Plasmacytoid mastitis, also called ductal dilatation, is called acantholytic canker sore in Chinese medicine, commonly known as ductitis, or plasmacytosis for short. Plasma milk is not caused by bacterial infection, but by the accumulation and overflow of fatty material in the ducts, causing chemical irritation and immune response around the ducts, resulting in a large number of plasma cell infiltrates, hence the name plasma cell mastitis. Repeated episodes and fistulas are formed after rupture, which can be followed by bacterial infections that do not heal for a long time. Therefore, it is a special kind of mastitis. Plasmacytoid mastitis occurs mostly in middle-aged and older women, and most patients have nipple invagination deformity.
Clinical manifestations
Plasmacytoid mastitis has a sudden onset and develops rapidly. The patient feels localized pain and discomfort in the breast, and a lump may be palpable. The lump is located under the areola or extends into one quadrant. The masses are hard and tough. The surface is nodular, with poorly defined borders and no adhesions to the chest wall. The skin of some breasts is edematous and orange peel-like, and there are usually no systemic symptoms such as fever. The nipples are often edematous and orange peel-like, usually without fever and other systemic symptoms.
The nipples often secrete powder-like material with a foul odor. A small number of patients have nipple discharge, which is bloody or watery, and may be accompanied by enlargement of the axillary lymph nodes on the affected side. In the late stage, the lump becomes softened and forms an abscess. The abscess breaks down and flows pus mixed with powder-like pus and causes fistulas in the areola, resulting in recurrent wounds and scarring, which causes the nipple to sink into a concave position. The clinical manifestations of plasmacytoid mastitis are varied, with some patients presenting with chronic nipple discharge, nipple invagination alone, or localized lumps that persist for years.
Clinical features
1. Not associated with pregnancy and lactation, i.e., not occurring during lactation.
2, Most patients are accompanied by various deformities of the nipple or dilated ducts.
3. There are many young women and many unmarried ones.
4, Recurrent, long-lasting parareolar fistulas or chronic inflammatory masses. There is a case with a history of up to 13 years.
5. This disease is not uncommon, accounting for about 10% of breast patients.
Clinical Stages
The clinical stage can be divided into three phases:
① The acute stage has the typical manifestations of acute mastitis, i.e., localized congestion, swelling, tingling, fever, and systemic inflammatory response. This acute inflammation is often located around the areola, but some patients may also have an insidious onset without chills and fever and elevated blood levels. Another characteristic of this phase is that once acute inflammation occurs, it often recurs several times, with a similar course.
The subacute stage is characterized by an inflammatory mammary mass, which can subside on its own after a period of acute inflammation, but can also be followed by bacterial infection and the formation of an abscess, which can break down after anti-inflammatory treatment, ulcers, and even long-lasting sinus tracts. Even if the wound heals after treatment, abscesses and ulcers will be formed again soon.
(3) Chronic stage: Breast lumps are the main manifestation in this stage. The lumps vary in size and are often painless, mostly around the areola or in a certain quadrant, and the surface skin may even become orange peel-like.
Treatment of plasma breast
1.Basic view
At present, surgery is the only effective method for this disease. For small lumps, local excision of the lump is performed; for those with early ductal expansion, the expanded ducts and surrounding tissues can be excised from the nipple root; for larger lumps, even occupying the entire breast, simple excision of the breast can be performed, and if necessary, breast reconstruction.
2.Stage treatment
Acute inflammatory stage This stage can often be combined with bacterial infection, especially anaerobic bacterial infection, so the application of antibiotics and other anti-inflammatory treatment, metronidazole anti-anaerobic drugs can often receive better results. The occult type is mostly a pathological change in postmenopausal women, and some believe it is mostly related to autoimmune reactions. If the nipple overflow is treated with oral prednisone; if the ductal dilatation of the breast is complicated by chronic mastopathy, potassium iodide or vitamin E can be taken at the same time, and if necessary, oral triamcinolone acetonide can also be taken. During the course of treatment, symptoms such as nipple discharge should be closely monitored, and attention should be paid to any other breast diseases. In particular, it is important to check the exfoliated cells of the hemorrhagic discharge to see if cancer cells are detected.
In the stage of abscess formation, incision and drainage are required. Drainage by simply cutting the skin on the surface of the abscess to reach the abscess cavity often leads to recurrence of abscesses. Therefore, it is important to reach the nipple during the incision, and the diseased ducts in the nipple should be cleaved, and the inner wall of the diseased tissue should be scraped to remove necrotic tissue before gradual healing. If there is an obvious abscess formation, the abscess should be drained by incision and local drug change, and the lesion should be excised after the inflammation has subsided. Otherwise, the incision is prone to infection and the formation of milk duct fistula.
Fistula formation stage
The only reliable method for this type is surgical excision of the fistula and some of the surrounding normal tissue. The lesion should be removed before the fistula heals and the next ulceration, or during the resting phase when there is little discharge from the fistula, with careful identification of the lesion and removal of the fistula up to the subpapillary dermis, and complete removal of the lesion and the affected duct is essential to avoid recurrence.
Surgery is the only effective treatment when the mass is formed. Depending on the size and location of the lump, lobectomy or total mastectomy may be performed.
Different surgical approaches can be used:
(1) mastectomy, this method is mainly suitable for subareolar lumps and nipple overflow with generalized dilatation of large ducts under the areola. A radial incision is made to remove all large ducts and wedge-shaped excision of the subareolar breast tissue.
(2) Local excision of the mass, this method is suitable for small masses.
(3) Segmental mastectomy, which is suitable for the lump located outside the areola and more limited, ductal dilatation with peri-mammary ductitis and most of the large ducts with pathological changes, and segmental excision from the root of the nipple.
(4) Simple mastectomy and, if necessary, one-stage or two-stage breast reconstruction. This is indicated for large masses or in advanced age, even if they occupy the entire breast.
It should be emphasized that all diseased tissues should be removed, otherwise the sutured incision will not heal easily and the lesion will be prone to recurrence. In cases of simple nipple overflow, Meridian Blue can be injected into the ductal opening of the dilated nipple and the colored breast tissue can be wedge-shaped excised.