Plasmacytoid mastitis is the modern medical name for a non-bacterial inflammatory reactive disease also known as ductal dilation of the breast, acantholytic mastitis, and occlusive mastitis. It is difficult to find a name for this disease in ancient Chinese medical texts. The early symptoms of nipple overflow can belong to the category of “epistaxis” and “breast weeping”; the middle stage of lumps in the breast, difficult to eliminate, difficult to decay, difficult to ulcerate, and similar to the evidence of breast gangrene; the late stage of lumps ulcerated, long time without closure, or side fleeing deep ulceration, one after another, recurrent, can also be It is also called “breast leakage”, “acne carbuncle”, “nipple leakage”, etc. In the early stage, nipple overflow, invagination, and breast lumps are easily misdiagnosed as breast cancer; in the acute stage, breast redness, swelling, heat, and pain are easily misdiagnosed as bacterial mastitis; after suppuration, the wound often does not heal easily, or it may become a fistula with deep ulceration, so it is often treated as a tuberculous ulcer. The incidence has been increasing in recent years, and it is a breast disease with a long course, a complex and variable disease, a poor outcome, and a large amount of damaged breast tissue, but a good prognosis.
Etiology of plasmacytic mastitis.
Blockage of the milk ducts and poor drainage are the underlying causes of the disease. The disease is caused by abnormal nipple development, malformation, blockage of the milk ducts, stagnation of Qi in the symphysis, or internal dampness and heat, external infection with evil toxins, congestion of Qi and blood in the breasts, heat and pus, and ulceration for a long time into leakage.
Modern medicine believes that: congenital dysplasia nipple deformity, sunken, trauma, unclean caused by obstruction of the milk ducts, non-lactation period, there is an obstacle to the excretion of secretions and retention, secondary to duct dilation, duct wall thinning, rupture, stagnant secretions or its decomposition products overflow, stimulate the duct wall or surrounding tissue, resulting in a chemical inflammatory reaction; or middle-aged and elderly women with reduced ovarian function, degenerative changes in the breast tissue The inflammatory reaction is caused by the accumulation and overflow of lipid substances in the ducts due to the degeneration of myoepithelial cells of the milk ducts, which leads to the accumulation of secretions in the ducts; or the inflammatory reaction is caused by the accumulation and overflow of lipid substances in the milk ducts due to the autoimmune and endocrine dysfunction, which stimulates the tissues around the milk ducts.
Pathology of plasmacytoid mastitis suggests that
Masses of moderately hard texture and variable size are seen on gross specimens; the cut surface is grayish or grayish-yellow, sometimes with cloudy foci of necrosis, and many dilated milk ducts can be seen in the subareolar breast tissue, with extrusion of a thick brownish or milky white material. Neutral fatty substances blocking the duct lumen irritate the duct wall, causing proliferation of fibrous tissue, which in turn destroys the duct wall. This is manifested by enlargement of the duct lumen, straightening, loss of folds, thinning of the epithelium, thickening of the fibrous tissue in the lumen, and retention of material in the lumen. There is a large plasma cell infiltrate with focal histolytic necrosis and focal neutrophil infiltration on top of ductal dilatation. The breast tissue showed nonspecific inflammatory lesions with focal small abscess formation, localized purulent granulomatous inflammation of the breast with massive plasma cell infiltration, more pronounced fat necrosis and small oily cysts and small purulent granuloma formation due to fat necrosis were seen in nonspecific purulent inflammatory lesions of the breast, occasional atypical phlebitis, and plasma cell infiltration in some areas. Special staining did not detect mycobacteria, but such lesions may be due to mycobacteria or specific infections. Some authors report that 17% of acute abscesses of plasmacytoid mastitis are associated with anaerobic infections, whereas 85% of chronic abscesses are associated with anaerobic infections.
Clinical management of plasmacytoid mastitis.
