The concept of ductal dilatation syndrome of the breast
Dilated breast duct syndrome: There are many causes of dilated breast ducts. In the process of not being detected and treated for a long time, the ductal secretions become stagnant, leading to inflammatory changes and eventually forming plasmacytoid mastitis, and the syndrome at all stages of such a pathological process is the dilated breast duct syndrome.
Pathologic basis: The pathologic basis of ductal dilatation of the breast is multifaceted.
Prevalent population: in non-lactating menstruating women aged 30-40 years, with another high prevalence in postmenopausal older women.
Etiology: It may be related to local ductal dilation due to breast degeneration, endocrine disorders, breast trauma, lactation disorders, etc.; nipple deformity, nipple invagination is also an obvious cause. The disease is more likely to occur around the nipple and areola; various lesions in the mammary gland that compress the milk ducts; ductal dilatation may be related to anaerobic bacterial infections, and pus common bacterial cultures are negative.
Plasmacytoid mastitis: Ductal dilatation of the breast, also known as plasmacytoid mastitis, is a chronic inflammatory disease characterized by marked expansion of the collecting ducts at the areola and infiltration of inflammatory cells, especially plasma cells. The clinical manifestations of this disease lack specificity and are difficult to distinguish from other breast diseases, especially breast cancer, which may lead to misdiagnosis.
Ductal dilatation of the breast is a common disease of the breast, accounting for 4% to 5% of benign breast diseases and plasma cell mastitis, accounting for 2% of breast diseases. The pathology of this disease is complex, conservative treatment is not effective, chronic and recurrent, the disease is prolonged, and inappropriate treatment in individual cases can easily lead to the formation of mammary fistula.
Lesions that cause ductal dilatation of the breast
Common diseases of the breast that cause ductal dilatation of the breast
Ductal dilatation of the breast
Malignant lesions of the breast
Fibroadenoma of the breast
Intraductal papilloma of the breast
Tuberculosis of the breast
Acute mastitis
Chronic fibrous mastitis
Intraductal lesions of dilated breast ducts
Dilated milk duct disease, acute and chronic inflammation of the milk duct, intraductal papilloma, intraductal cancerous lesions of the breast
Endoscopically detected lesions in the milk ducts.
Simple dilation of the milk ducts
Inflammatory disease of the milk ducts
Intraductal papilloma: solitary papilloma, multiple papillomas
Intraductal carcinoma: intraductal carcinoma in situ, early invasive ductal carcinoma, invasive ductal carcinoma
Ductal pathological changes of dilated breast ducts
In addition to the various breast lesions causing ductal dilatation, simple ductal lesions can be classified as
Early stage: pathological changes are irregular hyperplasia of breast duct epithelium and ductal secretion dysfunction, resulting in the accumulation of large amounts of lipid-containing secretions in the milk ducts, thus causing ductal dilatation.
Later stage: The lipid material accumulated in the ducts decomposes and forms breast masses. In addition to plasma cells, a large number of foam cells, multinucleated giant cells and epithelioid cells can also be seen, forming a tuberculosis-like granuloma, which resembles tuberculosis in structure but without caseous necrosis and Mycobacterium tuberculosis. In combination with severe infection, abscesses and sinus tracts may form, and the axillary lymph nodes are enlarged.
Late stage: fibrosis of the ductal wall of the dilated breast and proliferation of the surrounding fibrous connective tissue may result in nipple invagination and adhesion of the mass to the skin. Thus, most authors believe that ductal dilatation and plasmacytoid mastitis are manifestations of one disease in different stages of development.
Pathological features of plasmacytic mastitis.
1, visual inspection: most of the cut surface yellow-white, with skin adhesions; naked eye view has obvious ductal dilatation, containing yellowish paste, the texture is mostly hard, all without envelope.
2, microscopic examination: there is a large number of plasma cells and a certain amount of eosinophils, lymphocytes and other infiltration, the structure of the lobules of the breast is destroyed, there is a large number of neutrophil infiltration; with ductal dilatation, ducts with lipid-like material, surrounded by foam cells, and see multinucleated giant cells and epithelioid cells, without caseous necrosis.
Clinical manifestations of ductal dilatation syndrome of the breast
1. The disease is most common in non-lactating women aged 20 to 40 years.
2, the onset of the disease is more common in one side of the areola, but there are also bilateral simultaneous onset. Ductal dilatation of the breast involves the unilateral breast.
3, often accompanied by a history of nipple depression, in the depressed nipple can have a foul-smelling tofu-like material secretion.
4, nipple overflow: the most common clinical manifestation, nipple plasma, bloody, brownish-yellow, milk-like, purulent and other overflows. The initial manifestation can be spontaneous or intermittent nipple discharge, usually brownish-yellow or bloody and purulent, characterized by squeezing anywhere within the lesion to make the discharge flow from the nipple.
