Ductal Ectasia: Anatomo-Physiologic Variation

Ductal ectasia is most frequent in middle-aged women. In adolescence, ectasia has been described as an exaggeration of sinus duct development, with an epithelium disposed in ‘accordion’ pleats that allows dilatation and stagnation of secretions. At the initial stage of ductal ectasia, which is a variant of normality, a pathologic step such as an abscess can occur, where the stagnation in secretion leads to epithelial ulceration with secretions toward the support tissues, which causes secondary ductal inflammation and infection.

Clinically, ductal ectasia appears like a retro-areolar tumor of 1 - 3 cm; it is sensitive, discreetly blue and sometimes associated with brownish or even bloody nipple discharge, which occurs either spontaneously or on discreet nipple palpation. Its development is rapid and occurs early in reproductive life, before or just after menarche. Ultrasound confirms the hydroid lesion.

Spontaneous progression is mostly favorable with regression of tumefaction and disappearance of nipple discharge. During follow-up, the major risk is infection in the vulnerable nipple. Several relapses can occur in the same or the contralateral breast, or both.

If the disease course is long or if nipple discharge persists, surgical treatment is an option. The histological lesion is ductal ectasia, a distension of one duct associated with an inflammatory reaction, conjunctive fibrosis and sometimes benign epithelial hyperplasia.

The nipple discharge during the course of ductal ectasia must be distinguished from a juxta-areolar discharge from the sebaceous gland set on the areola (Montgomery tubercle). Cure is spontaneous without treatment.

Breast Abscess: Disease
Classically described in the post-partum period, breast abscess has also been reported in adolescence. Retro-areolar abscess is the most frequent occurrence, and it is the consequence of a ductal ectasia infection with rupture of the sinusal duct into surrounding tissue and abscess formation. Depending on the stage, nodule size varies, there may or may not be inflammatory signs, and it is often accompanied by fever. Early medical treatment consisting of local antiinflammatory dressings, and systemic antibiotherapy stops symptoms. Because of the frequency of recurrence, long-term antibiotherapy is needed and should continue even after the disappearance of clinical symptoms. For some authors, umbilical nipple is a risk factor for these recurrent abscesses. If the medical treatment is ineffective, surgery can be proposed. Recurrence is frequent after a simple incision and drain. A global resection of the concerned duct is therefore advised.