Emergency Department Care
Breast mass
Definitive diagnosis of the etiology can only be made by pathologic examination and is not an emergency. Timely follow-up care, including mammography and involvement of primary physician and surgeon, is essential.
Finding a breast mass can be stressful for patients; provide reassurance that not all breast masses are malignant.
Mastitis
For detailed therapy, see Mastitis Empiric Therapy and Mastitis Organism-Specific Therapy.
In general, mastitis is treated with antibiotic therapy for 10 to 14 days, warm or cold compresses, and (for patients with lactational mastitis) continued breast emptying via 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. [1, 9] The addition of appropriate antibiotic administration may relieve symptoms in 2.1 days, as compared with 4.2 days for supportive care or 6.7 days if no action is taken. [9] Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. [80] In breastfeeding mothers, use beta-lactamase stable penicillin. Other choices include dicloxacillin 500 mg orally 4 times daily or cephalexin 500 mg orally 4 times daily for 10 to 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. [81] 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]
Initial antibiotic selection for those with peri-prosthetic infections should be similar to those for patients without breast implants. [82, 83]
Corynebacterial infection is associated with longer treatment courses and an increased recurrence rate of complicated mastitis. [84]
Breast abscess
Historically, incision and drainage was considered the standard of care for abscesses. Although this method yields a lower recurrence rate, it is more invasive than needle aspiration and frequently results in scarring with structural damage and poor cosmetic outcomes. [69] 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] Although success has been reported with oral antistaphylococcal antibiotics and serial aspiration, [85] surgical excision may be required for infected or obstructed lactiferous ducts and provides a lower rate of recurrence for nonpuerperal abscess and mastitis. [70, 8]
In pediatric patients, treatment modality was not associated with persistent disease. [86] A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention. [86]
For persistent lesions, treatment options may include ultrasound-guided needle aspiration, [20] percutaneous drainage catheter, [77] and/or surgical drainage. Ultrasound-guided needle aspirations are more successful for abscesses smaller than 3 cm and for puerperal abscesses. [8, 71, 72, 73, 87] Loculations are associated with failure of resolution with aspiration, regardless of abscess volume. [74] Nonpuerperal abscesses have a higher recurrence rate and often require multiple drainage attempts. [8] Regardless of the underlying organism, the need for repeat aspiration is common in patients treated with aspiration versus incision and drainage. [75] In a US cohort of 54 abscess cases treated with needle-guided aspiration, the median number of drainage procedures was 2 (interquartile range, 1.0-4.0), with 24% requiring 5 or more drainage procedures. [43]
The vacuum-assisted breast biopsy (VABB) system is a viable option for the management of lactational breast abscesses and has been associated with a shorter healing time than simple needle aspiration. [76, 88] Furthermore, percutaneous catheter drainage may be considered for larger abscesses. [4, 77]
In one study, there was no difference in clinical characteristics between breast abscesses infected by methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-susceptible Staphylococcus aureus (MSSA), and the authors recommended no change in interventional treatment based on a positive MRSA culture result. [89]
Consultations
Patients with breast masses require a general surgeon for definitive treatment. Immediate consultation in the ED is not mandatory, but it may help facilitate faster follow-up care once patients are discharged from the hospital.
Patients with mastitis unresolved by a single course of correct antibiotics need urgent referral to a surgical breast specialist. [11] Similarly, refer patients with breast abscesses for surveillance of complications and possible recurrent breast abscesses.
Lactation nurses can also be of great help in advising about nipple hygiene and hand washing and preventing engorgement of the breast.
Long-Term Monitoring
Breast mass screening
For breast cancer screening guidelines, see the Guidelines section.
Future studies are needed to determine the efficacy and effectiveness of breast cancer screening with mammography in women aged 40 to 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. [35, 90]
Similar rates of cancer detection have been found between short-term interval follow-up (SIFU) and return to annual screening (RTAS) after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. [91] Additionally, positive predictive values have been reported not to change in patients receiving 6 and 12-month re-biopsy follow-up. [92] These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.
Mastitis
In addition to therapeutic breast emptying (if indicated), antibiotic therapy, and warm or cold compresses, emerging evidence suggests that therapeutic administration of lactobacilli strains that are naturally occurring in breast milk may be of therapeutic benefit for the management of infectious mastitis during lactation. [9, 93]
Mastitis that is refractory to standard treatment (see above) should prompt further workup to rule out uncommon infectious etiologies, granulomatous diseases, and/or idiopathic causes. [12]
Recurrent periductal mastitis may require combined total excision of the affected duct and the fistulous tract with encouraged smoking cessation (if applicable). [94]
Treatment of idiopathic granulomatous mastitis usually involves corticosteroids and methotrexate, with or without surgery.
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 and drainage, fine-needle aspiration, vacuum-assisted aspiration, and fistulectomy in the operating room. The wound can be left to close by secondary intention or with simple sutures over a drain. [4, 95] Cultures of the drained fluid should be obtained at this time and sent to determine antimicrobial susceptibility. [4]
Inpatient and 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 but should be avoided in breastfeeding mothers with concern for sedation and respiratory depression in the infant.
Prescribe parenteral narcotics for pain control while awaiting definitive surgical therapy.
Continue antibiotic therapy for 14 days after drainage.
Transfer
Transfer typically is not necessary for patients with breast mass, abscess, or mastitis.
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Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.
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Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.
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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.
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Eggshell or rim calcifications (arrows) have walls thinner than those of lucent-centered calcifications.
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This mass with associated large, coarse calcifications (arrows) is a degenerating fibroadenoma.
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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).
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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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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).
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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.
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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.
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Loculated breast abscess. A) A large loculated abscess is seen containing hypoechoic fluid 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.
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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.
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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.
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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.
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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.
