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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
the wound are unnecessary. Breast-feeding should be con- tinued if possible because this promotes drainage of the engorged segment and helps resolve infection. The infant is not harmed by bacteria in the milk, nor by flucloxacil- lin, amoxicillin–clavulanate, or erythromycin. Patients who have incision and drainage of their breast abscesses per- formed under general anesthesia are more likely to stop breast-feeding compared with those treated by mini-incision or aspiration and antibiotic therapy. Only rarely in women with severe and extensive breast infection is it necessary to suppress lactation with cabergoline. Rarely in patients
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
FIGURE 5-9 Ultrasound of an abscess.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
treated with multiple courses of antibiotics a walled-off abscess develops known as an antibioma. Previously these were excised. This is unnecessary and they are aspirated or drained through a small incision until no more pus is pres- ent and they resolve, although it can be many months before the mass resolves and the breast feels normal.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
| null |
Nonlactational infections can be divided into those occur- ring centrally in the breast in the periareolar region and those affecting peripheral breast tissue.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Periareolar Infection
|
Periareolar infection is most commonly seen in young women; the mean age of occurrence is 32 years, and most are cigarette smokers. The underlying pathologic process is periductal mastitis (29,31). It can present as periareolar inflammation, with or without a mass, a periareolar abscess, or a mammary duct fistula. A patient presenting with peri- areolar inflammation without a mass should be treated with antibiotics that are active against both the aerobic and anaerobic bacteria seen in these lesions (Table 5-1). If the infection does not resolve after one course of antibiotics, ultrasonography should be performed to determine whether a localized abscess is present. A patient who presents with or develops an abscess should be treated by recurrent aspi- ration and oral antibiotics or incision and drainage under local anesthesia (Fig. 5-10). After resolution of the infective episode, patients older than age 35 years should have mam- mography performed, because very rarely infection can develop in association with comedo necrosis in an area of ductal carcinoma in situ. Up to half of patients with peri- areolar sepsis experience recurrent episodes of infection; the only effective long-term treatment for these women is
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Periareolar Infection
|
FIGURE 5-10 Periareolar abscess with skin necrosis: the abscess can be drained by excision of the necrotic skin.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Periareolar Infection
|
removal of all the affected ducts by total duct excision. This operation to remove all the subareolar ducts up to the nip- ple skin is usually curative. Rarely subareolar abscesses can be caused by actinomyces species; these resolve following incision and drainage (32).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Mammary Duct Fistula
|
A mammary duct fistula is a communication between the skin, usually in the periareolar region, and a major subare- olar breast duct (29) (Fig. 5-11). Fistulae occur most com- monly after incision and drainage of nonlactational breast abscesses, although they can occur following spontane- ous discharge of a periareolar inflammatory mass or after biopsy of an area of periductal mastitis. Patients usually have preceding episodes of recurrent abscess formation and report purulent discharge through the fistula opening. Occasionally, more than one external opening is present usually at the areolar margin, either from a single affected duct or from multiple diseased ducts.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Mammary Duct Fistula
|
FIGURE 5-11 Mammary duct fistula. Bilateral mammary duct fistula. On each side the fistula is discharging in the periareolar region. The affected duct is pulled toward the fistula.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Mammary Duct Fistula
|
Treatment is surgical, and consists either of opening up the fistula tract and leaving it to granulate (33) or excising the fistula and affected duct or ducts (a total duct excision is also usually required) and closing the wound primarily under appropriate antibiotic cover. The incision to excise the fistula can be radial directly over the fistula tract or circumareolar incorporating the fistula opening. The latter incision produces a superior cosmetic outcome.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Nonlactational Infection
|
Mammary Duct Fistula
|
Peripheral Nonlactational Breast Abscess Peripheral nonlactational breast abscesses are less common than periareolar abscesses and have been reported to be associated with a variety of underlying disease states, such as diabetes, rheumatoid arthritis, steroid treatment, and trauma. S. aureus is the organism usually responsible, but some abscesses contain anaerobic organisms. Peripheral nonlactational breast abscesses are three times more com- mon in premenopausal women than in menopausal or post- menopausal women and in most no obvious underlying cause is evident; following resolution of infection, mammog- raphy is indicated in women older than 35 years to exclude any underlying comedo DCIS. Systemic evidence of malaise and fever is usually absent. Management is the same as for other breast abscesses, with aspiration or incision and drainage (Fig. 5-12).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Cellulitis
