Ductal disease

Question 1

What is ductal disease?

Answer 1

abnormality in the breast ductal tissue

aka ductal carcinoma

Question 2

Main types of ductal disease?

Answer 2

o Ductal carcinoma in situ

o Invasive ductal carcinoma

Question 3

Types of benign disease?

Answer 3

Ductal ectasia
Periductal mastitis
Papillomas
Papillomastosis

Question 4

Define ductal ectasia

Answer 4

• Nonspecific dilatation of one or more ducts (>2mm)
• Typically filled with fluids/thick secretions/cellular debris
• When located peripherally, favours a malignant process

Question 5

Define periductal mastitis

Answer 5

• Pre-menopausal women
• Ducts beneath the nipple become inflamed and infected
• Nipple rings are a risk factor

Question 6

Define papillomas

Answer 6

• Epithelial proliferation on a fibrovascular stalk in major ducts
• Usually within a few centimeters of the nipple
• Increased risk of breast cancer

Question 7

Define papillomastosis

Answer 7

• Multiple papillomas

* Tend to occur in distal ducts

Question 8

Name the types of malignant disease

Answer 8

 In situ papillary carcinoma (often deemed pre-malignant)

 Invasive papillary carcinoma

Question 9

What is the aetiology of malignant disease?

Answer 9

• Genetic mutations in lobular cells causing uncontrolled overgrowth of abnormal cells

Question 10

RF of malignant DD?

Answer 10

•	Family history
o	1.5x increased risk
o	BRCA1 or BRCA2
•	Prior benign breast disease
•	Hereditary breast ovarian cancer
•	Li-Fraumeni syndrome
•	Cowden’s syndrome
o	PTEN gene mutations
o	25-50% will develop BC
•	Klinefelter’s syndrome
•	Old age of menopause
•	Old age of first full-term pregnancy
•	Nulliparity (never been pregnant)

Question 11

Aetiology of ductal ectasia?

Answer 11

• Breast changes due to aging (glandular to fatty = involution)

Question 12

RF of ectasia?

Answer 12

• Smoking

* Nipple inversion

Question 13

Aetiology of periductal mastitis?

Answer 13

• Caused by bacteria infection entering through a cracked nipple or nipple piercing

Question 14

RF of periductal mastitis?

Answer 14

Smoking

Question 15

Epidemiology of DCIS?

Answer 15

o More common than lobular CIS
o 20-30% of untreated go on to develop BC
o 80% detected on mammography screening
o Diagnosis peaks age 70-75
o Only 7% of all male carcinomas
o Lower incidence in Black, Hispanic and Chinese
o No link with HRT

Question 16

Epidemiology of IDC

Answer 16

o Accounts for 80% of all BC

o 2/3 women are diagnosed over age of 55

Question 17

Presenting symptoms of ductal disease (malignant)?

Answer 17

•	In situ
o	Nipple discharge
	Serous or sanguineous (bloody)
	Unilateral
o	Breast mass
•	Invasive
o	Breast mass
	Usually painless (95%)
	Does not fluctuate with menstrual cycle
o	Nipple discharge
	Increased risk of invasive cancer with nipple discharge with age

Question 18

Presenting symptoms of ductal ectasia?

Answer 18

• Nipple discharge – green/brown/blood
• Pain
• Nipple retraction
• Breast lump (not always)

Question 19

Presenting symptoms of periductal mastisis?

Answer 19

• Tender breast

* Nipple discharge

Question 20

Presenting symptoms of intraductal papillomas?

Answer 20

• Bloody nipple discharge

* Pain between breast and nipple

Question 21

Signs of malignant ductal disease?

Answer 21

•	In situ
o	Breast mass (usually not present)
	Smooth or nodular
•	Invasive
o	Axillary lymphadenopathy
o	Skin changes (20%)
	Peau d’orange (dimpling), erythema, ulceration

Question 22

Signs of periductal mastitis?

Answer 22

• Tender, erythematous and warm

* Inverted nipple

Question 23

Signs of intraductal papillomas?

Answer 23

• Small breast mass

Question 24

What investigations would you do to diagnose a breast lump?

Answer 24

triple assessment

1. Clinical breast examination
2. Imaging (mammography, US)
3. Biopsy (pathology)

Question 25

Investigations for a DCIS?

Answer 25

``` o Mammography = first line  Calcifications o Biopsy (fine-needle/core)  Necrosis and high nuclear grade o Sentinel node biopsy  Metastasis o MRI o Ultrasonography  Cystic or solid lesion o Genetic testing for BRCA o Oestrogen receptor testing ```

Question 26

Investigations for IDC

Answer 26

o Mammography = first line  Irregular, speculated mass with clustered micro-calcifications o US  Hypoechoic irregular mass with internal calcifications  Enlarged axillary lymph nodes o MRI o Biopsy

Question 27

Investigations for ductal ectasia?

Answer 27

* US | * Mammography

Question 28

Investigations for periductal mastitis?

Answer 28

* Swab C+S * Mammogrophy * US

Question 29

Investigations for intraductal papillomas?

Answer 29

``` • Breast US o Dilated duct with oval mass • Mammogram o May be negative • Ductogram = galactography o Filling defect of duct • Breast biopsy ```