Susan writes:
<I received a call from a colleague last night re: a friend who was
experiencing recurrent episodes of bilateral breast swelling, pain, and
occasionally leaking. She has had some visual diagnostics done (not sure
which ones) and diagnosed by her MD with small ducts. The suggested
treatment is ductal removal.  This has already been done in one of her
breasts - to the right of nipple/areola.  She was in the ER last night
with an "abscess" which was incised/drained for 2 TBS of fluid/packed
and then started on antibiotics. Don't know culture reports or what her
blood work is like. She has seen an oncologist over this in the past and
is now being referred to an endocrinologist.  She is not presently on
birth control pills, the pain and leaking seems to be around
menstruation.  Anyone have similar situations to offer?  I know there are
gaps in the story here. >

Yes, too many gaps to guess at. It sounds as though the doctor is
simplifying the explanation to the patient a great deal. It also sounds
as if they are investigating thoroughly, though. It would be interesting
to find out if one of the visual tests was ductography, ductal lavage and
removal of some ductal lining cells for examination under the
microscope.This would need to be done on each breast if each had problems
deemed to require surgical removal of any ducts.

MR is also a test done on the nipple-areolar complex to differentiate
various types of disease processes:
Buadu AA, Buadu LD, Murakami J, Murayama S, Hashiguchi N, Masuda K,
Enhancement of the Nipple-areolar –Complex on Contrast-Enhanced MR
Imaging of the Breast, Breast cancer 1998 Jul 25; 5(3): 285-289.
There is such a thing as the normal lining of the small ducts that pass
through the nipple taking over the lining of the lactiferous sinuses, and
causing repeated abcesses unless the affected ducts/sinuses are not
removed.

Powell BC, Mauli KI, Sachatello CR Recurrent subareolar abscess of the
breast and squamous metaplasia of the lactiferous ducts: a clinical
syndrome. South Med J 1977 Aug;70(8): 935-7.

Passaro ME, Broughan TA, Sebek BA, Esselstyn CB Jr. Lactiferous fistula,
J Am Coll Surg 1994 Jan;178(1): 29.

"Lactiferous fistula or Zuska's disease, is a rare  recurrent condition .
. . .Because little is known . . . it is often misdiagnosed and
inappropriately treated. . . . . . . .Cleveland Clinic Foundation . .
.experienced breast pathologist . . .On histologic examination, we found
that, in all instance, keratinizing squamous epithelium had replaced the
lining of one or more lactiferous ducts for a variable distance into the
subareolar tissue. Core excision of the fistula and all of the
retroareolar fibroglandular tissue and the ductal tissue within the
nipple proved to be the definitive therapy in 47 of the 48 patients who
had follow-up evaluation."

Kaplan CR, Schenken RS, Endocrinology of the Breast, In: Textbook of
Breast Diseases, ed. by Isaacs JH, Mosby Yearbook, St. Louis 1992,
pp.22-44.

"Upon establishemnt of ovulatory menstrual cycles, rising estrogen and
progesterone levels during the cycle cause an increase in blood flow and
interlobular edema. A moderate degree of ductal and lobular proliferation
also occurs during each follicular and luteal phase. Histologic
examination of normal breast tissue shows limited glandular secretion
just before menses and milk dischaarge from the nipple may occur. At
menses, a reduction in the number and size of  glandular cells occurs,
with loss of edema and slight decrease in breast."

No doubt one of the things done on an endocrinology work up would be a
prolactin level and possible connection with frank galactorrhea
(secretion of milk under non-physiologic circumstances.)
It's of course impossible to second-guess the doctors who have the first
hand facts for the most complete insight. But if anyone is interested in
reading more in general, (as is sort of a "hobby" now with me) I have
found these to contain some insights into the anatomy and cellular make
up of the breast which were very interesting to me.
Azzopardi JG, Ahmed A, Millis RR. Nomenclature of the Microanatomy of the
Breast: Parts Affected in Different Diseases: Normal Structure and
Involution, In: Problems in Breast Pathology In: Major Problems in
Pathology, Vol. 11 in series, Bennington JL, Ed., W. B. Saunders Co.
Ltd., London, 1979.
Haagensen CD, Diseases of the Breast, Third Edition 1986 W.B. Saunders
Co: West Washington Square, Philadelphia, PA 19105

Jean (whiling away a snowy stay-at-home day in Ohio on LN when I should
be packing for vacation in Arizona and North Carolina!)
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA


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