Breast Abscess and Masses Clinical Presentation

  • Author: Andrew C Miller, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 2, 2010
 

History

Breast mass

  • Palpable mass, typically only in one breast
  • Family history of breast disease, malignant and/or benign
  • Menstrual and obstetrical histories are important.
  • Associated symptoms of pain, nipple discharge, and skin changes (eg, dimpling or inflammation, nipple inversion)
  • Length of time present, speed of growth

Mastitis

  • Localized breast erythema, warmth, and pain
  • May have fever and chills
  • May be lactating and may have recently missed feedings
  • May progress to breast abscess

Breast abscess

  • Localized breast edema, erythema, warmth, and pain
  • History of previous breast abscess is common.
  • Associated symptoms of fever, vomiting, and spontaneous drainage from the mass or nipple
  • May be lactating
Next

Physical

Perform a thorough breast examination for any patient presenting with a breast complaint and for any older woman presenting with unexplained weight loss, anorexia, or bone pain.

Breast mass

  • Firm mass of variable shape and size
  • Fifty percent of masses found in the upper outer quadrant of the breast
  • May have associated pain with palpation, but most are painless
  • Nipple discharge or inversion
  • Skin retraction or tethering
  • Axillary lymphadenopathy
  • Inflammatory changes of the skin (ie, peau d'orange)
  • Note, pay special attention to associated upper extremity neurologic motor or sensory abnormalities, as these may herald invasion of the brachial plexus — an indication for emergent radiation therapy.

Mastitis

  • Localized breast erythema, warmth, induration, and tenderness
  • May have associated fever

Breast abscess

  • Localized breast erythema, warmth, edema, and tenderness
  • Most frequently areolar or periareolar
  • Fluctuance
  • May have associated fever or axillary lymphadenopathy
  • Nipple discharge or inversion
Previous
Next

Causes

Malignant

  • Breast mass:
    • Risk factors for breast cancer include female sex, age older than 40 years, family history of a first-degree relative with breast cancer, nulliparity, menarche before age 12 years, menopause after age 55 years, and late pregnancy (>30 y of age).
    • The BRCA1 and BRCA2 genes are responsible for approximately 5% of all breast cancers and are inherited in an autosomal dominant fashion. Women with mutations in either of these genes have a lifetime risk of breast cancer of 60-85% and a lifetime risk of ovarian cancer of 15-40%.[11]

Benign

  • Fibrocystic changes:
    • Spectrum of features includes development of cysts and fibrosis.
    • Lobules of the breast may dilate and form cysts of varying sizes, due to hormonal changes in the menstrual cycle.
    • Cysts are found in about 1 in 3 women between 35 and 50 years old.[5]
    • Rupturing of the cysts can cause scarring and inflammation that leads to fibrotic changes, which feel rubbery, firm, or hard.
  • Hyperplasia:
    • Hyperplasia is caused by an overgrowth of cells that line the ducts or lobules.
    • About 1 in 4 women have mild or usual hyperplasia.[5]
    • About 1 in 25 women have atypical hyperplasia (associated with an increased risk of malignancy).[5]
  • Adenosis: This is an increase in the number of glands.
  • Fibroadenoma:[3]
    • The most common cause of breast mass in female patients younger than 25 years is fibroadenoma.
    • These arise from the terminal duct lobular unit and appear clinically as singular, firm, rubbery, smooth, mobile, painless masses ranging in size from 1-5 cm.
    • They may grow to a large size, thereby affecting the contours of the overlying skin and overall shape of the breast.
    • Ultrasonography reveals a well-defined hypoechoic homogeneous mass 1–20 cm in diameter.[6]
    • Fibroadenomas appear as multiple masses in 10–15% of patients.[6]
  • Phyllodes tumor:[3]
    • Phyllodes tumor is also known as cystosarcoma phyllodes or giant fibroadenoma.
    • Although generally benign, a malignant variant occurs in 10% of cases.
    • Incidence is highest among women in their 40s or 50s.
    • Most common presentation is that of a large (average size, 5 cm), solitary, firm, breast nodule.
  • Papillary adenoma of the nipple:[3]
    • Papillary adenoma is also known as erosive adenomatosis of the nipple, adenoma of the nipple, florid papillomatosis of the nipple, and subareolar duct papillomatosis of the nipple.
    • This is believed to originate in the terminal lactiferous ducts of the nipple and subareolar tissue.
    • Incidence is highest among women in their 40s.
    • It commonly presents with unilateral serous or bloody nipple discharge that increases before menses.
  • Breast abscess:
    • Staphylococcus aureus and streptococcal species are the most common organisms isolated in puerperal breast abscesses. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.
    • A study by Schafer et al found a significant correlation between cigarette smoking and subareolar breast abscess.[12]
  • Mastitis:
    • Mastitis occurs in 2-3% or more of lactating women, with its highest incidence in weeks 2-3 postpartum.[7, 13]
    • Periductal mastitis comprises 3-4% of all benign lesions of the breast.[3]
    • S aureus is the most common cause. Streptococci, enterococci, Staphylococcus epidermidis, Peptostreptococcus species, Prevotella species, and Escherichia coli are less common causes.
    • True fungal mastitis is rare and should prompt evaluation for coexisting diabetes mellitus.
    • In infants, infections with Shigella, E coli, and Klebsiella species have been reported.[9]
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Andrew C Miller, MD  Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC); Attending Physician, Department of Emergency Medicine, UPMC St Margaret's Hospital