|
Cellulitis is an uncommon infection in the breast and can be difficult to distinguish from inflammatory breast cancer or benign erythematous conditions of the breast (Fig. 5-13). Pain is a prominent feature of breast cellulitis associated with erythema, swelling, and warmth. Treatment is with antibiotics (Table 5-1).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Eczema
|
Patients with eczema involving the skin overlying the breast may develop secondary cellulitis. Appropriate treatments for eczema reduce the likelihood of recurrence.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Epidermoid Cysts
|
Epidermoid cysts are discrete nodules in the skin that often are referred to as sebaceous cysts, but there is no sebaceous component. These cysts are common within the skin of the breast and can become infected, forming local abscesses that are best treated by mini-incision and drainage rather than aspiration because the material in the abscess is too thick to aspirate.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Hidradenitis Suppurativa
|
Hidradenitis suppurativa is a condition that affects the apocrine sweat glands and can result in recurrent infection and abscess formation of the skin of the lower half of the breast as well as the axilla (29,32,34–36). It is more common in smokers. Treatment involves keeping the area of skin as clean and dry as possible, draining any abscesses, and stop- ping smoking. A variety of drug treatments have been tried but are only partially effective. Excision and skin grafting of the affected skin has been tried and has a success rate of up to 50%.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Intertrigo
|
Intertrigo is inflamed skin in the inframammary folds, often due to moisture and maceration (37) (Fig. 5-14). This can be a recurrent problem in women with large ptotic breasts that make contact with the chest wall. Fungi play
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Intertrigo
|
FIGURE 5-12 (A) Peripheral abscess: note the shiny thin skin. This abscess was treated by min-incision and drainage with resolution (B).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Intertrigo
|
no aetiological role in this condition. The primary manage- ment of intertrigo is to educate the patient about keeping the area as clean and dry as possible. The skin should be washed gently two or more times a day with simple soap, a mild cleansing solution, or hypoallergenic skin wipes, then dabbed dry with a towel or dried with a hair dryer at a low setting (37). Preventive measures include wear- ing cotton against the skin and keeping the skin dry and clean. Steroids and creams including antifungal agents are not effective; they may aggravate the condition and should be avoided.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Piercing
|
Nipple rings can result in subareolar breast abscess and recurrent nipple infections, particularly in smokers (38). One study noted that nipple piercing was a significant risk factor for a subareolar breast abscess (OR 10.2 95% CI 1.3– 454.4) as is smoking (OR 8.0 95% CI 3.4–19.4) (38).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Skin-Associated Infection
|
Pilonidal Sinuses
|
Pilonidal sinuses affecting the nipple have been reported in hair stylists and sheep shearers because loose hairs penetrate the skin and can result in inflammation and infection (29).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
| null |
Tuberculosis is rare in Western countries. The breast can be the primary site, but tuberculosis more commonly reaches the breast through lymphatic spread from axillary, mediastinal, or cervical nodes or directly from underlying structures, such as the ribs. Tuberculosis predominantly affects women in the lat- ter part of their childbearing years. An axillary or breast sinus is present in up to 50% of patients. The most common presen- tation is that of an acute abscess resulting from infection of an area of tuberculosis by pyogenic organisms (29,30). Treatment is with local surgery and antitubercular drug therapy.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
| null |
Primary actinomycosis (32), syphilis, mycotic, helmin- thic, and viral infections occasionally affect the breast, but are rare. Actinomycosis organisms can be seen in hidradenitis. Molluscum contagiosum can affect the areola and present as wart-like lesions.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Granulomatous Lobular Mastitis
|
Granulomatous lobular mastitis is characterized by noncase- ating granulomata and microabscesses confined to the breast lobule. The condition presents as a firm mass, which is often indistinguishable from breast cancer, or as multiple or recur- rent abscesses. Some patients with granulomatous lobular mastitis report that the mass is tender to touch and pain- ful and the overlying skin is sometimes ulcerated (Fig. 5-15). Young women, often within 5 years of pregnancy, are most
