideration of dopamine agonists if lactation increased. The following referrals were recommended: General Surgery for discussion of surgical options, Infectious Disease to evaluate and narrow antibiotics, and Rheumatology to rule out autoimmune disorders. A skin punch biopsy was performed to evaluate an area of skin dimpling at the edge of the left nipple-areolar complex. Pathology demonstrated subtle dermal edema, mild nonspecific perivascular chronic inflammation, and focal angioproliferative changes (Photos 1a-1b). Compression with a breast binder was performed to discourage milk production and to provide the patient with additional support. Dopamine agonist therapy was considered but ultimately not pursued because the patient was early in her postpartum course and milk production was still minimal. Finally, daily clinical breast exams were performed to evaluate the skin for any areas of necrosis. Infectious Disease recommended continuation of the antibiotic regimen. Rheumatology did not recommend further workup due to absence of any other symptoms or history suggestive of autoimmune conditions. General Surgery was consulted, with recommendations against imminent surgical intervention due to the acute infection and continued treatment of underlying mastitis. Referral to Plastic Surgery was suggested for discussion of future surgical options. The patient was discharged on hospital day 5 with normal vitals and in fair condition. She was prescribed a 2-week course of linezolid. She was afebrile by the time of discharge, with a white blood cell count of 6.9 x 109/L. At her 1-week follow up with Infectious Disease, she was noted to be clinically improving on linezolid. Repeat left breast ultrasound was recommended if there were still areas of induration to ensure no mass or abscess. She had a follow up postpartum visit 1 month after hospital discharge. At that time, her score from the Edinburgh Postnatal Depression Scale was 11. She reported that mood was worse in the first 2 weeks postpartum but had since improved. She denied suicidal ideation. Despite this, referral to Social Work was placed. The patient was offered medication for mood but declined (escitalopram was not listed in the patient’s active medication list at that time). Two attempts were made by social workers to contact the patient without success. Approximately 1 month later, repeat bilateral breast ultrasound was performed and demonstrated suspicious lesions with “large bilateral masses/conglomerates of masses in the medial aspects of both breasts, corresponding to palpable areas”. Right and left ultrasound-guided core biopsies of representative masses demonstrated benign breast tissue with extensive nodular ischemic necrosis, suggestive of infarction (Photo 2a). An adjacent area of viable breast parenchyma in the left breast biopsy was additionally notable for prominent stromal edema (Photo 2b). The sample was also cultured and was negative for fungal elements or leukocytes. Anaerobic culture was notable for rare coagulase negative staphylococcus and rare cutibacterium (Propionibacterium) avidum. The patient was seen 2 months later by Plastic Surgery, and reduction mammoplasty was discussed and offered. The patient’s surgery was originally denied insurance coverage but then subsequently approved and scheduled almost 1 year later. In the meantime, the patient underwent bilateral breast ultrasound with benign findings, noting an “overall significant decrease in the size of the biopsy proven benign bilateral breast masses, consistent with an improving inflammatory process and clinical diagnosis of pregnancy related macromastia.” However, when the patient was evaluated immediately prior to the scheduled surgery, she was deemed to have lost a significant volume of breast tissue since her prior exam. There was concern that surgery would substantially decrease remaining breast volume and may compromise the nipple-areolar blood supply. Though surgery was initially deferred, mastopexy is being explored as another option due to persistent symptoms such as significant ptosis and recurrent inframammary rashes.

 

Image 1: Photograph of gestational gigantomastia upon admission postpartum.