Gigantomastia during pregnancy: effect of a dopamine agonist

A Systematic Literature Review of the Clinical Presentation, Management, and Outcome of Gestational Gigantomastia in the 21st Century

BACKGROUND

Gestational gigantomastia (GG) is an uncommon pregnancy condition, and the underlying cause of GG has yet to be determined. Medical management and surgery are two treatment options for GG, and breast reduction or mastectomy with delayed reconstruction is the only available surgical option. We have conducted this systematic review to summarize and critically analyze all the GG data in the literature.

METHODS

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were adhered to in reporting this article. A systematic search was conducted in February 2022 for published case reports and case series on GG using the PubMed, MEDLINE, and Cochrane databases. The following keywords were used: macromastia, gestational gigantomastia, and gestational.

RESULTS

A total of 639 articles were searched, and only 66 case reports published between 1962 and 2022 were included. The mean patient's age at presentation was 28.79 years old. The majority of the patients were in their first trimester (n = 23, 47%). The main complaint was rapid bilateral breast enlargement (n = 54, 80.59%). Bromocriptine was the most common medical management used (n = 19/35, 54.28%). Bilateral breast reduction was the most common surgery (n = 24/48, 50%). Most patients had uneventful recovery (n = 40/54, 74.07%).

CONCLUSION

Gigantomastia is a difficult condition, in terms of its management. We have found that surgery is the gold-standard among all the cases reported; while Bromocriptine was the most commonly administered medical therapy. This systematic review provides a guideline for plastic surgeons to better facilitate their care of these patients.

LEVEL OF EVIDENCE III

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Interdisciplinary Approach for the Medical Management of Gestational Gigantomastia

Background  Gestational gigantomastia is a rare and debilitating condition that is thought to result from hormone hypersensitivity. Several definitions have been proposed using breast weight and change in body mass index, but the breast growth is best summarized as rapid, diffuse, and excessive. Case  We report a case of a 31-year-old woman with a history of infertility and cystic fibrosis that developed pathologic breast growth during hormonal preparation for in vitro fertilization. Her serum laboratories were unremarkable, and she was medically managed until 31 weeks of gestation. After delivery, she experienced rapid decrease in breast size and was followed by plastic surgery with plan to allow spontaneous regression with interval breast reduction Conclusion  We highlight a successful interdisciplinary medical management approach, which helped to avoid a morbid, intrapartum breast reduction.

Gestational Gigantomastia

Gestational gigantomastia is a rare condition characterized by fast, disproportionate and excessive breast growth, decreased quality of life in pregnancy, and presence of psychologic as well as physical complications. The etiology is not fully understood, although hormonal changes in pregnancy are considered responsible. Prolactin is the most important hormone. To date, 125 cases of gigantomastia have been reported in the literature. In this case presentation, we report a pregnant woman aged 26 years with a 22-week gestational age with gestational gigantomastia and review the diagnosis and treatment of this rare disease in relation with the literature.

Management and follow-up of a case of gestational gigantomastia in a brazilian hospital

Gigantomastia is a breast disorder that is associated with an exaggerated, rapid growth of the breasts, generally bilaterally. Since the pathology is rare and has seldom been described, its etiology has yet to be fully established, although there are speculations that a hormonal component may play an important role. Treatment is aimed at improving the clinical and psychological symptoms; however, the best therapeutic option varies from case to case. The present report describes a case of gestational gigantomastia seen at the Department of Obstetrics and Gynecology of the Hospital da Santa Casa de Misericórdia, Vitória, Espírito Santo, Brazil, in a primigravida in the second trimester of pregnancy. The report follows this patient from her diagnosis until the completion of treatment with a third and final surgical procedure.

[Gigantomastia: report of a case and review of the literature]

L'hypertrophie virginale ou gigantomastie est une mastopathie rare de cause inconnue. Elle survient au moment de la puberté et se manifeste cliniquement par un accroissement rapide et bilatéral du volume des seins. Les dosages hormonaux sont habituellement normaux et la biopsie du sein montre une accentuation du tissu mésenchymateux. Du fait des complications mécaniques et psychologiques liées aux poids et volume excessifs des seins, un traitement chirurgical rapide et efficace s'impose. Le But est de rapporter un cas rare de gigantomastie juvénile, discuter les éventualités thérapeutiques ainsi que le pronostic.

"Gestational gigantomastia": a review article and case presentation of a new surgical management option

BACKGROUND

Gestational gigantomastia is a nightmare to pregnant women. The currently available surgical intervention is either reduction mammoplasty or simple mastectomy. Reduction mammoplasty carries high risk of recurrence. Simple mastectomy is a mutilating option for a benign condition.

METHODS

A thorough literature research was performed for all reported gestational gigantomastia cases. In addition, this study presents a case that was diagnosed and treated at the authors' center.

