Abscess definition
• Local accumulation of pus within the breast due to infection
how common is an abscess
- 3-11% of women with mastitis, and about 10-33% of ladies lactating get mastitis
- affects mainly lactating women
causes of an abscess
• Severe complication of mastitis, although it may occur without apparent preceding mastitis
• LACTATING WOMEN ¬– milk stasis is the primary cause of mastitis, milk stasis causes an inflammatory response that may or may not progress to an infection
• Most common organism is Staph Aureus or possible strains of MRSA
• NON-LACTATING – mastitis is usually accompanied by infection, which can be categorised as either central or subareolar or peripheral
- Central/Subareolar Infection – usually secondary to periductal mastitis or duct extasia
- Peripheral Non-Lactating Infection – has been associated with diabetes mellitus, rheumatoid arthritis, trauma, corticosteroid treatment, and granulomatous lobular mastitis but often there is no underlying cause
risk factors of an abscess
- MASTITIS IN LACTATING WOMEN – poor infant attachement to the breast, reduced number or duration of feeds (e.g. partial bottle feeding, painful breasts, maternal stress and fatigue etc), no ebeidence that breast size is related, 30-34 years of age is the most likely time
- MASTITIS IN NON-LACTATING WOMEN – smoking is the biggest, nipple damage (piercing, eczema infection, Raynaud’s), trauma, underlying breast abnormality, immunosuppression, shaving or plucking areolar hair, foreign body (implants)
- BREAST ABSCESS – previous mastitis, sudden cessation of breastfeeding in women with lactational mastitis, staph aureus carriage, poor SES, poor hygiene
symptoms/signs of an abscess
- History of recent mastitis
- Fever or general malaise (these may have subsided if the women has taken antibiotics for suspected infectious mastitis)
- Painful swollen lump in the breast, with redness, heat and swelling of the overlying skin
DDx of an abscess
- CONDITIONS THAT CAUSE BREAST PAIN AND ARE ASSOCIATED WITH LACTATION: full breasts, engorged breasts, a blocked duct, galactocele and infection of the mammary glands
- CONDITIONS THAT CAUSE BREAST PAIN THAT ARE NOT ASSOCIATED WITH LACTATIO INCLUDE: breast cancer, duct ectasia, cellulitis, fibroadenosis, ruptured breast cyst, necrotising fasciitis of the breast, fat necrosis of the breast
- CONDITIONS THAT CAUSE NIPPLE PAIN INCLUDE: poor infant attachment, candida infection of the nipple, blanching of the nipple, bacterial infection of the nipple, Raynaud’s disease of the nipple
Investigations for an abscess
- USS
* Culture fluid from abscess
management for an abscess
- 1ST LINE SURGICAL INTERVENTION – ultrasound-guided needle aspiration AND IV OR ORAL ANTIBIOTIC WITH ACTIVITY AGAINST METHICILLIN-SENSITIVE STAPHYLOCOCCI – dicloxacillin, cephalexin, doxcycline
- Advise lactating women to continue breastfeeding if possible (including from the affected breast)
- If this is too painful or the infant refuses the milk, express the milk either by hand or by pump until she is able to resume
Fibrocystic Disease (Fibrocystic Breast Condition) definition
- Fibrocystic breast disease AKA fibrocystic breasts or fibrocystic change
- Benign condition in which the breasts feel lumpy
- Fibrocystic breasts aren’t harmful or dangerous but may be bothersome or uncomfortable for some women
how common is Fibrocystic Disease (Fibrocystic Breast Condition)
- 30-60% of women, 70-90% lifetime prevalence
* Women of childbearing age normally
causes for Fibrocystic Disease (Fibrocystic Breast Condition)
• Not fully understood, due to hormone levels (oestrogen, progesterone and prolactin) as the condition tends to subside after the menopause
risk factors for Fibrocystic Disease (Fibrocystic Breast Condition)
- Age – 30-50
* Birth control pills may lower the likelihood but hormone therapy may increase them
symptoms for Fibrocystic Disease (Fibrocystic Breast Condition)
- Non-cancerous breast lumps that can sometimes cause discomfort, often periodically related to hormonal influence from the menstrual cycle – diffuse symmetrical lumpiness through both breasts
- May experience a persistent or intermittent breast aching or breast tenderness related to periodic swelling
- Breast or nipples may be tender or itchy
- Thickening of tissue
signs for Fibrocystic Disease (Fibrocystic Breast Condition)
- Lumps are smooth with defined edges
- Usually free moving in regards to surrounding tissue
- Most often found in the upper, outer section of the breast
DDx for Fibrocystic Disease (Fibrocystic Breast Condition)
• Breast malignancy
Investigations for Fibrocystic Disease (Fibrocystic Breast Condition)
• 1st LINE BREAST USS and MAMMOGRAPHY
• 2nd LINE
- SYMPTOMATIC BREAST CYSTS – cyst aspiration, fluid = straw-coloured and cyst drained no need for cytological studies, fluid = bloody cytology recommended
- SOLID MASSES ON PALPATION OR IMAGES (EVEN WHEN PALPABLE BUT NOT VISIBLE ON IMAGES) – breast biopsy to exclude malignancy
Management for Fibrocystic Disease (Fibrocystic Breast Condition)
• MASTALGIA:
- 1ST Line: reassurance through an explanation of the effects of menstrual hormonal cycling and oestrogen effects is effective in relieving patient anxiety, finding a bra that provides good support
o ADJUNCT: over the counter painkillers e.g. paracetomal (500-100mg every 4-6 hours) or ibuprofen (300-400mg every 6-8 hours) both when required
- 2ND Line: hormonal therapy tamoxifen (primary), bromocriptine (secondary), danazol (tertiary)
• NIPPLE DISCHARGE:
- NON-SUSPICIOUS AND BREAST MASS NOT PRESENT reassurance with observation
- NON-SUSPICIOUS AND BREAST MASS PRESENT refer to oncologist
- SUSPICIOUS referral and surgery
Intraductal Papilloma (NOT CANCER) definition
- Wart like lump that develops in one or more of the milk ducts in the breast
- Usually close to the nipple but can be found anywhere in the body
how common is Intraductal Papilloma (NOT CANCER)
- 2-3% incidence
* Most common in women over 40 and usually develop naturally as the breast ages
causes of Intraductal Papilloma (NOT CANCER)
• Can be associated with atypical hyperplasia – abnormal growth of cells
risk factors for Intraductal Papilloma (NOT CANCER)
- CENTRAL develop near the nipple, generally in women nearing the menopause
- PERIPHERAL often multiple papilloma’s, younger women
symptoms /signs of Intraductal Papilloma (NOT CANCER)
- Bloody dischare
- Aged 20-40
- Generally do not show up on mammogram due ot their small size
- Small lump on examination
- Generally not painful but may have some pain or discomfort in that area
• Often too small to be palpated or felt
DDx of Intraductal Papilloma (NOT CANCER)
• Malignancy
Investigations for Intraductal Papilloma (NOT CANCER)
• 1st LINE:
- MAMMOGRAM – may be negative
- BREAST ULTRASOUND – dilated duct with oval mass
- BREAST DUCTOGRAM – filling defect of duct
• Other Investigations:
- BREAST BIOPSY – papillary growth pattern: benign papilloma or atypia, papillar ductal carcinoma in situ or invasive papillary carcinoma
