DUCTECTASIA

Natasa Pujic Stanisavljev MD

Jelena Simovic MD

Department of Radiology, General Hospital Sremska Mitrovica

1.What is the definition of ductectaisa?

Ductectasia is dilated milk duct. The breast consists of milk glands, thousands of hormone-sensitive, potentially milk-producing structures, called lobules. Each lobule is drained by a terminal duct and together they form a terminal ductal lobular unit (TDLU). The TDLUs are attached to the lactiferous duct system, i.e. the subsegmental, segmental and main lactiferous ducts and together they form a lobe. The human breast contains 15-18 lobes. Each lobe has a main duct with an opening in the nipple. Dilatation of subsegmental, segmental or main lactiferous ducts is called ductectasia.

2.How ducectasia is formed?

Ductectasia is the result of increased intraluminal pressure either due to accumulation of fluid or accumulation of cells. Acumulation of fluid can be physiological (accumulation of milk during breastfeeding) or pathological (when some benign or malignant process inside of milk duct is the cause of fluid producing). When ducts are dilated because of accumulation of cells, these are usually malignant cells.

3.What are physiological causes of fluid accumulation in milk ducts?

  • The most frequent and physiological cause of ductal distention is breastfeeding after childbirth, when the lobules and ducts become greatly distended with milk.
  • The lobules produce fluid throughout the fertile age, even in the absence of lactation. This turbid fluid contains cellular debris and a high concentration of protein. Fluid production peaks during the secretory phase of the menstrual cycle, contributing to premenstrual pain. This fluid reabsorbs in the ductal system and rarely causes nipple discharge. Fluid reabsorbing may not be complete, and debris may accumulate within the ducts, causing dilatation. The residual alkaline, proteinaceous material filling the ducts, may calcify. These calcifications can be seen on mammogram. Process is commonly called “secretory disease” or “plasma cell mastitis”, it is bilateral, which explains the usual bilateral presentation of the calcifications on mammogram.
  • Some women after entering menopausal period of life, have prominent retroareolar ducts surrounded by fibrous tissue, while the rest of the breast parenchyma is fatty replaced with atrophied lobules. The most common explanation of the presence of retroareolar prominent ducts is fluid accumulation associated with increased periductal fibrous tissue. In the presence of nipple discharge, a dilated duct can be demonstrated with galactography. In the absence of nipple discharge, ultrasound can demonstrate the fluid-filled duct. This type of breast structure belongs to one of the normal mammographic parenchymal patterns, Pattern III according to Tabar.

4. What are benign causes of fluid accumulation in milk ducts?

  • Hormonal changes may alter the cell layer lining the acini within the TDLU resulting in “apocrine metaplastic cells”. These cells produce a protein-rich fluid, quite different in composition from milk. Occasionally this cloudy fluid leaks out through several openings of both nipples. The color of the fluid may be greenish, grey, brownish or yellow. If the fluid does not leak out it will accumulate inside dilated ducts. This is the mechanism of pathogenesis of fibrocystic changes in the breast. Cysts are easily confirmed by ultrasound examination.
  • Another benign process that can be seen inside dilated ducts is papilloma, one of the few hyperplastic breast lesions that originate outside the terminal ductal-lobular unit (TDLU). The excess amount of fluid associated with some of the papillomas dilates the duct and its branches between the papilloma and the nipple, often resulting in serous or bloody nipple discharge. If there was a nipple discharge, galactography is method of choice for showing the number and localization of papillomas. In other occasions, mammography, ultrasound and magnetic resonance (MR) are methods we use to establish the diagnosis.

5.What malignant processes can lead to accumulation of fluid or cells inside the ducts and be the cause of dilatation?

If the duct containing a papillary lesion becomes cystically dilated because of fluid accumulation, the lesion is designated as an intracystic papilloma. The histopathologic diagnosis may occasionally be encapsulated/intracystic papillary carcinoma when the intracystic papillary growth contains large areas of malignant cells (usually grade I) grouped into papillary structures with a less evident fibrotic core and myoepithelium. Diagnosis can be established by histopathology examination of the tissue.