RESULTS

The patients' age mean age was 26.8 years. Surgical intervention is the only currently available curative option. The authors were able to introduce an alternative surgical technique: bilateral subcutaneous mastectomy (BSCM) with latissimus dorsi muscle flaps (LDF) and free nipple areola complex grafting (FNAG).

CONCLUSION

Despite being a benign condition, gestational gigantomastia could turn to be a catastrophe. BSCM with LDF and FNAG represents an excellent alternative breast saving surgical option. It offers the advantage of restoring normal breast shape with no fear of future recurrences.

[Bilateral gestational macromastia: case report]

PURPOSE

We report a case of bilateral gestationnal macromastia in order to discuss the pathogeny, the diagnosis and the treatment.

METHODOLOGY

It was a case of a 33-year-old woman, admitted for a bilateral massive hypertrophy of the breast occurring on pregnancy and with progressive evolution. She had three pregnancies and one born-infant. Biological exams have shown a hyperprolactinemia. Pathological exam of the mammary biopsy had shown a benign hyperplasia.

RESULTS

Medical treatment of our patient by bromocriptin was inefficient. She has had a bilateral mastectomy. She is waiting for mammary plastic surgery.

CONCLUSION

Gravidic macromastia is a rare pathology whose etiology and treatment are much debated. Frequent recurrence after mammary reduction justify the mastectomy followed by prothesis.

Management of gestational gigantomastia

BACKGROUND

Gigantomastia of pregnancy is a rare, severely debilitating condition characterized by massive enlargement of breasts and resulting in tissue necrosis, ulceration, infection, and, occasionally, hemorrhage. Typically, resolution of breast hypertrophy to near prepregnancy size occurs in the postpartum period. Treatment is controversial.

METHODS

The authors present a patient with gestational gigantomastia for whom nonoperative management failed and who subsequently required bilateral mastectomies. In addition, the authors performed a comprehensive review of reported cases and generated a treatment algorithm.

RESULTS

The patient tolerated the mastectomies well and went on to deliver a healthy child. Postpartum delayed breast reconstruction with tissue expansion and implant placement yielded good results. The literature review demonstrates that medical management has successfully avoided surgery during gestation in 39 percent of cases since 1968. However, 35 percent of patients eventually underwent breast reduction (12 percent) or mastectomy (88 percent) during pregnancy. Spontaneous or elective termination of the pregnancy accounted for 30 percent of outcomes. Patients who underwent breast reduction and then became pregnant had a 100 percent (four of four patients) chance of recurrence. Two women had mastectomy and subsequent pregnancies. One woman developed multiple small areas of recurrence that were surgically excised. The other woman had two additional pregnancies with no recurrence of symptoms.

CONCLUSIONS

Medical therapies to manage gestational gigantomastia are inconsistent in outcome. Since some patients respond, these therapies are worth trying. However, if the patient and/or fetus are experiencing significant morbidity, then surgical intervention is warranted. Breast reduction or mastectomy with delayed reconstruction is the preferred procedure. If the mother is considering future pregnancies, mastectomy offers the lowest risk of recurrence.

Extreme gigantomastia in pregnancy: case report and review of literature

We present an extreme case of Gigantomastia in pregnancy in a 24-year old woman, gravida 2, in a 28 weeks' of gestation, with a total breast weight of 33 kg, complicated by infection, ulcerations and subsequent hemorrhage. Thorough laboratory analyses did not reveal any hint as to the cause of this enormous breast enlargement. Gynecological examinations and ultrasound revealed a viable, progressive normal fetus. The severity of the problem is further emphasized by the patients' breathing problems and even big difficulty in standing and walking. We performed bilateral simple mastectomy as a life-saving procedure to prevent fatal complications. The procedure finished without any complications or large amount of blood loss. There are less than 100 cases of gravid gigantomastia reported, but never to such extreme breast weight. Etiology remains uncertain, and controversy exists in therapeutic modality. According to the literature the most reliable conservative treatment is bromocriptine therapy, but if the condition progresses surgical intervention, in the form of reduction mammoplasty or simple mastectomy, is the treatment of choice.

[Relapse of gigantomastia after mammoplasty. Report of a case and literature review]

Gigantomastia is a very rare entity of undetermined aetiology that may be due to hormonal imbalance, decreased hormonal catabolism or hypersensitivity of the target organ. It poses the problem of surgical treatment, which can be exceptionally radical of necessity. We report a case of a 32-year-old woman of whom volume and vasculocutaneous complications required a simple bilateral mastectomy to treat a recurrence of gigantomastia occurring some months after a mammoplasty. Most of the cases of gigantomastia found in the literature are associated to the pregnancy or puberty and very rare cases of spontaneous gigantomastia were listed.

