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

Surgical Management of Gestational Gigantomastia: A Case Report Highlighting Therapeutic Intervention

Gigantomastia is an exceedingly rare condition characterized by extraordinary growth of breasts during pregnancy, and its underlying etiology remains elusive. Although surgical intervention is the primary treatment modality, there have been emerging prospects for utilizing adjunctive medical therapies, such as bromocriptine, to address this challenging condition. Herein, we report the case of a 26-year-old woman who experienced abrupt and asymmetric bilateral breast enlargement commencing in the second month of her pregnancy. Remarkably, this enlargement persisted for an extended duration of 3 years. Despite the absence of prior medical therapy involving bromocriptine or other interventions, the patient ultimately underwent a simple mastectomy coupled with nipple-areola complex reconstruction. Although bromocriptine treatment holds potential benefits, its availability may vary in different healthcare settings. Therefore, the consideration of surgical management as an alternative approach becomes crucial, particularly when bromocriptine is not accessible or proves ineffective. This approach ensures the appropriate management of gestational gigantomastia, with the choice of treatment tailored to the individual patient's needs and resource availability.

Innovative surgical management of gestational gigantomastia

Gigantomastia is a rare condition characterized by excessive breast enlargement, which can lead to physical and psychological distress. Gestational gigantomastia (GG) occurs during pregnancy, often presenting significant management challenges. This case contributes to the limited literature on GG management by highlighting the successful use of the Goldilocks technique combined with free nipple grafting, offering insights into an effective surgical approach. A pregnant woman presented with severe GG. She underwent bilateral skin-sparing mastectomy and immediate reconstruction using the Goldilocks technique with free nipple grafting. The intervention provided both functional and aesthetic outcomes, significantly improving the patient's quality of life. This case underscores the effectiveness of modern reconstructive surgical techniques in managing GG, particularly in complex cases where hormonal therapy is insufficient.

Gestational macromastia complicating pregnancy: A case report of unusual bilateral giant breasts in a patient who had no such problem in her previous pregnancies

Key Clinical Message

Gestational macromastia is a rare disorder involving excessive breast tissue enlargement during pregnancy, potentially threatening the fetus and the mother. Our patient's previous pregnancies were more physiological, without any associated symptoms.

Abstract

Moderate bilateral enlargement of the breasts is a normal finding during pregnancy and lactation. Occasionally, there is a continuity from this physiological hypertrophy to massive breast hyperplasia or gigantomastia, causing complications that threaten the wellbeing of the fetus and the mother or raising alarm for a malignant disease. We present a case of a 28-year-old G3P2L2 with a gestational age of 29 weeks complaining of massive bilateral breast enlargement for 6 months, accompanied by a threatened abortion. The masses began gradually after conception and increased gradually over time. Notably, the breasts had been unremarkable in her two previous pregnancies. The breast ultrasonography and mammography findings pointed to a benign neoplasm. Histopathology of the lesions reported bilateral ductal hyperplasia. Conservative management and close follow-up were initiated. A cesarean section was performed due to cord prolapse, and a 1.3 kg male baby was extracted. Unfortunately, the neonate succumbed after 3 days due to apnea of prematurity. The patients' breast size subsided considerably with time. Unusually large tumors can cause alarm for other pathologies, such as breast cancer. The radiological tests should reassure the attending practitioner, and the histological examination should confirm the diagnosis. An understanding of the typical and atypical clinico-pathologic characteristics of breast lesions occurring in pregnancy and lactation is essential for appropriate patient care.

