mammary duct dilatation
Introduction
Introduction to mammary duct dilatation Dilation of mammary duct is a chronic breast disease with a long course and complicated and diverse lesions. In the past, I have not known enough about this disease. I have used a variety of names. Bloodgood (1923) is a cord-like duct that is often accessible to the dilated breast duct in the areola area. It is similar to a noodle-like worm or a brown-red tubular mass. Called "venous dilatation", Ewing (1925) found a large number of plasma cell infiltration under the microscope; Adai (1933) found in a more detailed study, the disease progresses to the later stage, breast duct secretions not only stimulate the catheter It expands and can overflow the tube, causing an inflammatory reaction mainly caused by plasma cell infiltration around the tube, and is named "plasma mastitis". basic knowledge The proportion of illness: 0.001% Susceptible people: women Mode of infection: non-infectious Complications: edema
Cause
Causes of mammary duct dilatation
Catheter drainage disorder (35%):
Such as congenital nipple deformity, depression, unclean or foreign hair, fiber, etc. caused by blockage of the milk hole, abnormal catheter development, poor mammary gland structure, resulting in epithelial hyperplasia, inflammation, injury, etc. caused by catheter stenosis, interruption or occlusion, accumulation of ductal secretions, Caused by catheter dilatation, in part, in older women, due to ovarian dysfunction, mammary ducts are degenerative, the wall is loose, and the contractile force of myoepithelial cells is reduced, leading to the accumulation of ductal secretions and lumen expansion leading to the disease.
Abnormal hormone levels (25%):
Some scholars have found that patients with abnormal blood levels of sex hormones, estradiol (E2), luteinizing hormone (LH) levels in the pre-ovulatory period are lower than normal, and prolactin (PRL) levels are higher than normal, abnormal sex hormone stimulation can promote the catheter The epithelium produces abnormal secretion, and the catheter is obviously dilated. Generally speaking, there is a single obstruction without abnormal hormone stimulation to promote epithelial secretion, no catheter dilation, and poor catheter excretion, which is often the main cause of the development of the galactorrhea.
Infection (20%):
Some scholars believe that this disease is accompanied by anaerobic infection or areola infection, invading the subcutaneous wave and the milk duct, forming a fistula after the passage of the milk duct, or on the basis of obstruction of the catheter, a large number of epithelial cells and lipid secretions are shed in the tube. Accumulates and escapes from the decomposition of the tube wall to produce chemical substances, causing chemical stimulation and antigen reaction of surrounding tissues, causing inflammatory processes dominated by plasma cells.
Pathogenesis:
The pathological changes in mammary duct dilatation are:
1. Gross shape: there are twisted and dilated milk ducts and large catheters in the lower part of the nipple and areola, some form sacs, and the number of affected ducts is usually 3 to 4, and more than a dozen can be involved at the same time. The diameter of the catheter can reach 3~4mm or larger. The dilated tube and the capsule are filled with yellow-brown, creamy or tofu-like viscous material. The pericardium has fibrous tissue hyperplasia and transparent denaturation, forming a white translucent fibrous thick. Walls, adjacent fibrous thick walls adhere to each other to form a yellow-white induration, or a solid boundary with unclear masses.
2. Under the microscope: early changes can be seen under the areola, the ducts and catheters have different degrees of expansion, the expanded ductal epithelial cells are compressed and atrophied, thinned into a single layer of cubic epithelium or squamous epithelium, part of the ductal epithelial necrosis, shedding The epithelial cells and lipids fill and block the lumen. If the contents of the dilatation catheter overflow or part of the wall is destroyed, a large number of plasma cells, tissue cells, neutrophils and lymphocytes infiltrate, or appear in the perivascular tissue. Foreign body giant cell reaction, tuberculous small nodules or pseudo-abscess formation, attention should be paid to the identification of tuberculosis and breast cancer.
Prevention
Breast duct dilatation prevention
1. Women should have a breast examination every year to find out the correct diagnosis and treatment.
2, pay attention to the cleanliness of the breast, prevent inflammation and infection.
3. Lactating women are reasonably breastfeeding.
4. Choose the right underwear to reduce the incidence of breast disease.
Complication
Complications of mammary duct dilatation Complications edema
Can be complicated by breast pain.
