Introduction

The discovery of accessory breast tissue usually occurs during the first pregnancy as a consequence of the secondary changes initiated with hormonal changes. Symptomatic axillary breast tissue becomes painfully enlarged and, on rare occasions, may develop galactoceles.₁ The risk of a milk fistula after drainage of a breast abscess or after excisional biopsy of a breast mass during lactation is well known to the surgeons.₂ The incidence of a milk fistula in an accessory breast is rare and the incidence of a spontaneous fistula without any predisposing cause i.e., presence of an abscess or surgical intervention, is still rarer.

Case Report

A 23-year-old female, who was breastfeeding her first baby for the last three months, presented to us with complaints of left axillary swelling along with milky discharge from the swelling. The axillary swelling was present for the last year with history of increase in size during breastfeeding associated with discharge of milk from an opening in it. On examination, there was a swelling in the left axilla of 4×3cm, with a fine opening in its dependent part through which milk was seen exuding, on slight pressure over the swelling (Fig.1).

Figure 1

Figure 1: Left axillary accessory breast with milk fistula.

The patient was initially managed conservatively for her complaints by local hygiene, pressure dressings, analgesics, etc. for about one month but the milky discharge did not stop. When she was unable to tolerate this, she was advised to wean her baby. During a two-week weaning period, the milk leak diminished slowly and then sealed off completely. After complete resolution of the milk fistula, excision of the axillary accessory breast was carried out to prevent this complaint in future pregnancies.

Discussion

Ectopic axillary breast tissue is a relatively uncommon condition which develops due to persistence of mammalian tissue along the milk line. This congenital anomaly is commonly bilateral and is often unaccompanied by areola or nipple. This may present as a diagnostic problem as lymphadenopathy, primary or secondary carcinoma of breast or soft-tissue tumors can present in a similar way. Greer noted the presence of accessory axillary breast tissue to be apparent only at or after puberty, with the most rapid growth observed during pregnancy.₃ Symptomatic axillary breast tissue becomes painfully enlarged and, on rare occasions, may develop galactoceles.₁ Once the lesions are recognised, they continue to recur with subsequent pregnancies and may undergo cyclical changes during menstruation. Various pathological lesions seen in accessory breasts are: cystic disease, fibroadenoma, mastitis, atypical hyperplasia and, rarely, carcinoma. But the incidence of milk fistula from an accessory breast is almost unknown.

A milk fistula is a tract between the skin and a lactiferous duct that is acquired during lactation and is usually associated with surgical intervention, such as excision biopsy of a breast mass. With open biopsy, the risk of milk fistula is low for peripheral lesions but significantly higher for central and deep lesions.₄ This complication has also been occasionally seen in patients with breast lumps where trucut biopsy was taken to establish the diagnosis.₅ The risk of milk leak is also well known to surgeons in patients with breast abscess, duct-ectasia, etc. specially in patients having these lesions in the periareolar area.₆ A milk fistula is more an annoyance than a threat. It disrupts the patient’s life style and can delay her return to work. A fistula can dry up spontaneously while lactation continues, but this is not certain and closure can take several weeks. The only reliable means of stopping a milk leak is to suppress lactation.₇

The patient in consideration was a lactating female with left axillary accessory breast with milk fistula. The exact cause of milk fistula was not obvious in this case. The probable explanation is that the patient might have developed a galactocele in the accessory breast initially, followed by some minor trauma of overlying skin leading to milk leak from it. The milk leak was stopped by suppressing lactation after failure of conservative treatment. This was followed by excision of the accessory breast to prevent this complication in future pregnancies. The case is being reported to highlight the fact that,

• Milk fistula associated with accessory breast – and of spontaneous origin – is a very rare clinical entity, and that

• The excision of accessory breasts should be carried out at the first opportunity to avoid this annoying complication during pregnancy and lactation.

Correspondence to

Dr. Satish Dalal 9J/54, Medical Campus, PGIMS, Rohtak-124001 (Haryana) INDIA Tel. No. +91-1262-213459, Mobile: 09315326802 E-mail: drsatishdalal@rediffmail.com