Failure of bromocriptine therapy to control juvenile mammary hypertrophy

Rapid massive breast hypertrophy occasionally occurs at the time of puberty or during pregnancy, with breast size eventually becoming burdensome or incapacitating to the patient. Pregnancy-related breast hypertrophy is often arrested or reversed by reducing serum prolactin levels with bromocriptine therapy. Unfortunately, breast enlargement in our 12-year-old patient with massive juvenile mammary hypertrophy was unaffected by bromocriptine therapy despite a reduction of her prolactin to normal levels. Two reduction mammaplasties followed by subcutaneous mastectomy were required to control breast hypertrophy. Breast-tissue hypersensitivity to prolactin appears to be a characteristic of pregnancy-related gigantomastia. Our pubertal patient with juvenile mammary hypertrophy failed to respond to bromocriptine therapy, so the aetiology of this syndrome may involve breast-tissue hypersensitivity to hormones other than prolactin.

Pregnancy-related gigantomastia. Case report

The term gigantomastia has been used to describe breast enlargement to extreme size, with sloughing, haemorrhage and infection. The condition is rare and a case of pregnancy-related gigantomastia is reported.

Gravidic macromastia: case report

Gravidic macromastia is a rare condition. Breast enlargement in pregnancy is influenced by several hormones, including ovarian steroids and somatotropic or lactogenic polypeptide hormone. Evaluation showed minimal reactive stromal and periductal fibrosis. The treatment is surgical.

The safety of bromocriptine in long-term use: a review of the literature

This paper reviews the safety data on bromocriptine administration for 1 to 10 years at daily doses of 1.25 to 80 mg in over 1100 patients with pituitary hormone overproduction (mainly from prolactinomas and growth-hormone producing adenomas), at daily doses of 3.75 to 170 mg in over 700 patients with Parkinson's disease, and at daily doses of 2.5 to 20 mg in 28 patients with various other conditions. In addition, information is provided on the safety for mother and child of bromocriptine administered at daily doses of 2.5 to 35 mg throughout gestation (54 pregnancies) or during its later stages (39 pregnancies). The side-effects of long-term bromocriptine treatment are usually no different from those seen during short-term treatment; most of them are relatively benign, and they have been shown in virtually all patients to be reversible. Bromocriptine appears to have no harmful effect on hepatic, renal, haematologic, or cardiac functions. It is considered that a hitherto unknown, severe though rare side-effect of bromocriptine is unlikely to be reported after such long experience.

The safety of bromocriptine in hyperprolactinaemic female infertility: a literature review

The dopamine agonist bromocriptine has been widely used to facilitate pregnancy in hyperprolactinaemic women, with a success rate of 80% in relevant cases. Neither the inappropriate hyperprolactinaemia consequent upon bromocriptine withdrawal after conception nor the relative hypoprolactinaemia caused by treatment throughout gestation appears to affect adversely the course and outcome of pregnancy or the endocrine status of the fetus. No teratogenic effect of bromocriptine has been evidenced in humans, and no disturbances in the physical, psychomotor, and intellectual development of the offspring have been observed. Pituitary-tumor enlargement during closely supervised pregnancies very rarely leads to severe and irreversible complications; both the re-institution of bromocriptine treatment in the event of tumor enlargement and its preventive use throughout pregnancy have been shown to be effective measures. It is interesting, moreover, that a reduction of hyperprolactinaemia, compared with pregestational levels, may be seen after bromocriptine-facilitated pregnancies.

Prophylactic bromocriptine treatment during pregnancy in women with macroprolactinomas: report of 13 pregnancies

Ten women with a macroprolactinoma had prophylactic bromocriptine treatment during 13 pregnancies in the second and third trimesters. One patient had signs of tumour enlargement during the first trimester, but none of them showed tumour enlargement during prophylactic bromocriptine treatment. Prolactin levels were reduced in both maternal and cord sera, but they were normal in amniotic fluid. All pregnancies progressed to term. Thirteen healthy infants were born without congenital malformations and growth and psychomotor development were normal during the follow-up period (7 months to 5 years). The safety of bromocriptine treatment during pregnancy is discussed and our current policy of management of patients with prolactinomas is outlined.

Ovarian and placental hormones during prolactin suppression and stimulation in early human pregnancy

Twenty-seven healthy females referred for legal abortion between the sixth and ninth week of pregnancy were treated for 1 week with either bromocriptine, metoclopramide or placebo. Serum prolactin was significantly (P < 0.01) elevated by metoclopramide and suppressed by bromocriptine. Despite a more than tenfold difference in circulating prolactin levels among these two groups, no significant difference was found in serum levels of progesterone, oestradiol, human chorionic gonadotrophin (hCG) human placental lactogen (hPL) or pregnancy specific B1-glycoprotein (SP1). These data suggest that circulating levels of prolactin below 150 ng/ml are without effect on either luteal or placental hormone secretion during early human pregnancy.