Management of Gestational Gigantomastia with Goldilocks Procedure after Mastectomy: A Case Report and Review of Literature

Gestational gigantomastia is characterized by the rapid growth of breasts during pregnancy. The treatment method of gestational gigantomastia is unclear; if the medical treatment is ineffective, surgery is considered. However, sufficient research on which method is best to perform breast reconstruction for the gestational gigantomastia patient has not yet been conducted. Our patient was young and had aesthetic needs; thus, we did not recommend modified radical mastectomy. However, it was difficult for the patient to consider active reconstruction using an implant or autologous tissue because of the expected complications and economic problems. The patient had a thin body shape and very large breasts compared with the trunk. Therefore, breast volume was not significantly required after reconstruction. Additionally, we expected that a considerable portion of skin would remain after mastectomy as a tubular-shaped breast. It was expected that the Goldilocks technique would be sufficient to meet the patient's volume needs. Therefore, we proceeded with total mastectomy and reconstruction using the Goldilocks procedure. No complications were recorded after the operation; most of the patient's discomfort was resolved, and the shape and size of the breasts were satisfactory.

Severe Gestational Gigantomastia: from Mastectomy to Staged Autologous Breast Reconstruction. A Case Report

Gestational gigantomastia (GGM) is a rare condition characterized by a massive overgrowth of breast tissue during pregnancy. Surgical sanction may be required when conservative measures fail. In this study, we report the case of a 29-year-old woman who presented with an evolutive GGM responsible for physical and emotional distress, despite medical treatment. A multidisciplinary decision was made to induce delivery at 32 weeks. In the postdelivery period, the patient developed breast wounds, complicated with septic cardiomyopathy. An emergency bilateral mastectomy was then carried out, together with banking of both nipple-areola complexes. Thereafter, delayed bilateral 2-stage breast reconstruction was started at 12 months with subcutaneous tissue expanders, later on followed by implants removal and autologous reconstruction with bilateral deep inferior epigastric artery perforator flaps and bilateral nipple replantation.

Management of gestational gigantomastia with breast reconstruction after mastectomy: case report and literature review

Gestational gigantomastia (GGM) is a rare complication of pregnancy. The etiology of GGM is yet to be fully established. Treatment methods for GGM include medical therapy and surgery. If medical treatment is unsuccessful, surgery may be required. Currently available surgical interventions are either breast reduction or mastectomy with delayed reconstruction. We report a case of a 25-year-old woman (G1P1) who presented with massive enlargement of both breasts during puerperium. Because of the limited effect of medical therapy, surgical intervention was considered to be the first choice. Bilateral mastectomies with grafting of the nipple–areola complex and immediate bilateral tissue expander implantation were performed. Reconstruction was fully completed 8 months after the initial procedure by replacing tissue expanders with definitive implants. Despite being a benign condition, GGM can turn into a serious problem. GGM can be successfully reconstructed by mastectomy with delayed reconstruction and grafting of the nipple–areola complex.

[Bilateral erythematous swelling of the breasts in a pregnant patient]

Mastitis is an infectious or noninfectious inflammation of the mammary glands. The most important differential diagnosis of mastitis is an inflammatory carcinoma, which can be excluded by imaging and a biopsy. Noninfectious mastitis can also occur during pregnancy and knowledge of the possible differential diagnoses is essential for appropriate diagnostics and treatment.

Clinical Presentations of Breast Disorders in Pregnancy and Lactation

The breast tissue undergoes significant physiological change during pregnancy and lactation. These changes can give rise to some unique disorders during pregnancy , puerperium and lactation or exaggerate pre-existing conditions. Clinical examination becomes less reliable due to textural change and density of breast tissue as a result of hormonal changes. The main symptoms during pregnancy and lactation are breast pain, mastitis, lactational abscess, breast lump, and blood- stained nipple discharge.Lactational mastitis/ abscess must be treated without delay. Open incision and drainage of lactational abscess is rarely required, any lactational abscess should be treated with appropriate antibiotics and ultrasound guided aspiration of the pus.Any breast lump during pregnancy and lactation should be investigated with triple assessment. Pregnancy associated breast cancer (PABC ) must be ruled out. The choice of investigations and treatment needs careful consideration. While ultrasound is the investigation of choice, mammography can be performed with abdominal shielding if malignancy is suspected. Core biopsy is necessary for evaluation of any breast pathology but it comes with risk of infection, bleeding, hematoma and even milk fistula.The treating clinical specialist must be aware of certain unusual unique clinical conditions in pregnancy and lactation including accessory axillary breast tissue, gigantomastia and Raynaud's phenomenon.

