Fibroadenoma of bilateral axillary ectopic breast tissue: A rare case report based on Orem’s Self Care theory

Introduction: Ectopic Breast Tissue (EBT) is still a condition seen as sporadic (2-5%), and it is often delayed and ignored due to lack of awareness, whereas it may be exposed to malignant diseases. it must be always kept in mind for differential diagnosis of an EBT. We think that this case report is important because EBT associated with fi bro-adenoma is a quiet rare condition. Method: A 41-year-old female who has just given birth presented in bilateral axillary EBT with fi broadenoma. In order to present the nursing management to our case during hospitalization, Orem’s (2001) self-care defi cit theory and North American Nursing Diagnosis Association (NANDA) classifi cation system were used. Results: Both axillary nodules were swelling and painful during lactation, measuring 6 cm × 3 cm and of 4 cm × 3 cm in left and right axilla respectively. There was no nipple or areola over the both axillary nodules. However, we encountered a nipple without areola under the right breast. An excisional biopsy was performed under local anesthesia for the nipple and it revealed EBT. An EBT with fi bro-adenoma was detected in the cytopathology of fi ne needle biopsy performed in both axillary nodules. Mammograms of both breasts were normal, no carcinoma was found. Based on Orem’s self-care theory, this problem which has occurred as acute, led to the patient experience discomfort, decrease in daily activities, aesthetic concern, self-care problem and anxiety related to breast health. A patient-specifi c nursing plan was applied using NANDA classifi cation system and each process of self-care needs was evaluated with patient data. Our case was discharged on the 7th day without any complications. After one week, her sutures were removed when she came for control examination. Conclusion: It was determined that our patient entered the normalization process, regained her selfconfi dence and self-care power. Case Report Fibroadenoma of bilateral axillary ectopic breast tissue: A rare case report based on Orem’s Self Care theory Hülya Erbaba1 and Gül Pinar2* 1Hülya Erbaba, Nursing Department, Ankara Yıldırım Beyazıt University, Turkey 2Gül Pinar, Nursing Department, Ankara Yıldırım Beyazıt University, Turkey Received: 31 May, 2019 Accepted: 16 July, 2019 Published: 17 July, 2019 *Corresponding author: Gül Pınar, Yıldırım Beyazıt University, Faculty of Health Science, Department of Nursing (Formerly), Bilkent Campus, zip code: 0810, Ankara-Turkey, Tel: 05337278255; E-mail:


Introduction
The presence of more than two breasts called polymastia or EBT is a developmental anomaly and is a rare condition (2%-4%). However, a high level of suspicion for carcinoma is necessary when confronted with a nodule in this region. EBT can be located in different regions between inguinal region and axilla ( Figure 1) along milk line [1,2]. In the literature, EBT is most commonly seen in the axilla, it has also been reported in the neck, chest, hip, vulva, shoulder, thigh, perineum, upper extremities and middle back including the facial region. EBT may be affected by hormonal changes, like normal breast times more in females [4,5]. EBT can be sporadic or familial. In hereditary; X-linked autosomal dominant inheritance or X-linked recessive transition may occur through. In the pedigree studies related to polymastia; Although an X-linked dominant inheritance could not be ruled out, it was found to be consistent with the autosomal dominant gene in variable expression [6,7].
EBT usually occurs as an accessory breast without an areola and a nipple. It is generally asymptomatic and can be silent or manifest itself with menarche in adolescence or with symptoms during menstruation, pregnancy and lactation because the glandular epithelium shows positive reaction for estrogen and progesterone receptors [8]. Along with symptoms such as limitation of arm movements or pain, pathologies such as cosmetic problems, swelling, abscess, mastitis, breast fi stula, cysts, fi bro-adenoma, hematoma, phyllodes tumor, and rare carcinoma may also occur [9,10]. The diagnosis of EBT can be performed easily by USG and fi ne needle aspiration, and can be seen with pyloric stenosis, heart, ear, urinary tract anomalies, and kidney adenocancer [11]. However, still no specifi c protocols on EBT for diagnosis and treatment are available.
As the self-care power increased in the previous studies, it was found that the quality of life increased statistically highly signifi cantly [12][13][14]. Therefore, it is recommended that EBT should be included during regular screening surveillance to avoid any delay in diagnosis and treatment. The purpose of this case presentation is to review the information on EBT with fi bro-adenoma, then to determine the self-care needs according to the Orem's theory and to offer suggestions to the literature for clinical follow or health-care ( Figure 1).

