Surgery MCQ 201

A 52-year-old postmenopausal woman presents to the clinic with a complaint of a lump beneath her right nipple. She reports a sticky discharge from the nipple that has ranged in color from yellow to greenish. The lump is not painful, and there is no history of fever or trauma. On examination, the nipple appears slightly retracted, and there is mild tenderness in the subareolar region. There are no signs of erythema or fluctuance. What is the most likely diagnosis?

A. Duct ectasia
B. Lactational mastitis
C. Mastalgia
D. Breast cyst
E. Breast abscess


Correct Answer: A. Duct ectasia


Explanation:

Duct ectasia is a benign breast condition characterized by the dilation of the subareolar ducts, often leading to periductal inflammation. It most commonly occurs in perimenopausal and postmenopausal women.

  • Key Features of Duct Ectasia:
    • Subareolar Mass: A palpable lump beneath the nipple is a hallmark of duct ectasia. This results from the distended ducts and associated inflammation or fibrosis.
    • Nipple Discharge: The discharge is typically sticky, thick, and may vary in color, including white, yellow, or greenish hues. This occurs due to the accumulation of secretions within the dilated ducts.
    • Nipple Retraction: Chronic inflammation and fibrosis can cause tethering of the nipple, leading to slight retraction or distortion.
    • Mild Tenderness: While the condition is often painless, mild tenderness may be present due to the inflammatory response.

Pathophysiology:
Duct ectasia arises due to degenerative changes in the ductal epithelium, leading to duct dilation, stasis of secretions, and subsequent inflammation (periductal mastitis). Over time, fibrosis may replace the inflammation, leading to a firm mass beneath the nipple.

Management:

  • Most cases resolve spontaneously or with symptomatic management, including analgesics for tenderness.
  • Warm compresses can alleviate discomfort.
  • If infection is suspected, antibiotics targeting common pathogens may be prescribed.
  • Surgical excision of the affected duct is reserved for persistent cases or when malignancy cannot be ruled out.

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Analysis of Incorrect Options:

B. Lactational mastitis:

  • Typically occurs in lactating women, particularly during the first few months postpartum.
  • Presents with a painful, erythematous area in the breast, systemic symptoms like fever, and possibly an abscess if untreated.
  • This patient is postmenopausal, and there are no signs of systemic infection, making this diagnosis unlikely.

C. Mastalgia:

  • Refers to breast pain, often cyclical and related to hormonal fluctuations during the menstrual cycle.
  • It does not involve nipple discharge or a subareolar mass, ruling it out in this case.

D. Breast cyst:

  • Cysts are fluid-filled sacs in the breast, commonly found in premenopausal women.
  • They typically present as smooth, round, mobile masses that can be tender, especially before menstruation.
  • Nipple discharge and retraction are not common features, making this diagnosis less likely.

E. Breast abscess:

  • Presents with a painful, fluctuant mass, typically associated with erythema, warmth, and systemic signs like fever.
  • While abscesses can cause nipple discharge, the absence of acute inflammatory signs and systemic symptoms in this case makes it an unlikely diagnosis.

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