Breast Abscess and Masses 

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

Background

Breast masses can be broadly classified as benign or malignant. Common causes of a benign breast mass include fibrocystic disease, fibroadenoma, intraductal papilloma, and abscess. Malignant breast disease encompasses many histologic types that include, but are not limited to, infiltrating ductal or lobular carcinoma, in situ ductal or lobular carcinoma, and inflammatory carcinoma. The main concern of many women presenting with a breast mass is the likelihood of cancer; however, most breast masses are benign.

Breast infection most commonly affects women aged 18-50 years; in this age group, it can be divided into lactational and nonlactational infections. The process can affect the skin overlying the breast, where it can be a primary event, or it may occur secondary to a lesion such as a sebaceous cyst as hidradenitis suppurativa.[1, 2]

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Pathophysiology

The mammary glands arise along the milk lines that extend along the anterior surface of the body from the axilla to the groin. During puberty, pituitary and ovarian hormonal influences stimulate female breast enlargement, primarily due to accumulation of adipocytes. Each breast contains approximately 15-25 glandular units know as breast lobules, which are demarcated by Cooper ligaments. Each lobule is composed of a tubuloalveolar gland and adipose tissue. Each lobule drains into the lactiferous duct, which subsequently empties onto the surface of the nipple. Multiple lactiferous ducts converge to form one ampulla, which traverses the nipple to open at the apex.

Below the nipple surface, lactiferous ducts form large dilations called the lactiferous sinuses, which act as milk reservoirs during lactation.[3] When the lactiferous duct lining undergoes epidermalization, keratin production may cause plugging of the duct, resulting in abscess formation.[4] This may explain the high recurrence rate (an estimated 39-50%) of breast abscesses in patients treated with standard incision and drainage (I&D), as this technique does not address the basic mechanism by which breast abscesses are thought to occur.

Postpartum mastitis is a localized cellulitis caused by bacterial invasion through an irritated or fissured nipple. It typically occurs after the second postpartum week and may be precipitated by milk stasis. There is usually a history of a cracked nipple or skin abrasion. Staphylococcus aureus is the most common organism responsible, but Staphylococcus epidermidis and streptococci are occasionally isolated. Drainage of milk from the affected segment should be encouraged and is best achieved by continuing breastfeeding or use of a breast pump.[1]

Nonlactating infections may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections consist of active inflammation around nondilated subareolar breast ducts—a condition termed periductal mastitis. Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma.[1] Primary skin infections of the breast (cellulitis or abscess) most commonly affect the skin of the lower half of the breast and often recur in women who are overweight, have large breasts, or have poor personal hygiene.

Breast masses can involve any of the tissues that make up the breast, including overlying skin, ducts, lobules, and connective tissues. Fibrocystic disease, the most common breast mass in women, is found in 60-90% of breasts during routine autopsy. Fibroadenoma, the most common benign tumor, typically affects women younger than 30 years. Infiltrating ductal carcinoma is the most common malignant tumor; however, inflammatory carcinoma is the most aggressive and carries the worst prognosis.

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Epidemiology

Frequency

United States

Breast cancer is the most commonly diagnosed cancer in women, after skin cancer, accounting for approximately 1 in 4 cancers diagnosed in US women.[5]

Infectious complications occur in as many as 10% of lactating women.[6]

Lactational mastitis is seen in approximately 2-3% of lactating women,[3, 7] and breast abscess may develop in 5-11% of women with mastitis.[7]

Mortality/Morbidity

Breast mass

  • Morbidity and mortality depends on etiology.
  • Approximately 1 (3.6%) in 28 women die from breast cancer. In 2009, approximately 40,170 women were expected to die from breast cancer, second only to lung cancer.[5]
  • Associated morbidity may include scarring, disfigurement, lymphedema, and significant psychologic stress.

Breast abscess

  • Recurrent or chronic infections, pain, and scarring are causes of morbidity.
  • Mastitis is usually seen in lactating women, but the presence in a nonlactating woman should spur evaluation for an inflammatory carcinoma or new-onset diabetes.[6]
  • Abscess formation complicates postpartum mastitis in fewer than 10% of cases.
  • Neonatal mastitis usually occurs in term or near-term infants, is twice as common in females, and progresses to development of a breast abscess in approximately 50% of cases.[8, 9]

Race

  • African American women have a higher incidence rate before age 40 and are more likely to die from breast cancer at every age.[10]
  • White women have a higher incidence of breast cancer than African American women after age 40.

Sex

Greater than 99% of breast cancers are found in women. However, men with changes in breast size should have diagnostic workup completed as aggressively as women.[8, 9]

Age

Women older than 40 years account for more than 95% of new breast cancer cases and 97% of breast cancer deaths. The median age of diagnosis is 61 years of age.

  • Nonpuerperal breast masses encompass the third to eighth decades of life.
  • Puerperal breast abscesses and mastitis are commonly found in women of childbearing age (mean age of 32 years).[1]
  • Fibroadenoma is the most common cause of breast mass in women younger than 35 years.
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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.

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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.
 
 
 
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