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Breast Abscess and Masses Workup

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

Laboratory Studies

In patients suspected of having a breast abscess, a CBC count with differential may be helpful. Send an aerobic and anaerobic culture during surgical drainage.

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Imaging Studies

Ultrasonography is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage. Simple cysts are seen on sonograms as round or oval with sharply defined margins and posterior acoustic enhancement. Complex cysts are characterized by a significant solid component, septations, lobulations, varied wall thickness, and the presence of internal debris. Abscesses usually appear as ill-defined masses and have central hypoechoic areas with either septations or low-level internal echoes, and posterior enhancement.[30, 31, 8, 25]

Breast cyst. A) A simple, fairly round breast cyst 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).

Contrast-enhanced ultrasonography has also been found to be helpful in distinguishing benign from malignant breast masses. This modality has been shown to be 86% sensitive and 79% specific for differentiating between the two types of masses.[32] For more information, see Breast Cancer, Ultrasonography.

Various types of breast masses are shown in the images below.

Ultrasonogram demonstrates a hypoechoic mass with Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.
Breast cancer, ultrasonography. Mediolateral obliq 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 sonogra 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.

Schedule an outpatient mammography to further characterize the suspected breast mass. The sensitivity of mammography ranges from 74%-95%, and specificity ranges from 89%-99%.[33, 34] Approximately 5%-10% of screening examinations are interpreted as abnormal, but 90% of women with abnormal results do not have breast cancer.[33, 34] For more information, see Breast, Benign Calcifications, Breast, Fibroadenoma, Breast, Nipple Discharge Evaluation, and Breast Cancer, Mammography.

Computer-aided digital breast tomosynthesis is a new imaging modality that has shown some promise as an additional (or even sole) screening tool for breast cancer. Current studies of computer-aided digital breast tomosynthesis show sensitivity of detecting masses and microcalcifications ranging between 85% and 89%. Its utility in detecting masses in dense breast tissue is still a debated topic. Current US guidelines have recommended against its routine use.[35]

Various breast masses are shown in the mammograms below.

Craniocaudal mammograms obtained 1 year apart demo 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 th 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 Eggshell or rim calcifications (arrows) have walls thinner than those of lucent-centered calcifications.
This mass with associated large, coarse calcificat This mass with associated large, coarse calcifications (arrows) is a degenerating fibroadenoma.
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Procedures

Breast abscesses may be drained with incision and drainage (versus ultrasound-guided needle aspiration and irrigation). Ultrasound-guided needle aspirations are more successful on abscesses smaller than 3 cm and on puerperal abscesses.[36, 37, 38, 8] Nonpuerperal abscesses have a higher rate of recurrence and often require multiple drainage attempts.[8]

Catheter drainage for larger abscesses is sometimes considered,[4] although one study reported that serial needle aspiration and irrigation with sterile saline, when combined with intracavitary antibiotic injection, had a 91% cure rate.[39]

Historically, incision and drainage was considered the standard of care for abscesses. Although this method has a lower reoccurrence rate, it is more invasive than needle aspiration and frequently results in scarring with structural damage and poor cosmetic outcomes.[40] Fine-needle aspiration should be considered first-line therapy for abscesses smaller than 5 cm owing to its lower risks, followed by incision and drainage if recurrence occurs.[4] Surgical resection may be required for infected or obstructed lactiferous ducts and provides a lower rate of recurrence for nonpuerperal abscess and mastitis.[39, 8]

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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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