Benign Ductal Disease (duct ectasia and papilloma)

Question 1

Definition (benign breast disease)

Answer 1

Breast tissue changes ranging from normal to abnormal, either in development, cyclical change or involution (shrinking down of an organ in old age) phases. Includes:

o Fibrocystic change
o Breast cysts
o Fibroadenomas
o Sclerosing adenosis 
o Intraductal papillomas 
o Duct ectasia 
o Periductal mastitis
o Fat necrosis

Question 2

Definition (fibroadenomas)

Answer 2

Results from hypertrophy of a breast lobule

Question 3

Definition (sclerosing adenosis)

Answer 3

Aberration of normal involution

Question 4

Definition (intraductal papillomas)

Answer 4

A small, benign tumour that forms in a milk duct

Question 5

Definition (duct ectasia)

Answer 5

When central ducts become dilated with ductal secretions. These secretions leak into periductal tissues and cause an inflammatory reaction (periductal mastitis)

Question 6

Aetiology/Risk Factors

Answer 6

· Related to changes in hormone levels

· Fat necrosis occurs secondary to TRAUMA

· Risk Factors
o May be less common in patients on the oral contraceptive pill
o SMOKING is a risk factor for periductal mastitis

Question 7

Epidemiology

Answer 7

· VERY COMMON

· Diffuse fibrocystic changes are very common (60% of women)

· Fibroadenomas are more common in 15-35 yrs

Question 8

Presenting symptoms

Answer 8

· History of breast discomfort or pain (may be cyclical)

· Swelling or lump

· Nipple discharge
o NOTE: if this is bloody, malignancy should be suspected

· To assess risk factors for breast cancer, ask patient about:
o Family history
o Exposure to oestrogen (age of menarche, menopause, number of kids, breastfeeding, use of OCP/HRT)

Question 9

Signs on physical examination

Answer 9

· Focal or diffuse nodularity of breast

· Fibroadenoma - smooth, well circumscribed and mobile lumps (known as a ‘breast mouse’)

· Duct Ectasia (a condition in which central ducts become dilated with ductal secretion due to a blockage of the lactiferous ducts) - causes yellow/green discharge

· Features of malignancy will be ABSENT in benign breast disease:
o Dimpling
o Peau d’orange (orange peel skin)
o Enlarged axillary lymph nodes

Question 10

Investigations

Answer 10

· Patients usually undergo TRIPLE ASSESSMENT:

o Clinical Examination

o Imaging
· Mammography (two-view)
§ NOTE: benign lumps are less likely to be calcified
· Ultrasound - in younger patients (< 35 yrs)

o Cytology/Histology
· Fine Needle Aspiration - sent for cytological analysis
· Excision Biopsy - sent for histological analysis

Question 11

Management plan

Answer 11

· Conservative
o Symptomatic treatment (e.g. analgesia for mastalgia)
o Fibroadenomas may be treated conservatively

· Surgery
o Removal or excision biopsy of a breast lump
o Wide local incision if there is any suspicion of the lump not being benign
o Microdochectomy (surgical removal of a lactiferous duct) - performed for intraductal papillomas
o Hadfield’s Procedure (surgical removal of ALL lactiferous ducts under the nipple) - is used for duct ectasia

Question 12

Possible complications

Answer 12

Pain

Recurrence

Question 13

Prognosis

Answer 13

Good

However, recurrence is common