Method and Process
We determined the needs of our case according to Orem's (2001) self-care theory and we used the Nursing Care Plan-NANDA to help eliminate various problems in the hospitalization period [15,16]. In the self-care theory, for the nurse to help the patient, to teach the help methods and to provide the appropriate options seems important. In line with this theory, we aimed to evaluate the health of our patient, to organize the data, to analyze, to evaluate the attempts and to increase the self-effi cacy towards solving the problems as outcome. Verbal consent was obtained from her and her family and from the unit where she was being treated for using the scientifi c data of the case. In this stage, let's examine how we address the case and the problems of our case with nursing approaches according to the self-care theory of our patient who was admitted to the obstetrics and obstetric surgery due to birth and treated with the diagnosis of axillary EBT with fi broadenoma. Kajava (1915) published a classifi cation system for supernumerary EBT that still remains in use today [17]. This present case belonged to class-II (Table 1).

Case Report
The 41-year-old multiparous case had a height of 164 cm and weight 78 kg. She was a high school graduate, housewife, lives in nuclear family, and had social security and a moderate economic income. The cesarean section (C/S) was performed by spinal anesthesia to our case on 10/29/2015 and the patient was hospitalized to the service for postpartum care. The baby of our case was in the newborn unit and had no health problems. The contact of the mother and her baby was ensured during the breastfeeding process. At the end of the postpartum second day, the patient was taken to further examination with the complaint of acute pain and swelling in the both axilla. No co-morbid disease of our case. Family history of breast cancer was not found, her mother had also axillary EBT history during lactation. The patient's medical history; when she was 13 years old she admitted to the hospital with the changes such as in axillary region of the right breast with a hard swelling, and darkening of the skin pigment. The patient underwent excisional biopsy in the right axillary nodule. Histologically, an EBT-induced mass was diagnosed. When the patient was 19 years old, after severe pain and tenderness complaint, excisional surgery of axillary EBT was performed. Carcinoma was not found ( Figure 2).

Class I
Complete breast with nipple, areola, and glandular tissue

Class II
Consists of nipple and glandular tissue but no areola

Class III
Consists of areola and glandular tissue but no nipple

Class V
Consists of nipple and areola but no glandular tissue (pseudomamma)

Class VI
Consists of a nipple only (polythelia)

Class VII
Consists of an areola only (polythelia areolaris)

Class VIII
Consists of a patch of hair only (polythelia pilosa) According to the current patient chart, the fi rst and second births of our case were performed as normal vaginal delivery. The recurrence right axillary EBT was observed on 1 st postpartum day during lactation. At the third birth (C/S) on 2 nd postpartum day during lactation, right axillary EBT relapsed again. In this process, our patient stated that ordered 2x1 steroid painkillers were applied during the stay in the hospital. She had been breastfeeding her baby frequently due to engorgement on the advice of her doctor and nurse. The right axillary EBT had regressed gradually. Now, our case was the fourth birth (C/S) and on 2 nd day postpartum during lactation a local recurrence in the both axillary EBT with fi bro-adenoma was detected.
Because our patient could not comfortably breastfeed her baby due to the pain and pruritus on both axillary EBT and could not perform her daily activities. The nipple was also apparent under the right breast ( Figure 2). Ultrasonography confi rmed the presence of fi bro-glandular tissue at the site of axillary.
When the swellings were compressed, a small amount of colostrum-like fl uid was expressed from the nipple and skin pores. The pillow support between the arms and the body, she was followed more closely. In ultrasound examination was also detected at the right axilla, approximately 4x3 cm EBT, at the left axilla 6x3 cm EBT separated from the breast tissue. Both breasts were normal.
In our case, an excisional biopsy, which is diagnosis and treatment intended. As our case was not volunteering for excision related to both axillary EBT at that time. The nipple was just removed under the right breast with the local anesthesia.
The result of fi ne needle biopsy confi rmed EBT. In addition, urogenital and renal ultrasound and echocardiographic examinations were performed in our case to investigate any anomalies and no anomalies were detected.
The patient was taken to analgesic and antibiotic treatment. No complication related to the operation was observed during the follow-up. The region where EBT is located on day 2 and 5 postpartum is given (Figures 3,4). She continued breastfeeding, pumping and nursing care plan for complaints. The swelling was slightly smaller (about half of initially observed) by the next days and from it no milk could be expressed through the skin. Finally, satisfactory breast-feeding was soon established and the comfort of the patient was provided during hospitalization. The patient was advised regular follow-up by breast (examination and mammography), Our case was discharged on the postoperative 7th day and she was seen again after ten days, her complaints were much less as on the day of discharge (Figures 3,4).