Gestational gigantomastia with spontaneous resolution in an Indian woman

We present the case of a 20-year-old woman, primigravida with 24 weeks of amenorrhoea due to pregnancy. She came with symptoms of rapidly increasing size of both the breasts since 8 weeks. On examination, both breasts were grossly enlarged, right more than left, with the level of the nipples reaching beyond the level of the umbilicus. Breast circumference was measured to be 72 cm on the right, and left breast was 66 cm. No palpable lumps in both breasts. No axillary lymphadenopathy noted. Hormonal studies were found to be within the normal range. The pregnancy was terminated due to pre-eclampsia. The patient opted for regular follow-up and observation. While regularly following up, the size of both breasts was observed to gradually reduce to a circumference of 40 cm on the right and 30 cm on the left.

Pregnancy-associated gigantomastia recurrence and ectopic breast after reduction mammaplasty: A case report

It has been reported that majority of cases of gigantomastia, also known as breast hypertrophy and macromastia, occur during either pregnancy or puberty. Gigantomastia is a rare disorder that does not have a clear etiology or well-established risk factors. We present a 26-year-old female patient who appeared to have pregnancy-associated gigantomastia recurrence, large accessory breast and, ectopic breast tissue at external genital three years after bilateral breast reduction surgery. The patient successively underwent bilateral mastectomy and vulvar tumor resection. Breast hypertrophy and progenital ectopic breast were pathologically confirmed. This the first case of gigantomastia reported worldwide.

Gestational Gigantomastia: A Systematic Review of Case Reports

Introduction:

Gestational gigantomastia (GG) is a rare disease characterized by diffuse, extreme, and incapacitating enlargement of one or both breasts during pregnancy. Although benign, it can lead to a great social, emotional, and physical disability. A good and complete knowledge regarding this rare but distressing clinical situation is a must among all practicing physicians especially obstetricians.

Materials and Methods:

A systematic review of all the case reports and short case series, published in the English language in various databases in the last 40 years, i.e. 1976 to 2016 was carried out. The main aim was to provide a summary and critical analysis of all the data and evidence regarding GG published in recent years.

Results:

After considering all inclusion and exclusion criteria, a total of fifty case reports were finally analyzed. The risk factors, geographical distribution, associated diseases, and the main treatment modalities used for GG are discussed in detail in this article.

Conclusion:

Multidisciplinary team effort in the form of obstetrician, plastic surgeon and anesthetist, and pediatrician is required for a successful fetomaternal outcome.

Gestational Gigantomastia Complicating Pregnancy: A Case Report and Review of the Literature

Background. Gestational gigantomastia is a rare disorder without clear etiology or well-established risk factors. Several pathogenic mechanisms contributing to the disease process have been proposed, all of which can lead to a similar phenotype of breast hypertrophy. Case. A 28-year-old Guinean woman presented at 37 weeks of gestation with bilateral gigantomastia, mastalgia, peau d'orange, and back pain. Prolactin levels were 103.3 μg/L (with a normal reference value for prolactin in pregnancy being 36–372 μg/L). The patient was treated with bromocriptine (2.5 mg twice daily), scheduled for a repeat cesarean, and referred to surgery for bilateral mammoplasty. Conclusion. Gestational gigantomastia is a rare disorder, characterized by enlargement and hypertrophy of breast tissue. Our patient presented with no endocrine or hematological abnormalities, adding to a review of the literature for differential diagnoses, workup, and management of cases of gestational gigantomastia with normal hormone levels.

