From the Guidelines
Ductal ectasia, ductal papilloma, ductal papillomatosis, and adenomatous change are benign breast conditions that require prompt evaluation due to their potential association with malignancy, particularly in patients with pathologic nipple discharge, as reported in a study by Sanford et al 1.
Benign Breast Conditions
These conditions affect the milk ducts and can cause symptoms such as nipple discharge, retraction, or a small lump.
- Ductal ectasia occurs when milk ducts beneath the nipple become dilated and inflamed, typically affecting women approaching menopause.
- Ductal papilloma is a small, wart-like growth within a milk duct, usually near the nipple, causing clear or bloody discharge from a single duct.
- Ductal papillomatosis involves multiple papillomas throughout the ductal system, increasing breast cancer risk slightly.
- Adenomatous change refers to benign proliferation of glandular tissue in the breast.
Diagnostic Workup and Management
Management typically includes observation for asymptomatic cases, while symptomatic cases may require surgical excision, particularly for papillomas to rule out malignancy, as recommended by the American College of Radiology 1.
- Diagnostic workup includes mammography, ultrasound, and sometimes ductography or MRI.
- Mammography is the first-line imaging modality for evaluation of pathologic nipple discharge in male and female patients, with a high specificity and negative predictive value, as reported by Sanford et al 1.
- The risk of malignancy increases with age, and any new breast symptoms should be evaluated promptly, as some conditions (particularly multiple papillomas) carry a slightly increased risk of future breast cancer development, as noted by Seltzer et al 1.
Importance of Evaluation
Regular breast cancer screening should continue according to age-appropriate guidelines, and patients with pathologic nipple discharge should be evaluated further to exclude underlying malignancy, as emphasized by Lee et al 1 and Sanford et al 1.
From the Research
Ductal Ectasia, Ductal Papilloma, Ductal Papillomatosis, and Adenomatous Change
- Ductal ectasia is a benign breast condition of unknown etiology, which may present with symptoms such as nipple discharge, and can be mistaken for carcinoma of the breast in advanced stages 2.
- Ductal papilloma is a type of intraductal growth of the ductal epithelium, which can cause clinically significant discharge, and can be diagnosed using ultrasound, ductography, and ductoscopy 3.
- Ductal papillomatosis is a rare condition characterized by multiple papillomas within the breast ducts, which can cause nipple discharge and can be diagnosed using imaging techniques such as ultrasound and mammography 3, 4.
- Adenomatous change, also known as adenosis, is a type of benign breast lesion that can cause nipple discharge and can be diagnosed using imaging techniques such as ultrasound and biopsy 4.
Diagnosis and Imaging
- Ultrasound examination is highly sensitive (100%) but less specific (82.4%) in the diagnosis of intraductal pathology, and can be used to guide fine needle biopsy and fibro-optic ductoscopy 3.
- Colour and power Doppler are sensitive (94%) in detecting flow in intraductal echogenic masses, and can help differentiate them from insipissated secretions 3.
- Superb Microvascular Imaging (SMI) is more accurate and has more diagnostic ability than colour Doppler imaging (CDI) or power Doppler imaging (PDI) in distinguishing small intraductal papillomas from duct ectasia with secretion 5.
- Ductography is an underused procedure that is sensitive (100%) but less specific (60%) in characterization of intraductal filling defects, and can be used to diagnose ductal ectasia and other intraductal lesions 3, 4.
Pathological Criteria
- The accurate diagnosis of mammary papillary lesions is a challenge for pathologists, owing to the overlapping features among these lesions, and requires careful examination of morphological features such as fibrovascular cores and epithelial proliferation 6.
- Immunohistochemistry and myoepithelial cell markers can be used to aid in the diagnosis of papillary lesions, and novel biomarkers and genetic aberrations are being studied to improve diagnosis and treatment 6.