Practices for theory of self-care
Self-care requisites: In this section, the above-mentioned individual properties, the self-care power of her and limitations.

Health deviation self-care requisites
The self-care agent was our case in person. Our patient was doing partly take her self-care on. However, she needed health personnel and family caregivers as a dependent agent.
Despite the both axillary EBT, which recurred in her previous birth, our patient did not complete the recommended routine controls and treatment process except for palliative measures.
In terms of deviation from health, despite the complaints of our case, we saw that she experienced neglect and delay in receiving the health service. The solution to the problem was looked for on the increasing complaints in the early lactation
This approach has an important place in terms of supporting and guiding. Due to its suitability to our case, it was decided to use supportive and educative nursing system in this study.
The nursing approach in this model; 1) Assessment to determine the problem, 2) Diagnosis of nursing care plan, 3) Nursing intervention and evaluation. According to this, the process followed, nursing procedures are as follows:

-Nursing Diagnosis Classifi cation
Two separate interviews and assessments were held in the appropriate time and environment, which were determined as a result of the cooperation with the patient:

First interview and follow-up (the 1st day);
Prior to our fi rst meeting, it was noteworthy that the patient was drowsy, avoiding eye contact, and unwillingness to talk. In order to recognize the patient and to raise her selfcare awareness, she was helped to express herself by making her feel safe and secure. In this interview, our case has stated that the last pregnancy is not planned, that she consumes a lot of energy with the care of children and households, having both axillary EBT that has been recurring since childhood and causing both decreased self-confi dence and aesthetic care, and that she has not received enough support from her spouse in general, that she experienced frustration, fatigue and unwillingness to communicate with people as a result of recurrence with her last birth. In the clinical examination; her vital signs were normal (blood pressure: 120/80 mmHg, pulse: 80/min, respiration: 20/min, no fever, saturation: 99%).

Second interview and follow-up (the 2nd day);
Our case has stated that she has gradually increased sensitivity at the C/S site and at the both axillary region (it was obvious by the body language of our patient such as fi lling of our patient's eyes with tears, teeth tightening, groaning, grimace), reduced comfort, stress, anxiety, sleep problem, fatigue, weakness, pain, restriction in arm movements, diffi culty in fulfi lling self-care, engorgement, diffi culty in breastfeeding, delay in maternal-infant attachment, and that she experienced guilt and anxiety because of inability to fulfi ll care of and being separated from children at home and her newborn baby. Our case had been breast-feeding with diffi culty and seen that her breasts were beginning to become engorged, but there were no signs of mastitis. Because of the engorgement, mastalgia and acute pain in the axillary region, she also cannot move her arms and has diffi culty in postural changes. In this process, our patient felt tired because she could not sleep suffi ciently.
The patient's questions were answered. All these experienced problems are the factors that affect the self-care needs.
In the light of all these information, the list of the problems of our case according to NANDA classifi cation systems is given in Table 2.

-Nursing Interventions Classifi cation
• Our patient was welcomed with a smile and her orientation to clinic was provided with the necessary explanations regarding the hospital processes.
Her questions were answered, and then she was communicated continuously and trust was provided.
In order to improve family processes and motivation, the visit of her husband and family was provided and they were talked about the importance and results of the support to our patient. She was provided to spend time with her husband, mother and baby. Her husband also said that she should not worry that the children in the house are closely cared for by their relatives. · In our case, the ice pack application for both axillary engorgement and pain reduction was performed 10-12 times a day for 10 min every two hours, except for rest and sleep hours. In the application, the ice pads defi ned as gel pads were softened to be compatible with the site before use. Wrapped in a cloth to avoid direct contact with the skin and placed on the both axillary region.
The importance of the procedure and how it is done was taught to the patient, in addition to the planned periods with close follow-up, so as not to exceed 10 min, it was applied in person. Although our patient  · In order to develop self-care behaviors, both our patient and her family were informed that fi bro-adenoma associated with EBT was generally benign, may be malignant, and that breast cancer could be encountered and therefore periodic controls should be performed.
In addition, the patient was trained on family planning counseling, development of her baby, breastfeeding training, methods of coping with stress, exercise, nutrition and weight control, and she was discharged on the seventh day.

