Objectives:

Breast cancer is a leading cause of morbidity and mortality in women worldwide. Breast screening in normal and/or asymptomatic women is essential to reduce the burden of breast malignancies. Our study aimed to identify possible risk- and/or co-factors associated with breast screening in North Indian women.

Methods:

A public health research survey was conducted among 100 women of North Indian ethnicity during clinic visits in a 6-month timeline (April-October 2012). Demographic and clinical data, including mammography screening, were recorded in the questionnaire-based proforma after conducting a 10 minute interview. Written informed consent was taken from all the participants.

Results:

The mean age of the participants was 32.2±9.9 years. Out of 100 women, 6% had family history of breast disease. Breast-related complaints/malignancy, including galactorrhoea, mastitis, axillary lump, fibrocystic disease, fibroadenosis and adenocarcinoma were observed in 41% participants; age stratification revealed that 82.9% of this group (n=41) were <30 years, while 9.7% and 7.3% were >30 years and 30 years of age, respectively. 32% participants underwent mammography screening and 8% had breast ultrasound imaging. Age stratification in the mammography screening group demonstrated that 24 women were <40 years, while 7 women were >40 years.

Conclusions:

Our pilot study identified possible co-factors affecting breast screening in North Indian women. These findings may be beneficial in early detection of breast abnormalities, including malignancies in women susceptible to breast cancer, and thus aid in future design of cost-effective screening strategies to reduce the increasing burden of breast carcinoma in women worldwide.

OBJECTIVE:

To present a rare case of gigantism.

CASE REPORT:

A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years. She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory. Blood pressure was normal. Height 221 cm, weight 138 kg, body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal. Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.

Prolactin has, for long, been associated with galactorrhea and infertility in women while its role in men is largely unknown. Recently, expression of prolactin in various other tissues like the breast, prostate, decidua, and the brain has been recognized. This has led to evaluation of paracrine and autocrine actions of prolactin at these tissues and a possible role in development of various cancers. Increased expression of PRL receptors has also been implicated in carcinogenesis. Breast cancer has the strongest association with increased prolactin and prolactin receptor levels. Prostate cancer also has reported significant association, while the role of prolactin in colorectal, gynecological, laryngeal, and hepatocellular cancers is more tenuous. Prolactin/prolactin receptor pathway has also been implicated in development of resistance to chemotherapy. Thus, the effects of this pathway in carcinogenesis seem widespread. At the same time, they also offer an exciting new approach to hormonal manipulation of cancers, especially the treatment-resistant cancers.

A palpable mass, mastalgia, and nipple discharge are common breast symptoms for which patients seek medical attention. Patients should be evaluated initially with a detailed clinical history and physical examination. Most women presenting with a breast mass will require imaging and further workup to exclude cancer. Diagnostic mammography is usually the imaging study of choice, but ultrasonography is more sensitive in women younger than 30 years. Any suspicious mass that is detected on physical examination, mammography, or ultrasonography should be biopsied. Biopsy options include fine-needle aspiration, core needle biopsy, and excisional biopsy. Mastalgia is usually not an indication of underlying malignancy. Oral contraceptives, hormone therapy, psychotropic drugs, and some cardiovascular agents have been associated with mastalgia. Focal breast pain should be evaluated with diagnostic imaging. Targeted ultrasonography can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older. Treatment options include acetaminophen and nonsteroidal anti-inflammatory drugs. The first step in the diagnostic workup for patients with nipple discharge is classification of the discharge as pathologic or physiologic. Nipple discharge is classified as pathologic if it is spontaneous, bloody, unilateral, or associated with a breast mass. Patients with pathologic discharge should be referred to a surgeon. Galactorrhea is the most common cause of physiologic discharge not associated with pregnancy or lactation. Prolactin and thyroid-stimulating hormone levels should be checked in patients with galactorrhea.

