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Mammary Duct Ectasia

This is a benign breast disease that can mimic invasive carcinoma clinically. The process that causes the condition are still being debated, but histologically it is characterised by dilation of major ducts in the subareolar region. The ducts contain eosinophilic granular secretions and foamy histiocytes. The secretions may undergo calcification, and this may be the presenting sign.1

Epidemiology

Duct ectasia affects primarily middle-aged to elderly parous women. Smoking is a risk factor. One study found that smokers were three times more likely to develop the condition than non-smokers, and the risk appeared to be proportional to the duration of smoking.2

Presentation1,3

The condition may present in one of several ways:

  • Microcalcification on a routine mammogram (most common)4
  • Nipple discharge - often blood stained
  • A palpable subareolar mass
  • Non-cyclical mastalgia
  • Nipple inversion or retraction
Differential Diagnosis

Breast cancer

Investigations5,6

Imaging will be required. The choice of modality needs to be individualised according to the patient, and will depend on a number of factors, including the age of the patient, breast size, and whether or not a lump is palpable.

Mammogram

This is a useful screening tool. particulary in older women. It is especially sensitive in picking up microcalcification.

Ultrasound

This is used as an adjunct to mammography. Higher resolutions and the introduction of Doppler has facilitated the differentiation between benign and malignant lesions.

Galactography7

This method is occasionally used as an adjunct to mammography in parous women with a unilateral nipple discharge. A small amount of contrast medium is injected into a milk duct, and a mammogram performed.

Ductal lavage and cytology

This has provided promising results but more research is needed.3,8

Management

Despite advances in investigative techniques, the incidence of false negatives remain high. Excision of the duct remains the only reliable method of establishing the diagnosis and is also useful in alleviating the symptom of persistent nipple discharge. Image-guided surgery via ductal endoscopy is a promising development.3

Periductal mastitis

This term is sometimes used interchangeably with mammary duct ectasia.1 However, a growing body of evidence suggests that it is a separate entity. Smoking is a risk factor.9 It occurs in a younger age group than mammary duct ectasia and presents with pain, a periareolar mass, and pus discharge from the nipple. Fistula formation is an occasional complication. Although the aetiological process is still being researched, bacterial infection is involved, and broad spectrum antibiotics usually promote a rapid improvement. Surgery is occasionally required if there is a residual mass, to confirm the benign nature of the histology and prevent recurrence of infection.10

Document References
  1. Guray M, Sahin AA; Benign breast diseases: classification, diagnosis, and management. Oncologist. 2006 May;11(5):435-49. [abstract]
  2. Rahal RM, de Freitas-Junior R, Paulinelli RR; Risk factors for duct ectasia.; Breast J. 2005 Jul-Aug;11(4):262-5. [abstract]
  3. Vargas HI, Romero L, Chlebowski RT; Management of bloody nipple discharge.; Curr Treat Options Oncol. 2002 Apr;3(2):157-61. [abstract]
  4. Types of abnormalities on a mammogram; Breastdoc.com 2007; Pictures of calcification
  5. Singhal H, Kaur K; Breast Cancer Evaluation eMedicine.com 2006
  6. Sakorafas GH; Nipple discharge: current diagnostic and therapeutic approaches. Cancer Treat Rev. 2001 Oct;27(5):275-82. [abstract]
  7. Dinkel HP, Trusen A, Gassel AM, et al; Predictive value of galactographic patterns for benign and malignant neoplasms of the breast in patients with nipple discharge. Br J Radiol. 2000 Jul;73(871):706-14. [abstract]
  8. West KE, Wojcik EM, Dougherty TA, et al; Correlation of nipple aspiration and ductal lavage cytology with histopathologic findings for patients before scheduled breast biopsy examination. Am J Surg. 2006 Jan;191(1):57-60. [abstract]
  9. Dixon JM, Ravisekar O, Chetty U, et al; Periductal mastitis and duct ectasia: different conditions with different aetiologies. Br J Surg. 1996 Jun;83(6):820-2. [abstract]
  10. Ammari FF, Yaghan RJ, Omari AK; Periductal mastitis. Clinical characteristics and outcome. Saudi Med J. 2002 Jul;23(7):819-22. [abstract]
Acknowledgements EMIS is grateful to Dr Laurence Knott for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 6992
Document Version: 1
DocRef: bgp26066
Last Updated: 23 May 2007
Review Date: 22 May 2009












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