Chapter 11: Obesity and Benign and Malignant Disease of the Breast

INTRODUCTION

While the epidemic of obesity in this country has well-known detrimental effects on the cardiovascular system and increased problems with arthritis and diabetes, its effect on the female breast has only more recently been realized. This chapter reviews the effects that obesity has on benign breast problems, breast imaging, and breast cancer management. A better understanding of the overall negative impact that obesity has especially on cancer prognosis, recurrence, and treatment will allow the practicing gynecologist to have a more frank discussion about the importance of maintaining a healthy body mass index (BMI).

BENIGN DISEASE

Skin Diseases

A variety of common skin conditions manifest on the breast, in the inframammary folds, and in the axilla and are exacerbated by obesity. Obesity results in numerous changes to skin, including increased sweat gland function, changes in microcirculation, and additional shearing forces in dependent areas.¹

Intertrigo, erythematous skin plaques that develop in the inframammary skinfolds, is due to increased friction and moisture that leads to skin damage. Yeast, most commonly Candida albicans, often exists in these regions and requires treatment with topical antifungal powders. Some patients may require oral fluconazole for resistant cases.²

Other skin infections commonly seen in the obese patient include folliculitis, cellulitis, and even necrotizing soft tissue infections. The breast can be a site of these infections, especially in areas where increased skin friction leads to skin damage and susceptibility to infection. A recent study by Eggerstedt et al. examined all types and locations of necrotizing soft tissue infections; obesity and diabetes were commonly found. The mortality rate for superobese (BMI > 50) patients was 50% in this small study.³ It is important to closely monitor and evaluate breast infections in the obese population because these patients might be more vulnerable to more significant complications, especially when diabetes accompanies obesity.

Hidradenitis suppurativa is a disease that affects the apocrine glands and can be found in areas like the axilla, inframammary region, groin, and perineum. The disease is multifactorial and difficult to manage, but manifests as chronic abscesses and subcutaneous fistula tracts, which frequently drain and become infected.¹ The disease seems to be more frequently seen in the obese population. Medical management includes topical and oral antibiotics, but these treatments often have limited efficacy. The most effective treatment is surgical excision of the affected tissue and either primary skin closure or sometimes skin grafting with widespread disease.

Breast Parenchyma and Stroma

The breast parenchyma refers to all the functional breast tissue, including the glands and breast ducts, while the stroma is essentially the support structure to the breast, such as Cooper’s ligaments and the surrounding fatty tissue. A number of benign conditions affect the breast tissues; most are not associated with any increased risk for breast cancer. Some ...