5, the areola lumps: breast lumps can suddenly appear, lumps irregular shape, hard texture and tough border is not clear, can be adhered to the skin, the lump local pain, skin color slightly red, the formation of abscess, pus with odor after ulceration, or healing mouth and then recurrence, ipsilateral axilla can be accompanied by enlarged lymph nodes, there is tenderness.
6.Milk leakage: Inflammatory condition recurring, to late lumps break down after a long time without closing, forming a breast leakage.
7, no specific symptoms of breast, and non-breastfeeding, breast lumps and nipple overflow of bloody fluid; or a variety of asymptomatic lumps in the breast.
8.Other main clinical manifestations include: breast pain, swollen lymph nodes in the axilla, breast swelling with local skin redness, recurrent episodes of chronic inflammatory process, formation of chronic breast fistula, often with a small amount of purulent discharge overflow, nipple invagination, and “orange peel” changes in the breast skin.
9. The axillary lymph nodes may be enlarged.
Different methods of examination for intraductal lesions of the breast
Smear cytology: Although nipple smear is simple and easy to perform and can be repeated, the diagnostic rate of breast cancer with nipple discharge is only 31.1% to 55%.
Selective mammography: Mammography is not easy to detect microscopic lesions, negative results cannot exclude the presence of tumor, and mammography is not easy to be successful for those with small amount of nipple discharge. In order to make a clear diagnosis, further consultation and treatment are often required.
Mammography: It can understand the whole picture of the breast and clarify whether there are lumps and/or dilated milk ducts, but the localization of papillary tumors or cancer in the breast ducts is poor, and almost all of them cannot be shown.
Ultrasonography: It can roughly understand whether there are obvious ductal dilatation, cysts, lumps, etc. in the breast, and sometimes can detect microscopic lesions in the milk ducts.
Endoscopic examination of breast ducts: endoscopic examination of breast ducts can detect: simple dilation of breast ducts, inflammation of breast ducts, intraductal papilloma, solitary papilloma, multiple papillomas, intraductal carcinoma, invasive ductal carcinoma and intraductal carcinoma in situ. Intraductal carcinoma mostly presents as a manifestation of diffuse intraductal hyperplasia. The use of endoscopy provides the possibility to diagnose ductal carcinoma in situ without masses and calcifications located in the ducts of the breast. Finally, all of them were confirmed by histopathology.
Fine needle aspiration examination: Patients with breast lumps underwent fine needle aspiration cytology or pathology, and a large amount of necrotic material and the presence of a large number of plasma cells and lymphocytes were seen microscopically, in addition to malignant cells of the breast.
Etiology of ductal dilatation disease of the breast
The etiology of ductal dilatation of the breast is unclear, and most patients have no clinically significant causative factors. The factors that may be relevant are.
1, and congenital malformation due to nipple invagination, nipple dysplasia related;
2, due to breastfeeding disorders, breast trauma, inflammation, endocrine disorders and degenerative changes in the breast caused by poor ductal drainage, obstruction, stagnation of secretions, so that the duct dilates, the lumen of the neutral fat stimulates the duct wall, fibrous tissue proliferation, and then destroy the duct wall into the interstitial stroma caused by a violent aseptic reaction.
3.Younger patients may be related to chest binding;
4, the disease is related to smoking, smoking can lead to the accumulation of lipid-like peroxides, ferritin and other toxic substances in the milk ducts, causing restricted tissue damage, and beneficial to anaerobic bacteria breeding in the milk ducts, infection.
5, the disease is a non-bacterial inflammatory reactive disease with a long and varied course.
Examination of breast duct endoscopy
Breast duct endoscopy can detect and identify microscopic lesions in the milk ducts at an early stage, which is a method with a high diagnostic rate. However, some of the issues to be addressed by ductal endoscopy are.
1, biopsy of micro lesions in the ducts: because the ducts are very small, it is very difficult to perform biopsy from the ductal lumen, and biopsy is very important for definite diagnosis, which is a problem that needs to be solved in clinical practice;
2.The measurement of CEA in the ductal irrigation through endoscopic breast ducts has been reported to be of some significance in the diagnosis of breast diseases, but immunohistochemical examination of the exfoliated cells in the irrigation is rarely reported;
3. For micro lesions found by endoscopic examination of the breast ducts, preoperative localization needs to be studied, otherwise the lesion site may be missed;
4. How to treat benign intraductal lesions. If the above problems can be solved, the diagnosis and treatment of intraductal lesions will be further improved.
It has the advantages of easy operation, non-invasive, direct observation of intraductal lesions, repeatable examination, etc. Especially, it has a high diagnostic rate for microscopic lesions in the ducts, so that some patients can avoid unnecessary excisional biopsies and provide clear localization of lesions for patients who need surgery.
