202 • ewies et al. Figure 3. Enlarged left breast showing features of a necrotizing infection, including skin desquamation, blistering, and an area of necrosis on the medial aspect of the breast. extending into the axilla. Serosanguineous drainage was also noted as well as an area of necrosis on the medial aspect of the left breast (Fig. 3). Crepitus was also noted in the area of the axilla. The patient was taken emergently to the operating room where she underwent a modified radical mastectomy with sparing of the axilla and chest wall debridement (Fig. 4). Core needle biopsy is a safe, minimally invasive, and accurate procedure in the evaluation of women with suspected breast cancer. The most common complications associated with this procedure are severe bleeding, hematomas, and infections. However, these are fairly rare. Figure 4. Debrided tissue showing healthy tissue margins. In addition, necrotizing infections of the breast are uncommon. Similar to necrotizing infections in other anatomical sites, the presence of tense edema, skin discoloration, blisters/bullae, tissue necrosis and/or crepitus, suggest an advanced stage in the infectious process. When these findings are present, interventions should not be delayed and should include prompt debridement, broad spectrum antibiotics, aggressive resuscitation, repeated debridement when necessary and aggressive nutritional support. Unilateral Virginal Breast Hypertrophy in an 11-year-old Girl Tarek Ewies, MD,* Ahmed Abbas, MD,* Samir Amr, MD,† and Ali El Arini, MD* *Breast Surgery Division, Surgery Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia; Pathology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia † Address correspondence and reprint requests to: Tarek Ewies, MD, Breast Surgery Division, Surgery Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia, or e-mail: tewies@hotmail.com. DOI: 10.1111/tbj.12084 © 2013 Wiley Periodicals, Inc., 1075-122X/13 The Breast Journal, Volume 19 Number 2, 2013 202–204 A n 11-year-old girl, presented with progressive, painless left breast enlargement over a 2-year period. The overlying skin was scaly and stretched with visible dilated veins. There was no axillary lymphadenopathy. The other breast was normal for age (Fig. 1). Unilateral Virginal Breast Hypertrophy • 203 Figure 1. Huge unilateral breast enlargement, with scaly stretched skin and dilated veins. Figure 2. MRI: 15 9 13 9 12.5 cm, heterogenous mass, sparing the fat cleavage separating it from pectoralis major and overlying skin. Bilateral breast ultrasound revealed that the left breast was totally occupied by a large mass of heterogenous echo texture, reaching the underlying muscle and the overlying skin. Magnetic resonant imaging revealed a 15 9 13 9 12.5 cm mass, featuring heterogenous pattern of intense enhancement, resting on the pecroralis muscles, sparing the fat cleavage separating it from the pectoralis muscle as well as the overlying skin (Fig. 2). A core biopsy revealed proliferating benign hyperplastic mammary ducts within stroma featuring spin- Figure 3. Histopathology: proliferating benign hyperplastic mammary ducts within stroma featuring spindle mesenchymal cells free of atypia. dle mesenchymal cells free of atypia. It was interpreted as virginal mammary hypertrophy (Fig. 3). After multidisciplinary meetings, surgical management was decided, with the aim of doing reconstruction at a later stage when the contralateral breast develops fully. Total mastectomy of the left breast was performed. Two suction drains were inserted; the wound was closed with absorbable sutures. Her postoperative course was uneventful and the drains were taken out before discharge on the fifth postoperative day. She was given follow-up appointment through OPD. Virginal mammary hypertrophy—also known as juvenile mammary hypertrophy or juvenile gigantomastia is a rapid enlargement of one or both breasts that usually presents in the adolescent age. It is a rare condition that has been reported sporadically in the medical literature. The etiology of virginal breast hypertrophy remains elusive, but it is believed to represent end-organ hypersensitivity to normal levels of gonadal hormones. The most common causes of breast enlargement in adolescent girls are juvenile fibroadenoma, cystosarcoma phylloids, infection, and benign virginal hypertrophy. Patients with juvenile gigantomastia usually present with a history of alarmingly rapid growth of one or both breasts to massive proportions. Patients usually complain of breast, back, and neck pain, slouching posture, shoulder grooving from brassiere straps, hygienic difficulties, and intertriginous lesions at the inframammary folds. The psychological and social sequelae of the disorder are of great concern to patients and their families. 