Symptom
Symptoms of ductal dilatation of the breast Common symptoms Abscess cysts Lymph node swelling Edema nipple Invagination Breast degeneration Incomplete skin adhesion nipple discharge Purulent discharge High fever
According to the pathological changes and course of the disease, the clinical manifestations can be divided into three phases.
Acute phase
Early symptoms are not obvious, there may be spontaneous or interstitial nipple discharge, only secretions overflow when squeezed, the discharge is brown or bloody, purulent secretions, this symptom can last for many years, with the development of the disease The fatty secretions in the lactiferous duct are decomposed, stimulated, eroded the wall of the catheter and exuded to the interstitial mammary gland, causing an acute inflammatory reaction. At this time, the skin appears red, swollen, fever, tenderness, underarm in the areola range. It can reach the swollen lymph nodes and has tenderness. The whole body can have chills and high fever. The acute inflammatory symptoms will soon subside.
2. Subacute phase
In this stage, the acute inflammation has subsided. On the basis of the original inflammatory changes, reactive fibrous tissue hyperplasia occurs, and a mass with mild pain and tenderness is formed in the areola area. The edge of the mass is unclear, like a breast abscess, and the size of the mass is different. The mass often draws out the pus, and sometimes the mass breaks naturally and forms a purulent sputum. After the abscess is broken or cut, it will not heal for a long time, or a new small abscess will be formed after healing, so that the inflammation continues to develop.
3. Chronic phase
When the disease recurs, there may be one or more indurations with unclear borders, mostly in the areola range. The texture of the sputum is firm and adheres to the surrounding tissue. When it adheres to the skin, the local skin changes like orange peel, and the nipple is back. Contraction, severe breast deformation, visible serous or bloody discharge, axillary lymph nodes can be paralyzed, clinically difficult to distinguish from breast cancer, the duration of the disease varies from a few months to several years or longer.
The above clinical manifestations are not all patients appear according to their developmental rules, that is, their first symptoms are not necessarily the first nipple discharge or acute inflammation, may be the first appearance of the subarach mass, in the chronic phase may appear long-term unhealed areola.
Examine
Examination of mammary duct dilatation
1. The needle aspiration cytology examination, often can extract the pus; physical examination can be seen neutrophils, necrosis and a large number of plasma cells, lymphocytes and cell debris.
2. Histopathology: pathological examination after mass resection is the most reliable diagnostic basis. The specimen can be seen as an expanded catheter filled with yellow-brown, creamy or tofu-like viscous material. There may be fibrous tissue hyperplasia and transparency around the tube. Denaturation, microscopic examination revealed dilated ductal epithelial cells atrophy, thinning, detached epithelial cells and lipids filled and blocked the lumen, part of the wall was destroyed, a large number of plasma cells, tissue cells, neutrophils and Lymphocyte infiltration.
3. X-ray angiography: the lumen of the catheter is moderately to highly irregular, distorted, the wall is smooth, intact, continuous, a few cystic or fusiform expansion, no enlarged space in the lumen, angiography The agent evenly fills the lumen and can be distinguished from breast cancer.
4. B-ultrasound: The catheter is moderately to highly dilated, uneven in thickness, distorted, and a few may be saclike or fusiform, and there may be echogenic shadows formed in the center of the lumen.
Diagnosis
Diagnosis and differentiation of breast ductal dilatation
diagnosis
The diagnosis of this disease mainly depends on detailed medical history, to understand its clinical process, consider the age of onset, and then combine the following points to make a correct diagnosis.
1. This disease is more common in non-lactating or menopausal women over 40 years old. It often has a history of breast-feeding disorders. The lesions are often limited to one side, but there are also cases where both sides of the breast are affected at the same time.
2. The nipple discharge is sometimes the first symptom of the disease, and it is the only one. It can be seen as a single hole or porous discharge. Its nature can be serous or bloody. The compression of the breast in multiple parts can cause the secretion to overflow from the nipple. The lesions often involve a large number of milk ducts, which can also occupy more than half of the areola. The nipple discharge is often intermittent, sometimes not.
3. Sometimes the breast mass is the first symptom. The mass is mostly in the deep part of the areola, the edge is unclear, and the early mass is stuck to the skin, which is like breast cancer.
4. If the mass has become a pus, often accompanied by ipsilateral axillary lymph node enlargement, but the texture is soft and tender, and the lymph nodes that progress with the disease can gradually subside.
