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Benign Conditions of the Breast Quiz

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A 54-year-old woman presents to her GP with intermittent sticky, green-brown nipple discharge from one breast and recent nipple inversion. There is no breast pain and she is not breastfeeding. Which underlying pathological process best explains this presentation?

A Malignant transformation of ductal epithelial cells with stromal invasion
B Benign intraductal papilloma causing localised epithelial overgrowth
C Dilatation and chronic inflammation of subareolar lactiferous ducts ✓
D Hormone-driven proliferation of terminal duct lobular units
E Hyperprolactinaemia causing bilateral milk secretion

The answer is C: Dilatation and chronic inflammation of subareolar lactiferous ducts

Explanation

Why C is correct

See Duct Ectasia. Option C is correct. Duct ectasia means widening (dilation) of one or more of the lactiferous ducts, the milk ducts that run beneath the nipple, which become blocked and inflamed. Thick secretions collect in the dilated ducts, so there is sticky coloured nipple discharge, and the discharge can be bloody, serous (watery), creamy white or yellow. Chronic inflammation around the ducts is followed by scarring, and the scar tissue is thought to pull the nipple inwards, which is nipple retraction or inversion. The condition is benign and is usually managed conservatively with reassurance. The exam trap is that nipple discharge and a retracting nipple are also features of breast cancer. In the UK, a woman aged 50 or over with discharge or retraction in one nipple only is referred on the suspected cancer pathway, so this 54-year-old would be sent to a breast clinic even though the most likely cause is benign. If symptoms persist, surgery to remove the affected duct may be considered.

Duct ectasia: widening of the lactiferous ducts beneath the nipple, which become blocked and inflamed.
Features: sticky coloured nipple discharge, and scarring that pulls the nipple inwards (nipple retraction).
Nature: benign, and usually managed conservatively with reassurance.
Exam trap: discharge or retraction in one nipple only in a woman aged 50 or over is referred on the suspected cancer pathway.

Why the other options are incorrect

A. Malignant transformation of ductal epithelial cells with stromal invasion: Malignant change of duct cells with invasion of the stroma (the supporting tissue) can cause nipple discharge and retraction, which is why this woman is rightly referred urgently. However, the stem asks which process best explains the picture of sticky coloured discharge and no pain, which fits a benign duct condition better. It would be the answer if a hard, fixed lump or bloody discharge dominated the stem.
B. Benign intraductal papilloma causing localised epithelial overgrowth: An intraductal papilloma is a benign papillary growth within a lactiferous duct that classically causes serous or bloody discharge. It does not explain sticky green-brown discharge with nipple retraction, which fits chronic duct ectasia better than a focal papilloma.
D. Hormone-driven proliferation of terminal duct lobular units: Hormone-driven growth of the terminal duct lobular units (the milk-producing end of each duct system) causes lumps and cyclical pain, as in fibrocystic change, rather than nipple discharge with retraction. It does not narrow or pull in the nipple. This option would fit a younger woman with cyclical lumpy, painful breasts.
E. Hyperprolactinaemia causing bilateral milk secretion: Hyperprolactinaemia causes galactorrhoea, which is usually bilateral, milky, and not associated with nipple inversion. This woman has one-sided sticky green-brown discharge and retraction, so a local duct disorder such as duct ectasia fits better than a systemic hormone excess.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
Which microorganism is the most common cause of acute infective mastitis in breastfeeding women?
2
Which feature most reliably distinguishes a phyllodes tumour from a fibroadenoma of the breast?

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