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Breast Abscess and Masses Follow-up

  • Author: Andrew C Miller, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: May 24, 2016
 

Further Outpatient Care

Breast mass

Timely follow-up with primary physician and surgeon, mammography, and possible needle biopsy of the mass are indicated.

Mastitis

For detailed therapy, see Mastitis Empiric Therapy and Mastitis Organism-Specific Therapy

In general, treat with antibiotic therapy for 10-14 days, warm or cold compresses, and continued breast emptying by breastfeeding or breast pumping every 2 hours or when engorged.

Antibiotic therapy with continued breast emptying has been shown to be superior to breast emptying alone for resolving symptoms, decreasing recurrence rate, and decreasing the risk of abscess development.[9] The addition of appropriate antibiotic administration may relieve symptoms in 2.1 days as compared to 4.2 days for supportive care or 6.7 days if no action taken.[9] In breastfeeding mothers, use beta-lactamase stable penicillin (since breastfeeding). Other choices are dicloxacillin 500 mg orally 4 times daily or cephalexin 500 mg orally 4 times daily for 10-14 days. Instruct patients who are lactating that continued breastfeeding from the affected breast is not harmful to the baby. For nonpuerperal mastitis, use clindamycin 600 mg intravenously every 8 hours or 300 mg orally every 6 hours, or amoxicillin/clavulanate 500 mg orally 3 times daily.[42] If a breast abscess is suspected in a nursing mother, the affected breast should not be used to nurse the baby owing to the risk of passing infection to the baby.[4]

Screening tests

Multiple guidelines are available pertaining to breast cancer screening. The 3 most cited include those by the American College of Physicians (2015), the American Cancer Society (2015), and the United State Preventive Services Task Force (2016).

American College of Physicians (ACP) screening guidelines recommend the following:[43]

  • Mammography every 2 years from ages 50-74 years
  • For women aged 40-49 years, guidelines advocate an individualized approach in which clinicians should base decisions on the potential benefits and harms of mammography, the woman's preferences, and her breast cancer risk profile
  • Current evidence recommends against breast cancer screening with mammography in women younger than 40 years, women older than 75 years, and those with another serious medical condition with a life expectancy of less than 10 years. However, physicians and patients should discuss the risks and benefits of mammography based on the patient’s wishes and other associated breast cancer risks.

American Cancer Society (ACS) screening guidelines recommend the following:[44]

  • For women aged 40-44 years, the choice to begin annual breast cancer screening with mammography should be based on the potential risks/benefits and patient’s wishes.
  • For women aged 45-54 years, mammography should be completed annually.
  • For women aged 55 years and older, mammography should be completed every 2 years and continued until life expectancy falls below 10 years.

U.S. Preventive Services Task Force (USPSTF) screening guidelines recommend the following:[45]

  • Mammography every 2 years between ages 50 and 74 years
  • For women aged 40-49 years, guidelines advocate an individualized approach in which clinicians should base decisions on the potential benefits and harms of mammography, the woman's preferences, and her breast cancer risk profile
  • The USPSTF has found insufficient evidence to make a recommendation about breast cancer screening in women younger than 40 years or older than 75 years.

The above guidelines share the following recommendations:

  • No clear recommendations for breast self-examination
  • No clear recommendation for clinical breast examination

ACP and ACS guidelines do not recommend the use of MRI or digital breast tomosynthesis for the purposes of breast cancer screening. USPSTF has found insufficient evidence to provide a recommendation about either of these breast cancer screening modalities.

Future studies are needed to determine the efficacy and effectiveness of breast cancer screening with mammography in women aged 40-49 years. Some research shows a modest decrease in breast cancer mortality when women in this age group are screened; however, further research is needed to compare risks of overdiagnosis (one study suggests 1 in 424 women screened would be overdiagnosed) versus potential benefits of screening.[46, 47]

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Further Inpatient Care

Consider admitting patients with large or complex breast abscesses for pain management, parenteral antibiotic therapy, and definitive management. Admit patients with sepsis due to mastitis. Consider diabetic ketoacidosis in patients with nonpuerperal breast abscess.

Treatment may include incision, drainage, fine-needle aspiration, and fistulectomy in the operating room. The wound can be left to close by secondary intention or with simple sutures over a drain.[48, 4] Cultures of the drained fluid should be obtained at this time and sent to determine antimicrobial susceptibility.[4]

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Inpatient & Outpatient Medications

Prescribe pain medication to patients with a breast abscess as necessary. NSAIDs, such as ibuprofen, are preferred because they are not transferred through breastmilk. Preparations combining acetaminophen with codeine, oxycodone, or hydrocodone may be used depending on the level of discomfort.

Prescribe parenteral narcotics for pain control while awaiting definitive surgical therapy.

Continue antibiotic therapy for 14 days after drainage.

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Transfer

Transfer typically is not necessary for patients with breast mass, abscess, or mastitis.