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Granulomatous Lobular Mastitis
|
FIGURE 5-13 Cellulitis of the breast. FIGURE 5-14 Intertrigo pre and post.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Granulomatous Lobular Mastitis
|
FIGURE 5-15 Granulomatous lobular mastitis at presentation (A) and following resolution (B).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Granulomatous Lobular Mastitis
|
frequently affected, but not all women with this condition are parous. In contrast to periductal mastitis, it is common in Asian rather than white women and few are smokers. This condition has recently been reported to be associated with hyperprolactinemia (including drug-induced) (39). Prolactin can contribute to a wide variety of physiological and pathologi- cal granulomatous cutaneous lesions, and it may do the same in the breast. The frequency of hyperprolactinaemia in women with granulomatosis lobular mastitis is not well documented, so the relevance of this observation is not clear. Rare reported causes of granulomatous mastitis include alpha-1 antitrypsin deficiency and Wegener’s granulomatosis. The role of organ- isms in the etiology of this condition is unclear. One study did isolate corynebacteria from 9 of 12 women with granulomatous lobular mastitis (40). The most common species isolated was the newly described Corynebacterium kroppenstedtii, followed by C. amycolatum and C. tuberculostearicum. These organisms are usually sensitive to penicillin and tetracycline and when antibiotics effective against these organisms have been admin- istered to patients with this condition they do not produce resolution. Any antibiotic treatment should therefore be based on sensitivities as reported by the local bacteriologic service.
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Granulomatous Lobular Mastitis
|
A search for the etiology of this condition continues. In patients presenting with a breast mass diagnosed on core biopsy as granulomatous lobular mastitis, excision of the mass should be avoided because it is often followed by per- sistent wound discharge and failure of the wound to heal. Current treatment involves establishing the diagnosis and observation without any specific treatment because the condition usually resolves slowly over 6 to 12 months. Any abscesses that develop require aspiration or mini-incision and drainage. There is a strong tendency for this condition to recur, but eventually it does resolve spontaneously with- out treatment (29). Steroids have been tried but without consistent success. More recently, methotrexate as mono- therapy given at a dose of 7.5 mg per week, has been claimed to be effective (41). Similar claims were made for steroids. Whether methotrexate alters the course of the condition or merely suppresses the inflammatory component is not clear and given that the condition does resolve spontaneously more studies are required before methotrexate can be con- sidered as an effective therapy for this condition.
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Breast Infection after Breast Surgery
|
Rates of infection after breast surgery vary in relation to the extent of the surgery and risk factors including smoking, obe- sity, and the presence of diabetes. Rates of infection in excess of 10% are seen after mastectomy (42). Preoperative antibiot- ics reduce the risk of breast infection by 36% therefore pre- operative prophylactic antibiotics in breast surgery patients may be administered routinely. The relative risk of infection if antibiotics are administered in a recent meta-analysis was 0.64, 95% confidence intervals 0.50–0.83, p < .0005 (43).
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Factitial Disease
|
Cases of factitious abscess (caused by the patient them- selves) are occasionally seen. These patients can have psychiatric problems, but patients appear quite plausible. Factitial disease should be suspected when peripheral abscesses persist or recur despite appropriate treatment. The condition can be difficult to treat because patients are often resistant to help and may be very manipulative.
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Factitial Disease
|
MANAGEMENT SUMMARY
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Factitial Disease
|
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Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Other Rare Infections
|
Factitial Disease
|
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Factitial Disease
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Factitial Disease
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BREAST INFECTION
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Factitial Disease
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Other Rare Infections
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Factitial Disease
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Other Rare Infections
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Factitial Disease
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Factitial Disease
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Other Rare Infections
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Factitial Disease
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Paviour S, Musaad S, Roberts S, et al. Corynebacterium species isolated from patients with mastitis. Clin Infect Dis 2002;35:1434.