Andrew C Miller, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Tajinderpal S Saraon, MD  Cardiology Fellow, Department of Cardiovascular Disease, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Sadia Hussain, MD  Resident Physician, Department of Emergency Medicine, State University of New York, Downstate, Kings County Hospital

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, FACEP, MMB  Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn

Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Barry J Sheridan, DO  Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Howard A Blumstein, MD, and Amy K Rontal, MD, to the development and writing of this article.

References

  1. Dixon JM. ABC of breast diseases. Breast infection. BMJ. Oct 8 1994;309(6959):946-9. [Medline].

  2. Dixon JM. Outpatient treatment of non-lactational breast abscesses. Br J Surg. Jan 1992;79(1):56-7. [Medline].

  3. Whitaker-Worth DL, Carlone V, Susser WS, et al. Dermatologic diseases of the breast and nipple. J Am Acad Dermatol. Nov 2000;43(5 Pt 1):733-51; quiz 752-4. [Medline].

  4. Bland, Copeland, eds. The Breast: Comprehensive Management of Benign and Malignant Disorders. 3rd ed. Saunders; 2004.

  5. American Cancer Society. Breast Cancer Facts and Figures 2009-2010. American Cancer Society. Available at http://www.cancer.org/downloads/STT/F861009_final%209-08-09.pdf. Accessed Feb 1, 2010.

  6. Givens ML, Luszczak M. Breast disorders: a review for emergency physicians. J Emerg Med. Jan 2002;22(1):59-65. [Medline].

  7. Mass S. Breast pain: engorgement, nipple pain and mastitis. Clin Obstet Gynecol. Sep 2004;47(3):676-82. [Medline].

  8. Efrat M, Mogilner JG, Iujtman M, et al. Neonatal mastitis--diagnosis and treatment. Isr J Med Sci. Sep 1995;31(9):558-60. [Medline].

  9. De Silva NK, Brandt ML. Disorders of the breast in children and adolescents, Part 1: Disorders of growth and infections of the breast. J Pediatr Adolesc Gynecol. Oct 2006;19(5):345-9. [Medline].

  10. Anderson WF, Rosenberg PS, Menashe I, Mitani A, Pfeiffer RM. Age-related crossover in breast cancer incidence rates between black and white ethnic groups. J Natl Cancer Inst. Dec 2007;100(24):1804-14. [Medline].