Ductectasia can be seen also in malignant processes developing from the cells lining the major ducts (carcinoma of ductal origin, DAB) that are characterized by new duct formation (neoductgenesis). Neoductgenesis is characterized by cancer-filled, abnormal, contorted, duct-like structures tightly packed to each other. They are disorganized, tortuous and lack associated TDLUs. This extensive neoplastic process usually extends from the nipple to the chest wall, resulting in a very large tumor burden. Cancers originating from the major ducts and presented with neoductgenesis have poor prognosis in about 30% of the cases. Unfortunately, they are still commonly called high nuclear grade/poorly differentiated/Van Nuys group 3 type “DCIS” instead of invasive duct-forming canrcinoma. This is clearly incorrect, considered the poor outcome and frequent recurrence of these cancers.

6. What is the therapy method for ducectasia?

 “Secretory disease” or “plasma cell mastitis” as well as fibrocystic changes should not be treated. If the cyst in area of fibrocystic changes became large and patient felt discomfort or pain, we use needle to evacuate the fluid under ultrasound control.

One single papilloma does not need to be surgically removed after diagnosis made by core biopsy.

If there were many lesions in one duct, core biopsy and provement of benign origin can be done for only one of them and the rest is not proven to be only benign. In such cases excision of whole sick segments should be done after preoperative localization with help of ultrasound and radiologist. If core biopsy showed malignant papilloma or intracystic carcinoma, wide surgical excision is recommended.

Each subgroup of breast cancer originating within the major lactiferous ducts presented with neoductgenesis requires a radical approach – total mastectomy without skin and nipple sparing, because the process of neoductgenesis can be seen through entire lobe. The whole process is spreading from the chest wall to the main milk ducts.

IMPORTANT!

PLEASE HAVE THINGS YOU ARE IN THE VID!

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders. If you feel you have any of these symptoms, please contact your doctor. DO NOT use these therapies yourself without prior consultation with a doctor!

LITERATURE:

1.Tot T., Tabár L., Dean PB. Practical Breast Pathology. 2nd Edition. Thieme Verlag, Stuttgart. 2014.

2.Tabár L., Tot T., Dean PB. Breast Cancer. Early Detection with Mammography. Casting-Type Calcifications: Sign of a Subtype with Deceptive Features. Thieme Verlag, Stuttgart. 2007.

3.Tabár L, Tot T, Dean PB. Breast cancer originating from the major ducts (DAB), Part 5 Fluid producing DAB subtypes with associated calcifications. 2015.

4.Tabár L, Tot T, Dean PB. Breast Cancer. The Art and Science of Early Detection with Mammography. Perception, Interpretation, Histopathologic Correlation. Thieme Verlag Stuttgart. 2004

5.Tabár L., Tot T., Dean PB. Tarjan M. Prostate and Breast: Brother and Sister Organs. Hong Kong: C & C Offset. 2013.

6. Palazzo JP. Difficult Diagnoses in Breast Pathology Demos Medical, 1 edition. 2011.

7. Tibor T, Tabár L. Papillary lesions of the breast: histologic examination of contiguous tissue can predict the need for surgical excision. Poster exhibit at The 12th Annual Multidiscipline Symposium on Breast Disease. Febr 15-18, 2007.

8. Tabár L, Tot T, Dean PB. Ductal Adenocarcinoma of the Breast (DAB) Breast cancers originating from the major ducts, Part 2. Hong Kong: C & C Offset. 2014.

9. Tabár L, Tot T, Dean PB. Ductal Adenocarcinoma of the Breast (DAB) Breast cancers originating from the major ducts: Part 3. Hong Kong: C & C Offset. 2014.

10. Tabár L, Tot T, Dean PB. Ductal Adenocarcinoma of the Breast (DAB). Part I. Hong Kong: C & C Offset. 2014.

11. Tabár L, Tot T, Dean PB. Ductal Adenocarcinoma of the Breast (DAB) Breast cancers originating from the major ducts. Part 4. Hong Kong: C & C Offset. 2015.

This site is informative-educational. Our goal is to provide helpful information on symptoms and treatment of the disease to people with breast disorders.
If you feel you have any of these symptoms, please contact your doctor.

DO NOT use these therapies yourself without prior consultation with a doctor!

Prim. Milos Pocekovac MD, PhD
BREAST SURGEON

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