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Akbulut S, Yilmaz D, Bakir S. Methotrexate in the management of idio- pathic granulomatous mastitis: review of 108 published cases and reports of four cases. Breast J 2011;17(6):661–668.
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Olsen MA, Chu-Ongsakul S, Brandt KE, et al. Hospital-associated costs due to surgical site infection after breast surgery. Arch Surg 2008;143(1):53–60.
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Sajid MS, Hutson K, Akhter N, et al. An updated meta-analysis on the effec- tiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Breast J 2012;18(4):312–317.
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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Breast pain is one of the most common problems for which patients consult primary care physicians, gynecologists, and breast specialists. Patients mistakenly think the symptom is associated with early breast cancer, but data do not sup- port any strong relationship with breast pain. The Women’s Health Initiative Estrogen plus Progestin intervention trials showed no effect on breast cancer risk in women who took estrogens alone, but a mild effect in those taking equine estrogen plus medroxyprogesterone, particularly if baseline breast tenderness was present (hazard ratio [HR] 2.16), but the effect was much less if no baseline breast tenderness was present (1). Once cancer has been ruled out, reassurance alone will resolve the problem in 86% of those with mild and 52% of those with severe mastalgia (2). A survey of screened women in the UK national program revealed that 69% had experienced severe breast pain, although only 3% had sought treatment. Ader et al. in 2001 attempted to establish the prev- alence in the community in the United States. In their study, 874 women between 18 and 44 were recruited for interview by random number dialing in Virginia, and 68% reported some cyclical mastalgia, with 22% describing it as moderate or severe (3). Interestingly, patients on the oral contracep- tive pill had less trouble, while there was a positive asso- ciation with smoking, caffeine intake, and perceived stress. A study from the United States (4) showed the impact of breast pain among a population of 1,171 women attending a general obstetrics and gynaecology clinic. Sixty-nine percent suffered regular discomfort and 36% had consulted about their breast pain. A specialist breast clinic in Ghana reported in 2008 that 72% of women attended because of breast pain. Reading of the literature might suggest that the incidence of breast pain is different in many parts of the world, but these differences are mainly cultural in relation to the willingness of women to consult their physicians about breast pain.
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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The major clinical issue is to exclude cancer and deter-
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Management of Disorders of the Ductal System and Infections
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BREAST INFECTION
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Other Rare Infections
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Factitial Disease
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mine the impact on quality of life in patients complaining of breast pain, as this is the primary reason for medication. Only rarely is intervention required, but, after appropriate patient selection, some may derive great benefit from treatment.
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Management of Disorders of the Ductal System and Infections
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ETIOLOGY
| null | null |
Breast swelling is a frequent event in the late luteal phase of the menstrual cycle. Cyclic mastalgia is a more extreme form of this change, and researchers have sought endocrine abnormalities in those with severe breast pain, particu- larly measuring estradiol, progesterone, and prolactin, but no major abnormalities have been found (5). One hypoth- esis suggested that inadequate corpus luteal function is an etiologic factor in women with benign breast disease, but this term has been used to include all nonmalignant breast conditions, blurring the distinction between a vari- ety of benign breast conditions. No evidence of proges- terone deficiency has been found during the luteal phase in patients with mastalgia. The confusion in the literature between the symptom of breast pain and the large num- ber of variable pathological descriptions of benign breast conditions has resulted in the belief that the condition is a “disease,” rather than physiological responses to men- strual cycles. In the aberrations of normal development and involution (ANDI) classification of benign conditions, mastalgia is regarded as a physiologic disorder arising from hormonal activity with little connection to cancer risk, or true pathologic conditions (6). Another suitable term might be benign breast change as this does not suggest cancer or premalignancy.
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Management of Disorders of the Ductal System and Infections
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ETIOLOGY
| null | null |
No consistent abnormality of estradiol has been reported
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Management of Disorders of the Ductal System and Infections
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ETIOLOGY
| null | null |
in women with cyclic mastalgia; both normal levels and elevated levels have been reported during the luteal phase. Baseline levels of prolactin are either normal or marginally elevated, but increased prolactin release was found after domperidone stimulation in severe cyclic mastalgia, possi- bly representing a stress response to prolonged pain.