1. Simple nipple overflow phase.
This disease occurs mostly in women aged 25-50 years who are not pregnant or lactating, and rarely occurs in men; the course of the disease is mostly chronic or acute, but it can also occur acutely without a chronic course; the clinical condition is mostly seen with nipple deformity, depression, or partial or single breast duct depression, and also without nipple deformity, depression and other lesions; nipple overflow is mostly the first symptom, mostly unilateral breast, single-hole nipple overflow, but also seen in both breasts, multi-hole nipple The nipple overflow is the first symptom. Nipple discharge can be yellowish plasma, yellowish white, pus-like, pink slag-like, light red, dark red or pus and blood-like discharge. If the nipple deformity or depression is severe, the overflow is less and more viscous, and if there is no obvious nipple deformity or depression, the overflow is more and thinner. This type of disease is still early, mild, smaller lesions, pathological changes for the epithelial irregular hyperplasia of the breast ducts, ductal secretion dysfunction, so that a large number of lipid-containing secretions accumulate chemical reaction in the milk ducts, thus causing the duct wall elastic fibers suffer damage, duct expansion, ductal peri-inflammatory infiltration is light, so the clinical appearance of plasma,,, purulent, blood-like and other nipple overflow; ductal wall fibrosis so as to cause The fibrosis of the duct wall causes nipple invagination. The inflammatory disease is not obvious, so it is called “simple nipple overflow” or “occult”. The most appropriate term for this type is “ductal dilatation”. In cases where there is only nipple discharge and no other symptoms, mammography is a reliable method to diagnose ductal dilatation, showing coarse strips of columnar dilated ducts and small nodular shadows of distorted dilated ducts and limited cystic dilatation. Ductal endoscopy can also be done to exclude papillary tumors, papillomatosis, and breast cancer in the breast ducts for a definitive diagnosis. Other examinations such as ultrasound, mammogram and infrared are not specific.
(1) Chinese herbal medicine treatment: identify the color, shape, amount and odor of the nipple overflow and combine it with the tongue and pulse to identify and treat the symptoms. If the nipple overflow is pale yellow plasma or pus, with a light red tongue, thin yellow or white greasy coating, and a number of pulse or string, slippery, etc., it mostly belongs to damp heat in the liver and stomach, so the treatment is to dredge the liver and spleen, clear heat and dampness. Take one dose daily with water decoction. If the nipple overflow is red and blood-like, with red tongue and yellow coating and string veins, it is mostly due to heat in the breast complex, forcing blood to move. The treatment is to cool the blood and clear heat. The formula is based on Sheng Si Wu Tang with addition: Radix Angelicae Sinensis, Chuanxiong, Bai Shao, Sheng Di, Gardenia, Scutellaria, Gentianae, Mudanpi, Che Qian Cao, Sophora, Glycyrrhiza each 10 grams, fresh tile palm, lotus root as a guide. One dose is taken daily with water decoction. Catheter flushing therapy is also available.
(2) Tincture of iodine infusion method: Applicable to plasmacytic and hemorrhagic simple duct dilatation evidence. First do the iodine allergy test (iodine allergy is prohibited), routine disinfection of the breast, lay a towel, hold a 5ml disposable empty syringe, select the nipple overflow hole orifice, insert the needle (cut off the tip and flatten the needle sterilization spare) slowly about 1-2cm, try to squeeze out or pump the liquid in the catheter, replace the other syringe to extract 2-5ml of 2% tincture of iodine, slowly push until it overflows from time to time and then pull out the needle, stop 3-5 minutes After that, squeeze out the tincture of iodine into the catheter. Repeat after 1 week if 1 time does not heal. If it is not effective for 2 times, stop using it.
The application of iodine tincture infusion therapy should be preceded by a clear diagnosis of occult ductal dilatation, i.e., simple ductal dilatation. The only clinical symptom of simple ductal dilatation is nipple overflow, which is not unique to ductal dilatation and must be differentiated from intraductal papilloma, papillomatosis, ductal carcinoma, and hyperprolactinemia. This method is only appropriate for the treatment of those who have been clearly diagnosed with ductal dilatation of the breast without masses, abscesses, ulcers and sinus tracts. The basic principle of applying tincture of iodine infusion therapy for the treatment of ductal dilatation is, firstly, to use tincture of iodine, which has a good bactericidal and anti-inflammatory effect, to flush with it to remove the corrupt secretions accumulated in the ducts and to play the role of cleaning and disinfection; secondly, to use tincture of iodine to stimulate the action of the duct wall, which causes temporary dehydration and denaturation of its cells, reduces the exudation of interstitial fluid, and then produces temporary aseptic inflammatory-like changes, prompting The ducts of the dilated breast are reduced or closed.
