INTRODUCTION
Galactocele is a type of breast cyst. It is usually called a “milk-filled cyst” and may occur if the ducts are obstructed. Winkler J. 1964[1] stated that galactocele is initiated by several factors, namely activation of secretory breast epithelium, prolactin stimulation, and ductal obstruction. Boyle, Saray, Raso, Deloach and Peters[23456] reported some causes of non-lactational galactocele due to ductal obstruction by breast surgery, transplacental prolactin stimulation and oral contraceptives. It is important to differentiate malignancy-mimicking benign lesions and malignancy, especially in persistent lesions.
PRESENTATION
A 26-year-old, Para 1, woman presented with a large right breast lump 2 months before delivery of her first child and became even larger postpartum. She complained that her right breast has been larger since she was 12 years old and delivered her baby in October 2017 but unable to breastfeed from her right breast.
She attained menarche at 12 years old with no history of hormonal usage and no family history of malignancy.
Initial breast ultrasound (October 20, 2017) showed a large heavily septated cystic lesion occupying her entire right breast (size was too large to measure). Her axillary lymph nodes were enlarged with preserved fatty hilum [Figure 1].
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Figure 1: Breast ultrasound (October 20, 2017) showed a large heavily septated cystic lesion occupying her entire right breast (size was too large to measure). Her axillary lymph nodes were enlarged with preserved fatty hilum
Multiple breast aspirations (500 ml–1 L milk aspirated each time) were performed every 1–2 weeks for 2 months. Her fluid cytology revealed no malignant cells. She was scheduled for another breast ultrasound as it was persistent.
Her second breast ultrasound on October 31, 2017, which showed a right large, heavily septated lesion with increased vascularity occupying her entire breast measuring 13.9 cm × 11 cm × 8 cm.
We scheduled her for an ultrasound-guided core biopsy of her right breast lesion on March 15, 2018, which revealed fat and degenerative cells with a proteinaceous background. There were no ductal epithelial cells seen. With these results, we could not confirm the diagnosis of galactocele and are unable to completely rule out malignancy.
Computed tomography scan brain and serum prolactin was normal. We performed this to rule out pituitary prolactinoma due to the persistent breast lesion.
After 6 months postpartum, her right breast increased in size abruptly and she was referred to us for further management.
Examination revealed a grossly enlarged 20 cm × 20 cm, mobile firm mass in her right breast with dilated veins. There were no other skin changes, and axillary or supraclavicular lymph nodes were not palpable. Her contralateral breast is normal [Figure 2]. There were no other significant findings.
Figure 2: Examination revealed a grossly enlarged 20 cm × 20 cm, mobile firm mass in her right breast with dilated veins. There were no other skin changes, and axillary or supraclavicular lymph nodes were not palpable. Her contralateral breast is normal
Magnetic resonance imaging scan breast on August 17, 2018, showed a large complex cystic mass in the right breast causing gross breast enlargement [Figure 3]. All these differential diagnoses could be possible based on this imaging, and biopsy or surgery is needed for further evaluation.
Figure 3: Magnetic resonance imaging breast on August 17, 2018, showed a large complex cystic mass in the right breast causing gross breast enlargement
In view of this diagnostic and therapeutic dilemma, the patient was given options of total mastectomy and immediate reconstruction or lumpectomy with or without symmetrization for her contralateral breast. She opted for a simple lumpectomy and declined contralateral breast symmetrization as she wanted further pregnancy and was concerned about future breastfeeding.
Intraoperatively, there was a very large cystic mass with no infiltration to surrounding tissue, weighing about 2 kg [Figure 4].
Figure 4: Intraoperatively, a very large cystic mass with no infiltration to surrounding tissue, weighing about 2 kg
Histopathology report of entire right breast mass revealed an inflamed benign breast cyst. There were no malignant cells seen.
She is now well upon clinic review 7 months after the surgery and is now in her second pregnancy. There was no recurrence detected [Figure 5].
Figure 5: Seven months after surgery
CONCLUSION
Galactocele is a benign milk-filled cyst caused by ductal obstruction. It is generally seen in pregnancy or in the setting of chronic galactorrhea caused by a pituitary adenoma. Sekhon and Yadav 2015[7] reported that this is rare and its exact etiology is not known.
This case described a woman with persistent right breast cyst which abruptly increases in size postpartum. This lesion has been treated as galactocele and worsened despite multiple attempts of needle aspiration. After discussion on her options, a lumpectomy was performed due to diagnostic dilemma and therapeutic (aspiration) failure. Despite the alarming size of this lesion which encompassed the entire breast, mastectomy is avoided.
In conclusion, galactoceles are benign and treatable lesions. These cysts can resolve without any treatment and usually surgery is not required. Nonetheless, therapeutic needle aspiration or surgical removal may be attempted if it is enlarging.
The above case poses a diagnostic dilemma and a therapeutic challenge. It is important for surgeons to be aware of this rare, presenting feature of benign breast cysts which may mimic cystic breast malignancy. Mastectomy is not needed for large, benign breast cysts.
Main points
- Persistent large benign looking cyst could mimic cystic breast cancer
- Benign large breast cyst, even if it encompasses the whole breast, does not need mastectomy
- Surgeons, radiologists, and clinicians should be aware and vigilant about this entity of breast cyst
- Triple assessment that is concordant is of utmost importance in managing breast diseases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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3. Saray A, Aydin O, Ozer C, Tamer L. Galactocele: A rare cause of breast enlargement in an infant Plast Reconstr Surg. 2001;108:972–5
4. Raso DS, Greene WB, Silverman JF. Crystallizing galactocele: A case report Acta Cytol. 1997;41:863–70
5. Deloach ED, Lord SA, Ruf LE. Unilateral galactocele following augmentation mammoplasty Ann Plast Surg. 1994;33:68–71
6. Peters W, Smith D, Fornasier V., Lugowski S., Ibanez D.. An outcome analysis of 100 women after explantation of silicone gel breast implants Ann Plast Surg. 1997;39:9–19
7. Sekhon S, Yadav AK. Galactocele mimicking malignancy Adv Pathol Lab. Med. 2015;1(3&4)