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Management of Disorders of the Ductal System and Infections
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ETIOLOGY
| null | null |
Ecochard et al. measured a range of personal and endo- crine variables in 30 women with mastalgia and 70 control subjects (7). Cases were more likely to report foot swelling or abdominal bloating (43% vs. 19%). Women with mastalgia had higher mean luteal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
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Management of Disorders of the Ductal System and Infections
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ETIOLOGY
| null | null |
51
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Management of Disorders of the Ductal System and Infections
|
ETIOLOGY
| null | null |
No histologic differences have been detected in biopsies from women with and without mastalgia. Immunohistochemical examination of biopsies from 29 women with mastalgia and 29 control subjects revealed no differences in expression of interleukin-6, interleukin-1, and tumor necrosis factor.
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Management of Disorders of the Ductal System and Infections
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CLASSIFICATION
| null | null |
Preece et al. (8) proposed a classification with six subgroups based on a prospective study of 232 patients with breast pain: cyclic mastalgia, duct ectasia, Tietze’s syndrome, trauma, sclerosing adenosis, and cancer. This was subsequently sim- plified into two groups with noncyclic pain: true noncyclic breast pain and those with other causes of chest wall pain
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Management of Disorders of the Ductal System and Infections
|
CLASSIFICATION
| null | null |
(9). Although an accurate diagnosis can be achieved on the basis of history and examination, patients with breast pain can be more simply assigned to one of three groups: cyclic breast pain (around 70%), noncyclic breast pain (20%), or extramammary pain (10%).
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Management of Disorders of the Ductal System and Infections
|
CLASSIFICATION
| null | null |
Khan and Apkarian (10) studied the differences between cyclic and noncyclic pain using standardized pain questionnaires, including the McGill Pain instrument in 271 women, and found that the level of pain described by the subjects was equivalent to chronic cancer pain, and just less than the pain of rheumatoid arthritis. They noted that women with cyclic pain tended to refer to heaviness and tenderness as found in the Preece study, whereas women with noncyclic pain related the severity to the area of breast involved.
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Management of Disorders of the Ductal System and Infections
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EVALUATION
| null | null |
Important aspects of history-taking include the type of pain, relationship to menses, duration, location, and any other medical problems. The impact of the pain on the everyday activities of the patient, particularly sleep and work, should be established to assess the need for medication.
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Management of Disorders of the Ductal System and Infections
|
EVALUATION
| null | null |
After inspection, the first aspect of the breast examina- tion should be very gentle palpation of the breasts once the patient has indicated the site(s) of the pain. Having excluded discrete masses, a more probing evaluation should be performed, focusing on the site(s) of pain. After turning the patient half on her side so that the breast tissue falls away from the chest wall, it may be possible to identify that the pain is arising from the underlying rib or costal car- tilage. The pain can be reproduced by placing a fingertip on the affected rib and demonstrating to the patient its source. Nodularity can be associated with mastalgia, but the extent is unrelated to pain severity; in younger women, the finding is so common that it should be considered within the spectrum of normality. If it is apparent that the pain, whether cyclic or noncyclic, is mammary in origin, the decision to treat is based on the subjective assessment of severity, together with the duration of symptoms. This assessment may be facilitated by a daily pain chart that assesses the timing and severity (semiquantitative scale) of the pain. Generally, there should be a history of pain of at
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Management of Disorders of the Ductal System and Infections
|
EVALUATION
| null | null |
least 4 months before hormonal therapy is indicated.
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Management of Disorders of the Ductal System and Infections
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ROLE OF RADIOLOGY
| null | null |
The average age of women entered into trials of treatment for mastalgia is 32 years: In this age group, mammogra- phy is not a standard adjunct to clinical evaluation. In the absence of a discrete lump, ultrasonography is also
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Management of Disorders of the Ductal System and Infections
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ROLE OF RADIOLOGY
| null | null |
unlikely to give useful information, but any breast lump present requires triple assessment. No specific mammo- gram findings are associated with breast pain.