Hyperprolactinemia is a common, but neglected, adverse effect of conventional antipschycotics and of some of the atypical antipshycotics. It occurs in almost 42% of men and in 75% of women with schizophrenia who are treated with prolactin-raising antipshycotics, even though it has aroused minimal interest within the scientific community when compared with extra-pyramidal effects. Conventional antipsychotics and some of the atypical antipsychotics, such as risperidone, paliperidone, amisulpride and zotepine, are frequently associated with the raise in prolactin plasma levels. Because of this increment in prolactin secretion, they are usually known as prolactin-raising antipshycotics. On the contrary, some of the atypical antipsychotics, such as clozapine, quetiapine, olanzapine, aripiprazole and ziprazidone, have a minimal or no significant effect in prolactin levels, being known as prolactin-sparing antipsychotics. Hyperprolactinemia clinical symptoms include gynaecomastia, galactorrhoea, menstrual irregularities, infertility, sexual dysfunction, acne and hirsutism. Some of these symptoms are due to the prolactin direct action in body tissues, while a couple of them can be due to a hypothalamic-pituitary-gonadal axis dysregulation mediated by the elevation of prolactin. Some studies seem to point the evidence of an association between hyperprolactinemia and long-term consequences, such as bone mineral density decrement and breast cancer. However, these results must be confirmed through further studies. Antipsychotic treatment is the most common cause of hyperprolactinemia in psychiatric patients. However, the evidence of a prolactin increased plasma level demands the differential diagnosis with other pathologies, such as hyphotalamic and pituitary neoplasic disease. The management of a patient with antipsychotic-induced hyperprolactinemia must be adapted to each patient and it may include a reduction in the dosage of the offending antipsychotic, switching to a prolactin-sparing antipsychotic or the use of a dopamine receptor agonist, such as bromocriptine, cabergoline and amantadine. Given the osteopenic and osteoporosis risk, combined oral contraceptives must be considered in female patients in fertile age which have amenorrhoea for at least a one year period. With the exception of the Maudsley Prescribing Guidelines and the National Collaborating Centre for Mental Health, none of the current international psychiatric guidelines recommend a routine baseline prolactin determination, neither periodic prolactin levels without the presence of any hyperprolactinemia symptoms.

Galactorrhea is a known complication of breast surgery, particularly reduction mammoplasty. However, in augmentation mammoplasty, it is a rare event. There are only a few case reports concerning galactorrhea after augmentation mammoplasty. In this report, we present a case of galactorrhea that occurred at 2 weeks postoperatively in a 34-year-old woman who had undergone augmentation mammoplasty with silicone implants via a transaxillary approach. Endocrinologic tests including serum prolactin level, routine blood work, and breast ultrasonography were all normal. The authors decided to manage conservatively with close observation. After 1 month, the symptom resolved without sequelae, and no recurrence has been reported.

Upward migration of distal catheter of a ventriculoperitoneal shunt with coiling is very rare. Pseudocyst and galactorrhea are known breast-related complications. Here, we report a 13-year-old girl, known case of myelomeningocele and shunted hydrocephalus, who presented with right breast pseudocyst due to distal tube migration and coiling of the catheter. Plain radiography was not diagnostic because of severe levoscoliosis, but chest computed tomography scan was confirmatory of shunt coiling lateral to the breast. The possible mechanisms causing this uncommon complication are described.

Alprazolam belongs in the group of anxiolytics, medicaments used for reducing anxiety. As most other drugs, it can cause various adverse events, including hormonal disturbances and imbalance. Prolactin elevation is one such hormonal adverse event that can lead to galactorrhoea, or abnormal milk discharge from the breast and amenorrhoea. In this case report we will present the case of a female patient that developed galactorrhoea while treated with alprazolam, after all physical factors that can also cause these symptoms were excluded.

Galactorrhea and galactoceles are relatively uncommon complications after breast augmentation surgery, but should be considered in the differential of an enlarged breast. We present a case of a 34-year-old woman who had a remote history of bilateral breast augmentation and developed a unilateral galactocele while breast-feeding. She subsequently underwent an incision and drainage, as well as medical management with bromocriptine. Her galactocele resolved adequately with this treatment. Surgeons performing breast augmentation should be aware of the clinical presentation as well as the treatment options for this entity.

Enzyme replacement therapy (ERT) with imiglucerase is a well-established, effective treatment for Gaucher disease. However, there have been no published reports regarding the excretion of imiglucerase into human breast milk and its effects on the nursing infant.This letter reports on the successful pregnancy and lactation of a patient with Gaucher disease receiving treatment with imiglucerase, and the subsequent distribution and excretion of imiglucerase in human breast milk.A 39-year-old Japanese female (height, 164 cm; weight, 55 kg) with Gaucher disease had 2 successful pregnancies and continued ERT through both. The study was conducted 6 months after the first delivery. She was administered a 1-hour infusion of imiglucerase 60 U/kg that coincided with her regular every-2-week regimen. Serum and breast-milk samples were obtained before and up to 24 hours after administration. Breast-milk samples were also obtained from 10 nursing mothers with galactorrhea as controls.The preinfusion level of breast-milk β-glucocerebrosidase was 0.008 nmol/h/mL. The peak of serum β-glucocerebrosidase activity (0.119 nmol/h/mL) was obtained at the end of the 1-hour infusion period. Slightly increased enzymatic activity (0.016 nmol/h/mL) was observed in the first breast milk sampled after imiglucerase infusion.We report a case of successful pregnancy and breastfeeding in a Japanese patient with Gaucher disease. A small amount of imiglucerase was found to be excreted into human breast milk, but only in the first milk produced after infusion.