Historical Notes Concerning the Hitherto Hidden Data on the Intramammary Lymph Nodes

Abstract

Of late years, the existence of lymph nodes within the breast has been debated. Therefore, it is of note that there exists a review dating back to 1892 in which this subject was thoroughly addressed. This exemplifies the importance of searching historical sources in medical informatics

Keywords

Breast, Lymph nodes, Intramammary, History

Introduction

Burnet [1] pleaded that, in medical research, it is necessary that historical sources should be combed. One such subject is the question of the possible existence of lymph nodes within the breast itself. Concerning them, Egan and McSweeny [2] wrote from the United States in 1983 that “They have been disregarded by surgeons and anatomists.” In an English series of 132 cases of breast disease in outpatient surgical practice, there were only 2 such lymph nodes [3]. None was reported from Saudi Arabia [4] and Nigeria [5]. Accordingly, what does the old literature teach?

Abridged historical text

Stiles [6], assistant to the Professor of Surgery, University of Edinburgh, read before the Edinburgh Medico-Chirurgical Society on 6th January, 1892, his copious findings which may be abridged thus:

In the breast itself, especially when the seat of a rapidly infiltrating carcinoma, I have certainly observed the formation of lymphoid nodules and germ centres in connexion with the peri-vascular lymphatics of a small artery and vein, which occupied a delicate connective tissue lamella of the intra-mammary fat.

Lymphatic glands, when cancerous, are frequently so extensively diseased that no trace of the original lymphoid tissue remains. When this is the case, they are characterized clinically by marked induration, and usually by enlargement. Occasionally several cancerous glands are matted and conglomerated into a mass of the size of a child’s fist. In cases where the disease is confined to the medullary part of the gland, the cortical region responds to the irritation produced by the cancer, the result being an increase in the number and size of the germ centres, and a dense accumulation of lymphoid cells (young leucocytes) around them. All the varieties of lymphatic glands I have referred to may be cancerous, that is to say, may contain cancer cells. Theoretically the initial stage of the disease consists in the deposit in the gland of a single cancer cell, which has been conveyed to it from the cancerous mamma along the lymphatics. Although it is practically impossible actually to demonstrate this, one may nevertheless observe the condition in which only a few cancer cells exist in the gland; they generally occupy the subcapsular sinus, that is, just the place where anatomically we should expect to find them. I possess a microscopic section of a fatty lymphatic gland showing this state of affairs. The preparation was made to show the normal structure of the gland, which, to the naked eye, appeared to be absolutely healthy. Such a gland, in consequence of the fatty change which it has undergone, feels even softer than a normal gland when made up entirely of lymphoid tissue. It follows, therefore, that the absence of induration does not always signify freedom from malignancy. Again, it must be remembered that the smallest glands are sometimes malignant. As in this condition they may be no larger than an ordinary pin’s head, the absence of enlargement does not necessarily imply non-malignancy.

Discussion

The above is certainly persuasive. Personally, I have observed, in this local developing community, surgical specimens exhibiting intramammary lymph nodes. It was on account of this that one special example was reported as presentation accompanying tuberculosis [7].

Indeed, on making use of a UK group’s conclusion on the usefulness of epidemiological analysis based on a histopathology data pool [8], I analysed as many as 134 breast biopsies containing lymph nodes [9]. Actually, this was used to demonstrate that, in this very locality, the trend in decades revealed that breast self-examination is increasingly being performed. To sum up, worldwide comparative studies are hereby recommended!

Conclusion

Intramammary lymph nodes are probably not an uncommon lesion. They deserve to be more carefully sought. Perhaps, such a research may be fruitful by combing mammography series for them!.

References

1. Burnet M. Morphogenesis in cancer. Med J Aust. 1977;1:5-9.
2. Egan RL and McSweeney MB. Intramammary lymph nodes. Cancer. 1983;51:1838-1842.
3. Cox PJ, et al. Spectrum of breast disease in outpatient surgical practice. J Roy Soc Med. 1982;75:857-859.
4. Altaf FJ. Pattern of breast diseases: King Khalid National Guard Hospital experience. Ann Saudi Med. 2001;21:239-241.
5. Onuigbo WIB. Adolescent breast masses in Nigerian Igbos. Am J Surg. 1979;137:367-368.
6. Stiles HJ. Contribution to the surgical anatomy of the breast and axillary lymphatic glands. Edin Med J. 1892;38:26-42.
7. Onuigbo WIB and Njeze GE. Intramammary lymph node tuberculosis mimicking cancer. J Infect Pulm Dis. 2015;1
8. MacartneyJC, et al. Use of a histopathology data pool for epidemiological analysis. J ClinPathol. 1980;33:351-353.
9. Onuigbo WIB. Breast biopsy: the harvesting of lymph nodes presenting as lumps in a Nigerian community indicates that preventive cancer education is succeeding. J Cancer PrevCurr Res. 2015;3:00095.