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Management of Disorders of the Ductal System and Infections
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ROLE OF RADIOLOGY
| null | null |
Ultrasonography in 212 asymptomatic women and 212 with mastalgia showed the mean maximal duct dilatation was 1.8 mm in normal women compared with 2.34 mm in the 136 with cyclic pain and 3.89 mm in the 76 with non- cyclic pain. Dilated ducts were found in all quadrants, but mostly in the retroareolar area, and dilatation did not alter during the menstrual cycle. A highly significant association was found between the extent of ductal dilatation and pain severity.
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Management of Disorders of the Ductal System and Infections
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ROLE OF RADIOLOGY
| null | null |
The meaning of these findings are unclear as no relation- ship was shown in the cyclic pain patients with the consid- erable temporal symptoms in this group, but the noncyclic group could be explained by the periductal inflammation often seen in this group.
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Management of Disorders of the Ductal System and Infections
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MONDOR’S DISEASE
| null | null |
Mondor’s disease is a rare cause of breast pain, with diag- nostic clinical features of local pain associated with a ten- der, palpable subcutaneous cord or linear skin dimpling. The cause is superficial thrombophlebitis of the lateral tho- racic vein or a tributary. The condition resolves spontane- ously. Mondor’s disease can cause serious alarm because some patients assume that the skin tethering is secondary to an underlying carcinoma, so they are greatly relieved when informed of the benign nature of the condition.
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Management of Disorders of the Ductal System and Infections
|
MONDOR’S DISEASE
| null | null |
In a series of 63 cases of Mondor’s disease, no underly- ing pathologic process was found in 31 cases. Of the remain- ing 32, local trauma or surgical intervention was responsible in 15 (47%), an inflammatory process in 6 (19%), and carci- noma in 8 (25%). In view of this, mammography should be performed in women with Mondor’s disease who are aged 35 years or older to exclude an impalpable breast cancer.
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Management of Disorders of the Ductal System and Infections
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PSYCHOSOCIAL ASPECTS
| null | null |
Several studies have confirmed that patients with severe mastalgia have psychological morbidity that may be the result rather than the cause of their breast pain. Preece et al. (11) used the Middlesex Hospital Questionnaire to compare patients with mastalgia, psychiatric patients, and minor surgical cases. No significant differences were found between the patients with breast pain and the surgical cases, and both scored significantly lower than psychiat- ric cases. Only the scores of patients who failed treatment approached those of psychiatric patients. In a small study of 25 women with severe mastalgia, using the Composite International Diagnostic Interview, 45 diagnoses were made in 21 patients (84%): anxiety (n = 17), panic disorder (n = 5), somatization disorder (n = 7), and major depression (n = 16).
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Management of Disorders of the Ductal System and Infections
|
PSYCHOSOCIAL ASPECTS
| null | null |
A study using the Hospital Anxiety and Depression Scale (HADS) reported high levels of both anxiety and depression in 20 women with severe mastalgia. At Guy’s Hospital, HADS was also used to evaluate 54 patients with mastalgia (12). The 33 women with severe pain manifested levels of anxiety and depression comparable with those in women with breast cancer before surgery. Those who responded to treatment had a significant improvement in psychosocial function, but the nonresponders continued to have high levels of distress. Fox et al. (13) conducted a prospective trial in 45 women with mastalgia who kept pain diaries for 12 weeks, with half randomized to listen daily to a relaxation tape during weeks
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Management of Disorders of the Ductal System and Infections
|
PSYCHOSOCIAL ASPECTS
| null | null |
5 to 8. Abnormal or borderline HADS scores were found at entry in 54%, and a complete or substantial reduction in pain score was measured in 25% of the control subjects and 61% of those randomized to relaxation therapy (p < .005).
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Management of Disorders of the Ductal System and Infections
|
MASTALGIA AND BREAST CANCER RISK
| null | null |
Because of the lack of precision in classification of benign breast conditions in older studies, it was difficult to deter- mine whether breast pain led to an increased risk of subse- quent breast cancer. Foote and Stewart wrote in 1945, “Any point of view that one chooses to take concerning the rela- tion of so-called cystic mastitis to mammary cancer can be abundantly supported from the literature.”
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