Principles of treatment for ductal dilatation of the breast
In addition to surgery for diagnosed breast tumors, if the ducts are significantly dilated and cause different changes in the breast, surgery is an effective treatment for this disease, and different procedures are chosen depending on the situation.
Milk duct excision: Milk duct injection of melanoma can be used to guide the removal of diseased milk duct tissue in all cases of nipple overflow. Local ductal excision not only removes the breast lesion, but also maintains the appearance of the breast. This is in line with people’s demand for the beauty of breast appearance. Therefore, the diagnosis rate of this disease is improved. It is especially important to identify the exact site of the lesion and to minimize the scope of surgery.
Local lump excision: local lump excision is feasible for small breast lumps, recurrent inflammatory disease, and mastectomy.
Segmental mastectomy or quadrantal resection: for large masses outside the areola area with obvious ductal dilatation, segmental mastectomy is performed.
Simple mastectomy: for large masses or older patients; for fistulas and sinus tracts; for large masses with diffuse lesions and more than one breast quadrant in older women, simple mastectomy may be performed,
Excision and drainage of pus: In cases of combined acute infection and abscess formation, excision and drainage of pus should be performed in a timely manner on the basis of active anti-inflammation, and local excision of the mass should be performed 3 months after healing of the incision. If an abscess is formed, the abscess should first be opened and drained and treated with anti-inflammatory therapy, and then surgery should be performed after the inflammation has subsided.
Fistulotomy: If a fistula or sinus tract is formed, a fistulotomy with antimicrobial suture is performed; in the case of chronic abscess and fistula formation, the mass and fistula can be completely excised and part of the normal breast tissue around the lesion can be removed.
Intraoperative rapid pathological examination: postoperative pathological sections all confirmed ductal dilatation of the breast. Preoperative misdiagnosis of breast cancer and intraoperative suspicious malignant lesions were all examined intraoperatively. For those without preoperative pathological examination to confirm the diagnosis, intraoperative frozen section should be performed to confirm the diagnosis. Regardless of the clinical manifestation of breast cancer, enlarged excision should not be performed until histological confirmation is obtained, which will increase unnecessary trauma.
Surgical procedures for ductal dilatation of the breast
Surgical procedure: It depends on the scope and type of lesion.
In cases of nipple overflow without a mass, the lesioned duct is identified intraoperatively, and then the duct is excised by injecting methylene blue into the areola incision, and the lesioned duct is excised according to the extent indicated by methylene blue staining.
If the swelling is close to the nipple, it is best to perform preoperative mammography in the area to find out whether there is any accompanying ductal dilatation, and perform complete excision of the swelling and ductal excision in the area.
3.If the mass is located in the surrounding area, segmental excision of the mass is feasible, and care should be taken not to reduce the scope of the operation.
4. For larger masses, involvement of large parts of the breast tissue, or repeated fistulae in multiple parts of the breast, total mastectomy is feasible.
5. For fistula formation and acute inflammation control, fistula excision should be performed, paying attention to the normal breast tissue.
The procedure should be fully hemostatic, and the breast section should be sutured if it can be sutured, but if the wound is large, it may not be sutured.
7, for non-lactating breast abscess, we should consider the possibility of ductal dilatation of the breast, and remember not to casually cut and drain to prevent the formation of breast fistula, but to perform excision of the mass including the abscess after the infection is controlled and limited. The patient with a chronic abscess of the breast is excised, the mass is fully excised, hemostasis is complete, and the wound is flushed with methotrexate solution and left to drain, and the wound is healed in one stage.
In the case of nipple invagination, no nipple deformity correction was performed intraoperatively, and no recurrence was seen in the postoperative follow-up.
Differential diagnosis of ductal dilatation and breast cancer
Common symptoms of ductal dilatation of the breast.
1. The age of onset of simple ductal dilatation of the breast is relatively young, averaging 33.5 years.
2. History of inflammatory manifestations such as redness, swelling, heat and pain, history of swelling reduction, and localized swelling with tenderness.
3, the swelling is mostly located around the areola, and the axillary lymph nodes may be enlarged and painful, and shrink or disappear with the progress of the disease.
4. Ductal dilatation is often associated with breast fistula because of chronic recurrent attacks and poor conservative treatment.
Differentiation of ductal dilatation from breast cancer.
1. Single nipple or single breast hole with bloodstream overflow must be actively examined;
2.The age of onset of breast cancer is 40-60 years old. For those who can find obvious lumps in the breast, various examinations must be performed;
3.If there is an obvious lump in breast ductoscopy, perform surgical excision for pathological examination.
4.Some cases are difficult to be distinguished from breast cancer, so it is better to perform puncture pathological examination; or surgery and routine intraoperative frozen pathological examination.