(3) Antibiotics and other drugs flushing method: Applicable to those whose nipple overflow is purulent. Saline, ornidazole, levofloxacin, dexamethasone, etc. can be used. The breast is routinely disinfected and toweled, hold a 5ml disposable empty syringe, select the nipple overflow orifice, insert the needle (cut off the tip and smooth the needle after sterilization) slowly into about 0.5-1.52cm, try to squeeze or pump the liquid in the duct, and then replace it with another syringe to extract the drug used to repeatedly flush the diseased breast duct.
(4) Surgical excision method: select single-hole nipple overflow and ductal dilatation without breast masses, or masses of occult shape. According to the patient’s condition and indications, anesthesia is selected, routine disinfection is performed, the diseased breast duct is identified, a small amount of melanoma is slowly injected into the diseased breast duct with a blunt needle syringe, to the extent of overflow, a radial incision is made along the duct course from outside the areola, the length of the incision is determined by ductography or endoscopy, the skin and subcutaneous tissues are incised, and the entire lesion of the melanoma-stained duct and part of the surrounding tissues are dissected and separated from superficial to deep. The skin and subcutaneous tissues were incised, and all the lesions and some surrounding tissues of the Melan-stained ducts were dissected and separated from the Melan-stained ducts by superficial deep dissection, and the duct tissues were removed with curved hemostatic forceps around the base of the nipple, and the lesioned ducts were cut from the base of the nipple to preserve the glandular tissues under the nipple areola. Appropriate postoperative antimicrobial therapy is applied. Early treatment, less damage to the breast tissue, better prognosis, generally does not affect the aesthetics.
2. Breast lump phase.
When the breast orifice is obstructed, the evil toxins accumulate, the Qi and blood are congested, and the heat and pus are contained, i.e., the lipid material accumulated in the ducts decomposes, and its products can leak out of the ducts, causing inflammatory changes in the tissues around the ducts, often affecting multiple small ducts and breast lobules, which can form granulomas, and in severe cases, necrotic foci, so the clinical symptoms at this time are mainly hard lumps and pain, so it is called “lump type The clinical symptoms are mainly hard lumps and pain, so it is called “lumpy type”. The masses can be found in any quadrant of the breast, but they tend to occur in the central area near the areola; the size of the masses varies from small to large and can affect one quadrant, multiple quadrants or the whole breast, and can occur slowly from small to large, or suddenly and rapidly increase in size; the masses can be accompanied by pain, mainly vague pain, stabbing pain, and boring pain; the initial skin color of the masses is slightly red or not red, and the skin color gradually reddens over time, which can lead to nipple pulling depression. The mass is obvious or mildly painful to the touch, the initial boundary is unclear, and it can be gradually confined over time, the texture is initially hard but not firm, and after liquefying into pus, it is often both soft and hard; the mass can be accompanied by ipsilateral axillary lymph node enlargement, fever, spontaneous sweating, night sweating, etc. Chinese medicine treatment is based on the identification of swelling, pain, color and pus, combined with the overall physical condition, tongue and pulse. The general treatment principle is: for those with initial solid evidence, elimination is the most important, and the proposed treatment is to invigorate the camp and open the ligaments, soften the hardness and disperse the knots, clear heat and detoxify the toxins. The formula is chosen from the representative formula of elimination method, Xianfang Livestrong Drink, as the basic formula to identify the evidence and add and subtract; external treatment is to use Dragon Toad Xionghuang Wine to mix Mangyin San and Jinhuang San to apply externally, or apply chicken bone cream and Taiyi Cream externally. If the disease has been deficient for a long time, the patient should use the formula of “pus-transferring powder” as the base formula and add or subtract from it to nourish the blood, support the righteousness and dispel the evil, move the deeper and shallower, and promote the limitation, so that the poison can go out. Apply Taiyi Ointment externally. If the lump does not disappear, is more confined, and the inflammation is mild, breast lump and duct excision, breast segment or quadrant excision can be chosen.
It is worth mentioning that due to the relatively small incidence of this disease, the diversity of clinical symptoms, signs and changes in the course of the disease, the differences in the location, extent and degree of lesions, especially in the lump phase, there is no specific and effective examination method before a clear diagnosis is made without pathological section, and it is very easy to be confused with breast cancer, with a reported misdiagnosis rate of 50%-80%, so it should be taken seriously.
The major differentiation points between plasmacytoid mastitis and breast cancer are.