  11. Armstrong K, Eisen A, Weber B. Assessing the risk of breast cancer. N Engl J Med. Feb 24 2000;342(8):564-71. [Medline].

  12. Schafer P, Fürrer C, Mermillod B. An association of cigarette smoking with recurrent subareolar breast abscess. Int J Epidemiol. Dec 1988;17(4):810-3. [Medline].

  13. Brennan M, Houssami N, French J. Management of benign breast conditions. Part 3--Other breast problems. Aust Fam Physician. May 2005;34(5):353-5. [Medline].

  14. Muttarak M, Chaiwun B. Imaging of giant breast masses with pathological correlation. Singapore Med J. Mar 2004;45(3):132-9. [Medline].

  15. Kerlikowske K, Smith-Bindman R, Ljung BM, et al. Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern Med. Aug 19 2003;139(4):274-84. [Medline].

  16. Kerlikowske K, Creasman J, Leung JW, et al. Differences in screening mammography outcomes among White, Chinese, and Filipino women. Arch Intern Med. Sep 12 2005;165(16):1862-8. [Medline].

  17. Thirumalaikumar S, Kommu S. Best evidence topic reports. Aspiration of breast abscesses. Emerg Med J. 21(3);May 2004:333-4. [Medline].

  18. Hook GW, Ikeda DM. Treatment of breast abscesses with US-guided percutaneous needle drainage without indwelling catheter placement. Radiology. 1999;213:579-82. [Medline].

  19. Ozseker B, Ozcan UA, Rasa K, Cizmeli OM. Treatment of breast abscesses with ultrasound-guided aspiration and irrigation in the emergency setting. Emerg Radiol. Mar 2008;15(2):105-8. [Medline].

  20. Eryilmaz R, Sahin M, Hakan Tekelioglu M, Daldal E. Management of lactational breast abscesses. Breast. Oct 2005;14(5):375-9. [Medline].

  21. Arroyo R, Martín V, Maldonado A, Jiménez E, Fernández L, Rodríguez JM. Treatment of infectious mastitis during lactation: antibiotics versus oral administration of Lactobacilli isolated from breast milk. Clin Infect Dis. Jun 2010;50(12):1551-8. [Medline]. [Full Text].

  22. Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis. JAMA. Apr 2 2003;289(13):1609-12. [Medline].

  23. [Guideline] U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Nov 17 2009;151(10):716-26, W-236. [Medline]. [Full Text].

  24. Zylstra S, D'Orsi CJ, Ricci BA, et al. Defense of breast cancer malpractice claims. Breast J. Mar-Apr 2001;7(2):76-90. [Medline].

  25. American Cancer Society. Breast Cancer Facts & Figures 2007-2008. Available at http://www.cancer.org/downloads/STT/BCFF-Final.pdf. Accessed 04/01/2009.

  26. August DA, Sondak VK. Breast. In: Greenfield LJ, et al, eds. Surgery Scientific Principles and Practice. 2nd ed. Lippincott-Raven Publishers; 1997:1357-1415.

  27. Beckman C. Ling F, Barzansky B, Herbert W, Laube D, Smith R, eds. Obstetrics and Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

  28. Dener C, Inan A. Breast abscesses in lactating women. World J Surg. Feb 2003;27(2):130-3. [Medline].

  29. Dixon JM. Repeated aspiration of breast abscesses in lactating women. BMJ. Dec 10 1988;297(6662):1517-8. [Medline].

  30. Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. Sep 28 1994;272(12):947-54. [Medline].

  31. Eryilmaz R, Sahin M, Hakan Tekelioglu M, Daldal E. Management of lactational breast abscesses. Breast. Oct 2005;14(5):375-9. [Medline].

  32. Garcia CJ, Espinoza A, Dinamarca V, et al. Breast US in children and adolescents. Radiographics. Nov-Dec 2000;20(6):1605-12. [Medline].

