Dilation of mammary duct is a chronic breast disease with a long course and complex and diverse lesions. Bloodgood (1923) was called “dilation of mammary ducts” because of the dilated ducts that were often palpable under the skin in the areola area in the form of cords, resembling spaghetti-like worms or brownish-red tubular swellings, and Ewing (1925) found a large number of plasma cell infiltrates in the lesions under the microscope. Adai (1933), after a more detailed study, found that in the later stages of the disease, the ductal secretions of the breast not only stimulated the ducts to dilate, but also could overflow out of the ducts, causing an inflammatory reaction with a predominantly plasma cell infiltration around the ducts, and named it “plasmacytosis mastitis”. Payne called the disease “occlusive mastitis”. In 1956, Haagensen and Stout called the disease “ductal dilatation of the breast” based on its pathological features, and concluded that plasma cell infiltration is only an inflammatory reaction in the later stages of the disease, and that its primary lesion and its pathological features are based on the dilatation of the breast ducts. This has clarified the nature of the disease and has been recognized by all. Recently, it has been suggested that plasmacytic mastitis is not an inevitable process of ductal dilatation of the breast, and that plasmacytic mastitis has its characteristic morphology and clinical manifestations, and is treated as a special type of mastitis.
Ductal dilatation of the breast is a not uncommon benign disease that commonly occurs in middle-aged and older women, with a peak age of onset of 50-60 years. Due to its complex and variable clinical manifestations, it is easily misdiagnosed as breast cancer, causing patients to suffer unnecessary and expanded surgeries.
I. Etiology
1.Ductal drainage disorder
Such as congenital nipple deformity, depression, unclean or foreign hair or fiber causing blockage of breast pore, abnormal duct development, poor breast structure, resulting in epithelial hyperplasia inflammatory injury causing duct narrowing, interruption or occlusion. The accumulation of secretions in the ducts causes ductal dilatation. In some middle-aged and elderly women, the ducts of the breast are degenerated due to ovarian hypofunction, the walls of the ducts are relaxed, and the contractility of the myoepithelial cells is reduced, resulting in the accumulation of secretions in the ducts and the duct lumen expansion causing this disease.
2.Abnormal hormone stimulation
Some scholars found that the level of sex hormones in the blood of patients is abnormal. The level of estradiol (E2) and luteinizing hormone (LH) in the blood during the pre-ovulatory period is lower than normal, while the level of prolactin (PRL) is higher than normal. Abnormal sex hormone stimulation can induce abnormal ductal epithelial production and significant ductal dilatation. In general, the presence of obstruction alone without abnormal hormonal stimulation to induce epithelial secretion does not result in ductal dilatation. Poor ductal drainage is often the main cause of the development of the overflow phase to the lump phase.
3.Infection
Some scholars believe that the disease is accompanied by anaerobic bacterial infection or infection in the areola, which invades the subcutis and spreads to the milk ducts, forming a fistula after penetration through the milk ducts. Or on the basis of ductal obstruction, a large accumulation of epithelial cells and lipid-like secretions shed in the ducts and escaped from the duct wall and decomposed to produce chemicals, causing chemical irritation and antigenic reactions in the surrounding tissues, resulting in an inflammatory process dominated by plasma cells.
II. Clinical manifestations
According to the pathological changes of the disease and the course of the disease through the clinical manifestations can be divided into three stages.
1.Acute stage
Early symptoms are not obvious, there can be spontaneous or interstitial nipple overflow, only when squeezed there is secretion overflow, the overflow is brownish yellow or bloody purulent discharge, this symptom can last for many years. As the disease progresses the lipid secretions in the milk ducts decompose, stimulating and eroding the duct walls and exuding into the extra-ductal interstitial mammary glands, causing an acute inflammatory reaction. The skin within the areola is red, swollen, warm and painful to the touch. Swollen lymph nodes may be palpable in the axillae with pressure pain. The whole body may have chills and high fever. This acute inflammatory-like symptoms will soon subside.
2.Sub-acute stage
During this period, the acute inflammation has subsided and reactive fibrous tissue hyperplasia occurs on the basis of the original inflammatory changes. A lump with mild pain and pressure is formed in the areola area. The edges of the mass are indistinct and resemble a breast abscess mass of varying size. Pus can often be extracted by puncturing the mass. Sometimes the swelling naturally breaks down and forms an abscess fistula, and after the abscess breaks down or is incised, it does not heal for a long time, or after it heals, a new small abscess is formed, so that the inflammation continues to develop.
3.Chronic period
When the disease is repeated, one or more hard nodules with unclear boundaries may appear, mostly located within the areola, which are firm in texture and adherent to the surrounding tissues, with skin adhesions, the local skin is orange peel-like changes, nipple retraction, and in severe cases, breast deformation. Plasma or hemorrhagic overflow may be seen. Lymph nodes in the axilla can be located. It is sometimes difficult to distinguish from breast cancer clinically. The duration of the disease varies from a few months to several years or longer.
The above clinical manifestations do not appear in all patients according to their developmental pattern, i.e., the first symptom may not necessarily be nipple discharge or acute inflammatory manifestations, but may be a subareolar lump first, and in the chronic stage, a long-lasting parareolar fistula may appear.
III. Examination
(A) Laboratory tests
1. Needle aspiration cytology of the swelling
Pus-like material can often be extracted; microscopic examination reveals neutrophilic necrotic material and a large number of plasma cells, lymphocytes and cellular remnants.
(B) Histopathology
Pathological examination after excision of the mass is the most reliable basis for diagnosis. The specimen can be seen as a dilated duct filled with yellowish-brown, creamy or tofu-like mucus. There may be fibrous tissue hyperplasia and hyaline degeneration around the duct. Microscopic examination reveals atrophy and thinning of the epithelial cells of the dilated ducts, and shedding of epithelial cells with lipid-like material filling and blocking the lumen, with partial destruction of the duct wall. A large number of plasma cells, histiocytes, neutrophils and lymphocytes were infiltrated in the peritubular tissue.