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Complications

Potential complications are as follows:

  • Breast mass - Chronic pain, scarring or disfigurement, metastases, postsurgical complications (eg, ipsilateral lymphedema), and death
  • Mastitis - Breast abscess formation in less than 10% of cases
  • Breast abscess - Recurrent infection, scarring, loss of breast size, and noticeable breast asymmetry
  • Chronic breast abscess - Mammary duct fistulization, resection of the nipple-areolar complex [10]
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Prognosis

Breast mass: Prognosis varies from excellent in patients with a fibroadenoma to poor in those with inflammatory breast cancer. Influencing factors include tumor size, histology, nodal involvement, distant metastases, and comorbid conditions.

Breast abscess: Unfortunately, the recurrence rate of breast abscess is high (39%-50%) when treated with standard incision and drainage, and studies have shown even higher recurrence rates in women undergoing fine-needle aspiration.[46] Nonpuerperal abscesses recur more frequently, especially when associated with non-staphylococcal species (>50% recurrence rate).[8] Studies of patients with fistulectomy show lower recurrence rates.

Mastitis: Most patients experience resolution within 2-3 weeks. All patients with symptoms that have not resolved within 5 weeks should be evaluated for resistant infection or malignancy.

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Patient Education

Educate women who are lactating on nipple hygiene because cracking and abrasions of the skin increase risk of infection.

For excellent patient education resources, visit eMedicineHealth's Women's Health Center and Cancer Center. Also, see eMedicineHealth's patient education articles Breast Infection, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

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Contributor Information and Disclosures
Author

Andrew C Miller, MD Vice Chair of Research, Department of Emergency Medicine, Ruby Memorial Hospital, West Virginia University School of Medicine

Andrew C Miller, MD is a member of the following medical societies: American College of Emergency Physicians, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

John W Hall, IV West Virginia University School of Medicine

John W Hall, IV is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, Phi Beta Kappa

Disclosure: Nothing to disclose.

Suha Abdulkarim Khafaji, MBBS Research Physician, Department of Emergency Medicine, West Virginia University School of Medicine

Disclosure: Nothing to disclose.

Joseph J Minardi, MD Associate Professor, Department of Emergency Medicine, Department of Medical Education, West Virginia University School of Medicine; Director of Emergency Ultrasound, Department of Emergency Medicine, West Virginia University Hospitals

Joseph J Minardi, MD is a member of the following medical societies: Academy of Emergency Ultrasound, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, American Medical Association, American Registry for Diagnostic Medical Sonography, American Society of Echocardiography, Emergency Ultrasound Fellowship, Society for Academic Emergency Medicine, Society of Ultrasound in Medical Education

Disclosure: Received income in an amount equal to or greater than $250 from: General Electric.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Caitlin Kennedy, MD Resident Physician, Department of Emergency Medicine, West Virginia University School of Medicine

Caitlin Kennedy, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Sadia Hussain, MD, Tajinderpal Saraon, MD, Mark Silverberg, MD, Howard A Blumstein, MD, and Amy K Rontal, MD, to the development and writing of this article.

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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.
Breast cyst. A) A simple, fairly round breast cyst with hypo or anechoic contents and well-defined borders; B) Posterior acoustic enhancement is seen as well as edge shadows (arrows).
Breast adenoma. A) A breast adenoma is oval with well-defined borders. It may be hypoechoic and some internal echogenicity may be seen. It is wider than tall and posterior acoustic enhancement is NOT seen, helping distinguish from a cyst or other fluid collection. B) An arrow indicates the adenoma.
Breast hematoma. A) A breast hematoma is seen as a round echogenic collection with surrounding tissue edema. A hematoma may be hypoechoic, mixed, or fairly echogenic depending on the stage of the hematoma. B) The hematoma is outlined and tissue edema noted.
Loculated breast abscess. A) A large loculated abscess is seen containing hypoechoic fuid and some internal echoes. Posterior acoustic enhancement is seen. Care must be taken to image at an adequate depth to visualize posterior borders of breast lesions. B) The abscess is outlined in yellow and the posterior acoustic enhancement is noted.
Loculated breast abscess, curvilinear. A) This is the same abscess seen in the above image and is imaged with a curvilinear transducer to better appreciate the extent of the abscess. It is important to image the abscess completely for width and depth. B) The abscess is outlined in yellow and the ribs and posterior acoustic enhancement are noted.
Purulent breast abscess. A) A purulent breast abscess is seen. The fluid is echogenic, but can be recognized as a disruption of the surrounding tissue and posterior acoustic enhancement. B) The abscess is outlined in yellow and the posterior acoustic enhancement is noted.
Complex breast abscess. In this clip, the features of a loculated breast abscess containing echogenic purulent material are noted. Example of imaging with a linear high-frequency transducer.
Loculated breast abscess, curvilinear. In this clip, a large, loculated breast abscess and its features are noted. Example of imaging with a lower-frequency curvilinear transducer to better appreciate the extent of this large abscess.
 
 
 
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