5. Due to the proliferation and inflammation of the ductal wall and perivascular tissue of the breast, the catheter is shortened, the nipple is retracted, and sometimes it is "orange peel" due to local skin edema.
6. X-ray mammography can clearly show dilated catheters and cysts, to understand the extent of the lesion.
7. Swelling needle aspiration cytology, often can extract pus or find neutrophils, necrosis and a large number of plasma cells, lymphocytes and cell debris, which is very helpful for the diagnosis and differential diagnosis of this disease, tumor Pathological examination after resection is the most reliable basis for diagnosis.
Differential diagnosis
Due to the pathological changes and clinical manifestations of this disease, it is often confused with acute mastitis, cystic hyperplasia of the breast, especially intraductal papilloma, breast cancer. The preoperative diagnosis rate of this disease is as high as 67.4. %, of which 16.5% were misdiagnosed as breast cancer, and many patients who had misdiagnosed breast cancer due to misdiagnosis of breast cancer, so the focus of differential diagnosis of this disease should be placed on breast cancer.
1. The identification of breast cancer and mammary duct dilatation can be summarized as follows.
(1) The onset of breast cancer is slow, often inadvertently found in the breast mass, the mass is not associated with inflammation before the discovery, and the ductal dilatation of the breast before the appearance of the mass, often local inflammation, and from acute to chronic process .
(2) The masses of breast cancer are mostly located outside the breast, the upper upper quadrant, and the mass of the ductal dilatation of the breast is mostly located under the areola. The mass of the breast cancer often grows from small to large, and the process is enlarged by the breast duct. The mass of the dilatation can change from swelling to a process of contraction and recurrent.
(3) The mass of breast cancer often adheres to the skin in the late stage, and there is an orange peel-like change and a nipple depression. The mass of the ductal dilatation of the breast is adhered to the skin at an early stage and a nipple depression occurs.
(4) The axillary lymph nodes of breast cancer often become swollen and hard as the course of cancer progresses, and they adhere to each other to form a mass. In the early stage of ductal dilatation of the breast, axillary lymph nodes can be enlarged, soft and tender. As the local inflammation dissipates, the lymph nodes can become smaller or even disappear.
(5) mammography, in the breast cancer, see the tube has hyperplasia and destruction, the wall is interrupted, loss of continuity, and when the ductal dilatation of the breast, see the catheter expansion and thickening, the tube wall is smooth, complete, continuation , without interruption and destruction.
(6) sputum aspiration cytology examination, breast cancer can often find cancer cells, and in the breast duct dilatation, tumor needle suction and nipple discharge smear, often can find necrosis, pus cells, plasma cells, lymphocytes , foam cells, etc.
When there is still difficulty in clinical differential diagnosis, preoperative biopsy or intraoperative frozen section examination may be performed to confirm the diagnosis.
2. Intraductal papilloma: intraductal papilloma and mammary duct dilatation have nipple discharge, the former is often bloody, serous blood or serous, generally involving only one catheter, pressing a "pressure fluid" in the areola area At the point of "the nipple only has an overflow, while the latter's discharge is mostly serous, rare blood, serous blood, often involving multiple catheters with multiple tube discharge, pressing the breast several different parts can make the nipple discharge, Mammography: Intraductal papilloma is characterized by a round or ovoid filling defect in the large catheter, mostly single or multiple, which may cause incomplete obstruction or interruption of the catheter, proximal catheter dilation, and mammary gland In catheter dilatation, it often appears as multiple large, the middle catheter is dilated, and a few can be cystic dilatation. The dilated catheter is often distorted and has a braided shape. According to the above, it can often be diagnosed.
3. Breast tuberculosis: Breast tuberculosis can be a nodular mass in the mammary gland. It is hard, the boundary is unclear, the activity is poor, and the course of disease is long. It often forms a long-lasting fistula, and the cheese-like necrotic material flows out from the fistula. Sputum secretion smear, if the acid-fast bacilli can be diagnosed, the ductal dilatation of the breast can also form a fistula after the abscess is formed, and the purulent material flows out from the fistula. The smear is examined with pus cell necrosis, plasma cells, lymph. If the diagnosis is difficult, the tumor can be removed and confirmed by pathological biopsy.