(C) Other auxiliary examinations
1.X-ray angiography
The catheter lumen is moderately to highly irregularly dilated with tortuous travel, smooth, intact and continuous duct wall, and a few are cystic or pyknotic dilated. There is no occupying sign in the enlarged lumen, and the contrast agent fills the lumen evenly, which can be distinguished from breast cancer.
2.B ultrasound examination
The catheter is moderately to highly dilated, with uneven thickness and tortuous travel. A few of them may be cystic or pyknotic dilated, and there may be echogenic shadow formed by debris in the center of the lumen.
Diagnosis
The diagnosis of this disease mainly relies on detailed history, understanding its clinical course, considering its age of onset, and then combining the following points can often make the correct diagnosis.
1. The disease is most often seen in non-lactating or menopausal women over 40 years of age, often with a history of breastfeeding disorders. The lesion is often limited to one side, but there are cases where both mammary glands are involved at the same time.
2, nipple overflow is sometimes the first symptom of the disease, and is the only sign. Single or multiple holes may be seen, and the nature of the fluid may be plasma or bloody. Multiple sites of pressure on the mammary gland can cause discharge from the nipple, and the lesion often involves a larger number of milk ducts, which can also occupy a large portion of the areola. The nipple overflow is often intermittent and sporadic.
Sometimes breast lumps are the first symptom, and most of them are located deep in the areola with unclear edges, and early lumps adhere to the skin, resembling breast cancer.
If the lump has become pus, it is often accompanied by enlarged lymph nodes in the ipsilateral axilla, but the texture is soft and there is pressure pain, and the enlarged lymph nodes can gradually subside as the disease progresses.
5, due to hyperplasia of the duct wall and periductal fibrous tissue and inflammatory reaction, resulting in duct shortening and pulling back of the nipple. Sometimes there is an “orange peel” change due to local skin edema.
6.X-ray mammography can clearly show the dilated ducts and cysts, and can understand the extent of the lesions.
Needle aspiration cytology of the swelling can often extract pus-like material or find neutrophils, necrotic material and a large number of plasma cells, lymphocytes and cell remnants, which is very helpful for the diagnosis and differential diagnosis of the disease. Pathological examination after excision of the mass is the most reliable basis for diagnosis.
V. Treatment
Chinese medicine treatment for ductal dilatation of the breast
(A) Chinese medicine treatment
(1) Initial stage: nipple indentation, pimple-like discharge, foul odor, or painful lumps in the areola, treatment is to dredge the liver and regulate the qi, and regulate the flushing.
Radix Bupleurum, Eucommiae, Euphorbiae, Hawthorn, Gorgonian, Cistanches, Cynanchum, Lutong (each) 9g, Oyster, Dandelion, Rhizoma alba, Radix et Rhizoma cereus (each) 30g.
(2) Acute stage: Enlargement of the lump in the areola, swelling and pain, formation of abscess, fluctuating sensation, generalized fear of cold, fever, headache and other symptoms, treatment is to clear heat and detoxify, remove blood stasis and subdue swelling.
Yinhua, forsythia, Huangling, soapberry (each) 12g, dandelion 30g, whole gourd atrophy, red peony, raw earth, half branch lotus, salvia, raw astragalus (each) 15g, roasted silkworm 9g, white flowered snake’s tongue herb 50g.
(3) Sub-acute stage: At this time, the systemic and local inflammatory reflection is reduced, the limited mass has been ulcerated, purulent overflow is not only, the formation of sinus or fistula, the treatment is to clear heat and eliminate swelling, activate blood circulation and eliminate blood stasis. Dandelion, whole guajou, salvia, tiger stick (each) 15g, silver flower, forsythia, curcuma, raw hawthorn, xiaquan, liuxingzi, peach kernel, red peony (each) 9g, angelica 12g, white flower and snake tongue herb 30g.
(4) Chronic stage: After the subacute stage, local infection is controlled, residual sinus tracts, fistulas, and ulcers often have purulent secretions overflowing, and the skin of the breast is “orange peel-like” or deformed, at this time, generally no internal Chinese medicine treatment is given, and sinus tracts or fistulas should be incised and scraped, and the exposed hard and tough walls of the tracts and scar tissue and deformed skin should be excised and preserved as much as possible. The patient’s skin will be removed and the skin deformed, and the papillary tissue will be preserved as much as possible. After the operation, the wound will be embedded with a cotton ball of eighty-two dan to remove the pus and rot, and the medicine will be changed once a day; after 5-7 days, the pus and rot will be reduced and the wound will be embedded with nine one dan instead. The advantages of this type of surgery are less pain for the patient, less tissue damage, low recurrence rate, and basic maintenance of breast shape.
Western medical treatment for ductal dilatation of the breast
(B) Surgery
It is an effective treatment for this disease. Different surgical methods are adopted according to different stages of development.
1.Mastopexy
The method is to make a curved incision along the edge of the areola, preserve the nipple, remove all the dilated ducts from below the nipple, and wedge the tissue of the subareolar breast mass.
2.Segmental mastectomy
It is suitable for subareolar masses with peri-mammary ductitis. The large ducts and the tissue surrounding the mass should be removed from the nipple to prevent the formation of subareolar cysts, mammary fistulae and nipple overflow after surgery.
3.Simple mastectomy
It is suitable for those with extensive lesions and large masses, especially those located under the areola with skin adhesions forming sinus tracts. Total percutaneous mastectomy or simple mastectomy can be performed.