204 • hanna et al. The physical examination of such patients, will reveal an otherwise healthy, normally developed girl with markedly disproportionate enlargement of one or both breasts, with dilated superficial. Skin changes range from thinning to ulceration and necrosis secondary to compromised blood supply from excessive tension on the skin. A peau d’orange appearance of the breast skin has been reported. There is no clear diagnostic tool for virginal mammary hypertrophy. Imaging studies are of limited value but should be pursued to rule out tumors. Mammography is notoriously difficult to interpret in young women because of the density of the breast tissue. When a reading of the mammogram is possible, benign findings are the rule. Sonographic breast examination rarely provides useful information in these patients, and is indicated only if discrete masses are present and it is not clear whether they are solid or cystic. Magnetic resonance imaging may be of more use in defining the breast architecture and occult pathology. Because of the rarity of this condition, the current literature is based on case reports, with no prospective or observational trials. Traditionally, treatment has included breast reduction, mastectomy, and reconstruction, hormonal therapy, or a combination thereof. A subcutaneous mastectomy—if the breast skin is healthy—with complete removal of breast tissue is the procedure least likely to lead to recurrence but is more deforming. Reduction mammaplasty gives an improved aesthetic breast, but it is important to counsel the patient on the likelihood of increased recurrence. Hormonal therapy using tamoxifen may be considered based on previous literature. Unfortunately, tamoxifen is not a benign drug; many side effects must be taken into consideration, especially in the younger population that suffers from virginal hypertrophy. Primary Large-cell Neuroendocrine Tumor of the Breast Marcelino Yazbek Hanna, MD, MRCS,* Edmund Leung, MBBS, MRCS, MD,* Colin Rogers, BSc, MBBS,‡ and Simon Pilgrim, MA, MBBS, MD† *Department of Surgery, Queens Hospital, Burton on Trent UK; †Department of General Surgery, Norfolk & Norwich University Hospital, Norwich UK; ‡Queens Hospital Burton on Trent NHS Trust, Burton on Trent, Staffordshire UK A 60 year-old postmenopausal female was referred to the breast clinic by her general practitioner (GP) with a 2 month history of a palpable painful lump in her right axilla. The patient was referred to the specialist breast service at our hospital on a nonurgent basis, as she did not meet the local urgent referral criteria. Neither the patient nor her GP were unduly concerned as the axillary lump varied in size and no other abnormality of either breast or the contralateral axilla was detectable on clinical examination. She had Address correspondence and reprint requests to: Marcelino Y. Hanna, Department of Surgery, Queens Hospital, Burton on Trent DE13 0QX, UK, or e-mail: yazbekhanna@yahoo.co.uk,marcelino.yahbekhanna@nnuh.nh. DOI: 10.1111/tbj.12081 © 2013 Wiley Periodicals, Inc., 1075-122X/13 The Breast Journal, Volume 19 Number 2, 2013 204–206 experienced no weight loss, night sweats, and or loss of appetite. The patient was married and nulliparous, underwent menarche at the age of 16 years, and menopause at the age of 42, 18 years prior to presentation. She had taken the oral contraceptive pill for 4 years as well as hormone replacement therapy for the past 18 years. She had previously undergone open cholecystectomy, uterine polypectomy, and myomectomy. She also suffered from a cerebrovascular event and rheumatoid arthritis. There was no family history of any cancer especially breast or ovarian. On examination no discrete abnormality was palpable in either of her breasts or left axilla, but in the right axilla a single 20 mm palpable lesion suspicious of a lymph node was detected. Abdominal and respiratory examination was unremarkable.