(1) The age of onset is light, mostly around 40 years old, the course of the disease is short, more on the right side than on the left side, there is often nipple overflow, and the overflow is often yellowish plasma or purulent from multiple ducts, while the age of onset of breast cancer is about 10 years older than that, the course of the disease is long, less of them have nipple overflow, the overflow is extruded from a single duct, and it is mostly bloody.
(2) Early onset of the disease may have inflammatory manifestations such as redness, swelling, heat and pain, and as the disease progresses, the inflammatory symptoms gradually subside, and the growth rate of the lump is faster than that of breast cancer lump.
(3) The lump is mostly located around the areola with pain, and its long axis is consistent with the course of breast ducts, and sometimes thickened ducts can be palpated under the nipple or areola, while breast cancer is mostly located in the upper outer or inner quadrant, with unclear boundary, not easy to push, unsmooth surface and no pain.
(4) In early stage, axillary lymph nodes are enlarged, soft and disappear with the progress of the disease, while in late stage, breast cancer is enlarged, hard and can adhere to each other and fuse into a mass with the progress of the disease.
(5) Early lumps can show skin adhesions, cellulite-like changes, nipple retraction, etc., but they do not invade the muscle membrane and do not adhere to the chest wall, while breast cancer can show adhesions, cellulite-like changes and satellite nodules, invade the muscle membrane and adhere to the chest wall in advanced stage with disease progression. In addition, irregular large high-density shadow or burr-like shadow seen on mammogram should not be distinguished, but the former is less common than the former with the bull’s-horn sign, calcified foci and changes of large blood vessels. Needle aspiration cytology examination sometimes has some differentiation significance. Ultrasound and near-infrared scans can show a limited strip-like medium gray shadows with clear borders under the nipple in the early stage, and irregular medium gray shadows of masses without obvious collateral circulation vessels in the late stage. Therefore, in clinical practice, it is necessary to conduct detailed examination, take medical history, make correct diagnosis and differential diagnosis of breast lumps, be familiar with the clinical manifestations, characteristics, signs and general rules of occurrence of breast lumps and various diagnostic methods of breast lumps and clinical ideas of diagnosis and differential diagnosis of breast lumps, according to the etiology of breast diseases, the number of lumps, the presence or absence of pain and inflammation of lumps and the accompanying symptoms. The nature of the breast lump disease is analyzed comprehensively according to the cause of the breast disease, the number of lumps, the presence or absence of pain and inflammatory manifestations and concomitant symptoms, and if the diagnosis is not clear, it is best to do pathological section examination.
3.Breast abscess stage.
So far, there are no specific drugs and methods for this disease, once the lump is formed, especially larger lumps, the possibility of complete dissipation is smaller, and if treatment is delayed or improperly treated, it will septicize. Some septicemia is faster, some septicemia is very late. If the lump is more limited, the skin is dark red, gradually becomes soft, fluctuations should be referred to, afternoon fever, spontaneous sweating, red tongue with yellow coating and smooth pulse, the pus has become, and should be promptly incised and drained. The incision should be large enough to equal the abscess. If the abscess is close to the nipple, the incision must be extended to the nipple, and the nipple lesion ducts are cut together, and the net necrotic tissue is removed as much as possible, mixed with a little red Sheng Dan, filled with Vaseline gauze, covered with dressing, and changed once a day, and after 3-5 days it is changed to mixed with Wu Wu Dan, Qi San Dan or Jiuyi Dan, and changed once every two days until the ulcer is healed. The key to changing the medication for this ulcer is: there are more residual necrotic tissues mixed with more red-serum dan, to the extent that there is no obvious pain, less residual necrotic tissues, red-serum dan amount mixed with less, according to the amount of necrotic tissues, new meat buds, timely selection of five or five Dan, seven or three Dan or nine a Dan, filling Vaseline gauze should be from beginning to end, must make the ulcer base on the meat buds grow to the sore surface flat cover and then grow the skin layer, must not False healing must not occur to avoid the formation of sinus tracts again.
4, breast fistula period.
Fistula-type plasmacytoid mastitis, mostly from early delayed treatment or improper treatment, from abscess-shaped transformation, its clinical features are breast lumps, ulcers and pus, single or multiple fistulas and/or sinus tracts, ulcers do not heal for a long time, or recurring soon after temporary healing, the course of the disease is long, less than a few months, more than a few years. In fistula-type plasmacytoid mastitis, drug treatment is difficult to cure and most require surgery.