An idiopathic gigantomastia

Gigantomastia is a rare condition characterized by excessive breast growth. It has been reported that the majority of gigantomastia cases occur during either pregnancy or puberty. We were presented with a rare case of gigantomastia associated with neither pregnancy nor puberty, and successfully treated it with reduction mammaplasty and free nipple graft. This idiopathic gigantomastia is the very first case in Korea, and adds to the worldwide total of 9 reported cases.

[Breast reconstruction for gigantomastia complicating pregnancy. A case report]

The authors report a very rare case of gestational gigantomastia and the pregnancy could be carried out in term. The patient has been operated of bilateral mastectomy with immediate reconstruction. Surgery is the only radical treatment. Mastectomy with secondary reconstruction is reserved to cases where the intervention must be fast. Mastectomy with immediate reconstruction is the advised intervention if there is a later desire of pregnancy. Mammary reduction is more aesthetic, and allows only one intervention, but exposes to an important risk of recurrence and is not recommended if there is a later desire of pregnancy.

Stromal-epithelial cell interactions and alteration of branching morphogenesis in macromastic mammary glands

True macromastia is a rare but disabling condition characterized by massive breast growth. The aetiology and pathogenic mechanisms for this disorder remain largely unexplored because of the lack of in vivo or in vitro models. Previous studies suggested that regulation of epithelial cell growth and development by oestrogen was dependent on paracrine growth factors from the stroma. In this study, a co-culture model containing epithelial and stromal cells was used to investigate the interactions of these cells in macromastia. Epithelial cell proliferation and branching morphogenesis were measured to assess the effect of macromastic stromal cells on epithelial cells. We analysed the cytokines secreted by stromal cells and identified molecules that were critical for effects on epithelial cells. Our results indicated a significant increase in cell proliferation and branching morphogenesis of macromastic and non-macromastic epithelial cells when co-cultured with macromastic stromal cells or in conditioned medium from macromastic stromal cells. Hepatocyte growth factor (HGF) is a key factor in epithelial–stromal interactions of macromastia-derived cell cultures. Blockade of HGF with neutralizing antibodies dramatically attenuated epithelial cell proliferation in conditioned medium from macromastic stromal cells. The epithelial–stromal cell co-culture model demonstrated reliability for studying interactions of mammary stromal and epithelial cells in macromastia. In this model, HGF secreted by macromastic stromal cells was found to play an important role in modifying the behaviour of co-cultured epithelial cells. This model allows further studies to investigate basic cellular and molecular mechanisms in tissue from patients with true breast hypertrophy.

Utilization of Inferiorly Based Dermofat Flap in Breast Reconstruction after Simple Mastectomy due to Gigantomastia

Gigantomastia (GM) is a rare disabling condition characterized by excessive breast tissue growth. To date, there is no universal classification and definition of GM. At present, GM is determined as weight over 1.5 kg per breast (Dancey et al., 2008) or 3% or more of the patient's total body weight (Dafydd et al., 2011). The lack of generally acknowledged approach regarding GM is expressed by the different methods of its treatment ranging from hormonal prescription to mastectomy and subsequent complex breast reconstruction (Shoma et al., 2011). We describe a treatment approach, including simple mastectomy and immediate breast reconstruction by an inferiorly based dermofat flap with silicone implants and nipple grafting.

Breast reconstruction after mastectomy for gestational gigantomastia

BACKGROUND

Gestational gigantomastia (GGM) is a rare complication of pregnancy. Management usually is initiated with bromocriptine. If this is unsuccessful, surgery may be required. The surgical management may be by breast reduction or by mastectomy and delayed reconstruction.

CASE

A 24-year-old woman (G1P0) presented at 24 weeks gestation with massive hypertrophy of her breasts. A decision to operate was made by a multidisciplinary team. At 30 weeks gestation, bilateral mastectomies were performed, with removal of more than 8 kg per side. Reconstruction was started 10 months after delivery using tissue expanders followed by definitive implants.

CONCLUSION

GGM can be successfully reconstructed. Knowledge of the treatment process and the expected outcomes can help clinicians inform their patients.

LEVEL OF EVIDENCE V

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