A Comparative Study of Post-Menopausal Breast Abscesses in West Africa and West Indies

Between 20th February 1970 and 19th February 2000, 215 females with breast abscess were biopsied by 97 doctors working in 34 hospitals attended by patients of the Igbo or Ibo ethnic group in Nigeria, West Africa. Their ages ranged from 10 to 78 years, averaged 40.5 years and peaked between 31 and 40 years. Unlike a West Indian report on the unusual nature of the post-menopausal breast abscess, Igbo patients aged over 50 years numbered up to 48 (22.3%) while six were even in their 70s. Such differences in incidences are open to research in other parts of the world including Sudan.


Introduction
I drew attention to the significance of reprint requests in medical research [1].Here, I wish to make use of one such reprint [2] which I received in West Africa from the West Indies because it dealt with post-menopausal breast abscess.Therefore, let me contribute some observations made personally on breast abscess in general from developing community from which the West Indians mostly migrated.

Material and Methods
The surgical pathology records which I kept at Central Pathology Laboratory situated in Enugu, the capital city of the then Eastern Region of Nigeria, were reviewed.All the cases which I diagnosed between 20th February 1970 and 19th February 2000 as having breast abscess were included.The patients were Igbos or Ibos, whose life patterns were studied years ago by a British anthropologist [3].They constitute a major ethnic group in Nigeria, West Africa.The relevant clinical details were extracted by me from the Request Forms that accompanied the surgical specimens.The the pathological data were culled from Laboratory Reports.

Results
During the 30-year period, I encountered 215 localized breast abscesses in Igbo females in my surgical pathology practice.The age range was 10-78 years (average 40.5 years).Table 1 shows the overall distribution pattern, the peak age being 31-40 years.The menopausal status was often left out, but it was mentioned in 4 patients aged below 51 years.Unlike a West Indian report on the fewness of post-menopausal abscess [2] Igbo patients aged over 50 years numbered up to 48 (22.3%) while six were even in their 70s.The duration of breast symptoms before presentation varied from a few days to over 5 years (Table 2).It is clear that the majority of patients presented for treatment within a month of experiencing their symptoms.Three patients had a history of previous biopsy, one of them within 4 months and another within 9 years.In 58 patients, pain was noted; 11 instances of discharge were also documented.The result of physical examination was not expressly described 7 times.In the rest, it was called: "lump" 115; "swelling" 54; "mass" 34; "enlargement" 3; and "growth" or "tumour," once each.The highest preoperative diagnosis was cancer in 67 (31.2%) cases.Other diagnoses were abscess, 53; fibroadenoma, 43; tumour, 21; mammary dysplasia and galactocele, 10 each; and cyst, 6 cases.Five cases were not classified [3].

Journal of Gynecology and Women's Health
Many requests were silent on the location of the abscesses but 46 cases were described as being in various quadrants of the breast.The subareolar type numbered 16.The associated pathological conditions were almost always mammary dysplasia, to use one of the alternative names listed by Rosai [4].None showed squamous metaplasia while 6 exhibited apocrine metaplasia.In a single patient, there was a mixed picture of mammary dysplasia and fibroadenoma.In another patient, whereas both conditions were found, abscess formation was linked only with the dysplastic area.There were 4 of infiltration of skeletal muscle by the inflammatory process and 2 cases of infarcts.However, in a good number of specimens, there was insufficient mammary parenchyma for diagnosing any associated lesions.
The parity was stated in 93 patients.It ranged from 0 to 10 and averaged 4.8.Lactation was mentioned 32 times.Nine unilateral specimens were not expressly classified, there being 118 left-sided and right-sided lesions.A single patient had bilateral involvement.Concerning temporal trends, the three decades of the 1970s, 1980s, and 1990s showed the respective rising figures of 12, 56 and 147.
The doctors who submitted specimens numbered 97.The highest number of specimens sent by an individual doctor was 37, the next highest being 15.Up to 68 practitioners dispatched but single specimens.The hospitals situated in the cosmopolitan city of Enugu were the sources of as many as 118 cases (54.9%), the remaining 97 specimens coming from 33 other towns.

Discussion
It is acknowledged that the highest incidence of breast abscess occurs in lactating women [2].It was argued by Adler [5] that one cause of this infection is fissuring of the nipple from which bacteria gain entry into the peri glandular tissue, another cause being "missed or delayed feeding or attempted weaning, which leads to milk stasis and subsequent bacterial overgrowth and infection."Undoubtedly, these antecedents also prevail in the Igbo community.
Hughes [6] remarked on a recent school of thought that proposed "fibrocystic disease to be a 'non-disease.'"As he put it, "to regard it as a non entity is of little help in the clinical management of those patients who have severe symptoms."Certainly, the early presentation for treatment shown in this series demonstrates the importance and/or severity of such symptoms.
Another possible reason for attendance is breast cancer awareness.Elsewhere, I showed that such public awareness is manifest in cases of acute appendicitis in this community [7].The rising temporal trend evident in the present study is consistent with such awareness, seeing that there is local fear of breast malignancy.
Cox's et al. [8] were impressed by the fact that patients with either a lump, discharge from the nipple or pain in the breast represent a considerable work load at a general surgical clinic in England.Moreover, out of 434 biopsies in a Saudi Arabian hospital, Altaf [9] saw 47 cases of breast abscess.Furthermore, from the United States, Ekland & Zeigler [10] reported on 50 patients with abscess in the non-lactating breast.In their view, incision and drainage or excision results in satisfactory resolution of the inflammation.Such satisfaction is felt in this developing community, seeing that very few cases required second surgery.The pathogenesis of breast abscess is linked with rupture of mammary ducts [4].This was borne out in the present series.Thus, there was association not with fibroadenoma that exhibits cannaliculi but with mammary dysplasia where in ducts are ectatic.

Table 2 :
Delay period in presentation.