-Nursing Outcomes Classifi cation
• At the fi rst interview, it was observed that our patient had diffi culty in perceiving the procedures communicated to her, she appeared unwilling, however, she expressed herself better by being by her side and empathic approach, and increased attention, perception and ease of adaptation to the healing process was observed. · In the evaluation, it was determined that the breast fi lling at the end of milking and ice application decreased very much from the 3 rd day of lactation and healed in a shorter time. In addition our patient stated that her pain complaint was decreased substantially (pain scale: 2-3).
· As a result of decreasing engorgement and pain, it was observed that our patient had more comfortable activity, ease of breastfeeding, self-care could be more comfortable and rest periods increased.
· There was no infection in the operation site. Skin integrity was achieved.
· There was no vaginal bleeding or infection to suggest uterine atony as a result of follow-up and care. The involution process was as expected.
· Following the reduction of pain and tension, the activity restriction was greatly reduced. Our patient stated that she was able to make more comfortable arm movements and was mobilized. · Since our patient did not want to have a baby again, she stated that she was thinking about the intrauterine device as a method of family planning.
· The patient was discharged on the seventh postpartum day without any complications and one week later, her sutures were removed when she came for control examination. At this stage, the questions of our case were answered, necessary explanations were made and it was determined that our patient entered the normalization process according to her own statements, regained her self-confi dence and self-care power.

Results
In this study, patient's self-care needs were identifi ed under the guidance of "the self-care theory" and independency was improved by the compensatory care activities. Our evaluations also indicated that our patient was developed selfcare behaviors and the positive impact of using this care model on her life quality. EBT is a rare condition in the literature. These anomalies are frequently seen fi rst postnatal examination [22,23]. In our report EBT, a congenital condition, was localized in the both axilla. This problem has been identifi ed with the fi rst menarche in our patient. But, fi bro-adenoma with EBT was detected at the last postpartum period. Histologically similar to fi bro-adenoma of the breast, it is also a benign tumor of breast tissue. In some studies, it has been reported that patients with EBT have limited mobility, pain, sensitivity and sometimes shoulder-arm movement restriction [22,[24][25][26].
In our case, axillary EBT, which was noticed by puberty and then differentiated with recurrence, has been detected to grow rapidly and cause pain and aesthetic problems since the fi rst pregnancy. In other studies related to the subject, being seen of the pathologies such as fi bro-adenoma in EBT containing glandular parenchyma [27], being palpable of the particularly acute axillary EBT due to engorgement during lactation, the presence of complaints of swelling and pain accompanying the masses can cause anxiety in women by causing a malignant condition [5]. It was noted that our patient experienced this anxiety and emotional intensity in a similar way during her admission to the clinic. Although fi bro-adenoma of EBT is generally benign, it should be kept in mind that almost all of them can face breast cancer. In this sense, in addition to psychological support, our patient was informed about the importance of regular annual controls taking into account the recurrence and clinical features.
In our case, cold application was planned to relieve acute pain and engorgement complaints. Because cold application can be effective in reducing pain and edema in two ways either indirectly or directly. The tissue stimuli made with cold pads reduce the pain and engorgement by creating an analgesic effect with the door control mechanism and other mechanisms that provide the release of endorphins. In addition, as the tissue is cooled, the rate of nerve conduction is decreased and pain transmission blockage is achieved [5]. In our case, how the cold application will be performed and its importance was taught and the pain and engorgement problems were eliminated by providing the ice packets application in person in a way not to exceed 10 minutes in addition to the planned periods.
Besides, the patient's information about breastfeeding techniques were updated for avoiding the engorgement, and her breasts were emptied at planned intervals by milking and encouraged to breastfeed, and thus her engorgement problem was solved. The results obtained from other studies also support this fi nding. In a study conducted in order to reduce breast engorgement during lactating period, 53 mothers who had delivered by C/S were given training on breastfeeding techniques for 10 days and it was revealed that training signifi cantly reduced postpartum engorgement in postpartum period [28]. In another experimental study on 68 women, it was shown that frozen cabbage leaves and frozen gel pack were effective in inhibiting and reducing pain [29]. Two different studies in which cold and hot treatments were performed respectively, the cold compress was found to be more effective in reducing pain [23,30]. In the study of Goyal et al. (2014) excision of EBT was done for cosmetic, psychological and therapeutic reasons. Even liposuction has been tried with good results [31].

Conclusion
In conclusion, all these aforementioned positive development refl ect the self-care power and self-care behaviors of our case. It is thought that our case will be refl ected in management of health-care and thus literature will also be contributed. These interesting developmental anomalies should be taken into account by the health-care team due to the paucity of research in this area. Thus, it is suggested that this program be integrated into the multidisciplinary clinic plans of these patients. Further studies should be made an attempt to specify the effect of implementing the self-care program on healthy life-style in these patients.