If the inflammation is extensive and the skin is severely adherent to the whole or most of the breast, more fistulas are formed, simple mastectomy or subcutaneous simple mastectomy can be performed. The biggest advantage of Western medicine treatment is the short course of treatment, the effect is good, can be said to be immediate. The disadvantages are: the inflammation is not controlled, the secretion is more non-static period can not be operated; around the fistula lump is large, scar tissue hyperplasia is serious, the inflammation widely spread to the whole or most of the breast, the skin has serious adhesions, the formation of more fistulas, surgery damage to destroy more breast tissue; if only fistulotomy damage less breast tissue, but there is a legacy of chronic inflammatory lumps or the possibility of fistula recurrence.
(2) Chinese medicine treatment method: after the surgical incision is mixed with the decay and muscle medicine, the method is: routine disinfection, 2% lidocaine, the cocaine local infiltration anesthesia, with a head probe to explore the sinus tract, fistula direction. If the sinus single tube, inflammatory mass is more limited, the fistula or sinus local incision or excision, inflammation is not obvious to give a phase of suture; inflammation is obvious to open the wound, mixed with a little red Sheng Dan, filled with petroleum jelly gauze, covered with dressings, a day change, 3-5 days later changed to mixed with five five Dan or seven three Dan, two days change until the ulcer healed. For multiple complex fistulas or sinus tracts using surgical incision plus the use of Chinese medicine to dispel corruption and muscle medicine, that is, from the fistula inserted slotted probe, along the natural direction of the fistula completely cut the sinus tract or fistula, scrape the fistula granulation tissue, mixed with a little red rose Dan, filled with Vaseline gauze, covering the dressing, a day change, 3-5 days later changed to mixed with Wu Wu Dan, a day or two days to change the medicine, 3-5 days later, changed to mixed with the fistula, a day or two days to change the medicine. After 3-5 days, the dressing was changed to mixed with 7.3 dan and changed once every two days until the ulcer healed. Appropriate application of postoperative antibiotics can reduce the occurrence of incisional infection. If in the primary care unit, due to the surgical conditions, the traditional hanging method can be used: routine disinfection, 2% lidocaine, local infiltration of cocaine anesthesia, with a head probe to explore the sinus tract, fistula direction, will be tied with a thick wire and rubber band probe inserted into the papillary lesion catheter along the sinus tract, fistula to the distal end and lead out of the rubber band, followed by taut rubber band after the thick wire around the ligature, about a week fistula hanging open, the wound The red rose Dan, filled with Vaseline gauze, covered with dressing, a day change, 3-5 days later changed to mixed with five five Dan or seven three Dan, a day or two days to change the drug once, to be gradually removed from the rotting flesh, the main new flesh buds, mixed with nine a Dan or eight Dan, two days to change the drug once, until healed.
The red rose Dan, a three immortal Dan, by the fire nitrate, alum, mercury burning and refining, plus a little ice chips research very fine. High purity, used in large quantities, has a strong corrosive effect, can remove fistulas, sinus canal walls and bad granulation tissue; can make protein dehydration, denaturation, coagulation, so also has a very good sterilization effect. Five-5 Dan is five parts of red rose Dan plus five parts of cooked gypsum research very fine; 7-3 Dan is three parts of red rose Dan plus seven parts of cooked gypsum research very fine; 9-1 Dan is nine parts of cooked gypsum plus one part of red rose Dan research fine. Both of them add different doses of excipients, and the stimulation of tissues is relatively reduced. Wu Wu Dan promotes the shedding of necrotic tissues; Qi San Dan promotes the growth of new tissue cells. The biggest advantage of the TCM fistula hanging method with the addition of the decaying and regenerating medicine is that the damage to the breast tissue is less, but for some necrotic tissues forming lumps that are not yet pus, the patient is in more pain with the erosion method, and the procedure is longer if it is left to liquefy and fall off naturally. The use of Western medicine fistulotomy or local excision of the lump plus Chinese medicine to remove corruption and muscle-building medicine, absorbing the strengths of Chinese and Western medicine treatment methods, to make up for their respective shortcomings, reduce the damage to the breast tissue, reduce the patient’s pain, shorten the course of treatment, improve the cure rate, received better results, better than the application of Western medicine treatment and Chinese medicine treatment alone, worth promoting the application.