  33. Harris JR, Lippman ME, Veronesi U, et al. Breast cancer (1). N Engl J Med. Jul 30 1992;327(5):319-28. [Medline].

  34. Houssami N, Ciatto S, Ambrogetti D, Catarzi S, Risso G, Bonardi R, et al. Florence-Sydney Breast Biopsy Study: sensitivity of ultrasound-guided versus freehand fine needle biopsy of palpable breast cancer. Breast Cancer Res Treat. Jan 2005;89(1):55-9. [Medline]. [Full Text].

  35. Karstrup S, Solvig J, Nolsoe CP, et al. Acute puerperal breast abscesses: US-guided drainage. Radiology. 1993;188:807-9. [Medline].

  36. Khoda J, Lantsberg L, Yegev Y, et al. Management of periareolar abscess and mamillary fistula. Surg Gynecol Obstet. Oct 1992;175(4):306-8. [Medline].

  37. Kitchen PR. Management of sub-areolar abscess and mammary fistula. Aust N Z J Surg. Apr 1991;61(4):313-5. [Medline].

  38. Lau SK, McKee GT, Weir MM, Tambouret RH, Eichhorn JH, Pitman MB. The negative predicative value of breast fine-needle aspiration biopsy: the Massachusetts General Hospital experience. Breast J. Nov-Dec 2004;10(6):487-91. [Medline].

  39. Maier WP, Au FC, Tang CK. Nonlactational breast infection. Am Surg. Apr 1994;60(4):247-50. [Medline].

  40. Meguid MM, Oler A, Numann PJ, et al. Pathogenesis-based treatment of recurring subareolar breast abscesses. Surgery. Oct 1995;118(4):775-82. [Medline].

  41. Miller BA, Feuer EJ, Hankey BF. The significance of the rising incidence of breast cancer in the United States. Important Adv Oncol. 1994;193-207. [Medline].

  42. O'Hara RJ, Dexter SP, Fox JN. Conservative management of infective mastitis and breast abscesses after ultrasonographic assessment. Br J Surg. Oct 1996;83(10):1413-4. [Medline].

  43. Surveillance, Epidemiology, and End Results (SEER) Program, SEER 17 Registries, 2000-2004 [database online]. SEER.cancer.gov: Division of Cancer Control and Population Science, National Cancer Institute; 2007.

  44. Walker AP, Edmiston CE, Krepel CJ, et al. A prospective study of the microflora of nonpuerperal breast abscess. Arch Surg. 1988;123:908-11. [Medline].

  45. Watt-Boolsen S, Rasmussen NR, Blichert-Toft M. Primary periareolar abscess in the nonlactating breast: risk of recurrence. Am J Surg. Jun 1987;153(6):571-3. [Medline].

  46. Wiesenfeld HC, Sweet RL. Perinatal infections. In: Scott JR, et al, eds. Danforth's Obstetrics and Gynecology. 7th ed. Lippincott-Raven Publishers; 1994:469.

 
Previous
Next
 
Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.
Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.
Spot compression mammogram of the outer part of the breast demonstrates a new mass as smooth, margined, and oval. The findings are consistent with a fibroadenoma, a cyst, or a malignancy. In this patient, the diagnosis was a rapidly growing fibroadenoma.
Eggshell or rim calcifications (arrows) have walls thinner than those of lucent-centered calcifications.
This mass with associated large, coarse calcifications (arrows) is a degenerating fibroadenoma.
Breast cancer, ultrasonography. Mediolateral oblique digital mammogram of the right breast in a 66-year-old woman with a new, opaque, irregular mass approximately 1 cm in diameter. The mass has spiculated margins in the middle third of the right breast at the 10-o'clock position. Image demonstrates both the spiculated mass (black arrow) and separate anterior focal asymmetry (white arrow).
Breast cancer, ultrasonography. Antiradial sonogram of the spiculated mass (shown in the image above) demonstrates a hypoechoic mass with angular margins (black arrows). Cursors on the margins of the mass were used to electronically measure its dimensions of the mass, which was 0.9 X 0.8 cm.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.